Although this takes about 30-45 minutes to complete, it is essential that you read, understand, and complete this form in its entirety
If you are in crisis, call:
Kelly Muratorri, LPC/LMHC, will keep confidential the information discussed in counseling sessions. A written record of your sessions will be maintained. Note the following limits on confidentiality:
I have read and understand this disclosure of information regarding counseling with Kelly Muratorri, LPC/LMHC. I have read and understand the following basic rights:
Session times are 53 minutes. The out-of-pocket fee for sessions is $150. Client responsibility for this fee will likely decrease with insurance. Beginning January 1, 2025, the out-of-pocket fee for sessions will increase to $175 to meet market demands.
The fee to complete paperwork (e.g. FMLA, disability, etc.) is $125 per hour with a 2-hour minimum. The time required to print records, make copies, or or prepare and send mail, and any other administrative business (e.g. preparing releases of information) not directly related to the provision of clinical services, will also be assessed based on a rate of $125.
My fee for any requested appearance, subpoenaed appearance, settlement conference, or deposition is $500 per hour, with a minimum charge of two (2) hours. Such fees are due at least one (1) week before the scheduled appearance. If an appearance request is received without a minimum of one (1) week notice, the appearance fee is due immediately and there will be an additional $300.00 express charge. Failure to provide the fee as specified constitutes my release from the requested appearance.
Agreement
Note Regarding Insurance
Assignment and Release
To make our first meeting more productive, please give accurate and complete responses to every section of this form. All information is confidential as stated in the Informed Consent Form.
I consent to receive text messages or emails from Kelly Muratorri (“Provider”) on my cell phone or other devices. I understand that text messages and emails sent by Provider may include appointment reminders or changes in previously scheduled appointments, or may provide advice or education.
Provider does not charge for this service, but I understand that standard text messaging rates may apply as provided in my wireless plan. I will contact my carrier for pricing plans and details.
I understand that I may revoke my request for further communications via text or email at any time by notifying Provider in writing. However, if I continue to communicate with Provider via text or email, Provider can assume that my consent remains valid.
Because e-mails sent over the Internet or texts sent over the control channel without encryption are not secure, I understand the risks associated with e-mail and text messaging, including, without limitation, that e-mails and text messages could be intercepted by unknown third parties; e-mail content can be changed without the knowledge of the sender or receiver; backup copies of e-mail may still exist even after the sender and receiver have deleted the messages; and e-mail can contain harmful viruses and other programs.
Provider recommends that I delete all text messages or emails as soon as possible after reviewing them to limit any unauthorized exposure.
What is Telehealth?
Telehealth is healthcare provided by any means other than a face-to-face visit. In telehealth services, medical and mental health information is used for diagnosis, consultation, treatment, therapy, follow-up, and education. Health information is exchanged interactively from one site to another through electronic communications. Telephone consultation, videoconferencing, transmission of still images, e-health technologies, patient portals, and remote patient monitoring are all considered telehealth services
I hereby consent to participate in telehealth with Kelly Muratorri as part of my care.
I understand that telehealth is the practice of delivering clinical health care services via technology assisted media or other electronic means between a practitioner and a client who are located in two different locations.
I understand the following with respect to telehealth:
I have the right to withdraw consent at any time without affecting my right to future care, services, or program benefits to which I would otherwise be entitled.
There are risks, benefits, and consequences associated with telehealth, including but not limited to, disruption of transmission by technology failures, interruption and/or breaches of confidentiality by unauthorized persons, and/or limited ability to respond to emergencies.
There will be no recording of any of the online sessions by either party. All information disclosed within sessions and written records pertaining to those sessions are confidential and may not be disclosed to anyone without written authorization, except where the disclosure is permitted and/or required by law.
The privacy laws that protect the confidentiality of my protected health information (PHI) also apply to telehealth unless an exception to confidentiality applies (i.e. mandatory reporting of child, elder, or vulnerable adult abuse; danger to self or others; I raise mental/emotional health as an issue in a legal proceeding).
If I am having suicidal or homicidal thoughts, actively experiencing psychotic symptoms or experiencing a mental health crisis that cannot be resolved remotely, it may be determined that telehealth services are not appropriate and a higher level of care is required.
Electronic communication may be used to communicate highly sensitive medical information, such as treatment for or information related to HIV/AIDS, sexually transmitted diseases, or addiction treatment (alcohol, drug dependence, etc.).
During a telehealth session, we could encounter technical difficulties resulting in service interruptions. If this occurs, end and restart the session. If we are unable to reconnect within ten minutes, please call or email me to discuss since we may have to re-schedule.
My therapist may need to contact my emergency contact and/or appropriate authorities in case of an emergency.
Electronic communication should never be used for emergency communications or urgent requests. Emergency communications should be made to the provider’s office or to the existing emergency 911 services in my community.
I understand the inherent risks of errors or deficiencies in the electronic transmission of health information and images during a telehealth visit.
I understand that there is never a warranty or guarantee as to a particular result or outcome related to a condition or diagnosis when medical care is provided.
To the extent permitted by law, I agree to waive and release my healthcare provider and his or her institution or practice from any claims I may have about the telehealth visit.
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