General Information

The therapeutic relationship is unique in that it is a highly personal and, at the same time, a contractual agreement. Given this, it is essential for us to reach a clear understanding about how our relationship will work and what each of us can expect. This consent will provide a clear framework for our work together. Please feel free to talk about any of this with me. Please read and indicate that you have reviewed this information and agree to it by filling in the checkbox at the end of this document.

The Therapeutic Process

You have taken a very positive step by deciding to seek therapy. The outcome of your treatment depends largely on your willingness to engage in this process, which may sometimes result in considerable discomfort. Remembering unpleasant events and becoming aware of feelings attached to those events can bring on strong feelings of anger, depression, anxiety, etc. There are no miracle cures. We cannot promise that your behavior or circumstance will change. We can promise to support you and do our very best to understand you, repeating patterns, and help you clarify what you want for yourself.

Confidentiality

The session content and all relevant materials to the patient's treatment will be held confidential unless the patient requests in writing to have all or portions of such content released to a specifically named person/persons. Limitations of such patient-held privilege of confidentiality exist and are itemized below:

a) If a patient threatens or attempts to commit suicide or otherwise conducts themselves in a manner in which there is a substantial risk of incurring serious bodily harm.

b) If a patient threatens grave bodily harm or death to another person.

c) If the therapist has a reasonable suspicion that a patient or other named victim is the perpetrator, observer of, or actual victim of physical, emotional, or sexual abuse of children under the age of 18 years.

d) Suspicions, as stated above, in the case of an older adult who may be subjected to these abuses.

e) Suspected neglect of the parties named in items #3 and # 4.

f) If a court of law issues a legitimate subpoena for information stated on the subpoena.

g) If a patient is in therapy or being treated by order of a court of law, or if information is obtained to render an expert's report to an attorney.

Occasionally, we may need to consult with other professionals in their areas of expertise to provide the best treatment for you. You can share information about yourself in this context without using your name.

We will not acknowledge you first if we see each other accidentally outside the therapy office. Your right to privacy and confidentiality is of the utmost importance to us, and we do not wish to jeopardize your privacy. It is appropriate not to engage in lengthy discussions in public or outside the therapy office.

About the Psychotherapist

The State of Florida licenses Dr. LaMotte to diagnose and treat mental health disorders.  She is a Doctor of Social Work, Licensed Clinical Social Worker, Trained EMDR Therapist, Psychotherapist, Certified Holistic Nutritionist, Certified Advanced Children, Youth, and Family Social Worker, and an adjunct professor with a Certificate in Child Welfare from Florida Atlantic University.  She spent 17 years working with at-risk youth, families, and groups within the criminal justice system. She also has extensive experience working with individuals in law enforcement settings.  Dr. LaMotte's clinical experience includes working with children, youth, and adults with mild to severe mental health, behavioral health, and substance abuse/use issues in a variety of settings (private practice, criminal justice system, school system, law enforcement, hospital, etc.).    

Coordination of Care During Psychotherapist's Absence

When your assigned psychotherapist is unavailable for more than 48 hours or during emergencies, another assigned provider may provide services on behalf of Dr. LaMotte.    

Financial Responsibility and Payment Policy

The minor patient's legal guardian and adult patients are responsible for all charges for mental health services provided.  This includes any co-payments, deductibles, shared cost, out-of-network fees, and other fees that your insurance may not cover, such as no-show and late cancellation/late reschedule [less than 72 hours (4 business days) notice].  Last-minute cancellations/rescheduling/no-show impacts the patient, the psychotherapist, and other patients who could have utilized that time slot.  This policy is necessary since sessions are scheduled in advance and reserved for you.  By clicking on the checkbox below, I agree that I am responsible for any fees due to no insurance or expenses not covered by insurance (co-payments, shared cost, deductibles, out-of-network fees, late cancellation, and no-show).  I am also agreeing to pay all charges as a result.

BY SIGNING BELOW, I AGREE THAT I HAVE READ, UNDERSTOOD, AND AGREE TO THE ITEMS CONTAINED IN THIS DOCUMENT; I CONSENT TO TREATMENT AND SUBMISSION OF INSURANCE CLAIMS; AND I HAVE RECEIVED A COPY OF NOTICE OF PRIVACY AND PATIENT RIGHTS.

APPOINTMENTS AND CANCELLATIONS

a) Appointments & Cancellations can be done on the patient's portal page or by calling the office.

b) Please remember to cancel or reschedule 72 hours in advance (4 business days).

c) You may be responsible for the entire fee if cancellation/reschedule is less than 72 hours (4 business days). This is necessary because a time commitment is made to you and is held exclusively for you.

d) You may be responsible for the entire fee if you do not show for your scheduled appointment. This is necessary because a time commitment is made to you and is held exclusively for you.

e) The standard meeting time for a new patient (assessment/initial appointment) is 53 minutes.

f) The standard meeting time for a psychotherapy session is 45-53 minutes.

g) The standard meeting time for a family session with the patient is 45-53 minutes.

h) The standard meeting time for a family session without a patient is 35-45 minutes. 

i)  The standard meeting time for a crisis/high distress session is 60-120 minutes.

j)  If you are late for your session, you will lose some of that session time.

k) A $35 fee will be charged for any returned fees due to insufficient funds, overdraft, closed account, reverse charges that are actually owed for services, etc.

High Distress/Crisis Appointments are for those situations that require immediate psychotherapy services within twenty-three (23) hours; where the patient is not in immediate danger to self or others; not life-threatening; and not requiring medical or law enforcement services.

TELEPHONE ACCESSIBILITY

If you need to contact your psychotherapist between sessions, you may either contact the office at (561) 469-9670 and speak with a member of staff to have your request addressed, or you may send your psychotherapist an email in the patient portal.

a) Our psychotherapist is often not immediately available, and we want to ensure your needs are addressed.  Therefore, we encourage you to speak with a staff member to discuss possible options or send an email through the patient portal.

b) Voice messages - when leaving messages, please state the purpose of your call and any important details that can help address your needs.  

c) Our office will attempt to return "high distress" calls and emails within the hour.  We encourage patients in distress to speak with a staff member or send an email to schedule an immediate "high distress" appointment.  

d) A member of staff will attempt to respond to "non-high distress" calls as soon as possible or within one (1) business day.  Non-high-distress emails will be responded to throughout the day during business hours.

e) Face-to-face sessions are highly preferable to phone calls.

f) Secured messages can be sent to our psychotherapist via the patient portal page.  Emailing is a fast and effective way to contact your psychotherapist.

TELETHERAPY 

You must wear headphones and sit in a room with privacy-no coffee shops, malls, open areas, etc. Remember, the sessions are confidential, and be mindful of your environment. Treat it like a regular appointment. Arrive on time and be mindful of the duration of the appointment. 

If you choose to participate in Teletherapy, please understand that:

a) You retain the option to withhold or withdraw consent at any time without affecting the right to future care or treatment or risking the loss or withdrawal of any program benefits to which you would otherwise be entitled.

b) All existing confidentiality protections are equally applicable.

c) Dissemination of any identifiable images or information from the Teletherapy interaction to researchers or other entities shall not occur without your consent.

d) There are potential risks, consequences, and benefits to teletherapy. Potential benefits include, but are not limited to, improved communication capabilities, providing convenient access to up-to-date information, consultations, support, reduced costs, improved quality, change in the conditions of practice, improved access to therapy, better continuity of care, & reduction of lost work time and travel costs. Effective therapy is often facilitated when the psychotherapist gathers within a session or a series of sessions a multitude of observations, information, & experiences about the patient. A psychotherapist may make clinical assessments, diagnoses, & interventions based not only on direct verbal or auditory communications, written reports, & third-person consultations, but also from direct visual & olfactory observations, information, & experiences. When using information technology in therapy services, potential risks include, but are not limited to the psychotherapist's inability to make visual and olfactory observations of clinically or therapeutically potentially relevant issues such as: your physical condition including deformities, apparent height and weight, body type, attractiveness relative to social and cultural norms or standards, gait and motor coordination, posture, work speed, any noteworthy mannerism or gestures, physical or medical conditions including bruises or injuries, basic grooming & hygiene including appropriateness of dress, eye contact (including any changes in the previously listed issues), sex, chronological & apparent age, ethnicity, facial & body language, & congruence of language & facial or bodily expression. Potential consequences thus include the clinician not being aware of what they would consider important information that you may not recognize as significant to present to the psychotherapist verbally.

NON-LIFE THREATENING CRISIS/HIGH DISTRESS SITUATIONS - Not requiring medical care

When faced with a non-life-threatening mental health crisis not requiring medical care, we encourage the following:

1)  Call our office at (561) 469-9670 or send us an email in the patient portal to schedule an immediate "high distress" appointment.

2)  Call the National Suicide Prevention Lifeline at 1-800-273-8255 for additional support.

3)  Call Mobile Crisis at (561) 383-5777 for emergency assessment/de-escalation when unable to obtain an appointment with our psychotherapist.

EMERGENCY - LIFE THREATENING SITUATIONS - requires immediate medical care

When faced with a mental health emergency, we encourage the following:

a) Call 911 when appropriate (law enforcement issues/life-threatening, or assistance with transportation to obtain emergency medical care).

b) Go to the local emergency room for emergency medical care.

c) Go to the nearest receiving facility for self-harm or life-threatening emergency mental health services.

-------All ages   JFK Medical Center 2201 45th Street, WPB 

-------Ages 18+ JFK Medical Center 5301 S. Congress Ave, Atlantis

-------Ages 18+  St Mary's 901 45th Street, WPB 

------ Ages 18+Fair Oaks Hospital 5400 Linton Blvd, Delray Beach

After doing the above, call our office at (561) 469-9670 to notify us about your hospital admission, or email us in the Empower Me Clinical Practice's Patient Portal so that we may coordinate seeing you immediately after your hospital visit.

SOCIAL MEDIA AND TELECOMMUNICATION

Due to the importance of your confidentiality and the importance of minimizing dual relationships, our psychotherapist and Empower Me Clinical Practice, LLC staff members do not accept friend or contact requests from current or former patients on any social networking site (Facebook, LinkedIn, etc). We believe that adding patients 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. If you have questions about this, please get in touch with our office at (561) 469-9670.

ELECTRONIC COMMUNICATION

Our psychotherapist and Empower Me Clinical Practice, LLC staff members cannot ensure the confidentiality of any form of communication through electronic media, including text messages. We will respond to messages via our patient portal email.  We will not respond to outside emails or text messages.  While we may try to return messages in a timely manner, we cannot guarantee an immediate response, and we request that you do not use these methods of communication to discuss therapeutic content and/or request assistance for emergencies.

a) Secured Electronic Means - Empower Me Clinical Practice patient portal and fax.

b) Unsecured Electronic Means - social media, email accounts outside the patient portal, and text messages.

c) Recommended Electronic Means - Empower Me Clinical Practice patient portal and fax.

MINORS

Confidentiality does apply to minors.  Information will not be shared unless permission is given by the minor patient or during circumstances outlined under the confidentiality exception rules. Parents may be legally entitled to some information about therapy, such as coordination of care, progress report, treatment plan, and billing records. Please refer to the privacy law or speak with your psychotherapist for guidance.  

TERMINATION

Ending relationships can be complex. Therefore, it is essential to have a termination process to achieve some closure. The appropriate length of the termination depends on the length and intensity of the treatment. We will not terminate the therapeutic relationship without first discussing and exploring the reasons and purpose of terminating. If therapy is terminated for any reason, you will be given information to other referral sources.

We May Terminate Treatment If:

a) We determine that the psychotherapy is not being used effectively.

b) You threaten or verbally abuse our staff or patients.

c) You fail to schedule an appointment for three consecutive weeks, unless other arrangements have been made in advance, for legal and ethical reasons, we must consider the professional relationship discontinued.

RELEASE OF RECORDS/SHARING OF RECORDS

a) Treatment and assessment information is shared with your insurance company to coordinate benefits and care.

b) Treatment, payment, enrollment, or eligibility for benefits may not be conditioned on whether I sign this authorization.

c) Any disclosure of information has the potential for re-disclosure, and may not be protected by federal confidentiality rules.

d) Authorization to release/share records can be revoked at any time. 

e) Revocation must be made in writing to Empower Me Clinical Practice, LLC Records at 7765 Lake Worth Road #1042, FL  33467, or it can be submitted in the portal or via fax (561) 634-3861.  Contact our office for a revocation form or for more details. 

f) Revocation will not apply to information that has already been disclosed in response to this authorization.

g) Request for records can take up to 14 business days to process.  All requests must be in writing.

By signing the checkbox below, I agree that I have read, understood, and agree to the items contained in this document. 

THIS NOTICE DESCRIBES HOW HEALTH INFORMATION MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY.

I. PLEDGE REGARDING HEALTH INFORMATION

We understand that health information about you and your health care is personal. We are committed to protecting health information about you. We will create a record of the care and services you receive from our psychotherapists and EMPOWER ME CLINICAL PRACTICE, LLC d/b/a DR. SELENA LAMOTTE, DSW. We need this record to provide you with quality care and to comply with certain legal requirements. This notice applies to all of the records of your care generated by this mental health care practice. This notice will tell you about the ways in which we may use and disclose health information about you. We also describe your rights to the health information kept about you, and describe certain obligations we have regarding the use and disclosure of your health information. We are required by law to:

    a) Make sure that protected health information ("PHI") that identifies you is kept private.

    b) Give you this notice of my legal duties and privacy practices with respect to health information.

    c) Follow the terms of the notice that is currently in effect.

    d) We can change the terms of this Notice, and such changes will apply to all information we have about you. The new Notice will be available upon request and in the office.

II. HOW WE MAY USE AND DISCLOSE HEALTH INFORMATION ABOUT YOU

The following categories describe different ways that we use and disclose health information. For each category of uses or disclosures we will explain what we mean and try to give some examples. Not every use or disclosure in a category will be listed. However, all of the ways we are permitted to use and disclose information will fall within one of the categories:

1. Disclosure for Treatment Payment or Health Care Operations

a) Federal privacy rules (regulations) allow health care providers who have direct treatment relationship with the patient to use or disclose the patient's personal health information without the patient's written authorization, to carry out the health care provider's own treatment, payment or health care operations.

b) We may also disclose your protected health information for the treatment activities of any health care provider. This too can be done without your written authorization. For example, if a psychotherapist were to consult with another licensed health care provider about your condition, we would be permitted to use and disclose your person health information, which is otherwise confidential, in order to assist the psychotherapist in diagnosis and treatment of your mental health condition.

c) Disclosures for treatment purposes are not limited to the minimum necessary standard. Because psychotherapists and other health care providers need access to the full record and/or full and complete information in order to provide quality care. The word "treatment" includes, among other things, the coordination and management of health care providers with a third party, consultations between health care providers and referrals of a patient for health care from one health care provider to another.

2. Lawsuits and Disputes

a) If you are involved in a lawsuit, we may disclose health information in response to a court or administrative order.

b) We may also disclose health information about your child in response to a subpoena, discovery request, or other lawful process by someone else involved in the dispute, but only if efforts have been made to tell you about the request or to obtain an order protecting the information requested.

III. CERTAIN USES AND DISCLOSURES REQUIRE YOUR AUTHORIZATION

1. Psychotherapy Notes - We do keep "psychotherapy notes" as that term is defined in 45 CFR 164.501, and any use or disclosure of such notes requires your Authorization unless the use or disclosure is:

a) For our psychotherapists and Empower Me Clinical Practice, LLC use in treating you.

b) For our psychotherapists and Empower Me Clinical Practice, LLC use in training or supervising mental health practitioners to help them improve their skills in group, joint, family, or individual counseling or therapy.

c) For our psychotherapists and Empower Me Clinical Practice, LLC use in defending themselves/Empower Me in legal proceedings instituted by you.

d) For use by the Secretary of Health and Human Services to investigate our psychotherapists and/or Empower Me Clinical Practice, LLC  compliance with HIPAA.

e) Required by law and the use or disclosure is limited to the requirements of such law.

f) Required by law for certain health oversight activities pertaining to the originator of the psychotherapy notes.

g) Required by a coroner who is performing duties authorized by law.

h) Required to help avert a serious threat to the health and safety of others.

2. Marketing Purposes - we will not use or disclose your PHI for marketing purposes.

3. Sale of PHI - we will not sell your PHI in the regular course of business.

IV. CERTAIN USES AND DISCLOSURES DO NOT REQUIRE YOUR AUTHORIZATION

Subject to certain limitations in the law, we can use and disclose your PHI without your Authorization for the following reasons:

1. When disclosure is required by state or federal law, and the use or disclosure complies with and is limited to the relevant requirements of such law.

2. For public health activities, including reporting suspected child, elder, or dependent adult abuse, or preventing or reducing a serious threat to anyone's health or safety.

3. For health oversight activities, including audits and investigations.

4. For judicial and administrative proceedings, including responding to a court or administrative order, although my preference is to obtain an Authorization from you before doing so.

5. For law enforcement purposes, including reporting crimes occurring on my premises.

6. To coroners or medical examiners, when such individuals are performing duties authorized by law.

7. For research purposes, including studying and comparing the mental health of patients who received one form of therapy versus those who received another form of therapy for the same condition.

8. Specialized government functions, including, ensuring the proper execution of military missions; protecting the President of the United States; conducting intelligence or counter-intelligence operations; or, helping to ensure the safety of those working within or housed in correctional institutions.

9. For workers' compensation purposes. Although my preference is to obtain an Authorization from you, we may provide your PHI in order to comply with workers' compensation laws.

10. Appointment reminders and health related benefits or services. We may use and disclose your PHI to contact you to remind you that you have an appointment. We may also use and disclose your PHI to tell you about treatment alternatives, or other health care services or benefits that we offer.

V. CERTAIN USES AND DISCLOSURES REQUIRE YOU TO HAVE THE OPPORTUNITY TO OBJECT

1. Disclosures to family, friends, or others

a) We may provide your PHI to a family member, friend, or other person that you indicate is involved in your care or the payment for your health care, unless you object in whole or in part.

b) The opportunity to consent may be obtained retroactively in emergency situations. 

VI. YOU HAVE THE FOLLOWING RIGHTS WITH RESPECT TO YOUR PHI

1. The Right to Request Limits on Uses and Disclosures of Your PHI. You have the right to ask me not to use or disclose certain PHI for treatment, payment, or health care operations purposes. We are not required to agree to your request, and we may say "no" if we believe it would affect your health care.

2. The Right to Request Restrictions for Out-of-Pocket Expenses Paid for In Full. You have the right to request restrictions on disclosures of your PHI to health plans for payment or health care operations purposes if the PHI pertains solely to a health care item or a health care service that you have paid for out-of-pocket in full.

3. The Right to Choose How We Send PHI to You. You have the right to ask us to contact you in a specific way (for example, home or office phone) or to send mail to a different address, and we will agree to all reasonable requests.

4. The Right to See and Get Copies of Your PHI. Other than "psychotherapy notes," you have the right to get an electronic or paper copy of your medical record and other information that we have about you. We will provide you with a copy of your record, or a summary of it, if you agree to receive a summary, within 30 days of receiving your written request, and we may charge a reasonable, cost based fee for doing so.

5. The Right to Get a List of the Disclosures We Have Made. You have the right to request a list of instances in which we have disclosed your PHI for purposes other than treatment, payment, or health care operations, or for which you provided us with an Authorization. We will respond to your request for an accounting of disclosures within 60 days of receiving your request. The list we will give you will include disclosures made in the last six years unless you request a shorter time. We will provide the list to you at no charge, but if you make more than one request in the same year, we will charge you a reasonable cost-based fee for each additional request.

6. The Right to Correct or Update Your PHI. If you believe that there is a mistake in your PHI, or that a piece of important information is missing from your PHI, you have the right to request that we correct the existing information or add the missing information. We may say "no" to your request, but we will tell you why in writing within 60 days of receiving your request.

7. The Right to Get a Paper or Electronic Copy of this Notice. You have the right get a paper copy of this Notice, and you have the right to get a copy of this notice by e-mail. And, even if you have agreed to receive this Notice via e-mail, you also have the right to request a paper copy of it.

EFFECTIVE DATE OF THIS NOTICE

This notice went into effect on July 19, 2018. Acknowledgement of Receipt of Privacy Notice under the Health Insurance Portability and Accountability Act of 1996 (HIPAA), you have certain rights regarding the use and disclosure of your protected health information. By checking the box below, you are acknowledging that you have received a copy of HIPAA Notice of Privacy Practices.

BY SIGNING ON THE CHECKBOX BELOW I AM AGREEING THAT I HAVE READ, UNDERSTOOD, AND AGREE TO THE ITEMS CONTAINED IN THIS DOCUMENT.

I understand that telehealth is the use of electronic information and communication technologies (audio and video) by a health care provider to deliver services to an individual located at a site different from the provider's. I hereby consent to EMPOWER ME CLINICAL PRACTICE, LLC, psychotherapists providing Teletherapy Sessions to me via Telehealth. I understand that the laws that protect privacy and the confidentiality of medical information also apply to Telehealth/Teletherapy (sessions are not video recorded).  I understand that my insurance carrier will continue to have access to my medical records for quality review/audit.  I understand that I will be responsible for any co-payments, deductibles, or fees not covered by insurance for Telehealth/Teletherapy sessions. I understand that I have the right to withhold or withdraw my consent to the use of Telehealth/Teletherapy in the course of my care at any time, without affecting my right to future care or treatment. I may revoke my consent orally or in writing at any time by contacting my psychotherapist or EMPOWER ME CLINICAL PRACTICE, LLC at (561) 469-9670 or by the patient portal email.

As long as this consent is in force (has not been revoked) and the patient is located at a site different from the provider's, telehealth/teletherapy sessions will be provided without needing another consent form.

RISKS, CONSEQUENCES, & BENEFITS: You have been advised of all the potential risks, consequences, and benefits of Telehealth/Teletherapy sessions. You had the opportunity to ask questions about the information provided to you on this form during your consultation. All your questions have been answered,   and you understand the above written information.

TELEHEALTH/TELETHERAPY ACCESSIBILITY

You must wear headphones and sit in a room with privacy - no coffee shops, malls, open areas, etc. Remember, the sessions are confidential, and be mindful of your environment. Treat it like a regular appointment. Arrive on time and be mindful of the duration of the appointment. 

If you choose to participate in Teletherapy, please understand that:

a) You retain the option to withhold or withdraw consent at any time without affecting the right to future care or treatment or risking the loss or withdrawal of any program benefits to which you would otherwise be entitled.

b) All existing confidentiality protections are equally applicable.

c) Dissemination of any identifiable images or information from the Teletherapy interaction to researchers or other entities shall not occur without your consent.

d) There are potential risks, consequences, and benefits to teletherapy. Potential benefits include, but are not limited to, improved communication capabilities, providing convenient access to up-to-date information, consultations, support, reduced costs, improved quality, change in the conditions of practice, improved access to therapy, better continuity of care, & reduction of lost work time and travel costs. Effective therapy is often facilitated when the psychotherapist gathers within a session or a series of sessions a multitude of observations, information, & experiences about the patient. A psychotherapist may make clinical assessments, diagnoses, & interventions based not only on direct verbal or auditory communications, written reports, & third-person consultations, but also from direct visual & olfactory observations, information, & experiences. When using information technology in therapy services, potential risks include, but are not limited to the psychotherapist's inability to make visual and olfactory observations of clinically or therapeutically potentially relevant issues such as: your physical condition including deformities, apparent height and weight, body type, attractiveness relative to social and cultural norms or standards, gait and motor coordination, posture, work speed, any noteworthy mannerism or gestures, physical or medical conditions including bruises or injuries, basic grooming & hygiene including appropriateness of dress, eye contact (including any changes in the previously listed issues), sex, chronological & apparent age, ethnicity, facial & body language, & congruence of language & facial or bodily expression. Potential consequences thus include the clinician not being aware of what they would consider important information that you may not recognize as significant to present to the psychotherapist verbally.