Test Forms

Decision to Meet Face-to-Face
Generally speaking, research points to the importance of a variety of factors in determining a successful therapeutic outcome, chief among them is the ability to build what is known as the “therapeutic alliance” (Lynch, 2012), defined by Teyber & Teyber (2011) as a partnership where both counselor and client agree on shared goals, work together on tasks designed to bring a positive outcome, and establish a relationship built on trust, acceptance, and empathy. In short, Change, Inc. espouses a strong preference for in-person sessions when possible. However, global public health crises may require that we meet via telehealth (for more information on this, please see “CONFIDENTIALITY/PERSONAL HEALTH INFORMATION” below).

Client Risks of Opting for In-Person Services
By opting to come to any of our physical locations, you are assuming the risk of exposure to the coronavirus (or other communicable diseases). This risk has always been present, but COVID-19 makes the ramifications more tangible, concrete, and undeniable. Change, Inc. strongly encourages clients to consider their options accordingly.

Client Responsibility to Minimize Risk to Self, Attending Counselors, Other Clients
Clients who attend in-person sessions agree to take certain precautions to prevent the ramifications of exposure for yourself and others. If clients are found determined to have failed adhere to these safeguards, Change, Inc. reserves the right to require telehealth sessions or other actions at its sole discretion. By attending sessions and/or signing your agreement to this section, you consent that you will:
• Not attend appointments if you have known COVID-19 diagnoses in your physical proximity at home (e.g., someone has been diagnosed with COVID-19 who lives in your home) or vocational setting (e.g., someone who works with persons who have COVID-19 or who works in settings with COVID-19 positive persons).
• Only keep your in-person appointment if you are COVID-19 and other disease-symptom free.
• Check your own temperature before coming to each appointment, and if it is elevated (100 Fahrenheit or more), or if you have other symptoms of the coronavirus, you agree to use telehealth sessions in lieu of in-person.
• Make minimal use of the waiting room, instead waiting in your car or outside until no earlier than 5 minutes before our appointment time.
• Wash your hands or use alcohol-based hand sanitizer when you enter the building.
• Adhere to COVID-19/social-distancing/required personal protective equipment specifications required by Change, Inc., St. Louis City, Missouri, and federal guidelines.
• Wear a protective face mask in all designated areas of our physical locations. • Come to sessions alone or with your partner(s) who is also attending sessions (i.e., no additional non-therapy-attending guests may enter the building).
• Take steps between appointments to minimize your exposure to COVID-19 • If a medical provider or otherwise in any job, role, situation, or activity that directly exposes you to COVID-19 infected persons, attend sessions via telehealth only.
• If a resident of your home tests positive for the infection, immediately notify Change, Inc. and resume treatment via telehealth.

The above list may change in keeping with new developments or further directives from local, state, or federal agencies.

Right to Refuse Treatment
Clients who attend in-person appointments who show signs or symptoms of COVID-19 will be required to discontinue treatment in-person until a clean bill of health has been obtained and documented.

Confidentiality in the Case of Infection
If you have tested positive for the coronavirus, Change, Inc. may be required to notify local health authorities that you have been in our offices. In this event, Change, Inc. will provide the minimum information required, keeping all other pertinent counseling-related data confidential.

Change, Inc.’s Commitment to Minimize Exposure // Office Safety Precautions in Effect During the Pandemic
Change, Inc. is taking the specific measures listed at our COVID-19 Response Page to protect and serve clients and help slow the spread of the coronavirus.

Change, Inc. is what is known as the “least restrictive therapeutic environment,” meaning it works primarily with clients whose issues may be resolved on a limited outpatient basis. As such, there are a variety of presentations, situations, diagnoses, etc. that are not appropriate for treatment at Change, Inc. because they require additional/different facilities, training, expertise, time, costs, etc.
These include but not limited to:

Clinical Contraindications:
• persons who are registered sex offenders
• persons who have the diagnosis or symptoms of certain personality disorders, including but not necessarily limited to Borderline Personality Disorder, Antisocial Personality Disorder, and Histrionic Personality Disorder
• persons who have a significant history of violence
• persons who have a history of traumatic brain injury and the diagnosis or symptoms of intermittent explosive disorder
• persons who have the diagnosis or symptoms of Autism Spectrum Disorder (this does not include persons who have been diagnosed with what was previously known Asperger’s Disorder nor what is known as Social Anxiety Disorder, both of which are appropriate for our environment).
• persons with a history of opioid use with less than 24 months sobriety/clean time.

Clients who meet any of these criteria are required to disclose that information prior to starting therapy so that an appropriate referral can be made.

Other Contraindications
• In addition, Change, Inc. does not currently allow outside/individual "therapy animals" on the premises of any of our locations. This is to be differentiated from bonafide service animals, which are a protected right under the Americans with Disabilities Act.

The potential benefits of counseling and related services are many and include improved personal functioning, relationships, self-image, mood, and the attainment of personal goals. However, clients understand that healing and growth is difficult, and some discomfort will likely be a part of the change process. We believe you can feel better, but understanding that change occurs along a continuum is helpful. We will discuss this with you in your first session. Because the nature of therapeutic services is so heavily dependent on the ability, willingness, and cooperation of clients, Change, Inc. does not provide any expressed or implied warranty of its services to achieve treatment goals.

Change, Inc. welcomes diversity, including but not limited to clients of varying race, ethnicity, religion, sex (including pregnancy, childbirth or related medical conditions), gender, gender identity, national origin, ancestry, age, familial status, marital status, sexual orientation, relationship orientation, or status as a veteran in accordance with applicable federal laws. Counselors respect the diversity of clients and seek ongoing supervision to address any diversity related concerns or topics that may arise in session. Change, Inc. strives to understand the ways in which diverse identities (and others' responses to them) have impacted and continue to impact our clients' lives, and to apply that knowledge in clinical work.

Change, Inc. espouses a “holistic” approach to counseling which includes addressing multiple spheres of functioning. These spheres potentially include biological, psychological, sociocultural, and spiritual functioning or items that relate to those spheres of functioning. Each counselor with whom you work will:

• respect client desires regarding their desire to (or to not) approach any of these areas within treatment, though may offer reflections on how addressing/not addressing these issues are likely to impact treatment.

• only practice within scope of the discipline(s) for which they are trained, certified, educated, or otherwise credentialed, and clients may not solicit treatment recommendations from any member of Change, Inc. outside their scope of expertise.

A good-faith effort at personal growth and engage ment in the counseling process on the part of the client is central to reaching desired therapeutic outcomes. Clients must make counseling an important priority in their lives. Suspension, termination, or referral shall be discussed between counselor and client for a pattern of behavior showing disinterest, lack of commitment, or for any unresolved conflict or impasse.

Change, Inc. accepts only debit cards, credit cards, and cash for payment – no other payment methods are accepted. As such, in order to place an appointment on the calendar:

• at least one working credit/debit card (pre-paid debit/credit cards are not accepted) is required to be held securely on file, even if clients intend to pay by cash. This is true at both at the outset and throughout the course of treatment.

• At the time of appointment, the preferred credit/debit card on file is run for the full appointment charge, unless clients notify us ahead of time that they intend to pay in cash by calling our office number or emailing contact@changeincorporated.org (NOTE: Change is not provided for cash payments – a credit for cash overpayment will be issued for the following appointment).

• If it becomes clear that one or more credit/debit cards are non-functional for any reason (insufficient balance, improper account/address information, etc.), Change, Inc. will attempt to run alternate cards placed on file.

• In the event that no cards on file are functional and the payment due at time of service cannot be collected within 24 hours, ***all future appointments will be canceled and no (future) appointments may be scheduled until a functional card is provided.***

Change, Inc. accepts only debit cards, credit cards, and cash for payment of all items for persons paying cash, and for any outstanding balances not otherwise accounted for by insurance for those using manage care – no other payment methods are accepted. As such, in order to place an appointment on the calendar:

For all clients:

• at least one working credit/debit card (pre-paid debit/credit cards are not accepted) is required to be held securely on file, even if clients are billing insurance. This is true at both at the outset and throughout the course of treatment.

• If it becomes clear that one or more credit/debit cards are non-functional for any reason (insufficient balance, improper account/address information, etc.), Change, Inc., Inc. will require a new, functional card to be submitted in order to continue services.

For cash-paying clients:
• at least one working credit/debit card (pre-paid debit/credit cards are not accepted) is required to be held securely on file, even if clients intend to pay by cash. This is true at both at the outset and throughout the course of treatment.

• On the same business day as the appointment (before, during, or after the session timeslot), the preferred credit/debit card on file is run for the full appointment charge, unless clients notify us ahead of time that they intend to pay in physical literal cash by calling our office number or emailing contact@changeincorporated.org (NOTE: Change is not provided for cash payments – a credit for cash overpayment will be issued for the following appointment).

Change, Inc. accepts only debit cards, credit cards, and cash for payment – no other payment methods are accepted. As such, all appointments paid for by credit and debit cards will be processed via a third-party, and thus, those third parties will have access to your name and payment information. Change, Inc. may employ a variety of payment processors throughout the duration of treatment and may switch between payment processors at its sole discretion and without notice.

Each session must be paid for **using a single payment method** -- Change, Inc. will not split payment for a single session across multiple credit/debit cards or payment methods.

Change, Inc. accepts only debit cards, credit cards, and cash for payment of all items for persons paying cash, and for any outstanding balances not otherwise accounted for by insurance for those using manage care – no other payment methods are accepted. As such, all balances paid for by credit and debit cards will be processed via a third-party, and thus, those third parties will have access to your name and payment information. Change, Inc. may employ a variety of payment processors throughout the duration of treatment and may switch between payment processors at its sole discretion and without notice.

Each such balance must generally be paid for **using a single payment method** -- Change, Inc. will not split payment for a single balance across multiple credit/debit cards or payment methods.

Payment is due at the time of service.

If a charge for a session declines partially or fully, and/or clients fail to pay by cash or any other method, and no [alternate] cards on file are able to be run for the applicable charge, a balance will remain on the account. That balance is immediately considered past due. In this event:

• 24 hours is provided to provide a working card and rectify the past due balance.

• After 24 hours has elapsed with past due balance unrectified and no working card on file, ***all currently scheduled future appointments are considered no future appointments can be scheduled until the past due balance is rectified and a working credit/debit card is placed on file.***

• Change, Inc. personnel will continue to run the card on file each day in an attempt to collect the balance.

• Change, Inc. personnel will contact clients via phone and email regularly in an attempt to rectify the balance.

• Past due balances that are outstanding longer than 4 (four) weeks will be sent to collections, and an administrative fee for lost time of no less than $100 will be added to the past due balance.

We understand that this has an impact on therapeutic rapport and engagement, and strongly desire to avoid such impasses. Please take care to communicate efficiently and effectively with us in the event of payment.

Clients often ask us how long counseling will take to resolve their issues. Because of the amazing variety of factors that influence counseling including severity/intensity of presenting problems, type of problems, lengths of time between onset of problem and beginning off counseling, scheduling, setbacks, treatment compliance, etc., there is no "typical" length of treatment.

Perhaps the greatest clarity about treatment length can be achieved by understanding that counseling frequency is correlated with successful therapeutic outcomes – you must come to counseling in order to receive the benefits of counseling because problems which have taken some months or years to develop will likely take some time to remit. The more clients come to counseling, the quicker their issues may resolve. Coming less frequently may naturally delay the ultimate completion of therapy.

As such, for the first 90-days Change, Inc. requires that clients come in for weekly or bi-weekly sessions at minimum, and your counselor will provide the recommended frequency during your first session. Persons wanting to be seen less frequently (e.g., monthly, every three weeks, etc.) during the first 90-days will be referred to settings/counselors without frequency requirements.

As part of its commitment to excellence, Change, Inc. requires clients to complete empirically validated initial assessments prior to the start of therapy so that treatment providers can have a thorough background. Correspondingly, an initial startup fee equal to the cost of the first appointment charge is included in addition to the first appointment charge itself, making the first appointment total the appointment fee x 2. This startup fee includes but is not limited to the costs associated with the provision of these assessments and other overhead costs.

As part of its commitment to excellence, Change, Inc. requires clients to complete empirically validated initial assessments prior to the start of therapy so that treatment providers can have a thorough background. Correspondingly, for cash-paying clients, an initial startup fee equal to the cost of the first appointment charge is included in addition to the first appointment charge itself, making the first appointment total the appointment fee x 2. For insurance-paying clients, an non-insurance-billable initial startup fee of $99 will be charged to the card on file.

In either case, this startup fee includes but is not limited to the costs associated with the provision of these assessments and other overhead costs.

Therapy sessions are 50-minutes long -- this is considered a standard "therapeutic hour." However, sessions may last as long as 60 minutes, and may vary from 50 to 60 minutes over the course of treatment, depending on factors such as items covered during therapy, available therapist time on any given date, and more.

These guidelines are offered in the interest that clients anticipate that sessions may run modestly longer or shorter week to week without compromising quality or expectations. Please anticipate some variance within this 10-minute window.

Change, Inc. and most counseling practices thrive on an hour by hour appointment scheduling process as an industry standard. Essentially, when you schedule an appointment with us, you are reserving that hour of your counselor's time, which naturally means we are turning down others for that same time slot. It is in both of our best interests that scheduled appointments are maintained. However, we understand and fully anticipate that clients will need to cancel from time to time but even in the event of emergencies, Change, Inc. is still unable to recoup lost time.

Because our counselors providers depend on billable time for their livelihood, for all cancellation needs, including emergencies, our cancellation policies are as follows:

• With at least 24 hours notice, appointments can be cancelled and rescheduled free of charge.

• ***Canceled or missed appointments that were not cancelled at least 24 hours ahead of time are simply "lost" and cannot be made up. The applicable session fee is still charged. For cash-paying clients, the applicable session fee is defined as the rate you pay per session. For insurance-based clients, the applicable session fee is defined as our current $60K and above sliding scale bracket.***

• If you call with less than 24 hours notice (including the day of the appointment) and move your appointment to a different time slot, you will be charged for both appointments.

• Appointments are considered canceled if clients are more than 25 minutes late - the remaining portion of the therapy session will not be usable.

• Email and voice phone calls are the only acceptable method of cancelation/reschedule. Text messages or other forms of contact will not be considered sufficient notice.

• Clients are responsible for their own appointments and scheduling – Change, Inc. does not provide text, email, or other reminders in advance of appointments.


Frequency and Consistency of Therapy Requirements:

Extensive research and experience has shown that counseling is less effective at facilitating goals when treatment is inconsistent or there are significant gaps in appointments. Thus, frequent canceling, rescheduling, and missed appointments grossly reduces your likelihood to achieve desired change. i.e., Clients must come to therapy regularly to receive the benefits of therapy. As such:

• Clients having 3 missed/canceled/rescheduled appointments within a 60-day period will be provided an outline of the sessions missed/canceled/rescheduled to date via email, copying both your counselor and a member of our Managing Direction Team. At your next counseling session, your counselor will discuss these issues with you, including but not limited to requesting a recommitment to counseling, changes to the cadence of sessions, a break from sessions, or a referral to another setting that can better meet your scheduling needs.

• Clients exceeding the limit of 3 missed, canceled, or rescheduled appointments in a 60-day period may be administratively discharged at the sole discretion of Change, Inc., including referral to other settings which may better suit their treatment needs.

• Clients who exceed the 3 missed, canceled, or scheduled appointments in a 60-day period who believe they have experienced extenuating circumstances that warrant additional consideration should follow the “RESOLUTION OF ADMINISTRATIVE/LOGISTICAL GRIEVANCES” procedure below.

Inclement Weather/Power Outage:

At Change, Inc., our therapists plan to attend sessions with you even in the event of inclement weather/power outages (etc.), operating under the belief that what you’re doing with them each session in therapy is crucial to your health and well-being. As such, our inclement weather/power outage policy is as follows:

• If you believe inclement weather/power outage is sufficient to prevent you from attending sessions in-person due to a verifiable road/weather hazard or catastrophic power wipeout consistent with local news reports and weather agencies, please let your therapist know as soon as you are able, and plan to attend your session via online video conferencing modalities in lieu of in-person therapy. When you write to notify us, your therapist will provide a URL where you may login at the scheduled day/time, or you may access therapist Virtual Waiting Room links here.

• If you fail to notify your therapist about your inclement weather/power outage limitation, or fail to attend an online video conferencing session in lieu of your in-person session, the applicable session fee will still be charged in line with our standard missed appointments policy.

Virtual Sessions At-Large:
• If Change, Inc. or your clinician determines that sessions must be moved online due to inclement weather, power outages, prevention of communicable disease transmission, or other circumstances requiring a temporary change in session format, you are expected to attend at your scheduled time using our secure virtual platform. Your clinician and/or our Client Liaison Team will notify you as soon as this information is available and provide instructions for accessing your session. Our standard cancellation and missed appointment policies continue to apply.

As part of a well-rounded approach to therapy, Change, Inc. therapists may recommend and/or Change, Inc. may require separate or additional parent/family/partner(s) sessions focused on receiving parent/family/partner(s) feedback, conceptualizing the client's role within the family/partnership, and on desirable parent/family/partnership changes to enable client success. These sessions are billed at the same hourly rate as standard sessions, and will adhere generally to reasonably protective confidentiality limitations based on agreed upon therapy goals.

• Parent/family/partner(s) sessions *may* be recommended/required when treating otherwise individual adult clients (18+). These sessions generally occur with the same therapist who is seeing the otherwise individual adult client, but could also occur with a co-treating separate therapist.

• Parent/family sessions *are* required every 6-12 weeks for the parents/family of adolescent clients. These sessions will occur with a co-treating separate therapist who is abreast of case details.

All services at Change, Inc. can be terminated by either party at any time without reason or cause. This does not in any way, shape, or form, alter our right to collect payment for services rendered or contracted.

All communications and records with your counselor are held in strict confidence. Information may be released, in accordance with state or federal law, when any of the following conditions are present:

• the client signs a written release indicating consent to release;

• the client expresses serious intent to harm self or someone else;

• there is reasonable suspicion of abuse against a minor, elderly person, or dependent adult;

• to acquire payment for services or billing purposes;

• a court-issued subpoena or order is received directing the disclosure of information.

Electronic Communications:

Clients should know that electronic communications are generally not secure methods of communication, and there is risk that one’s confidentiality could be compromised with their use. Online counseling methods, including email, text, phone (through methods such as Google Voice), video chat (through all modalities including but not limited to Skype, Google Hangout, Zoom, Doxy.me, Facetime, Facebook Messenger, etc.), and all others are likewise not totally secure and could also be breached, though the likelihood of such breaches is considered extremely low.
Counselors at Change, Inc., as a means of general practice, do communicate with clients using these mediums, and Change, Inc. also may collect various other kinds of information including pre and post assessments, feedback, payment, etc. using forms on our website which also vary in security level. Change, Inc. makes every effort to provide each of these items and all others in the most reasonable and electronically secure fashion possible, and according to generally accepted industry standards. However, there are implicit security risks that cannot be reasonably accounted for by Change, Inc. without adding undue cost sufficient to render the methods unusable. Change, Inc. clients acknowledge this fundamental insecurity and agree to hold Change, Inc. and all its agents and officers harmless for any related breaches.

Other Provisions:
• In order to conduct official business regarding cancelations, reschedules, billing, etc., Change, Inc. counselors will always communicate with you via email. Likewise, please understand that these are the only methods of communication will we will accept from you regarding these matters.

• The material disclosed in conjoint family or couples sessions, in which each party discloses such information in each other’s presence, is kept in a single file/note. At client request, separate files may be kept for information disclosed that is of a confidential nature to a particular disclosing party involved in treatment. Clients not requesting separate documentation will have a single case file and/or note.

• Information about clients may be disclosed in consultations with other professionals in order to provide the best possible treatment. In such cases the name of the client, or any identifying information, is not disclosed, except to co-treating consultants or agents of Change, Inc. However, clinical information about the client may be discussed/disclosed, and in some cases, notes and reports are dictated/typed within Change, Inc. or by outside sources specializing (and held accountable) for such procedures.

This information includes but is not limited to:
• testing results

• information given to the mental health professional not in the presence of other person(s) utilizing services

• information received from other sources about the client

• diagnosis

• treatment plans

• individual reports/summaries

• information that has been requested to be separate

Change, Inc. is managed care-free, meaning we've chosen not to be in-network for any insurance providers (why?). For standard insurance reimbursement requests (i.e., where your healthcare insurance plan offers to reimburse you some portion of the fee you pay us), we provide Insurance Reimbursement Documentation (IRD) directly to clients -- a .pdf via email that includes the information the insurance company needs to file things appropriately. For this purpose, insurance companies typically require the following information in order to file a claim for reimbursement on out of network policy benefits, and all such information will be provided on all Change, Inc.-provided IRD:

• Client Name

• Client Diagnosis

• Dates of Service

• Associated Charges

• CPT Codes for each service provided

• Practice tax ID #

• Provider credentials


As a managed care-free practice, Change, Inc. does not directly communicate with insurance companies or other like entities, including when they request that you instruct us to fill out additional forms or interact with us in order to file some claim -- i.e., Change, Inc. therapists will not complete insurance or other entity provided forms or communicate directly with these entities in any way. Also, Change, Inc. does not provide any expressed or implied warranty that its services are reimbursable or that our documentation will be effective in facilitating your request. It may help to check with your insurance company prior to our first meeting to understand your outpatient counseling benefits. You will want to ask your insurance company about:

• Coverage for “outpatient counseling services.”
• The percentage of reimbursement for an “out of network counselor” including any deductible amount.

Moreover, Change, Inc. generally does not voluntarily communicate with any outside entities at all except where required by law, including insurance companies, insurance providers (such as Medicaid), doctors, employers, social security personnel, disability insurers, educational institutions, attorneys, non-authorized family members, etc.

Further, Change, Inc. will not liaise between clients and outside entities and will not act as intermediary in any way. Change, Inc. will not notify clients of contacts from outside entities on their behalf (e.g., If your insurance company sends us documentation, we will simply place it in your file and we will not notify you).

Finally, Change, Inc. does not release psychotherapy notes to either outside entities or clients except where required by law (generally, only via subpoena). Client HIPAA entitlements do not include psychotherapy notes, and instead only include access to the "medical record," consisting of the following:

• a copy of any assessments provided

• an itemized bill

These items can be provided to clients by contacting the Client Liaison Team.

If your counselor is paneled with your insurance company, you will have been made aware of this during scheduling.  You are not required to utilize that insurance coverage to pay for sessions, but in the event you do, please be aware of the following:

You are immediately and ultimately responsible for all charges for your mental health services via Change, Inc.

Change, Inc. is responsible to provide requested information to your insurance company, but is not ultimately responsible for the facilitation of your claim, and does not provide any expressed or implied warranty that its services are able to be covered or that our documentation will be effective in facilitating your request.

Authorization from the insurance company may be required before they will cover counseling fees.

Both you and Change, Inc. will be providing your billing, health, and other information information to a third party biller which will facilitate claims.  If you fail to provide the third party biller with your insurance, payment, and other required information, you will be required to cover counseling fees.

The level of coverage varies by individual plan.  Change, Inc. will not know until your claim has been submitted what portion of your services will be covered.   

Essentially all insurance companies require us to give you a "clinical mental health diagnosis" from the DSM/ICD that describe the nature of your problems in clinical language.  If you do not meet criteria for one of these disorders, we will be required to let you and your insurance company know, and they may decline to pay for services, meaning that you will be required to cover counseling fees. 

Additionally, sometimes we may be required to provide other information such as treatment plans, summaries, notes, assessments, and more. This information will become part of the insurance company files and we have no control over how they use that information subsequently.  

Most insurance policies leave a percentage of the fee ("co-insurance") or a flat dollar amount ("co-payment") to be covered by you. This will be collected automatically by our third party biller. 

Some insurance companies also have a "deductible," which is an out-of-pocket amount that must be paid by you before the insurance companies are willing to begin paying any amount for services.  If you have a deductible on your policy, generally speaking, this means that you will be responsible to pay for initial sessions until your deductible has been met, and whatever amount you have paid toward that deductible typically resets at the beginning of each calendar year (i.e., you start over and are responsible for session fees until that deductible is met again).  

In the event that your insurance company declines to pay for all or part of the services we provide, your will be charged for the balance due either through our third party biller or directly with the card you keep on file with Change, Inc.

 Change, Inc. is not responsible for the facilitation of your claim outside the provision of required items.  You should ask your insurance company about coverage for outpatient counseling services for in-network and out of network counselors, including any deductible amount, prior to start counseling to understand your responsibilities and their coverages.

Otherwise, please know that Change, Inc. restricts communication with all outside entities, including insurance companies, to the maximum extent possible and legally permissible.  i.e., Change, Inc. only communicates with insurance companies through a third party biller, and does not directly communicate with insurance companies or other like entities in any way.  Moreover, Change, Inc. generally does not voluntarily communicate with any outside entities at all except where required by law, including insurance companies, insurance providers, doctors, employers, social security personnel, disability insurers, educational institutions, attorneys, non-authorized family members, etc.

Further, Change, Inc. will not liaise between clients and outside entities and will not act as intermediary in any way, and Change, Inc. will not notify clients of contacts from outside entities on their behalf (e.g., If your insurance company sends us documentation, we will simply place it in your file and we will not notify you).

Finally, Change, Inc. does not release psychotherapy notes to either outside entities or clients except where required by law, and please be advised that the legal threshold is generally only via subpoena.  We will deny all requests for psychotherapy notes by you or others unless that threshold is met.  Additionally, please be advised that client HIPAA entitlements do not include psychotherapy notes, and instead only include access to the "medical record," consisting of the following:

• a copy of any assessments provided

• an itemized bill

These items can be provided to clients by contacting the Client Liaison Team via email our through our Client Portal.

HIPAA PRIVACY NOTICES:
A copy of our HIPAA Privacy Notices is provided for you as required by law here.

HEADWAY PRIVACY NOTICES:
A copy of Headway's HIPAA Privacy Notices is provided for you as required by law here.

SOCIAL MEDIA POLICIES:
Friending:
As a rule, Change, Inc. therapists do not accept friend or contact requests from current or former clients on any social networking site (Facebook, LinkedIn, etc), because adding clients as friends or contacts on these sites can compromise your confidentiality and our respective privacy. It may also blur the boundaries of our therapeutic relationship.

Facebook Business Page:
Change, Inc. does keep a Facebook Page for professional practice to allow people to contact us more readily. We use it to share blog posts and practice updates with other Facebook users. All of the information shared on this page is available on our website. You may “like” this page, but please understand that others are able to see who has done so, and it may constitute a compromise of your confidentiality in that sense.

Following:
Change, Inc. and Change, Inc. therapists have blogs that you can follow, and publish information to their respective Twitter pages. Blogs/Twitter Streams of individual Change, Inc. therapists may contain thoughts about therapy or therapeutic relationships, but will never contain client names or personal information that would constitute a breach of confidentiality. Clients should also note, however, that Blogs/Twitter Streams of individual Change, Inc. therapists may contain information about the therapist that clients may consider “personal.” If you choose to follow your therapist, please let them know so that they can discuss its personal impact upon you and your therapeutic relationship. Please note that the therapist will not follow you back as casual viewing of clients’ online content outside of the therapy hour can create confusion regarding whether it is part of treatment or to satisfy personal curiosity. In addition, viewing your online activities without your consent and without our explicit arrangement towards a specific purpose could potentially have a negative influence on our working relationship. If there are things from your online life that you wish to share with your therapist, please bring them into our sessions where you can view and explore them together during the therapy hour.

Interacting/Messaging:
Please do not use Twitter, Facebook, or LinkedIn to contact Change, Inc. therapists, including wall postings, @replies, or messages. If you do use one of these methods, please do not expect your therapist to respond. If you need to contact your therapist between sessions, the best way to do so is through the methods they will have provided you – their Change, Inc. email address and our office phone number. If your therapist has provided a cell phone number, you may use that as well.

Business Review Sites:
You may find Change, Inc. on sites such as Google Reviews, Yelp, Healthgrades, Yahoo Local, Bing, etc. Some of these sites include forums for users to rate providers and add reviews. Many of these sites comb search engines for business listings and automatically add listings regardless of whether the business has added itself to the site. If you should find a Change, Inc. listing on any of these sites, please know that our listing is not a request for a testimonial, rating, or endorsement from you. You may provide a rating if you so desire, but be aware that others may see your screen name and recognize you as a client, thus breaching your confidentiality. Also, be aware that if you are using these sites to communicate indirectly with your therapist regarding your feelings about something, there is a good possibility that he/she may never see it.

Location-Based Services/Checking-In:
If you use location-based services on your phone or smart device or elect to use these devices to “check-in” at places of business, others may surmise that you are a therapy client due to regular check-ins at our office on a weekly basis, constituting a breach of your confidentiality.

Change, Inc.’s Right to Reply and Authorization to Disclose Information:
If you leave a review for Change, Inc., and/or post about, tag, depict, discuss, and/or otherwise interact with or reference Change, Inc. in any way on social media, the internet, or any electronic medium, you authorize Change, Inc. to reply and interact with you in that setting, including releasing details about treatment or interactions with you that may be germane to your commentary and Change, Inc.’s need to ensure its own longevity and reputation, and defensibility, particularly in statements that are or may reasonably be considered to be derogatory or detrimental to Change, Inc., its services or employees or owners or affiliates, whether true or false.

Individual Email:
Change, Inc. does prefer using email only to arrange or modify appointments, but as aforementioned, it is not completely secure. If you choose to communicate with your therapist via email, be aware that all emails are retained in the logs of our respective Internet service providers even when deleted from our inboxes. While it is unlikely that someone will be looking at these logs, they are, in theory, available to be read by the system administrator(s) of the Internet service provider. Any emails Change, Inc. receives from you and any responses that Change, Inc. sends to you become part of your client records and are subject to the same confidentiality rules aforementioned.

Group Email:
Change, Inc. routinely sends out group emails to its entire client base to keep clients abreast of issues, including items that may have a direct impact on therapy such as changes to this informed consent agreement, changes to policies, changes to price structure, information about inclement weather, etc. If you unsubscribe from this email list you agree to forfeit these notices, but are nonetheless held responsible for them.

In consideration of participating in services at Change, Inc., it is worth noting that there are some risks involved in the exploration of mental, physical, emotional, and spiritual processes. As such, you hereby release, waive, discharge, and covenant not to sue Change, Inc., their officers, agents, or contractors (hereinafter referred to as Releasees) from any and all liability, claims, demands, actions, and causes of action whatsoever arising out of or related to any loss, damage, or injury, including death, that may be sustained by you, or to any property belonging to you, while participating in such activity, while in, on or upon the premises where the activities are being conducted, or regardless of whether such liability arises in tort, contract, strict liability, or otherwise, to the fullest extent allowed by law.

While our processes are considered to be healing in nature, there are risks and hazards connected with the activities of mental health therapy, exercise, yoga, wellness consultations, and spiritual consultations. These may include physical, emotional, mental, or spiritual injury. These are considered extremely unlikely, but you hereby elect to voluntarily participate in said activities, knowing that the activities may be hazardous, and voluntarily assume full responsibility for any risks of loss, property damage, or personal injury, including death, that may be sustained by you, or any loss or damage to property owned by you, as a result of being engaged in such an activities, whether caused by the negligence of releases or otherwise, to the fullest extent allowed by law.

You further hereby agree to indemnify and hold harmless the releasees from any loss, liability, damage, or costs, including court costs and attorneys' fees that Releases may incur due to my participation in said activities, whether caused by the negligence of releases or otherwise, to the fullest extent allowed by law.

This waiver and hold harmless agreement shall bind the members of your family and spouse, if you are alive, and heirs, assigns and personal representative, if deceased, and shall be deemed as a release, waiver, discharge and covenant not to sue the releasees. You agree that this Waiver of Liability and Hold Harmless Agreement shall be construed in accordance with US state and federal law, and that any mediation, suit, or other proceeding must be filed or entered into only in the State of Missouri and the federal or state courts of Missouri. Any portion of this document deemed unlawful or unenforceable is severable and shall be stricken without any effect on the enforceability of the remaining provisions.

In the event that clients wish to receive additional consideration or address issues that arise with administrative or logistical provisions within this Informed Consent Agreement, they may notify Change, Inc. in writing at contact@changeincorporated.org. This contact should include the nature of the grievance, any relevant details or extenuating circumstances, and a proposed resolution. Upon receipt, Change, Inc. personnel will respond, directing clients to the appropriate personnel within our management structure to whom their message should be forwarded. Change, Inc. will provide a formal response within 1-2 business days of receipt. Clients agree not to pursue additional action prior to this timeframe in order to allow sufficient response time. While we provide this in the hopes of resolving administrative/logistical impasses, Change, Inc. is no way obligated to release clients from the terms of this Informed Consent Agreement.

While the overwhelming majority of grievances or impasses are able to be resolved, it is possible that clients and Change, Inc. may not ultimately see eye to eye on things. In that event and all others, it is agreed that clients will not disparage or denigrate in any manner Change, Inc., its leadership, management, officers, employees, clients/customers, or business activities or actions of Change, Inc., either orally or in writing, to any third party, including, but in no way limited to, any present or former employees of Change, Inc., any present or former clients of Change, Inc., the media, or to any other person or entity, through any means, including through social media, including reviews or commentary on Google, Yelp, Facebook, etc.

It is agreed that any and all disputes shall be negotiated directly between the client and Change, Inc. For items of a more serious nature for which these negotiations are not satisfactory and about which both parties consent to further efforts, the parties agree to mediate any differences with a mutually acceptable third-party mediator. If these are unsatisfactory, then the parties shall move to arbitration, and then binding arbitration, choosing an arbitrator mutually agreeable to both. The only exception to this rule is that legal intervention may be pursued to collect past due balances.

This written agreement contains the sole and entire agreement between the undersigned client and Change, Inc. and supersedes any and all other agreements between them. Therefore, clients acknowledge and agree that no other representations made are material with respect to the subject matter of this agreement or any representations inducing the execution and delivery hereof except such representations as are specifically set forth herein, and that he or she has relied on his or her own judgment in entering into the agreement. Clients further acknowledge that any statements or representations that may have heretofore been made previously are void and of no effect and that their consent to this agreement is based on the terms set forth herein.

This agreement and performance hereunder and all suits and special proceedings hereunder shall be construed in accordance with US State and Federal Law.