Terms Of Service | 143 Counseling

Consent to Treatment

Informed consent: We ask that all clients sign the following general consent to treatment. You may at any time decline specific recommendations, with the understanding that you are responsible for your care as a client of the 143 Counseling & Consultation Services. You also have the right to know about the limits to confidentiality.

The code of ethics for the American Psychological Association (APA), the state of Pennsylvania counselor, social worker, and marriage and family therapy board, and the health insurance portability and accountability act of 1996 (HIPPA), ensure that your records and conversations at the 143 Counseling & Consultation Services are to remain confidential and private, and not be discussed with anyone without your expressed written consent. However, there are certain limits and exceptions to your rights to confidentiality that we are required to uphold by the same codes of ethics, and state and federal laws. They are as follows:

The child and elder abuse reporting laws of the state of Pennsylvania require that any suspected abuse or neglect of any minor child under the age of 18, or any elder over the age of 60, be reported to the appropriate authorities.

Recent court decisions have mandated exceptions to the right to confidentiality when a client poses the imminent risk of harm to self or others.

If it is deemed in the best interest of your treatment, your treatment provider(s) here at the 143 Counseling & Consultation Services reserve the right to consult with other qualified professionals about you, but only as it relates to your care.

If you ask us to bill your insurance company to pay for your services, you are giving your insurance company the right to inquire about you and your treatment. Some insurance companies require specific information in order to process your claims, and your treatment provider(s) will be required to respond in order for you to maintain your benefits.

I give my consent for services to be provided by: Thanh-Dung “Sandy” Bui MS, NCC, LPC, at143 Counseling & Consultation Services, and associated professional staff to include evaluation, psychotherapy, testing (if indicated), psychiatry (if indicated), and be involved in the treatment planning process.

Telemedicine / Teleheatlh Informed Consent

I hereby consent to engaging in telemedicine at 143 Counseling & Consultation Services as part of my psychotherapy. I understand that “telemedicine” includes the practice of health care delivery, assessment, diagnosis, consultation, treatment, transfer of medical data, and psychoeducation using interactive audio, video, or data communications. I understand that, with my signed consent, telemedicine may also involve the communication of my mental health information, both orally and visually, to other health care practitioners located in the state of Pennsylvania.

Technology: I understand that I will need to have access to an email account to participate in telemedicine / telehealth. I also need to have a broadband Internet connection or a smart phone device with a good cellular connection at home or at the location deemed appropriate for services. I also understand that in case of technology failure, I may contact 143 Counseling & Consultation Services via phone to coordinate alternative methods of treatment.

Financial Obligations: Fees associated with telemedicine appointments are payable by Venmo, CashApp, Paypal, Zelle, credit or debit card only. If fees may be associated with my telemedicine services, I agree to have my credit/debit card information on file with 143 Counseling & Consultation Services. My card will be billed the same day as my scheduled telemedicine appointment. If my card is declined, 143 Counseling & Consultation Services will cancel my appointment and I will be charged in accordance with the cancelation policy.

Clients using insurance: I am responsible for contacting my insurance company, if applicable, to determine what my out-of-pockets costs may be. I authorize insurance benefits to be paid directly to 143 Counseling & Consultation Services and that 143 Counseling & Consultation Services may release any information to my insurance provider required for processing my claims.

Self-Pay clients: I am aware of the fees associated with telemedicine appointments and agree to pay at the time of my appointment. I understand that I am responsible for cancelled telemedicine appointments in accordance with 143 Counseling & Consultation Services’ cancellation policy and am aware of the cancellation policy.

I understand that using the Telemedicine platform allows access to mental health services that might not otherwise be available to me due to my mental health, and/or my physical, resource, or geographic limitations.

Scheduling: I understand that scheduling is conducted through 143 Counseling & Consultation Services and is based on my provider’s normal clinic hours. Telemedicine appointments are considered outpatient services and not intended as a substitute for emergency or crisis services. Crisis or mental health emergencies should be directed to the local county crisis line or by dialing 911.

Video/Audio Recording: As a general practice 143 Counseling & Consultation Services DOES NOT record Telemedicine sessions without prior permission.

Confidentiality: The laws that protect the confidentiality of my medical information also apply to telemedicine. As such, I understand that the information disclosed by me during the course of my therapy is generally confidential. However, there are both mandatory and permissive exceptions to confidentiality including, but not limited to: reporting child, elder, and dependent adult abuse; expressed threats of violence towards an ascertainable victim; and where I make my mental or emotional state an issue in a legal proceeding. 143 Counseling & Consultation Services’ telehealth platform is HIPAA compliant to protect my privacy and confidentiality.

I understand that I have the following rights with respect to telemedicine:

I have the right to withdraw my consent at any time.
I understand that there are risks and consequences associated with telemedicine including, but not limited to the possibility, despite reasonable efforts on the part of my counselor/therapist/clinical intern, that the transmission of my medical information could be disrupted or distorted by technical failures. In addition
I understand that telemedicine-based services and care may not be as complete as face-to-face services. I also understand that if my counselor/therapist/clinical intern believes I would be better served by another form of psychotherapeutic services (e.g. face-to-face services) I will be referred to a counselor/therapist who can provide such services in my geographic area.
I understand that I may benefit from telemedicine but that results cannot be guaranteed or assured.
I understand that 143 Counseling & Consultation Services may not provide telemedicine services to me if I am outside of the State of Pennsylvania, and I understand that I may access telemedicine services from 143 Counseling & Consultation Services from within the State of Pennsylvania only.
I understand that I have a right to access my mental health information and copies of medical records in accordance with Pennsylvania state law.
I have read and understand the information provided above. I have discussed it with my counselor/therapist/clinical intern, and all of my questions have been answered to my satisfaction. Accepting the Terms of Service indicates my informed and willful consent to treatment using this platform.

Consent for Electronic Communication

It may become useful during treatment to communicate by email, text message (e.g., “SMS”), voicemail, or other electronic methods of communication. Be advised that these methods, in their typical form, are not confidential means of communication. If you use these methods to communicate with me, there is a reasonable chance that a third party may be able to intercept these messages. Also, if you choose to send emails, texts, or voicemails, they will be part of your clinical record.

Some of the potential risks you might encounter using these methods of communication include:

People in your home or other environments who access your phone, computer, or other devices that you use might read your email or text messages.
Loss of cellular phone, computer, or other devices.
Email accounts can be hacked.
Text messages and emails are stored on servers.
Misdelivery of email to an incorrectly typed address.
Third parties on the Internet such as server administrators who monitor Internet traffic might intercept your communication.

Email communication is not appropriate for all circumstances. Please remember the following:

Emails are not to be used for emergencies or time-sensitive issues.
Emails are not to be used as a therapy session.
No one can guarantee the privacy of e-mail messages.

Texting is a convenient method of communicating brief information, but it is not secure.

Not for emergencies
Not to be used for therapy services
To be used as a reminder or services only
No one can guarantee the privacy of text messages.

Unsecured methods in which you may be contacted for appointment reminders, receive receipts, psycho-educational material etc. includes but not limited to email, text, and voicemail.

I have been informed of the risks, including but not limited to my confidentiality in treatment, of transmitting my protected health information by unsecured means. I understand that I am not required to sign this agreement in order to receive treatment. I also understand that I may terminate this consent at any time.

Social Media Policy

Social Media Platforms

Social media is a good way of keeping people connected and informed. I use social media for my practice, and so I have created a social media policy to help you understand my intentions, and how I will be using social media in my practice. The basis for this policy is to protect our relationship and your confidentiality during therapy and beyond.

Confidentiality

If you decide to tell others about your sessions with me, or the progress made with your therapy, that is entirely your choice. However, I must keep my relationship with you completely confidential except in cases of where you might harm yourself or others. If you choose to post on any of my social media pages, you invite the possibility of people making assumptions about our relationship or asking you about your connection to me. You get to decide what you tell people. You have a choice as to what you reveal about yourself online; however, I will not reveal my connection to you.

Friending

In order to respect your privacy and confidentiality, I do not accept friend requests from current or former clients on social networking sites (Facebook, Instagram, LinkedIn, etc.) or any other social media platform within 2 years of last session. I believe that adding clients as friends or contacts on these sites can compromise your confidentiality. It may also blur the boundaries of our therapeutic relationship.

You may like my Facebook business page if you want to do so. However, if you like my page, you are choosing to expose that you are connected to me in some way. My business Facebook page exists to be

a forum of information and inspiration. I will not engage in conversations with you on that page. However, I will be happy if you find it helpful.

Following

I often put out information on social media and may post to Facebook, Instagram, and other social media platforms. You are not obliged as my client to follow me in any way on social media. It is your choice if you do, but I will not follow you back. I believe casual viewing of clients’ online content outside of the therapy hour can create confusion regarding whether it’s being done as a part of your treatment or to satisfy personal curiosity. In addition, viewing your online activities without your consent and without our explicit arrangement towards a specific purpose could potentially have a negative influence on our working relationship. If there are things from your online life that you wish to share with me, please bring them into our sessions where we can view and explore them together.

Interacting

Please do not use messaging on social networking sites such as Facebook, Instagram, LinkedIn or any other, to contact me. These sites are not secure, and I may not read these messages in a timely fashion. The best way to interact with me is by email or phone. If you post on my Facebook feed, it may also create the possibility that these exchanges become a part of your legal medical record and will need to be documented and archived in your chart.

Search Engines

I do not “Google” my clients or look up information on them for any reason. If I do come across your information online, I will move on and avoid reading content.

Business Review Sites

You may find my business in an online directory. Some of these sites include places where users can provide ratings and reviews. Many of these sites scrape search engines for businesses and automatically add entries, regardless of whether the business has added itself to the site. If you should find my business on any of these sites, please know that my listing is not a request for a testimonial, rating, or endorsement from you as my client. You have a right to express yourself on any site you

wish, but I am not asking you to do so. If you do post a review, I cannot respond on any of these sites, whether it is positive or negative.

Location-Based Services (LBS)

If you use location-based services on your mobile phone, you may wish to be aware of the privacy issues related to using these services. If you have GPS tracking enabled on your device, it is possible that others may surmise that you are a client due to regular check-ins at our office on a weekly basis. Please be aware of this risk if you are intentionally “checking in” from our office or if you have a passive LBS app enabled on your phone.

I prefer using email only to arrange or modify appointments. Please do not email me content related to your therapy or assessment sessions, as email is not 100% secure or confidential. If you choose to communicate with me by email, be aware that all emails are retained in the logs of both your and my internet service providers. While it is unlikely that someone will be looking at these logs, they are, in theory, available to be read by the system administrator(s) of the internet service provider.

Text

Sometimes clients text me to request an appointment time or to let me know if they are running late to an appointment. Please know that text isn’t always secure. I am fine with texts as this is included in your session fee. I may not return text right away but will try to return that night on the weekdays.

Conclusion

I urge you to take your own privacy as seriously as I take my commitment of confidentiality to you. If we are working together, I hope that you will bring your feelings and reactions to our work directly into the therapy process. This can be an important part of therapy.

HIPAA NOTICE OF PRIVACY PRACTICES

This policy explains how our counseling practice protects your health information in accordance with the Health Insurance Portability and Accountability Act (HIPAA). It applies to all clients who receive services from our practice.

1. Protected Health Information (PHI) We collect and maintain information about your mental health treatment, including session notes, diagnoses, treatment plans, and any information you share during counseling. This information is considered Protected Health Information (PHI) under HIPAA.

2. How Your Information Is Used We use your PHI only for purposes related to your care, including:

Providing counseling and related services
Coordinating care with other providers (with your written permission)
Billing and payment
Practice operations such as scheduling, recordkeeping, and quality improvement

3. Your Rights Under HIPAA You have the right to:

Access and request copies of your records
Request corrections to your records
Request limits on how your information is used or shared
Request confidential communication methods (e.g., email, phone)
Receive a list of disclosures made without your authorization • Receive a copy of this privacy policy

4. When Information May Be Shared Without Your Consent HIPAA allows disclosure of PHI without your written permission in specific situations, including:

If required by law
To prevent serious harm to yourself or others
Suspected abuse or neglect • Court orders or legal proceedings
Public health and safety reporting

5. Confidentiality Limits in Counseling While counseling sessions are private, confidentiality is limited when: • You express intent to harm yourself or someone else

There is suspected abuse of a child, elder, or vulnerable adult
Records are subpoenaed by a court

6. How Your Information Is Protected We use administrative, physical, and technical safeguards to protect your PHI, including secure electronic systems, encrypted communication when possible, and restricted access to records.

7. Electronic Communication Email, text messaging, and telehealth platforms may involve some risk. By using these methods, you acknowledge these risks. We use HIPAA‑aligned tools whenever possible.

8. Your Consent By receiving services from our practice, you acknowledge that you have reviewed this HIPAA Privacy Policy and understand how your information may be used and protected.

9. Questions or Concerns If you have questions about this policy or your privacy rights, please contact us directly.

Patient Rights and Responsibilities

As a client of the 143 Counseling & Consultation Services, you have the following rights:

Services shall not be denied to any person on the grounds of race, ethnicity, age, color, religion, gender, nationality, sexual orientation, handicap, or developmental disability.
To be treated with courtesy and respect by all staff.
To receive appropriate mental health care or to be provided with a referral to another qualified provider, if necessary.
To participate in the planning of your treatment throughout the counseling process.
To ask questions and learn about the counseling process, and the qualifications of your provider(s).
As a competent individual, consent to or refuse treatment.
To confidentiality of your records and the right to inspect your records.
To be informed of your condition and to know the costs of services.
And the following responsibilities:
To make your payment at the time of service (whether self or co-payment).
To have your insurance company billed for covered services. You are responsible for all co-payments, deductibles, and/or coinsurance payments as required by your insurance policy.
To schedule and keep appointments. Should you need to cancel or reschedule an appointment, we require at least 48 hours’ notice when possible. Should you not provide this notice, or not show for an appointment, you will be charged $50. We will automatically bill this to the credit card on file.
To not come to any appointment under the influence of any mood-altering substances, unless prescribed and only as prescribed by a physician. If you do, you will be asked to reschedule and charged $50.
To give your treatment provider the necessary information about you, and to be involved in the planning of your treatment.
To follow the recommendations of your treatment provider, including those for psychiatric evaluations for medication therapy and testing, and to follow the agreed upon treatment plan.

I have read, understand, and agree with my rights and responsibilities.