Informed Consent

Treatment Process

Brave Soul Therapy (Brave Soul) is a private group practice. Brave Soul therapists are trained in a variety of therapeutic techniques. Your therapist will work with you during the first several sessions to develop a treatment plan and discuss treatment preferences. As the client, you have the right to ask your therapist questions about his or her background, qualifications and therapeutic orientation. Important factors in the success of therapy include good communication and a good rapport and relationship between the therapist and the client. However, not all individuals benefit from therapy or working with a particular therapist.

You have a right to understand the therapist’s assessment, the recommended course of service and the estimated duration of counseling. The goals and outcomes of our work together are jointly determined and are tailored to fit the client’s needs and desired outcome. Although we are committed to working with you towards healthy outcomes, there is no guarantee of a particular outcome of therapy. As the client, you have the right to expect professional, courteous treatment.

Children’s Therapy: Both parents are entitled to access and understand their child’s course of treatment unless your child’s therapist is provided with legal documentation limiting access or communication. In situations where both parents are not present it is expected that both parents will talk with each other about the child’s treatment. For parents who do not attend sessions it is their responsibility to communicate with the child’s therapist. It is unrealistic to expect your child’s therapist to regularly call or email you after each session.

Legal: Brave Soul clinicians do not appear on behalf of clients and do not maintain records with the intended purpose of court involvement. In the situation where all legal guardians are not present at a child’s intake, it is important that the therapist receive necessary contact information for all legal guardians. It is not the responsibility of the clinician to notify the other legal guardian about the child’s involvement in therapy and expected that the guardian attending the session will notify the other guardian/parent.

Billing and Insurance

Brave Soul is an In-Network provider for most major insurance plans. You will need to consult with your medical benefits provider to determine if benefits apply. Benefits quoted from insurance companies are not a guarantee of payment. You agree to be financially responsible for all charges whether or not paid by your insurance company (including co-pays, deductibles and co-insurance), and by signing this form, you authorize Brave Soul to release all medical information to your insurance company deemed necessary for processing insurance claims. Brave Soul does NOT process Secondary Insurance Claims – this is the responsibility of the client to seek payment under any applicable Secondary insurance policies.

Brave Soul offers a discounted fee of $150 for payments made at the time of service (private pay). Fees may increase periodically, however, 30 days notice will be provided to clients in such instances.

Brave Soul reserves the right to suspend all services, including providing written documentation, until payment of any unpaid balance is received. If you end treatment at any time, you are responsible for any remaining balance on your account. If there is any balance that has not been paid within 60 days, Brave Soul reserves the right to submit the bill to a collection agency. You acknowledge that in this circumstance, you are waiving your right to confidentiality.

Brave Soul requires a credit card be kept on file for purposes of paying any unpaid account balances (Credit Card Authorization Form to be filled out and signed by the client). We are happy to arrange an affordable payment plan, but require a minimum payment of $150 be paid each month towards unpaid account balances. Client agrees to a $150/month payment to be processed on the 1st of every month, unless an alternate payment plan has been arranged between Brave Soul and the client.

PAYMENT FOR PRIVATE PAY CLIENTS OR CO-PAYS ARE DUE AT THE BEGINNING OF EACH SESSION

Code	Service	Fee
90791	Diagnostic Evaluation/Initial Intake	$250
90837	Psychotherapy (with patient) 53+ minutes	$200
90834	Psychotherapy (with patient) 45 minutes	$175
90846	Family Psychotherapy (without patient) 55 minutes	$200
90847	Family Psychotherapy (with patient) 55 minutes	$200
Not covered by insurance	Late Cancellation/No Show Fee	$75
Not covered by insurance	Out-of-session work (report writing, phone calls, letters) 15 minutes	$37.50
Not covered by insurance	Consultation 20-25 minutes	Free
Not covered by insurance	Court Appearances (60 minutes billed in 15-minute increments) Requires $1,000 retainer fee to be paid before services rendered	$250+

Cancellation Policy / Missed Appointments

If you are more than 15 minutes late for your appointment and have not contacted Brave Soul, we reserve the right to cancel your appointment, so we do not run into another person's session time.

If you need to cancel or reschedule your appointment, please give Brave Soul a 24-hour's notice to your scheduled appointment time. If you know sooner than 24 hours in advance that you cannot make a scheduled appointment, please contact Brave Soul to reschedule at your earliest possible convenience.

While exceptions will be made for illnesses and emergencies, if an appointment is missed without giving 24-hour notice, a late cancellation fee or no-show fee of $75 may be charged. Insurance providers will not cover the payments for missed appointments, so you will be fully responsible for this fee.

Health and Wellness

Your Responsibility

To obtain services in person, you agree to take certain precautions which will help keep everyone you, me, and our families, other clinicians and other clients) safer from virus exposure, other sickness and possible death. If you do not adhere to these safeguards, it may result in our starting or returning to a telemedicine arrangement.

You will only keep your in-person appointment if you are symptom free.
Clinicians have the right to briefly screen how the client is feeling prior to the session beginning, and if client is not feeling well or exhibits symptoms, the clinician may ask the client to leave and reschedule the session or do session via telemedicine.
No additional family members may come to the appointment unless specifically asked to do so by your clinician.
If you have a job that exposes you to other people who are infected, you will immediately let me know.
Clients must not come into the office if they themselves or someone in their family has tested positive for COVID19.
If a resident of your home tests positive for COVID-19, you will immediately let me know and we will then begin or resume therapy via telemedicine.

Brave Soul may change the above precautions if additional local, state or federal orders or guidelines are published. If that happens, we will talk about any necessary changes.

Risks of Opting for In-Person Services:

You understand that by coming to the office, you are assuming the risk of exposure to COVID-19 or other public health risk).

Telemedicine Service Agreement

Brave Soul Therapy emphasizes the importance of the face-to-face relationship with a client, however, there are a variety of reasons for why this is not always possible. In those circumstances, telemedicine services may serve as an effective alternative.

Telemedicine services provide an opportunity for clinicians to conduct mental health services through electronic means such as audio and video communications.

By signing this form, I am aware the I have the following rights and responsibilities:

Telemedicine is confidential. Any personal information I choose to share with my therapist(s) will be held in the strictest confidence. Brave Soul Therapy will not release any information without prior approval or as required by law, including mandated reporting laws.
Telemedicine sessions are not to be recorded by either the therapist or the client.
It is important, in case of emergency, that my therapist knows my location at the beginning of every session.
I understand that if I am having a mental health crisis or emergency, I will call 911 or my local crisis unit because I understand that telemedicine would not be appropriate at a time like this.
I understand that there are risks associated with telemedicine. Risks include the potential release of private information due to the problems that may arise with the internet and phone systems. I also understand that viruses and other involuntary intrusions may inadvertently lead to confidential information being shared. I understand that it is my responsibility to secure a private location for the therapy to occur and it is also my responsibility to manage my own internet security on my device. Brave Soul Therapy will use Doxy.me or an alternative HIPAA compliant platform for telemedicine services.
Internet and audio connections sometimes fail, and I am aware that if the connection cannot be maintained, the session may need to be canceled and/or rescheduled.
I understand that my therapist is governed by the laws of the State of MN regarding telemedicine services and as such, I am consenting to telemedicine services only in the state of MN.
I am aware that if I relocate or change my legal residence to a location outside of Minnesota, I will no longer be able to continue telemedicine services and must determine an appropriate continuity of care plan with my therapist.
I understand that there may be circumstances in which the therapist deems face-to-face therapy is more effective for me or my presenting situation and has a right to change service arrangements.
Most insurance companies will provide coverage for telemedicine services; however, I am responsible for both ensuring my plan covers telemedicine services, and/or paying any expenses not covered by my insurance provider and plan.

Communication and Contact Information

Clients may leave messages for their therapist by phone, text or email. Your therapist will respond to your communication within a 24 to 48-hour period or within 2 business days (excluding weekends).

Emails and texts are not considered confidential and Brave Soul is not responsible for any information transmitted via email or text except under provider misconduct.

Phone, text or email contact is not a replacement for therapy sessions, nor should they be used in emergency situations. If there is an emergency, please contact the Washington County Crisis Connection at 651-275-7400 or dial 911.

Bill of Rights

Consumers of marriage and family therapy services offered by marriage and family therapists licensed by the state of Minnesota have the right

To expect that a therapist has met the minimal qualifications of education, training, and experience required by state law:
To examine public records maintained by the Board of Marriage and Family Therapy that contain the credentials of a therapist.
To report complaints to the Board of Marriage and Family Therapy.
To be informed of the cost of professional services before receiving services.
To privacy as defined and limited by rule and law.
To be free from being the object of unlawful discrimination while receiving services.
To have access to their records as provided in Minnesota Statutes, section 144.291 to 144.298, except as otherwise provided by law or prior written agreement; and
To be free from exploitation for the benefit or advantage of a therapist.

Confidentiality

Information that a client shares with a therapist is considered privileged and confidential, except where otherwise specified by law. The following are limits to your confidentiality unless you authorize a release of information:

Suspected abuse or neglect of a child, elderly person or disabled person.
Any prenatal exposure to controlled substances.
When your therapist believes you are in danger of harming yourself or another person or you are unable to care for yourself.
If you report that you intend to physically injure someone, the law requires your therapist to inform that person as well as the legal authorities.
If your therapist is ordered by court to release information as part of a legal involvement in company litigation, etc.
Involving your insurance company in filing a claim, insurance audits, case review or appeals, etc.
In natural disasters whereby protected records may become exposed; and
When required by law.

Privacy Notice (HIPAA)

Brave Soul is committed to keeping your Protected Health Information secure and confidential. HIPAA requires Brave Soul to maintain your privacy, give you notice and follow the terms of the notice. You may obtain a copy of Brave Soul’s privacy policy at www.bravesoul.org under New Client Forms or request a paper copy.