Welcome to North Country Counseling, PLLC. This document provides important information about virtual therapy services and your rights as a client. Please review this carefully and ask any questions before signing.

1. Nature of Virtual Therapy
Virtual therapy (telehealth) involves mental health services delivered via secure video conferencing, phone, or other HIPAA-compliant platforms. While effective for many individuals, it differs from in-person therapy and may not be suitable for all situations.

2. Confidentiality & Privacy

• Your privacy is a priority. Virtual sessions use encrypted, HIPAA-compliant technology to ensure confidentiality.

• Despite security measures, risks exist, including unauthorized access due to technology vulnerabilities.

• You are responsible for ensuring privacy on your end (e.g., using a secure internet connection and private space during sessions).

3. Benefits & Risks
Potential Benefits:

• Increased accessibility and convenience

• Continuity of care regardless of location

• Comfort of receiving therapy from your own space

Potential Risks:

• Technical issues (internet failure, software glitches, etc.)

• Reduced ability to read nonverbal cues

• Privacy concerns if sessions are overheard or recorded without consent

4. Emergencies & Crisis Situations

• Virtual therapy is not appropriate for crisis situations requiring immediate intervention.

• If you experience a crisis or are in immediate danger, call 911 or go to the nearest emergency room.

• Additional resources include the National Suicide Prevention Lifeline (988) and the Crisis Text Line (Text HOME to 741741).

5. Session Structure & Fees

• Sessions are conducted by video or phone at the agreed-upon time.

• Payment is due at the time of service unless otherwise arranged.

• Cancellations require 24-hour notice to avoid being charged for the session.

6. Technology Requirements

• A stable internet connection and a private, quiet location are necessary.

• It is the client's responsibility to test and troubleshoot technology before sessions.

7. Client Responsibilities

• Engage in sessions in a distraction-free environment.

• Inform your therapist of any concerns or difficulties.

• Notify your therapist of any changes in contact information or mental health status.

8. Termination of Services

• Therapy may be terminated by mutual agreement, if services are no longer beneficial, or if noncompliance with policies occurs.

• Referrals to alternative services may be provided if needed.

Consent & Agreement
By signing below, I acknowledge that I have read, understood, and agree to the terms outlined in this informed consent form. I understand the nature, benefits, risks, and limitations of virtual therapy and agree to participate in telehealth services with North Country Counseling, PLLC.

At North Country Counseling, I aim to provide accessible mental health services with clear and transparent payment options. Below is an overview of insurance billing and private pay options.

Insurance Billing

I have partnered with Mindful Therapy Group to handle insurance billing for in-network services. If you plan to use insurance:

• Verification: Mindful Therapy Group will verify your benefits and provide details on coverage before your first session.

• Copays & Deductibles: Any copays, coinsurance, or deductibles will be due at the time of service.

• Claims Processing: Mindful Therapy Group will submit claims on your behalf.

Private Pay Clients

For clients who prefer to pay out-of-pocket or are out-of-network:

• Session Fee: $120 per session

• Accepted Payment Methods: Payments can be made via Zelle or PayPal

Cancellation & No-Show Policy

• Cancellations require at least 24 hours' notice to avoid a cancellation fee.

• Late cancellations or missed appointments may be subject to a $100 charge, as this time is reserved for you.

For any questions regarding billing, insurance, or payment options, feel free to contact me or reach out to Mindful Therapy Group for assistance.

1. Purpose and Goals of Supervision:

The purpose of supervision is to provide the supervisee with guidance and support in developing their clinical skills, ensuring ethical practice, and meeting the necessary requirements for licensure as an LMHC or SUDP. Specific goals include:

• Developing and refining clinical competencies (e.g., assessment, intervention, and case conceptualization).

• Enhancing ethical awareness and decision-making.

• Strengthening professional identity and growth.

• Preparing for successful completion of licensure requirements.

2. Supervision Schedule:

• Frequency of Supervision:
  Supervision sessions will occur weekly for one hour (individual) or bi-weekly for two hours (group when available).

• Supervision Format:
  Sessions will be held virtually through a HIPAA-compliant telehealth platform, with an option to transition to in-person supervision to be discussed on an individual basis.

• Duration of Supervision:
  Supervision will continue until the supervisee meets all required hours for licensure or mutually agreed upon.

3. Expectations and Responsibilities:

• Supervisor Responsibilities:

  • Provide a structured environment for case discussion, ethical guidance, and clinical development.

  • Offer constructive feedback and resources to enhance the supervisee's learning.

  • Monitor progress toward professional goals and licensure requirements.

  • Uphold ethical and legal standards of the counseling profession.

  • Maintain confidentiality except where mandatory reporting or legal obligations arise.

• Supervisee Responsibilities:

  • Attend supervision sessions consistently and arrive prepared to discuss cases, challenges, and areas for growth.

  • Engage in active self-reflection and demonstrate openness to feedback.

  • Uphold ethical standards and confidentiality in client care.

  • Maintain accurate documentation of client sessions and ensure timely submission of required supervision forms.

  • Notify the supervisor of any ethical dilemmas or potential harm to clients.

4. Ethical Guidelines:

• Both the supervisor and supervisee are bound by the ethical guidelines outlined by the American Counseling Association (ACA) and Washington State regulatory boards. Any breach of ethical guidelines (e.g., dual relationships, confidentiality violations) must be reported immediately.

5. Evaluation and Feedback:

• Ongoing Feedback:
  The supervisee will receive regular verbal feedback during each supervision session to track their progress.

• Formal Evaluation:
  A formal evaluation will be conducted every 3 months to assess the supervisee's development, strengths, and areas needing improvement. This evaluation will be documented and shared with the supervisee.

6. Record Keeping and Documentation:

• The supervisee is responsible for maintaining records of their clinical hours and supervision sessions. The supervisor will also maintain documentation of supervision meetings, including topics discussed, feedback provided, and any concerns that arise.

7. Termination of Supervision:

Supervision may be terminated by either party with 30 days' notice. Termination may also occur if the supervisee fails to meet the responsibilities outlined in this agreement or engages in unethical behavior.

8. Conflict Resolution:

In the event of a disagreement or conflict, the supervisee is encouraged to discuss concerns with the supervisor directly. If resolution is not achieved, a third-party mediator may be consulted, adhering to the guidelines set by the ACA and state regulations.

9. Compensation:

• Supervision Fee:
  Individual supervision will be billed at $120 per hour (supervisee’s in private or group practice), $75 per hour (associates in community mental health & social services).

• 5-10 Minute Consultation Call: $0

10. Confidentiality:

Both parties agree to maintain the confidentiality of all cases discussed in supervision, with exceptions made for cases involving mandatory reporting, ethical concerns, or legal obligations.