Provider and Client Care Agreement

Disclosure Statement

Melanie Goetz, LMFT Upward Roots: Relational Therapy Serving all of California melaniegoetz@upwardroots.com 760-453-0373 The purpose of this document is to inform you about certain aspects of the counseling relationship that we hope to establish. Please read it thoroughly and carefully. Feel free to ask me any questions or seek clarification about any of the following statements before signing it.

Qualifications of Your Therapist:

I am a Licensed Marriage and Family Therapist (#128217). I have worked in mental health for 12 years. In between undergraduate and graduate studies, I worked as a Registered Behavioral Technician with children with Autism Spectrum Disorder and volunteered as a Suicide Prevention Hotline Counselor. Additionally, I have volunteered with organizations working with girls rescued from human trafficking, Ethiopian refugees, and intercity homeless young adults. I have a bachelors' in psychology with a minor in leadership from Colorado Christian University, and two masters' degrees from New Orleans Baptist Theological Seminary including an M.A. in Marriage and Family Counseling. As a clinical intern, I counseled women at a rehabilitation program, adolescents at a juvenile detention center, foster families in community-based workshops, and an array of children, individuals, couples, and families at a community clinic. Following graduation, I returned to San Diego county and worked for two separate group private practices where I continued to work with adults, couples, adolescents, and children from a Gottman, Trust-Based Relational Intervention, and EMDR orientation. In 2019 and 2020, I focused on increasing my Gottman, DARe (attachment-somatic), and parts work skills. With the COVID pandemic, I began working online from home and transitioned to working exclusively with adult individuals and couples. Upon passing my exam for licensure in 2020, I started my private practice: Upward Roots. In 2023, I switched my focus in training to PACT and pursuing certification in EMDR. Couples counseling with me will integrate Gottman Method Couples Counseling, Attachment Core Pattern Therapy, and Psychobiological Approach to Couples Therapy (PACT) with other approaches. Individual therapy for those who have experienced trauma will likely utilize Eye Movement Desensitization and Reprocessing (EMDR) and Dynamic Attachment Re-patterning Experience (DARe), a somatic therapy technique for treating attachment disruptions, along with different approaches to Ego State or Parts Work. Additionally, as appropriate, I integrate shame resiliency, boundaries, and emotion regulation work from experts in the field such as: Peter Levine, Dr. Stephen Prorges, Dr. Daniel Siegel, Dr. Daniel Amen, Brene Brown, Dr. Christian Conte, Dr. Caroline Leaf, and Dr. Rick Hanson. Somatic and sensory-input work may incorporate touch, smell, taste, sight, and sound. I will ask permission and get verbal confirmation prior to incorporating or adjusting any sense-related experience. My work focuses on mind-body integration and pulls from skills and techniques that best meet the needs of each client. This concept of integration is about a sense of wholeness: spiritual, mental, emotional, social, physical, playful/creative, with experiences of awe. Therefore, sessions may blend bodywork, reflective questions and cognitive work, deeper processing, along with emotional regulation and awareness. In each session, we will balance strengthening what is going well and feels good with working through what is difficult. Your presenting issue(s), present awareness, goal(s), and worldview will contribute greatly to guiding the direction of our work.

Counseling Relationship

Counseling is a process in which the client and the counselor collaborate. Through mutual respect and developed trust, we will work as a team to explore and define present problem situations, develop future goals for an improved life, and work in a systemic fashion toward realizing those goals. You must make your own decisions regarding things such as deciding to marry, separate, divorce, reconcile, and how to set up custody and visitation. I can assist you in thinking through the possibilities and consequences of decisions, at the same time, the Code of Ethics for all mental health providers does not allow counselors to make any specific decisions for a client. As a professional counselor, I abide by certain ethical codes regarding dual relationships. One such guideline instructs that counselors are not to be “friends” with clients on any type of social media. Likewise, I do not partake in any social or sexual relations with current or former clients. I respond to calls, texts, and emails Monday through Friday from 7 am until 4 pm, and will check messages Sunday evenings for scheduling changes or other matters requiring attention before our next scheduled session. If I am in session or am otherwise unable to answer your call, I will attempt to respond within 24 hours. Communication—calls, texts, emails—totaling less than 10 minutes of my time in a week is free, anything beyond 10 minutes is charged at a prorated amount of our agreed-upon session rate. Throughout the year, I will be away from the office for extended vacations and professional trainings. With any expected absence, I will give plenty of warning, and will provide a plan for continued care if needed. I will supply the name and contact information of another therapist who will cover my practice during my absence. If at any time you experience an emergency, please call the San Diego Access & Crisis Line at (888) 724-7240, 911, or visit your nearest emergency room and request the psychologist or psychiatrist on call.

Your Financial Responsibilities:

Clients are seen by appointment only and may text (760) 453-0373, email melaniegoetz@upwardroots.com, or sign into your client portal to schedule an appointment. You are responsible for coming to your session on time, at the time we have scheduled. Sessions are 50-minutes, unless we have discussed longer sessions together (usually appropriate for EMDR or couples counseling). The fee for a 50-minute session is $195, unless we have agreed upon a different fee. Longer sessions are charged at a prorated rate based on the ratio of fee per minute. If I have the flexibility of time and it seems therapeutically beneficial, we may decide together to extend our session at the additional prorated rate per the extra time spent in the session. If either of us disagrees for whatever reason, we will end our session at the agreed-upon time and fee. If we have already discussed that I have current flexibility for a sliding fee scale spot: The sliding fee scale policy asks clients to be honest about their financial ability. We do not want finances to prevent you from being consistent with therapy in meeting your therapeutic goals. Please assess the most you can pay per session in order to remain consistent with the frequency we planned during our consultation, and confirmed during our goal-setting session. Additionally, if finances shift whether due to job loss, emergency expenses, promotion, raise, trust, or something else, please reassess your ability and we can re-establish the new rate per session and/or identify alternative support if a fee within my scale range is not possible. Payment is completed via the Credit Card kept securely on file. Simple Practice’s AutoPay service charges the credit card at midnight following our session. If you miss a session without canceling or cancel with less than 36-hour notice for a weekday session and 48-hour notice for a weekend session, Simple Practice will charge 75% of the total fee. If you are running late to a session, please text “late” with an ETA to (760) 453-0373 or message in your Client Portal and drive safely to your meeting location for the session. We will begin when you arrive and conclude at the scheduled conclusion time, as I will not dip into another client's time. The fee for the session will remain the normal session fee. If you are running 15 minutes late or later, I will consider the session as a late cancellation, as we will not have sufficient time to make progress and reach closure in your session if it is 50-minutes. If for some reason I am late, I will inform you through the Zoom Waiting Room Chat for online sessions, or, Simple Practice Messages for an in-person session. We will meet for our entire duration, ending the same amount of minutes late as we started, as long as the ending time works with your schedule.

Diagnosis:

Generally third parties, including insurance providers, require a diagnosis in order to pay towards a client's therapy. Diagnoses are technical terms that describe the nature of your problems and something about whether they are short-term or long-term problems.

Managed Mental Health Care:

If your therapy is being paid for in full, or in part by a managed care company, there are usually limitations to your rights as a client imposed by the contract of the managed-care firm. These are usually conditions that are specific to your policy, and may include a limit to the number of sessions available to you, or the time period within which you much complete your therapy. Although rare, some companies may require progress notes, or copies of your case file. I do not have control over these requirements, and must oblige with their requests.

Treatment of a Minor:

I generally require the consent of both parents prior to providing any services to a minor child. However, in some cases, a child over twelve years old is able to consent to his/her own therapy without the written approval of a parent or guardian. In the event that the parents are separated or divorced, I will require that the parent/guardian seeking therapy submit supporting legal documentation (such as a custody order) prior to beginning services. This is to assure that we are working in accordance with the custody order, and to determine if both parents need to consent to the services. Psychotherapy can only be effective if there is a trusting, confidential relationship between the therapist and client. This is a standard that I ask parents/guardians to respect and to allow there to be privacy in the sessions with the minor. The parent/guardian can expect to be kept up to date about the client's progress in therapy, but will typically not be privy to detailed discussions between the therapist and client. However, they can expect to be informed in the event of any serious concerns I might have regarding the safety or well-being of the client, including suicidality.

Confidentiality:

With the exception of certain specific exceptions described below, you have the absolute right to the confidentiality of your therapy. I cannot, and will not tell anyone else what you have told me, or even that you are in therapy with me (without your prior written permission). Under the provisions of the Health Care Information Act of 1992, I may legally speak to your health care providers. Additionally, in case of emergency, I may contact a member of your family without your prior consent. You may direct me to share information with whomever you chose (with written consent), and you can change your mind and revoke that permission at any time. You are also protected under the provisions of the Federal Health Insurance Portability and Accountability Act (HIPPA). This law ensures the confidentiality of all electronic transmission of information about you. If you elect to communicate with me by email, Skype, or via text at some point in our work together, please be aware that these forms of communication are not completely confidential. Following are the limits to confidentiality: 1. If you threaten grave bodily harm or death to another person or to yourself. I must attempt to warn the individual of your intentions and call on the police to protect your intended victim. 2. If you report to me your knowledge of past or continuing physical or sexual abuse of a minor child, dependent adult, or elder adult by an adult, I am required to inform the appropriate child welfare or law enforcement agency. 3. Counseling records may be released if subpoenaed by a court of law. 4. I partake in frequent consultation meetings with other therapists. Each therapist is also bound by confidentiality. In consultation, I will only discuss the pertinent information and leave out any identifying information. Consultation is a practice to ensure each therapist is providing individualized care that meets each clients’ needs effectively and appropriately. You have the right at any time to request any information we discuss not be shared in these meetings. Please be aware that video therapy through Skype or FaceTime, email, text, and calls are not HIPPA compliant. Although I work to maintain confidentiality, I cannot guarantee the security of communication through non-protected portals.

Telehealth Remote Therapy:

Remote therapy includes using electronics to conduct therapy when the client and counselor are in two separate locations. By signing this document, you understand that I cannot be held responsible for providing care in the event of an emergency for any remote clients. In initiating remote therapy, I ask that you identify local resources you may reach out to if the need arises for local care. Emergency situations that are outside the scope of my responsibility include, but are not limited to suicide risk assessment and other emergency situations that require immediate care. If you receive remote therapy and have symptoms requiring medical attention, please contact your local provider for assistance in getting you care. You understand that I cannot be held liable for the loss of privacy and confidentially due to problems in electronic transmission beyond our control.

Patient Litigation:

I will not voluntarily participate in any litigation, or custody dispute in which the client and another individual, or entity, are parties. I have a policy of not communicating with the client's attorney, or legal representative, and will generally not write or sign letters, reports, declarations, or affidavits to be used in the client's legal matter. I will not make any recommendation as to custody or visitation regarding a minor client. I will generally not provide records, unless given a written request from the client (see Record Keeping below). For minor clients, I will generally not provide records, unless ordered to do so by the court. Should I be subpoenaed, or ordered by a court of law, to appear as a witness in an action involving the client, the client, or the parent/guardian agrees to reimburse me for any time spent for preparation, travel, or other time in which I have made myself available for such an appearance at my rate of $150 per an hour.

Psychotherapist-Client Privileged Communication:

The information disclosed by the client, as well as any records created, is subject to the psychotherapist-client privilege. The psychotherapist-client privilege results from the special relationship between the therapist and the client in the eyes of the law. It is similar to the attorney-client privilege or the doctor-patient privilege. Typically, the client is the holder of the psychotherapist-client privilege. IF I receive a subpoena for records, deposition, testimony, or testimony in a court of law, I will assert the psychotherapist-client privilege on the client's behalf until instructed, in writing, to do otherwise by the client or the client's representative. The client should be aware that he/she might be waiving the psychotherapist-client privilege if he/she makes his/her mental or emotional state an issue in a legal proceeding. The client should address any concerns he/she might have regarding the psychotherapist-client privilege with his/her attorney. When the client is a minor, the court-appointed guardian or the minor's counsel is the holder of the psychotherapist-client privilege. Parents typically do not have the authority to waive the psychotherapist-client privilege for their minor children, unless given such authority by a court of law. The representative is encouraged to discuss any concerns regarding the psychotherapist-client privilege with his/her attorney.

Record Keeping:

I keep SOAP progress notes including your presenting problem, clinical observations, the intervention(s) and/or assessment(s) used, and a plan for the next session, including a written account of the homework assigned between sessions. If participating in EMDR therapy, notes include the “chapter title” of events, ages, the image that represents the worst part of the event, cognitions, emotions, body sensations, resources utilized, and progress achieved during processing. Any personal psychotherapy notes I take are kept separate from your file. Under the provisions of the Health Care Information Act of 1992, you have the right to a copy of your file at any time. You have the right to request that I correct any errors in your file. You have the right to request that I make a copy of your file available to any other health care provider at your written request. Your records are securely maintained through Simple Practice.

Client Responsibilities:

You, the client, are a full partner in counseling. Your honesty and effort are essential to success. If at any point in counseling you have concerns about our work, I expect you to express your concern in order for us to make the necessary adjustments to the joint-created treatment plan. If you would prefer to work with another mental health professional, I will help you through the referral process. If you feel that I have acted unethically, you may choose to complain about my behavior to the Board of Behavioral Sciences. If in addition to counseling, you are seeking care from another mental health professional, I expect permission to be granted for he/she and I to share information in order to best care for you as members of your team. Progress towards the treatment goal(s) is measured and achieved by the effort and willingness of the client to fully engage in the therapy process, and by the client’s commitment to health: sleeping 8 hours a night, drinking 8 glasses of water, eating 3 balanced meals, physical activity, social engagement, emotional acceptance, and caring for proper hygiene to identify a few. Physical health can be an important factor in the emotional well-being of an individual. If you have not had a physical examination in the last year, it is recommended that you do so. As counseling continues, counselors should be informed of any changes in medication.

Potential Risks of Counseling:

Clients should be aware that counseling may carry certain risks: 1. The client may become aware of additional problems they were not aware of prior to starting therapy. 2. Studies suggest that marital counseling involving only one party may lead to the dissolution of the marriage. 3. Changes in relationship patterns that may result from family counseling may produce unpredicted and/or possibly adverse responses from other people in the client’s social system. Similarly, an individual’s personal growth may not be widely accepted by their social system. If experienced, please feel free to share these new concerns within the counseling session.

ACKNOWLEDGMENT OF READING THE DECLARATION OF PRACTICES AND PROCEDURES

I have read this statement, had sufficient time to be sure that I considered it carefully, asked any questions that I needed to, and understand it. I understand the limits to confidentiality required by law. I consent to the use of a diagnosis in billing, and to the release of that information and other information necessary to complete the billing process, and/or, offer a multidisciplinary team approach to care. I agree to pay the fee of $___ per ___ minute session. I acknowledge that I will be charged $80 for any late cancellations with less than 24-hours notice of the scheduled session time. I understand my rights and responsibilities as a client, and my therapist's responsibilities to me. I agree to undertake therapy with Upward Roots: Relational Therapy. I know I can end therapy at any time I wish and that I can refuse any requests or suggestions made to me.

Fee:

Agreed upon length of session:

50-minute session

80-minute session

110-minute session

170-minute session

Alternative session length

I agree with the above-outlined conditions of therapy. Additionally, I am over the age of eighteen, and able to sign on my own behalf.

Legal Name:

Client Signature:

Date of Signature:

AUTHORIZATION FOR MINORS

I, [parent/guardian], give permission for Melanie Goetz to conduct counseling with my son/daughter, [name of minor].

Client's Legal Name:

First Parent/Guardian Name:

First Parent/Guardian:

Date of Signature:

Second Parent/Guardian Name:

Second Parent/Guardian:

Date of Signature: