CONSENT FOR SERVICES and privacy notification:
General Services
I understand that I wish to engage in an In-Office consultation, In-Home consultation, teletherapy Live Video consultation and/or Talk Time interaction online. I understand that licensed clinicians are bound by rules and regulations governing their state. I understand that Talk Time staff are not being advertised as a psychologist or counselor providing services that require license by appropriate jurisdiction. I understand that the activities of Talk Time staff under SEYLA Counseling, inc., are supervised by licensed clinical staff.
I understand that SEYLA Counseling, inc., has made every reasonable effort to enable HIPAA compliant protocols and Secure Web Browsing from available vendors.
I understand there are potential risks to the technology related to the Client Portal and other website features, including interruptions, unauthorized access, and technical difficulties.
I hereby authorize the treatment and support staff of SEYLA Counseling, Inc. to provide treatment for the problem(s) I indicated on this intake form. I agree to pay the fee listed on the this website for the service I receive.
I understand service may be interrupted by holidays and occasions where the doctor will be unavailable and I will be notified by my preferred contact method.
I understand it is my responsibility to notify us if I will be unable to attend a session. I understand I will have the option of requesting an Online Session or an In-Home Counseling session to avoid any lapse in treatment. I understand that telephone counseling is not a recognized therapeutic format and is not an available option. I understand that If notice is given between 0 and 48 hours, no fee will be charged if someone else utilizes a service during that time. I understand a fee will be incurred if notice is received no sooner than 48 hours, or if no notice is given, I will be charged the No Show fee. SEYLA Counseling, Inc. is not responsible for failures in communication (such as delayed texts/emails or dropped calls).
Under our privacy policy, I understand whatever I discuss to my doctor is private and will not be shared with anyone without my authorization. I understand that certain identifying information and diagnostic coding are used for billing purposes and may be shared with second parties. I understand some insurance companies request treatment plans or session notes and I have the right to refuse the provision of that information and doing so may likely affect coverage by your insurer. I understand there are circumstances where the doctor may be legally compelled to release information to courts, law enforcement, or others necessary to preserve safety.
I understand that information may be transmitted electronically on my behalf. I also agree to receive electronic communications. I may opt out at a later date.
I understand I may express any concerns at any (appropriate) time without reprisal.
I understand that participation is voluntary and I may elect to terminate therapeutic services without penalty at any time.
I understand that SEYLA Counseling, inc., has made every reasonable effort to enable HIPAA compliant protocols and Secure Web Browsing from available vendors.
I understand there are potential risks to the technology related to the Client Portal and other website features, including interruptions, unauthorized access, and technical difficulties.
I hereby authorize the treatment and support staff of SEYLA Counseling, Inc. to provide treatment for the problem(s) I indicated on this intake form. I agree to pay the fee listed on the this website for the service I receive.
I understand service may be interrupted by holidays and occasions where the doctor will be unavailable and I will be notified by my preferred contact method.
I understand it is my responsibility to notify us if I will be unable to attend a session. I understand I will have the option of requesting an Online Session or an In-Home Counseling session to avoid any lapse in treatment. I understand that telephone counseling is not a recognized therapeutic format and is not an available option. I understand that If notice is given between 0 and 48 hours, no fee will be charged if someone else utilizes a service during that time. I understand a fee will be incurred if notice is received no sooner than 48 hours, or if no notice is given, I will be charged the No Show fee. SEYLA Counseling, Inc. is not responsible for failures in communication (such as delayed texts/emails or dropped calls).
Under our privacy policy, I understand whatever I discuss to my doctor is private and will not be shared with anyone without my authorization. I understand that certain identifying information and diagnostic coding are used for billing purposes and may be shared with second parties. I understand some insurance companies request treatment plans or session notes and I have the right to refuse the provision of that information and doing so may likely affect coverage by your insurer. I understand there are circumstances where the doctor may be legally compelled to release information to courts, law enforcement, or others necessary to preserve safety.
I understand that information may be transmitted electronically on my behalf. I also agree to receive electronic communications. I may opt out at a later date.
I understand I may express any concerns at any (appropriate) time without reprisal.
I understand that participation is voluntary and I may elect to terminate therapeutic services without penalty at any time.
