Informed Consent

Professional Disclosure Statement

Vox Cura

Telephone Counseling / Technology Assisted Counseling Notice

This Professional Disclosure Statement informs clients about the nature, expectations, benefits, risks, and limitations of psychotherapy-counseling services provided through Vox Cura. It includes practice policies, confidentiality limits, telephone counseling procedures, fees, billing, and consent to treatment. This document is provided in addition to Vox Cura’s Notice of Privacy Practices for Protected Health Information, commonly known as HIPAA.

Welcome

• This disclosure statement is intended to educate clients and prospective clients about psychotherapy-counseling with Vox Cura.
• Vox Cura provides psychotherapy-counseling services through licensed or otherwise legally authorized clinicians.
• Services are provided according to applicable:
  • Ethical standards
  • Legal requirements
  • Professional standards
  • Jurisdictional rules where the clinician is authorized to practice
  • Jurisdictional rules where the client is physically located at the time of service

Psychotherapy Philosophy and Approach

• Psychotherapy is both an art and a science that may help with:
  • Mental health concerns
  • Emotional challenges
  • Relational difficulties
  • Personal growth and insight
• The goal of psychotherapy is not to provide a quick fix, but to support a process of relational discovery that may help clients:
  • Develop insight
  • Reduce suffering
  • Create meaningful change
• Vox Cura’s clinical approach emphasizes:
  • Present-moment awareness
  • Mindfulness
  • A safe therapeutic space
• Therapy may include evidence-based and clinically appropriate interventions such as:
  • Cognitive Behavioral Therapy, or CBT
  • Mindfulness-based interventions
  • Psychodynamic exploration
  • Trauma-informed care
  • Other methods based on the client’s needs
• Clinicians may help clients identify and process emotional or cognitive blockages, including:
  • Sadness
  • Anxiety
  • Anger
  • Grief
  • Trauma
  • Confusion
  • Interpersonal patterns

Client and Clinician Roles

Client’s Role

• Participate honestly and as fully as possible.
• Discuss thoughts, feelings, behaviors, concerns, and goals.
• Engage in the therapeutic process in a thoughtful and collaborative way.

Vox Cura’s Role

• Guide the therapeutic process.
• Provide appropriate clinical interventions.
• Consider multicultural and identity-related factors.
• Tailor treatment to the client’s:
  • Needs
  • Values
  • Belief system
  • Goals
  • Clinical circumstances

Technology Assisted Counseling, or TAC

Telephone Counseling Only

• For this disclosure statement, Technology Assisted Counseling, or TAC, refers to psychotherapy-counseling provided by telephone only.
• Vox Cura does not use video counseling under this telephone-only TAC notice.
• Email or text communication may be used for:
  • Scheduling
  • Administrative coordination
  • Other limited purposes when clinically and legally appropriate
• Email and text are not a substitute for psychotherapy sessions unless specifically agreed upon in writing.

Appropriateness of Telephone Counseling

Before telephone counseling begins, a Vox Cura clinician will determine whether telephone counseling appears appropriate based on the client’s:

• Specific needs
• Presenting concerns
• Risk level
• Location
• Clinical circumstances

Telephone counseling may not be appropriate for every client or every clinical situation.

Benefits of Telephone Counseling

Telephone counseling may offer the following benefits:

• Increased access to mental health services
• Greater convenience when the client and clinician are not in the same physical location
• Reduced travel time and travel burden
• Increased scheduling flexibility
• Improved access for:
  • Homebound clients
  • Clients with limited mobility
  • Clients without convenient transportation options
• Research suggests that telehealth services, including telephone counseling, may be effective for many clients and concerns

Limitations of Telephone Counseling

Telephone counseling has limitations that may affect the quality or effectiveness of services, including:

• The clinician cannot see the client’s:
  • Body language
  • Nonverbal responses
  • Physical presentation
• Due to telephone or connection issues:
  • The clinician may not hear everything the client says
  • The clinician may need to ask the client to repeat information
• Phone service, devices, or other technology may fail before or during a session.
• Telephone counseling may not be appropriate when a client:
  • Is in crisis
  • Requires a higher level of care
  • Requires support that cannot reasonably be provided by telephone
• Vox Cura may decline, pause, or discontinue telephone counseling when clinically appropriate.
• Although reasonable efforts are made to protect confidentiality, breaches may occur for reasons beyond Vox Cura’s control.
• Because visual cues are absent, the clinician may ask the client to describe the following in more detail:
  • Thoughts
  • Emotions
  • Behaviors
  • Location
  • Safety concerns

Telephone Counseling Logistics and Client Responsibilities

Session Procedures

• A Vox Cura clinician will call the client at the scheduled appointment time.
• The clinician will use the phone number provided by the client unless another arrangement has been made in advance.
• The client is expected to be available at the scheduled time and prepared to participate.

Client Responsibilities

The client agrees to:

• Participate from a private and confidential location.
• Speak from a place where the client can talk openly without being overheard or interrupted.
• Make reasonable efforts to reduce interruptions and distractions during the appointment.
• Understand that telephone conversations may be intercepted accidentally or intentionally.
• Understand that absolute confidentiality of phone communications cannot be guaranteed.
• Use a headset or other privacy-enhancing device when appropriate to improve confidentiality and sound quality.
• Not drive, operate a motor vehicle, or engage in any activity requiring full attention during telephone psychotherapy or counseling.

Safety During Sessions

• If the client is driving or operating a vehicle at the time of the session, the session may be ended and rescheduled for safety reasons.

Clinician Responsibilities

• The clinician will make reasonable efforts to:
  • Conduct sessions from a private location
  • Protect the client’s confidentiality

Location and Licensure

• Vox Cura clinicians may only provide psychotherapy-counseling services in states or jurisdictions where they are licensed or otherwise legally authorized to practice.
• The client must be physically located in a state or jurisdiction where the assigned clinician is authorized to practice at the time of the session.
• The client agrees to inform Vox Cura if:
  • The client’s physical location changes before a session
  • The client’s physical location changes during a session
  • The client relocates to another state or jurisdiction

Emergency and Crisis Situations

Telephone counseling is not a substitute for emergency services or crisis intervention.

If the client is experiencing a mental health emergency, is at risk of harming self or others, or requires immediate support, the client should:

• Call 911
• Go to the nearest emergency room
• Contact the 988 Suicide & Crisis Lifeline by calling or texting 988

Risks and Benefits of Psychotherapy

Potential Benefits

Psychotherapy may support clients in:

• Increasing awareness
• Healing
• Reducing symptoms
• Improving functioning
• Understanding themselves and others more deeply

Potential Risks

Psychotherapy may also involve difficult experiences, including:

• Uncomfortable emotions
• Painful memories
• Difficult realizations
• Feeling worse before beginning to feel better

Therapy may also affect:

• Relationships
• Work life
• Home life
• The client’s self-understanding
• The client’s understanding of others

Treatment Guidance

Vox Cura clinicians aim to proceed carefully and ethically while helping clients increase insight into mental and emotional challenges. Treatment will be guided by:

• Clinical judgment
• Client goals
• Client safety
• Individualized treatment needs

Length of Therapy

The length of therapy is determined on a case-by-case basis and may depend on:

• Client goals
• Presenting concerns
• Progress
• Treatment needs
• Clinical circumstances

If Vox Cura determines that the client is not benefiting from services, or if the client and clinician agree that limited progress is occurring:

• The clinician will discuss this with the client.
• When appropriate and available, referrals may be provided to:
  • Another clinician
  • Another level of care
  • Services that may better meet the client’s needs

Professional Qualifications and Clinician Assignment

Clinician Assignment

Vox Cura provides psychotherapy-counseling services through licensed or legally authorized clinicians.

The specific clinician assigned may depend on:

• Availability
• Client needs
• Clinical fit
• Language needs
• Insurance or direct-pay arrangements
• Licensure requirements
• Continuity-of-care considerations

A client may be:

• Assigned to another Vox Cura clinician
• Transferred to another Vox Cura clinician
• Supported by another Vox Cura clinician

This may occur when clinically appropriate, administratively necessary, or requested and available.

Clinician Information

Clients may request information about the assigned clinician’s:

• License
• Education
• Training
• Experience
• Scope of practice

Vox Cura will make reasonable efforts to ensure clients know:

• Which clinician is providing services
• How to contact Vox Cura regarding clinical or administrative concerns

Example Clinician Information

Services may be provided by Gian Michael Sarabia, LMFT, when clinically appropriate and available.

• Gian Michael Sarabia is a Licensed Marriage and Family Therapist in California.
• License Number: 150458
• Education:
  • Master of Arts in Counseling Psychology from Santa Clara University
  • Master of Education from California State University, Monterey Bay

Services may also be provided by other Vox Cura clinicians who are licensed or otherwise legally authorized to provide psychotherapy-counseling services.

Clinical Experience and Areas of Focus

Clinical experience among Vox Cura clinicians may include work in:

• Mental health agencies
• Psychiatric hospitals
• Outpatient settings
• Crisis response programs
• School settings
• Telehealth settings
• In-person clinical work

Areas of clinical focus may include:

• Developmental trauma
• Anxiety
• Depression
• Interpersonal difficulties
• Complex trauma
• Personality-related concerns
• Other emotional or behavioral challenges

Services may be offered in English or Spanish when clinically appropriate and within the clinician’s competence.

Confidentiality

Vox Cura is legally and ethically required to protect client confidentiality, subject to certain exceptions.

Information shared in psychotherapy is confidential except where disclosure is:

• Required by law
• Permitted by law
• Required or permitted by ethical standards
• Authorized by the client

Limits of Confidentiality

Limits of confidentiality may include, but are not limited to:

• Good reason to believe the client presents a serious risk of harm to another person.
• Reason to suspect abuse or neglect of:
  • A child
  • A dependent adult
  • An elder
  • Another protected person as required by law
• Good reason to believe the client is in imminent danger of harming self.
• Disclosure required by:
  • Court order
  • Subpoena
  • Legal mandate
  • Other applicable law
• Disclosure necessary for:
  • Consultation
  • Supervision
  • Billing
  • Operations
  • Coordination of care

These disclosures will be handled consistent with applicable privacy laws and minimum necessary standards.

Required or Permitted Disclosure

If a confidentiality exception applies, Vox Cura may be required to contact:

• Emergency services
• A crisis team
• Law enforcement
• Protective services
• An intended victim
• Another legally appropriate party

Except as described above or otherwise permitted by law, Vox Cura will release client information only with the client’s written authorization.

Fees, Billing, and Cancellations

Billing

• Vox Cura handles billing for psychotherapy-counseling services.
• Services may be provided through:
  • Direct pay
  • Insurance billing, if and when available and accepted by Vox Cura

The client is responsible for any applicable:

• Direct-pay fees
• Copayments
• Coinsurance
• Deductibles
• Non-covered services
• Denied claims
• Other amounts allowed by applicable law and the client’s insurance plan

Direct-Pay Fees

• Standard out-of-pocket fee:
  • $79 for a 53-minute psychotherapy session
• Approved sliding-scale fee:
  • $59 per 53-minute psychotherapy session
• Sliding-scale arrangements must be available and documented in writing.
• Fees are due at the beginning of each session unless otherwise agreed in writing.
• Vox Cura may offer reduced-fee or sliding-scale services in limited circumstances when:
  • Clinically appropriate
  • Financially appropriate
  • Available

Cancellations and No-Shows

Clients are expected to provide at least 24 hours’ notice to cancel or reschedule a session.

Cancellation or rescheduling notice must be submitted by:

• Email to Vox Cura
• The scheduling system

If less than 24 hours’ notice is provided, or if the client does not attend the scheduled session:

• Vox Cura may charge a $50 late-cancellation/no-show fee.
• This fee will not apply if prohibited by:
  • Applicable law
  • Insurance contract
  • Other written agreement

Late-cancellation/no-show fees are generally the client’s responsibility and may not be billable to insurance.

501(c)(3) Nonprofit Fee and Insurance Notice

Vox Cura is organized to provide services consistent with its charitable and clinical mission.

Direct-pay fees, insurance billing availability, insurance reimbursement, and client responsibility amounts may vary depending on:

• Payer contracts
• Plan benefits
• Eligibility
• Authorization requirements
• Deductibles
• Copayments
• Coinsurance
• Claim determinations
• Funding availability
• Applicable law

During Vox Cura’s early stages of operation:

• Fees and billing policies may be adjusted as the organization develops its programs and contracts.
• Any fee change will be provided with reasonable advance written notice before the new fee applies.
• Fee changes will not be applied retroactively to services already provided.

Uninsured or self-pay clients may request, and where required will receive, a Good Faith Estimate of expected charges.

Consent to Treatment

By signing this disclosure statement or by engaging and continuing in psychotherapy-counseling services with Vox Cura, the client acknowledges that the client has read, understood, and agrees to the terms of this Professional Disclosure Statement.

The client consents to psychotherapy-counseling services through Vox Cura and understands the nature of:

• Services
• Confidentiality and its limits
• Telephone counseling expectations
• Risks and benefits
• Fees
• Billing
• Clinician assignment
• Relevant practice policies