Register

Registration is only required if you do not have a username. Please check your spam & junk mail folders to ensure you have not already received an email with a username and password. If you already have a username log in here

Each account must have a unique email address associated with it. Please contact us if you need multiple accounts with the same email address (i.e. related family members).

After registering, please log in and complete all required forms. This will allow time for the doctor to review your records in advance to better assist your needs. Failure to complete the forms in advance will require you doing so during your session time. As a result, this will reduce your face-to-face visit with Dr LaMotte. Your cooperation is greatly appreciated to help maximize your session time!

Patient Information

/ Middle Initial

( optional )
 

( MM-DD-YYYY )






( for Text Message Reminders )

Emergency Contact

First Name
Last Name
Phone
Mobile
Relation
Email

Log in Details

( If patient is a minor, the legal guardian must enter their email address below. )



Between 8 and 40 letters and numbers

Challenge Questions

( These will be used to retrieve your password. Answers must be between 4 and 30 characters, cannot contain any spaces. )




( If you feel you must write down your questions in order to remember them, make sure to keep it in a safe place. )

Terms and Policy

Consent Form

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 important 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. Feel free to discuss 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, at times, 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. I cannot promise that your behavior or circumstance will change. I can promise to support you and do my very best to understand you and repeating patterns, as well as to help you clarify what it is that you want for yourself.


Confidentiality

The session content and all relevant materials to the patient's treatment will be held confidential unless the client 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 him/her self 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 elderly person 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 for the purpose of rendering an expert's report to an attorney.

Occasionally I may need to consult with other professionals in their areas of expertise in order to provide the best treatment for you. Information about you may be shared in this context without using your name.

If we see each other accidentally outside of the therapy office, I will not acknowledge you first. Your right to privacy and confidentiality is of the utmost importance to me, and I do not wish to jeopardize your privacy. However, if you acknowledge me first, I will be more than happy to speak briefly with you, but feel it appropriate not to engage in any lengthy discussions in public or outside of the therapy office.


About the Mental Health Clinical Practitioner

Dr. Selena LaMotte, DSW, LCSW is licensed by the State of Florida to diagnose and treat mental health disorders.  She is Doctor of Social Work; Licensed Clinical Social Worker; Certified Holistic Nutritionist; and a Certified Advanced, Children, Youth, and Family Social Worker with a Certificate in Child Welfare. All clinical services will be performed by 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 may not be covered by your insurance such as no-show and late cancellation/late reschedule [less than 72 hours (4 business days) notice].  By clicking on the checkbox below, I am agreeing that I am responsible for any fees as a result of no insurance or fees 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 AM AGREEING 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.

( Type Full Name )
Practice Policies

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 60 minutes.

f) The standard meeting time for a psychotherapy session is 45-55 minutes.

g) The standard meeting time for a family session with patient is 45-50 minutes.

h) The standard meeting time for a family session without patient is 35-50 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 $10.00 service charge will be charged for any checks returned for any reason for special handling.


TELEPHONE ACCESSIBILITY

If you need to contact Dr. LaMotte between sessions, please contact the office at (561) 469-9670 and speak with a member of staff to have your request addressed.

a) Dr. LaMotte is often not immediately available and we want to make sure that your needs are addressed.  Therefore, we encourage you to speak with a staff member to discuss possible options.

b) Voice messages are received by all staff members within minutes of leaving message. 

c) Dr. LaMotte will attempt to return "high distress" calls within the hour.  However, we encourage patients in distress to speak with a staff member to schedule an immediate "high distress" appointment.  

d) Dr. LaMotte or a member of staff will attempt to return "non-high distress" after hours calls within one (1) business day.

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

f) Secured messages can be sent to Dr. LaMotte via the patient portal page.


TELETHERAPY ACCESSIBILITY

Teletherapy is a combination of audio and live interactive video method of service delivery through a secured platform (HIPAA Compliant Technology; Skype and FaceTime are not considered HIPAA Compliant).

a) In the event that you are unable to attend session(s) in the office, online Teletherapy Sessions may be an option.  Contact our office to see if you qualify.

b) Teletherapy is not covered by all insurance. You must contact your insurance company to verify coverage.

c) Teletherapy Sessions must be paid 24 hours in advance. 

d) Teletherapy fee is non-refundable once appointment is paid.

e) Teletherapy is offered on Saturdays and Sundays.

f) You must wear a headphone and sit in a room with privacy.  No coffee shops, malls, open areas, etc.


If you and Dr. LaMotte choose to use Teletherapy for some or all of your treatment, you need to 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) Your access to all medical information transmitted during a Teletherapy consultation is guaranteed, and copies of this information are available for a reasonable fee.

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

e) There are potential risks, consequences, and benefits of 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 therapist/clinician gathers within a session or a series of sessions, a multitude of observations, information, & experiences about the patient. Clinicians may make clinical assessments, diagnosis, & 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 clinician'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 he or she would consider important information that you may not recognize as significant to present verbally the clinician.


EMERGENCY AND CRISIS/HIGH DISTRESS SITUATIONS

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

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

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

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

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

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

6) Call Dr. LaMotte's office at (561) 469-9670 to schedule a "high distress" appointment (non-life threatening situations).


SOCIAL MEDIA AND TELECOMMUNICATION

Due to the importance of your confidentiality and the importance of minimizing dual relationships, Dr. LaMotte 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 contact our office at (561) 469-9670.


ELECTRONIC COMMUNICATION

Dr. LaMotte and Empower Me Clinical Practice, LLC cannot ensure the confidentiality of any form of communication through electronic media, including text messages. If you prefer to communicate via email or text messaging for issues regarding scheduling or cancellations, we will do so. While we may try to return messages in a timely manner, we cannot guarantee immediate response and 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's Portal Page, email, and fax platforms.

b) Unsecured Electronic Means - patient's email and text platforms.

c) Recommended Electronic Means - Empower Me Clinical Practice's Portal Page


MINORS

If you are a minor, your parents may be legally entitled to some information about your therapy. We will discuss with you and your parents what information is appropriate for them to receive and which issues are more appropriately kept confidential.


TERMINATION

Ending relationships can be difficult. Therefore, it is important to have a termination process in order 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 we will provide you with a list of psychotherapists. You may also choose someone on your own or from another referral source.


We May Terminate Treatment If:

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

b) You are a threat to 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, payment, enrollment, or eligibility for benefits may not be conditioned on whether I sign this authorization.

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

c) Authorization to release/share records can be revoke at any time. 

d) Revocation must be made in writing to Empower Me Clinical Practice, LLC Records at 5350 10th Ave N., Ste. 5, Greenacres, FL  33463.  Contact our office for a revocation form or for more details. 

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


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

( Type Full Name )
Notice of Privacy Practices

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 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 clinician 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 clinician in diagnosis and treatment of your mental health condition.

c) Disclosures for treatment purposes are not limited to the minimum necessary standard. Because clinicians 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 Dr.LaMotte/Empower Me use in treating you.

b) For Dr.LaMotte/Empower Me 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 Dr.LaMotte/Empower Me use in defending herself/Empower Me in legal proceedings instituted by you.

d) For use by the Secretary of Health and Human Services to investigate Dr.LaMotte/Empower Me 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.

( Type Full Name )