Consent Form
This document provides important information that your psychologist will review with you during your initial appointment. By completing the intake and attending the initial session, you agree to these policies.
Therapy Process
Your psychologist is committed to helping you work toward the goals identified during your initial evaluation. You will receive treatment recommendations tailored to your individual needs. Therapy is a collaborative process, and you have the right to agree or disagree with the recommended approach.
A treatment plan will be created and re-evaluated periodically to assess progress. Due to the complexity of emotional and psychological concerns, the length of treatment and specific outcomes cannot be predicted.
Termination of therapy may be initiated by either you or your psychologist. Common reasons for termination include:
Confidentiality
Communication between you and your psychologist is confidential. However, there are specific exceptions as required by law:
In Connecticut, minors under the age of 18 may receive up to 6 sessions of mental health services without parental notification if they demonstrate emotional maturity and if treatment is deemed clinically necessary. If extending treatment beyond 6 sessions, this can only occur if parental involvement would negatively impact the therapeutic process or cause the minor to disengage.
Uninformed parents are not financially responsible for services unless covered by insurance. Minors may choose to use their own insurance, pay privately, or be referred to low-cost or no-cost alternatives.
While parents typically have access to a minor's mental health records, under HIPAA, a psychologist may deny access if doing so would compromise the minor’s physical or emotional safety.
Statutory abuse must be reported if a minor under 16 discloses sexual activity with someone more than 3 years older (or 2 years older if the minor is under 13).
Availability of your Psychologist
Most communication should occur during scheduled sessions. However, you may contact your psychologist between sessions if needed. If your call is not answered, please leave a message with your name, the reason for your call, and a phone number where you can be reached.
Although email communication is conducted through an encrypted, secure system, it is recommended that you use discretion when sharing sensitive or detailed information by email.
Your psychologist will respond to phone calls within 72 business hours, excluding weekends and holidays.
In the event of an emergency or safety concern, call 911 immediately. Do not wait for your psychologist to respond.
Cost of Therapy and Insurance
JSB Wellness LLC provides virtual therapy services to clients residing in the state of Connecticut. Limited in-person appointments are available and take place in Rocky Hill, CT.
Private Pay Rates:
Insurance Accepted:
JSB Wellness LLC is currently in-network with the following insurance providers:
Aetna, Cigna, Optum, Anthem, and Medicaid (Husky).
You will be informed of any applicable copays before services begin. To ensure uninterrupted service and timely billing, a valid credit or debit card is required to be kept on file.
You are financially responsible for the full session fee if your insurance is inactive or denied at the time of service.
By receiving services, you authorize JSB Wellness LLC to share the necessary information with your insurance provider for billing purposes. This may include mental health diagnoses, service dates, treatment notes, and other relevant clinical details.
It is your responsibility to confirm whether your insurance plan covers teletherapy. If your plan does not provide coverage, you will be responsible for paying the private rate for sessions. Please contact your insurance provider to verify telehealth benefits before beginning treatment.
Additional Fees
ADHD Assessment Fee and Structure
The total cost for the ADHD assessment is $650. The assessment process begins with a $250 non-refundable deposit, which secures your first appointment. The number of sessions required will be determined by the psychologist at the initial appointment, with a minimum of three and a maximum of five sessions. The first session will consist of a comprehensive intake to gather clinical and historical information. The final session will include a full feedback review and delivery of a written report with clinical impressions and recommendations. The remaining balance must be paid in full prior to the feedback session and release of the report.
Cancellation Policy
Session frequency is typically weekly or bi-weekly but will be determined collaboratively based on your needs and goals. Consistent attendance is essential for therapeutic progress.
If you need to cancel or reschedule an appointment, you must provide at least 24 hours’ notice via phone, voicemail, or email. Failure to do so may result in a $50 no-show or late cancellation fee, which applies to both private pay and commercial insurance clients. This fee will be automatically charged to the card on file.
A pattern of cancellations or missed appointments is defined as three or more late cancellations or no-shows in a row without valid justification and may result in discharge from services.
To formally end services, your request must be submitted in writing, and your account must be paid in full with no outstanding balance.
Additional Document Information
If you require psychiatric documentation (e.g., for disability benefits, work accommodations, etc.), you must have been in consistent treatment for at least 3 months, with regular attendance and no significant gaps in care. This is necessary to ensure clinical accuracy and ethical documentation.
Clinical records are maintained securely and retained for a minimum of seven (7) years after the last date of service, in accordance with state and federal regulations. After this period, records may be destroyed in a secure manner.
Therapy Process
Your psychologist is committed to helping you work toward the goals identified during your initial evaluation. You will receive treatment recommendations tailored to your individual needs. Therapy is a collaborative process, and you have the right to agree or disagree with the recommended approach.
A treatment plan will be created and re-evaluated periodically to assess progress. Due to the complexity of emotional and psychological concerns, the length of treatment and specific outcomes cannot be predicted.
Termination of therapy may be initiated by either you or your psychologist. Common reasons for termination include:
- Your treatment goals have been achieved.
- A higher level of care is clinically indicated, and appropriate referrals will be provided.
- You request to end services.
- Your psychologist determines that treatment is no longer beneficial and discusses alternative options with you.
Confidentiality
Communication between you and your psychologist is confidential. However, there are specific exceptions as required by law:
- If you provide verbal or written consent for your psychologist to share information with someone you identify.
- If a court orders the release of records during legal proceedings.
- If required by your health insurance provider for billing or treatment authorization.
- In the event of a medical or psychiatric emergency where your life or the life of another person is at risk.
- If there is reasonable suspicion of abuse or neglect of a minor, elder, or person with a disability, your psychologist is mandated to report.
- In non-emergency situations, your psychologist may consult with colleagues for clinical insight. Identifying information will not be shared during these consultations.
In Connecticut, minors under the age of 18 may receive up to 6 sessions of mental health services without parental notification if they demonstrate emotional maturity and if treatment is deemed clinically necessary. If extending treatment beyond 6 sessions, this can only occur if parental involvement would negatively impact the therapeutic process or cause the minor to disengage.
Uninformed parents are not financially responsible for services unless covered by insurance. Minors may choose to use their own insurance, pay privately, or be referred to low-cost or no-cost alternatives.
While parents typically have access to a minor's mental health records, under HIPAA, a psychologist may deny access if doing so would compromise the minor’s physical or emotional safety.
Statutory abuse must be reported if a minor under 16 discloses sexual activity with someone more than 3 years older (or 2 years older if the minor is under 13).
Availability of your Psychologist
Most communication should occur during scheduled sessions. However, you may contact your psychologist between sessions if needed. If your call is not answered, please leave a message with your name, the reason for your call, and a phone number where you can be reached.
Although email communication is conducted through an encrypted, secure system, it is recommended that you use discretion when sharing sensitive or detailed information by email.
Your psychologist will respond to phone calls within 72 business hours, excluding weekends and holidays.
In the event of an emergency or safety concern, call 911 immediately. Do not wait for your psychologist to respond.
Cost of Therapy and Insurance
JSB Wellness LLC provides virtual therapy services to clients residing in the state of Connecticut. Limited in-person appointments are available and take place in Rocky Hill, CT.
Private Pay Rates:
- Initial Evaluation: $250
- Individual Sessions: $180
Insurance Accepted:
JSB Wellness LLC is currently in-network with the following insurance providers:
Aetna, Cigna, Optum, Anthem, and Medicaid (Husky).
You will be informed of any applicable copays before services begin. To ensure uninterrupted service and timely billing, a valid credit or debit card is required to be kept on file.
You are financially responsible for the full session fee if your insurance is inactive or denied at the time of service.
By receiving services, you authorize JSB Wellness LLC to share the necessary information with your insurance provider for billing purposes. This may include mental health diagnoses, service dates, treatment notes, and other relevant clinical details.
It is your responsibility to confirm whether your insurance plan covers teletherapy. If your plan does not provide coverage, you will be responsible for paying the private rate for sessions. Please contact your insurance provider to verify telehealth benefits before beginning treatment.
Additional Fees
- Letters or Documentation: $25 per letter (must be paid in advance) for clients using commercial insurance. Clients who are private pay may request up to three letters per calendar year at no additional charge.
- Court-Related Services: Court-related services are billed separately and must be paid in advance. This includes any instance in which your psychologist is required to testify or appear in court, regardless of which party initiates the request. Fees will vary depending on the nature and extent of involvement and will be discussed upon request.
ADHD Assessment Fee and Structure
The total cost for the ADHD assessment is $650. The assessment process begins with a $250 non-refundable deposit, which secures your first appointment. The number of sessions required will be determined by the psychologist at the initial appointment, with a minimum of three and a maximum of five sessions. The first session will consist of a comprehensive intake to gather clinical and historical information. The final session will include a full feedback review and delivery of a written report with clinical impressions and recommendations. The remaining balance must be paid in full prior to the feedback session and release of the report.
Cancellation Policy
Session frequency is typically weekly or bi-weekly but will be determined collaboratively based on your needs and goals. Consistent attendance is essential for therapeutic progress.
If you need to cancel or reschedule an appointment, you must provide at least 24 hours’ notice via phone, voicemail, or email. Failure to do so may result in a $50 no-show or late cancellation fee, which applies to both private pay and commercial insurance clients. This fee will be automatically charged to the card on file.
A pattern of cancellations or missed appointments is defined as three or more late cancellations or no-shows in a row without valid justification and may result in discharge from services.
To formally end services, your request must be submitted in writing, and your account must be paid in full with no outstanding balance.
Additional Document Information
If you require psychiatric documentation (e.g., for disability benefits, work accommodations, etc.), you must have been in consistent treatment for at least 3 months, with regular attendance and no significant gaps in care. This is necessary to ensure clinical accuracy and ethical documentation.
Clinical records are maintained securely and retained for a minimum of seven (7) years after the last date of service, in accordance with state and federal regulations. After this period, records may be destroyed in a secure manner.
Teletherapy
For the purposes of this document, the terms virtual appointments, teletherapy, telecommunication, video calls, telemedicine, and telehealth are used interchangeably and refer to the same service format. Sessions are conducted via secure video platforms. Clients only need access to the internet and a device with a camera, such as a smartphone or computer. Session links will be sent by email or text message prior to your appointment. Clients must be physically located in the state of Connecticut at the time of each telehealth session. Services cannot be provided to clients who are out of state, even temporarily, due to licensing regulations.
Benefits and Risks of Teletherapy
Benefits:
JSB Wellness LLC will use email and text messaging for administrative purposes only, such as scheduling or sharing session links, and only with your authorization. Clinical concerns should be addressed during appointments.
Video Session Recordings
Recording of video therapy sessions by the client is not permitted. Your psychologist will maintain clinical records as required by professional and legal standards.
Benefits and Risks of Teletherapy
Benefits:
- Provides access to therapy without requiring travel or physical presence.
- Offers flexibility and convenience, especially for clients with limited mobility, time, or transportation.
- Confidentiality: Clients are responsible for ensuring they are in a private, secure space during sessions to protect their privacy. A virtual appointment should be treated the same as an in-person appointment.
- Technology Issues: Technical problems such as poor internet connection or device failure may interrupt sessions. In rare cases, there is a potential risk of unauthorized access to data. If such a breach occurs, you will be notified promptly.
- Emergency Limitations: Teletherapy is not appropriate for emergency situations or crises. If you are experiencing a psychiatric or medical emergency, call 911 immediately. If your psychologist determines that your situation requires a higher level of care, emergency services (e.g., 911 or relevant authorities) may be contacted for your safety.
JSB Wellness LLC will use email and text messaging for administrative purposes only, such as scheduling or sharing session links, and only with your authorization. Clinical concerns should be addressed during appointments.
Video Session Recordings
Recording of video therapy sessions by the client is not permitted. Your psychologist will maintain clinical records as required by professional and legal standards.
HIPAA Privacy Rule
Your personally identifiable health information is referred to as Protected Health Information (PHI) and is safeguarded under the HIPAA Privacy Rule. JSB Wellness LLC is committed to maintaining the privacy and security of your PHI and will take all reasonable steps to protect your information. JSB Wellness LLC reserves the right to update or revise its privacy practices at any time. If changes are made, clients will be notified accordingly.
Permitted Uses and Disclosures Without Authorization
Your PHI may be used or disclosed without your written consent in the following circumstances:
You have the right to request restrictions on how your PHI is used or disclosed. While JSB Wellness LLC is not legally required to agree to all requested restrictions, any accepted restrictions will be honored. You may revoke your consent for the disclosure of your PHI at any time, in writing, except when disclosure has already occurred based on your previous authorization. By revoking consent, you release JSB Wellness LLC from any liability related to disclosures made prior to the date of withdrawal. If you would like an additional copy of this privacy policy, you may request one from your psychologist. It can be sent to you via mail or email, depending on your preference.
Permitted Uses and Disclosures Without Authorization
Your PHI may be used or disclosed without your written consent in the following circumstances:
- For treatment purposes, including coordinating or managing your care and sharing information with other healthcare or mental health providers directly or indirectly involved in your treatment.
- To obtain payment from your health insurance provider or billing entity.
- In the case of a medical or psychiatric emergency, to protect your safety or the safety of others.
- As required by law, such as in cases of suspected abuse or neglect of a minor, elderly adult, or a person with a disability.
- To communicate with you for administrative purposes such as appointment reminders or service updates.
You have the right to request restrictions on how your PHI is used or disclosed. While JSB Wellness LLC is not legally required to agree to all requested restrictions, any accepted restrictions will be honored. You may revoke your consent for the disclosure of your PHI at any time, in writing, except when disclosure has already occurred based on your previous authorization. By revoking consent, you release JSB Wellness LLC from any liability related to disclosures made prior to the date of withdrawal. If you would like an additional copy of this privacy policy, you may request one from your psychologist. It can be sent to you via mail or email, depending on your preference.
Client's Rights
Clients receiving services from JSB Wellness LLC have the right to:
- Be treated with respect, dignity, and compassion at all times.
- Receive individualized and specialized care tailored to their unique needs.
- Access services without discrimination based on race, color, sex, sexual orientation, age, national origin, religion, or any other protected characteristic.
- Receive treatment in a language they understand whenever possible.
- Be informed of and give informed consent before any procedure, technique, or treatment is initiated by the psychologist.
- Know the name, credentials, and professional title of their psychologist.
- Request that their health records be corrected if they believe the information is inaccurate or incomplete.
- File a grievance or complaint if they disagree with any aspect of their care or feel their rights have been violated. All complaints must be submitted in writing and will be reviewed professionally and in a timely manner.
Client's Responsabilities
As a client receiving services from JSB Wellness LLC, you are expected to:
The therapeutic relationship between you and your psychologist is strictly professional and is designed to support your mental health, healing, and personal growth. To maintain clear and ethical boundaries, personal contact outside of sessions is not permitted and clients are asked not to offer gifts.
To further protect your confidentiality and uphold professional ethics, your psychologist does not accept friend or contact requests from clients on personal social media accounts. Any interaction on public platforms such as social media, blogs, or online forums is not considered part of the therapeutic relationship and will not be used for clinical communication or support.
- Attend scheduled appointments and provide at least 24 hours’ notice for cancellations or rescheduling.
- Provide accurate and timely information to your psychologist, including updates to your personal and insurance information.
- Engage openly and honestly in the therapy process to support your treatment goals.
- Treat your psychologist with respect and maintain a professional therapeutic relationship.
- Follow the policies and procedures outlined in this document and any additional agreements related to your care.
The therapeutic relationship between you and your psychologist is strictly professional and is designed to support your mental health, healing, and personal growth. To maintain clear and ethical boundaries, personal contact outside of sessions is not permitted and clients are asked not to offer gifts.
To further protect your confidentiality and uphold professional ethics, your psychologist does not accept friend or contact requests from clients on personal social media accounts. Any interaction on public platforms such as social media, blogs, or online forums is not considered part of the therapeutic relationship and will not be used for clinical communication or support.