Welcome to True North Emotional Wellness, a division of Cleveland Emotional Health, LLC.  Before starting counseling sessions with me, it is important for you to know what to expect and to understand your rights and commitments in therapy.  This consent form is an attempt to be as transparent with you as I can about the counseling process so that you are fully informed prior to beginning our work together.

What to expect from counseling
Mental health counseling is a process of sharing about your life experiences, genuine thoughts and feelings and what you are struggling with in order to reach your unique therapeutic goals.  I approach the counseling relationship collaboratively, meaning that we will work together to understand your psychological and emotional conflicts that may be keeping you stuck in unwanted patterns and causing your suffering.  In a non-judgmental and supportive space, we will work to increase your self-awareness, reduce your psychological distress and improve your relationships to yourself and others and enhance your overall wellbeing.

My approach to counseling is experiential, psychodynamic, emotion-focused, attachment-based, strengths-based, humanistic, compassionate and trauma-informed.  These approaches help you to do the profound work of uncovering the root causes of your psychological suffering and contributing to your current life distress.  At times, this work can involve temporary periods of discomfort as you begin to work through traumatic experiences or confront psychological conflicts that you may have previously avoided.  However, as these conflicts are processed and released, patients typically experience a reduction in distressing psychological symptoms and significant improvement in their wellbeing.

Fees for counseling
Individual counseling sessions are billed at a rate of $140.00 (credit card or HSA/FSA) or $125.00 (cash with no insurance reimbursement) for a 50-minute session.  Couples' sessions are billed at a rate of $160.00 (credit card or HAS/FSA) or $145.00 (cash, with no insurance reimbursement) for a 50-minute session.

If you have an unpaid balance from a previous session, new sessions will not be available for booking. 

I accept cash, credit card, HSA and FSA payments.  I do not accept insurance for services as I am an out-of-network provider (OON).  However, as an OON provider, I am able to provide you with a Superbill for potential reimbursement of services through your insurance carrier.  If you are interested in these potential benefits please pay careful attention to the insurance section below. 

Insurance
I am an out-of-network (OON) provider, meaning that I do not accept insurance payment directly through health insurance plans.  However, many insurance companies reimburse part of your counseling expenses for OON coverage when provided with an invoice, known as a Superbill, from your clinician.  Upon request, I am happy to provide you with a Superbill, which will be emailed to you and that you can include when filing your claim with your insurance company.

Out-of-network reimbursement is often contingent upon receiving a medical or mental health diagnosis and certain diagnoses may not qualify.  I do not accept responsibility for collecting payment from your insurance company and cannot guarantee that you will be reimbursed or that you will qualify for a reimbursable diagnosis.  Please contact your insurance provider to find out if you have OON coverage prior to your first counseling appointment.  Some important questions you may want to ask your provider include:

 - What percentage is reimbursed for each out-of-network psychotherapy session?

 - Is there a limit on the number of sessions covered per calendar year?

 - Do I need to meet a deductible before I can receive reimbursement?

 - Do I need pre-authorization for psychotherapy or a referral from my primary care physician?

Cancellation Policy
In the event that you must cancel your session, please contact me at least 24 hours prior to your scheduled session.  If you do not cancel your session with at least 24 hours' notice, you will automatically be charged a cancellation fee equal to the full session fee.  Additionally, if you do not contact me and do not attend a scheduled session, you will also be charged the full session fee.

The implementation of cancellation fees for no-shows or late cancellations is standard practice in the field and takes into account not only the commitment to paying for services rendered but for the reservation of a time slot which I cannot offer to someone else on short notice.

Telehealth (online) Counseling Sessions
Online counseling is a relatively new development in mental health in which counseling is provided over the internet through a secure video portal.  Although in-person counseling develops a more personalized connection, there are situations in which an online option may be a better fit for you.  Time constraints, distance, illness or ability and other life situations may get in the way of preferred in-person treatment.  Luckily, research supports the efficacy and efficiency of online counseling, which has been found to be just as effective as in-person sessions.

For online counseling, I use fiber optic internet that limits attenuation and prevents conferencing interruptions.  If you choose video counseling, it is recommended that you have quality internet service (not cellular).  Full session fees will be charged regardless of any technology problems that cause any interruptions in your session.

Confidentiality
The information that you share with me during counseling sessions is considered confidential information and is protected by New York State law.  As a mental health counselor, I cannot reveal to third parties whether or not you are a past or current patient, and cannot disclose any of the information you discuss during our sessions without first obtaining your written consent to.

However, there are some instances when I may be mandated or permitted to share information without your written consent.  These are outlined below:

 - If you share information detailing the risk of emotional, physical, or sexual abuse, neglect or exploitation of a child under the age of 18, an elderly person, or a disabled person, I am required by NYS law, as a mandated reporter, to make a report to New York Family and Protective Services, with or without your consent.

 - If you are not yet 18 years of age, your parents or legal guardians may have access to your records and may authorize release of information to other parties on your behalf.

 - If you disclose sexual misconduct by a previous counselor/therapist, I am required by law to make a report to the licensing board governing the license of the therapist.

 - If a judge in a court of law orders me to release information or if I need to respond to a lawfully issued subpoena, I am required to do so.  I do not respond to lawyers or physicians without a written consent by you to release information.

 - If you submit for out-of-network health insurance reimbursement and the insurance provider requires information to authorize the counseling services or billing.

 - If during your counseling, you are deemed to pose a threat of harm to someone else or to yourself, I am allowed to collaborate with the police or a hospital to take necessary measures to prevent harm from occurring.

Professional Records
All counseling records are kept on a secure server and under double lock and key.  Records will not be released without your written permission except as mandated by law.  You are entitled to receive a copy of your records with a written and signed request.

Voicemails, emails, faxes, instant messages, and video sessions are kept strictly confidential within the limits of technology, but confidentiality is not and cannot be guaranteed.  Any computer files kept regarding counseling communications are maintained using secure measures.

Emergencies and Regular Contact
If you are experiencing an emergency, please call 911, 988, or 211 (Lifelines). I keep regular office hours Monday and Tuesday from 10AM - 4PM and Wednesday and Thursday from 1PM - 7PM.  For routine communication (non-emergencies), you can contact me by text, call, or email for any reason relating to counseling and your mental health and I will respond within 48 hours or less.

Email & Text Notifications
When appointments are scheduled, automatic email/text reminders for your appointment will be sent to you when scheduling your first appointment. By signing this consent form, you agree to receive these notifications, and understand that email/text is not a confidential medium for transmitting health care information.

Scope of Practice and Services
I am qualified to work with a wide variety of patients with various types of struggles, but sometimes I may not have the training or expertise needed to address a particular concern. If this is the case, I will discuss it with you and make sure that you receive a referral to another professional who is better qualified to help with your particular needs.  If you are having current hallucinations, delusions, severe psychosis, active thoughts and plans of suicide/self-harm or homicide, extreme bipolar mood swings, or are in active addiction to substances you may need more support than I can offer through weekly counseling. I reserve the right to refer you to a different or more intensive treatment if I believe your needs exceed the level of care I can offer.

I, the patient, consent to the above terms, agree to the fees and to mental health treatment with Vanessa Mangione MHC LP, True North Emotional Wellness.