A hard copy of this agreement will be provided to you.
PLEASE READ THIS SECTION THOROUGHLY BEFORE STARTING THE INTAKE OR ANSWERING QUESTIONS:
Estimated time to complete all pages is approximately 30-45 minutes (possibly more) depending on required sections of the intake and provided that all requested information is available to you while completing this form (psychological and medical history).
Refresh or reload the page to clear the form and start over. if necessary.
There is no save form feature, so you will NOT be able to save entered data, so please complete when you have the allotted time available, and feel you have information necessary to complete form.
Please provide the following information and answer "ALL" the questions of the intake. Please input NA or None, if not applicable on any required question. Please note: All the information you provide here is protected as confidential information on a secure and encrypted website that will only be viewed by the therapist. "ALL" general intake questions are "REQUIRED" by the therapist for an accurate assessment, and must be answered to request an appointment. Although there are a lot of questions, all are very relevant and necessary for appropriate treatment.
Please also note that if you don't know an exact date on the physical, dental, hearing and vision exam questions, it is okay to estimate!
Financial Assistance questions are optional, and only required if requesting a sliding fee scale.
**If you are competing this intake for ESA Disability and Treatment Recommendation Letter Service, please be sure to complete all intake questions sections and the last/required ESA section in its entirety. Please note that you can skip the Financial Assistance section, as a sliding fee scale is not available with this service due to the additional clinical requirements and service.
If you are not requesting ESA Letter Service, that section can be skipped.
PLEASE BE HONEST AND COMPLETE IN YOUR ANSWERS AND DO NOT SUBMIT AN INCOMPLETE OR FALSE INTAKE, AS IT WILL NOT PROVIDE THE THERAPIST WITH THE INFORMATION TO PROVE A COMPREHENSIVE AND ACCURATE ASSESSMENT!
I AM CHECKING THIS BOX INDICATING THAT
These questions are NOT required. Please answer the following question if you would like to apply for reduced rates:
If you do not want to apply scroll down and click the next button. Please note that a sliding fee scale is not available for requested ESA Letter request, as it is an additional service and requires other therapeutic services.
Online Terms of Service and Informed Consent for Tele-Health Psychotherapy
This information is required for your file.
PLEASE NOTE THAT VERIFICATION OF IDENTITY WILL BE REQUIRED.
Client's are asked to verify their identity more formally by showing a government issued photo ID on the video screen and or an emailed or faxed copy.
INTRODUCTION: A GENERAL DESCRIPTION OF PSYCHOTHERAPY, RISKS, AND BENEFITS
Psychotherapy is an intentional and goal-directed relationship with a professional therapist, and has been shown to be beneficial for individuals who fully engage in the process. Psychotherapy often leads to a significant reduction in feelings of distress, increased satisfaction in interpersonal relationships, greater personal awareness and insight, and increased skills for managing stress and resolutions to specific problems; however, there are no guarantees that this will happen. The process of psychotherapy often involves discussing unpleasant aspects of your life, and you may, to some degree, experience uncomfortable or negative feelings. If you feel this, please let your therapist know.
THERAPIST AND THERAPEUTIC APPROACHES
Tina C. Christian, LPC, NCC is a Licensed Professional counselor in the state of Missouri and a Nationally Certified Counselor with the National Board of Certified Counselors. Tina C. Christian, LPC, NCC uses a variety of interventions from many different approaches, including, but not limited to, Trauma Focused-Cognitive Behavioral Therapy (TF-CBT), Rational Emotive Therapy (REBT), Cognitive-Behavioral Therapy (CBT), Interpersonal Therapy, Family Systems Therapy, Psycho-Education, Solution Focused Therapy (SFT), Brief Strategic Family Therapy (BSFT), and Parent-Management Training. Please discuss with your therapist any questions you may have about her
approach. If you are unhappy with the services you are receiving, you feel free to share your comments or concerns, without fear of jeopardizing therapeutic relationship. This is YOUR therapy and you should feel safe and comfortable expressing any feelings regarding treatment at all times.
INITIAL ASSESSMENTS, TERMINATION OF TREATMENT, AND REFERRAL TO OTHERS
Tina C. Christian, LPC, NCC will complete an initial intake assessment that will involve getting to know you by gathering relevant information about your background and your presenting concerns. After gathering this information, treatment options will be discussed. If Tina C. Christian, LPC, NCC believes she can be of assistance to you, she will recommend continuing to work together and will engage you in treatment planning. If she believes that she is
likely not going to be able to be helpful, she will refer you to other clinicians she thinks would be effective. If at any point, she believes she is not effective in assisting you, she is ethically obligated to terminate treatment and refer you to other providers. All clients have the right to terminate treatment at any time, for any reason. If you make this choice, Tina C. Christian, LPC, NCC will provide you with the names of other qualified professionals or will direct you back
to your insurance carrier to identify other providers. Finally, if you disengage in the therapeutic process (i.e., fail to schedule or attend appointments; do not respond to your therapist’s attempts to reach you), Tina C. Christian, LPC, NCC reserves the right to close your file. At that time, you may be informed by mail that your file is closed.
Information shared within the context of the therapeutic relationship will be held in confidence and will not be released without your written consent, except for professional consultation if needed and unless required by law. Tina C. Christian, LPC, NCC is required to break confidentiality if she suspects child or elder abuse or neglect. Additionally, if there are threats of harm to self (i.e., suicide) or others (i.e., homicide), then she is obligated to break confidentiality. If you are involved in court proceedings and a judge issues a court order for your records, Tina C. Christian, LPC, NCC may be required to release this information. Information regarding treatment and diagnosis will be provided to your insurance company if you are utilizing insurance.
Tina C. Christian, LPC, NCC work toward engaging caregivers in the treatment of their clients as much as possible when clinically indicated. Parents or legal guardians of non-emancipated minor clients have the right to access the clients’ records, and do have a right to know their child’s diagnosis, the dates, time, and duration of sessions, the types of treatment provided and the aftercare plan at the time of termination of services.
CLIENT/RESPONSIBLE PARTY ACKNOWLEDGEMENT AND ACCEPTANCE OF TERMS
I understand that this agreement is valid during the time that I am participating in services with Tina C. Christian, LPC, NCC . I have read, understand, and agree with this document’s content and have been offered a copy of the Informed Consent for Psychotherapy. I acknowledge that I have had an opportunity to have my questions answered
prior to signing this consent and participating in services. I am aware that I can stop therapy at any time.
For qualifying online counseling clients(per Missouri State law and Statues), mental health is assessed through videoconferencing telemental health services care, including an mental/physical interview/assessment, review of any medical records available, through informed consent, evidence-based assessment measures and evaluations based upon the presenting problem and concerns of the patient, and as required to determine diagnosis and plan for treatment. Email and chat telemental health services are an additional service available, not a primary service and is not used to assess a patients mental health.
An electronic record is kept for each client for whom remote services are provided. Records includes an assessment, client identification information, contact information, history, treatment plan, informed consent, and information about fees and billing.
A treatment plan based upon an assessment of the patient’s needs is developed and documented. The plan includes a description of what services are to be provided and the goals for services. Services are accurately documented as remote services and include dates, duration and type of service(s) provided. Documentation complies with applicable jurisdictional and federal laws and regulations. Policies for record retention and disposal are place. All communications with the patient are documented in the client’s record and stored in compliance with relevant government regulations, such as HIPAA and Health Information Technology for Economic and Clinical Health Act (HI-TECH). Requests for access to such records require written authorization from the patient with a clear indication of what types of data and which information is to be released. Upon direction and written approval by the patient, the client's record will be made available to another provider that is caring for the client.
All billing and administrative data related to the client is secured to protect confidentiality. All records are confidential; HIPAA regulations regarding psychotherapy notes are adhered to; and only relevant information is released for reimbursement purposes as outlined by HIPAA.
I understand that:
Contents of all therapy sessions are considered to be confidential. Both verbal information and
written records about a client cannot be shared with another party without the written consent of
the client or the client’s legal guardian. Noted exceptions are as follows:
Duty to Warn and Protect
When a client discloses intentions or a plan to harm another person, the mental health professional is required to warn the intended victim and report this information to legal authorities. In cases in which the client discloses or implies a plan for suicide, the health care professional is required to notify legal authorities and make reasonable attempts to notify the family of the client.
Abuse of Children and Vulnerable Adults
If a client states or suggests that he or she is abusing a child (or vulnerable adult) or has recently abused a child (or vulnerable adult), or a child (or vulnerable adult) is in danger of abuse, the mental health professional is required to report this information to the appropriate social service and/or legal authorities.
Prenatal Exposure to Controlled Substances
Mental Health care professionals are required to report admitted prenatal exposure to controlled
substances that are potentially harmful.
Parents or legal guardians of non-emancipated minor clients have the right to access the clients’
Insurance Providers Or Other Third-Parties (when applicable)
Insurance companies, other third-party payers, and other third-parties are given information that they request regarding services to clients. Information that may be requested includes, but is not limited to: types of service, dates/times of
service, diagnosis, treatment plan, description of impairment, progress of therapy, case notes,
I understand that the acceptable payments are American Express, Discover, Health Savings Account, MasterCard, PayPal, and Visa.
I understand that the therapist is not in network with any insurance companies, so ALL services are strictly client pay services, which MAY be eligible for reimbursement by the my insurance company, based upon the insurance online counseling and or out-of-network policy/coverage.
I understand that If I have a Preferred Provider Organization (PPO) Plan, I MAY be able to be reimbursed for out-of-network services, and that I will be given Superbill with required information to submit to my insurance company for reimbursement upon my request.
I understand that I may receive a percentage of the customary rate of counseling determined by my insurance company (minus my co-pay), reimbursed to me.
I understand that Health Maintenance Organization (HMO) plan clients will NOT receive any reimbursement from the insurance companies.
I understand that the therapist cannot assume responsibility for interpreting my insurance policy or for my specific insurance coverage.
I understand that it is my responsibility to check with my insurance plan policy or contact my insurance company to confirm my online counseling and or out-of-network coverage (co-pays, fees, deductibles, and reimbursement eligibility).
I understand that the first payment is taken at time of agreement
I understand that fees are payable based upon term of payment plan (one-time, weekly, monthly, quarterly, semi-annually, or annually) . So if you start weekly on a Monday, fees are due each Monday. If you start monthly on the 5th then fees are due each month on the 5th.
I understand that all payments are due prior to service rendered.
I understand that all billing and administrative data is secured.
PRIVACY - I understand that for the purpose of the collection, use and disclosure of my personal information is for the provision of professional counseling, including supervision for the purposes of improving provision of such counseling services. Only my therapist and my therapist's supervisor have complete access to my records while they are in the therapist's custody. Administrative staff cannot access my therapy records, but may have access to general account information.
ALTERNATIVE METHODS OF PAYMENT - I understand that if I do not have insurance, don't have out-of-network insurance coverage, or if by chance I am in need of assistance and/or interested in receiving reduced face-to-face rates, I may inquire about enrolling with Open Path Psychotherapy Collective to apply to receive therapy at a steeply reduced rate, available through the program to individuals in need. I understand that Open Path allows my therapist to offer mental health care-sessions at a reduced rate of $30 - $60 per session to a limited number of clients. OpenPath is not an available service for ESA service only.
I understand that if I qualify, a sliding scale fee can be applied. Sliding fee is not an available service for ESA service only.
Sliding Scale Criteria
1. No health insurance coverage for mental health outpatient services.
3. Any insurance which will not pay mental health/out-of-network benefits.
4. Income (from employment, disability, or otherwise) below $30,000 per year.
5. Within the last 6 months, discharged from an in-patient psychiatric hospitalization or long-term medical care.
6. Unemployed for at least 6 months or have never been employed.
7. Currently on some form of public assistance or social security/disability.
8. A single mother or father.
9. A full time student.
If qualified, the sliding scale fee will be determined prior to or during your initial assessment and will be based upon the criteria met above.
Should your financial situation change, your fee will be reassessed and it is your responsibility to notify us of any changes.
I understand that my signature below indicates my understanding of, and agreement with, the policies outlined above, and my agreement to pay my therapist for services rendered by him/her.
(Please note that rates are subject to change with a 30 day notice.)
INITIAL PHONE CONSULTATION
I understand that upon request, prior to scheduling an appointment, all potential clients are offered a free 10 minute initial phone consultation.
I understand that live phone consultations are scheduled.
I understand that insurance will may not cover electronic communications at this time.
I understand that I am still responsible for paying my therapist for missed or cancellations of a scheduled appointment with less than a 24 hours notice unless it is due to illness or an emergency. Therapist will make every effort to reschedule any properly scheduled sessions.
I understand that my insurance does not cover such charges.
I understand that if I fail to cancel a scheduled appointment, therapist cannot use this time for another client and I will be billed for the entire cost of my missed appointment.
I understand that if I cancel all future services, and if payment has been received, I will be refund for all unused services at a prorated amount (minus any discounts) with 45 days from my request. If after that time I have not received a refund, I am to email to [email protected]
Please note that with ESA letter service, you are paying to be assessed using an online client intake diagnostic and evaluation assessment, and counseling sessions with Tina C. Christian, LPC, NCC. Once you have completed the assessment and spoken to Tina C. Christian, LPC, NCC, refund for services will not be warranted.
My office is equipped with voicemail (816) 873-1968, which I frequently check throughout the day and evening for updated messages. I will make every reasonable attempt to respond to all messages within the same day, but it may be up to 24 hours before I return your call.
If you are in a “mental health emergency,” in which you are in need of an immediate therapeutic response, please contact the CommCare‘s Access Community Hotline, at 1-888-279-8188. Inform the responding clinician of your immediate mental health needs, and follow their responses. Please inform the emergency clinician of your current status as a client enrolled in treatment with me, and sign any consents provided so that I may receive
information regarding any emergency assessments &/or treatment recommendations.
In the event that I am not available for more than 48 hours, I will provide a “covering clinician,” who will be available to respond to your emergency needs, either by telephone, online or with a face-to-face session. The clinician will be provided with a Coordination of Client Care Index Card that includes your first name and very basic potential clinical emergency information, so that he/she may appropriately and sensitively assist you in my absence. This
information will be discussed with you prior to my absence. Upon my return, the “covering clinician” will inform me of any contacts (telephone or face-to-face session), and will then destroy any materials &/or information obtained in my absence.
"Any fees which may be charged by the covering clinician will also be discussed with you in advance.”
If your counseling is taking place only online, I cannot be held responsible for helping you manage a crisis.
Because of the delays associated with the use of asynchronous communication, I cannot act as a crisis center.
If you experience an emotional crisis (intense feelings of distress, emergency or life threatening situation, or any other crisis) during the course of your treatment, merely sending an asynchronous private conversation message to your counselor is not appropriate. Rather than turning to online counseling to help you manage intense feelings of distress, emergencies or life threatening situations, or an emotional crisis, you must agree to manage the crisis by using resources other than those offered by my online counseling service. Please call 911 or visit the nearest emergency room in the event of crisis.
An emergency plan will be created for your file with your emergency contact's information, the nearest emergency room in your area, and the contact information for the local authorities.
My email address is: [email protected]
Clients are welcome to email me with scheduling questions or other concerns. Because the privacy of email cannot be guaranteed, I encourage clients to consider other methods for communicating sensitive information. I do return phone calls as promptly as possible. Because I may not see an email notification promptly, please do not use email to notify me of an
emergency. If you are in crisis, please leave an urgent message at 816-873-1968. If you have a medical emergency, please go to a hospital or call 911.
I frequently come across information that may be pertinent to a particular client's issues. Clients are welcome to provide me an email address with permission to contact them, and I will send links to useful information as I come across it. This information is not intended to be diagnostic or as treatment, but simply as an educational adjunct to the therapy process.
SOCIAL MEDIA POLICY
Because I want to share resources and helpful mental health information with as many people as possible, I do maintain a page on Facebook. This is a public page, without any of the privacy settings that are available to individuals. I use this page to share resources, and answer questions if they are appropriate for a public forum. Clients may browse this page without "liking" it. However, if you choose to "like" the page, please make sure that you are fully aware of the level of sharing and privacy that you have enabled on Facebook. The settings for the page include a publicly visible list of those who have "liked" it. I do not "friend" clients on Facebook because I believe that puts us at risk of forming a dual-role relationship, which is prohibited by my ethical guidelines.
While I use the Facebook page primarily to share information, I also maintain both a Twitter account and a LinkedIn profile. These tools provide me outlets to share information, and a way for me to network with professional colleagues. My Twitter account is a publicly shared account, so anything posted on my Twitter feed is public information. I do not answer questions via Twitter because of its public status. Please use email or telephone for questions. I do not follow clients on Twitter, and I don't encourage clients to follow me, although if you choose to do so, be aware that the account is public, and your name
would be listed in my "Followers" list. I do not connect with clients through my LinkedIn profile, because that is also a public forum.
My primary concern is that my clients' privacy be as protected as possible. Any connection through social media presents a possible compromise of that privacy, so I do not encourage clients to do so.
Please contact me directly with any questions or concerns.
If you wish to receive my periodical newsletters, or educational information by email, please provide your email address below:
I understand and
The following specifies your rights about this authorization under the Health Insurance Portability
and Accountability Act of 1996, as amended from time to time (“HIPAA”).
1. Tell your mental health professional if you don’t understand this authorization, and they will explain it to you.
2. You have the right to revoke or cancel this authorization at any time, except: (a) to the extent information has already been shared based on this authorization; or (b) this authorization was obtained as a condition of obtaining insurance coverage. To revoke or cancel this authorization, you must submit your request in writing to your mental health
professional and your insurance company, or other third-party if applicable.
3. You may refuse to sign this authorization. Your refusal to sign will not affect your ability to obtain treatment, make payment, or affect your eligibility for benefits. If you refuse to sign this authorization, and you are in a research-related treatment program, or have authorized your provider to disclose information about you to a third party, your provider has the right
to decide not to treat you or accept you as a client in their practice.
4. Once the information about you leaves this office according to the terms of this authorization, this office has no control over how it will be used by the recipient. You need to be aware that at that point your information may no longer be protected by HIPAA.
5. If this office initiated this authorization, you must receive a copy of the signed authorization.
6. Special Instructions for completing the authorization for the use and disclosure of
Psychotherapy Notes. HIPAA provides special protections to certain medical records known as “Psychotherapy Notes.” All Psychotherapy Notes recorded on any medium (i.e., paper, electronic) by a mental health professional (such as a psychologist or psychiatrist) must be kept by the author and filed separate from the rest of the client’s medical records
to maintain a higher standard of protection. “Psychotherapy Notes” are defined under HIPAA as notes recorded by a health care provider who is a mental health professional documenting or analyzing the contents of conversation during a private counseling session or a group, joint, or family counseling session and that are separate from the rest of the individual’s medical records. Excluded from the “Psychotherapy Notes” definition are the following: (a) medication prescription and monitoring, (b) counseling session start and stop times, (c) the modalities and frequencies of treatment furnished, (d) the results of clinical tests, and (e) any summary of: diagnosis, functional status, the treatment plan, symptoms, prognosis, and progress to date.
If you have an unpaid debt to and should the counselor decide to take legal or other action to collect the debt, including engaging the services of a third-party collection agency, you waive your right to confidentiality, to the extent permitted by the Personal Information Protection Act of United States of America. My ability to fulfill their obligations as described above are limited by the information that you provide. You must agree to provide and maintain correct information your address, telephone number, and e-mail address. Failure to do so releases me of ethical and/or legal obligations as described above.
In order for a medical provider to release “Psychotherapy Notes” to a third party, the client who is the subject of the Psychotherapy Notes must sign this authorization to specifically allow for the release of Psychotherapy Notes. Such authorization must be separate from an authorization to release other medical records.
If you would like for Tina C. Christian to release any information to any other person or provider, please let the therapist know so that she can email you the AUTHORIZATION FOR USE OR DISCLOSURE OF PROTECTED HEALTH INFORMATION form which you will have to physically sign and return to the therapist before any information will be
Please note that if you are requiring or requesting a verification form for a landlord or airline with the ESA letter service, completion of this form will be required!
You can download and print the form now by clicking here, if you like.
For more information on HIPAA, including fact sheets, and who does and who does not have to follow these laws, please visit the U.S. Department of Health and Human Services https://www.hhs.gov/hipaa/index.html
The purpose of the collection, use and disclosure of your personal information is for the provision of
professional online counseling, including supervision for the purposes of improving provision of such
YOUR RESPONSIBILITY TO PROTECT YOUR OWN PRIVACY
I cannot protect your confidential information when that information is not in my control at the location of your computer or stored on your computer. You are responsible to prevent any and all third parties at your location from detecting your involvement in online counseling. You are responsible to select and control the environment in which you engage in online counseling. We strongly discourage you from disseminating, distributing or copying your counseling records — for example posting to social networking sites or on a website. However, if you believe it may be beneficial to take any such action, we urge you first to consult with your counselor.
I do the utmost to protect and safeguard your personal information with internet and email security and encryption, and firewall protection. However, I do not warrant that the Internet systems will be error free, that you will be able to operate them without experiencing problems or interruptions, or that they are not susceptible
to intrusion, attack or computer virus infection.
I do not warrant the security of confidential material that becomes insecure because of actions you may take or that is a result of software that I did not supply.
Examples of security breaches that we do not warrant include, but are not limited to:
•leaving confidential material on a computer screen for others to see
•storing confidential material on the computer you are using
•use of monitoring software (this could be spyware or legitimate monitoring by an employer, or other
monitoring systems not listed here)
You must agree to use secure communication measure and system for all therapeutic communications to and from me or associated staff, or otherwise waive your privilege to confidentiality. In addition, you must assume full responsibility for the risks inherent in insecure Internet transmissions, including any losses or damages.
STORAGE OF CLIENT RECORDS AND PERSONAL INFORMATION
Verbatim recordings of all counseling communications except those that take place through Video counseling
(when and if this service becomes available) are created. Verbatim recordings of written counseling sessions are called “transcripts.” All records containing personal information, including transcripts, for a period of seven years from the last entry in your counseling record.
RIGHT TO ACCESS YOUR RECORDS
You have the right to access the information in your clinical records or to obtain a copy of those records, upon payment of any reasonable fees for such services.
RESPONSE TIME AND TECHNOLOGICAL FAILURE
I'll make every attempt to reply to you using Private Conversations after your completed registration and
payment, within one business days. Thereafter, you be will inform of anticipated availability to answer each Private Conversation message (or to schedule time with you to conduct Chat counseling or Video counseling sessions, if/when available). Counseling replies and real-time sessions are typically approximately one week apart. However, there are
several reasons that your scheduled session could be disrupted. It is possible that my technological equipment or your equipment could fail unexpectedly and at any time. It is also possible that I may become unavailable to provide services of counselor due suffering incapacitated in some form or fashion. If you suspect that any of these possible conditions have happened, or if you think there has been an unwarranted delay in my response, please contact me by telephone at 816-863-1968.
DURATION OF THIS AGREEMENT
This Agreement will remain in effect for seven years from the date of your last counseling session. Tina C. Christian, LPC, NCC reserves the right to change the terms of this Agreement at any time, as long as you are allowed the ability to agree to the new terms.
SCOPE OF THIS AGREEMENT
If any part of this Agreement is deemed by a American court of appropriate jurisdiction to be illegal, invalid, or unenforceable, that part of the Agreement shall be limited or eliminated to the minimum extent necessary so that this Agreement shall otherwise remain in full force and effect and enforceable. This agreement constitutes the entire, final, complete and exclusive agreement between the parties and supersedes all previous agreements, proposals or representations, oral or written, relating to this agreement. You are not permitted to modify or amend this agreement.
Any claims against Tina C. Christian, LPC, NCC or associates, which give rise to suits or judicial proceedings must be filed and tried only within the United States, and specifically in the state of Missouri.
By agreeing to this Client Consent and Service Agreement, you irrevocably submit to the exclusive jurisdiction of the courts of the state of Missouri, United States of America. In the event you initiate any claim, demand, action or proceeding relating to your counseling services or this document (collectively, “Claims”), you agree that the resolution of all Claims will be governed by and construed in accordance with the laws of the state of Missouri, United States of America, and the substantive law of the United States, not including my choice of law provisions.
I make no representation that my counseling services are appropriate or available for use in locations outside of the United States. If you are a citizen or resident of any country other than United States, the laws in your place of residence may require counseling practitioners to register and/or be licensed to practice in your location. Since you agree that my online counseling services take place in the United States only, and specifically, in the state of Missouri, laws and regulations pertaining to any country other than United States do not apply to your relationship with me.
Without limiting any other term herein, you expressly waive any right you may have to initiate any Claims
against Tina C. Christian, LPC, NCC and any associates in any other foreign jurisdiction in respect of the
Services you receive or of this document.
If you construe the location of my online counseling services to be any location other than the United States, you are prohibited from accessing my online counseling services for any reason. If you construe the jurisdictional laws under which I am governed to be any jurisdiction other than the United States, you are prohibited from accessing my online counseling services for any reason.
LIMITATIONS ON DAMAGES
In any lawsuit arising out of these services, consequential damages, emotional distress damages, and punitive damages awarded shall not exceed the fees paid for these services.
You must agree to indemnify and hold Tina C. Christian, LPC, NCC and any associates harmless from any and all liability, costs, attorney fees, and other legal expenses arising out of negligence or the provision of services offered by online counseling services provided, to the maximum extent allowed by law.
REFUSAL AND WITHDRAWAL
You may refuse to accept this advice or opinions expressed to you, and you may withdraw from online
counseling at any time with no obligation to Tina C. Christian, LPC, NCC and any associates.
I and any associated support staff are committed to providing you with caring, ethical, and professional services.
If, at any time, you feel that has not occurred to your complete satisfaction, please let me know as soon as
I will take immediate corrective action to resolve your concern. If, after bringing your concern to my attention,and you still feel that you are not satisfied as addressed, you have a right to file a written complaint against the counselor with:
Committee for Professional Counselors
3605 Missouri Boulevard
P.O. Box 1335
Jefferson City, MO 65102-1335
800.735.2466 Voice Relay
***You agree that the counseling services provided by Tina C. Christian, LPC, for all legal purposes, take place in the United States only, and specifically, in the state of Missouri.***
I have read, understand, and
Submission of this information indicates that you have READ, TRUTHFULLY AND ACCURATELY COMPLETED, AND AGREE to ALL the terms of these forms. You will be contacted by the therapist soon as the information has been assessed to schedule your appointment.
Please note that a secured and encrypted copy of the forms you're submitting will be provided to you by the therapist, through a secured online file sharing option during your first appointment. Please feel free to contact the therapist at anytime by phone at (816) 873-1968.
Thank you for taking the time to submit your online consent forms, and I look forward to being your ally in your journey to total well-being!
TINA C. CHRISTIAN, LPC, NCC,TF-CBT Trained
This next section is for ESA Disability Assessment and Treatment Recommendation Letter Service (ONLY).
Please Note: This section is required to be completed in its entirety in order to received this requested service. You may skip this section and go to file upload, if necessary to upload a file for the therapist. Otherwise, you can skip to submit if, ESA letter service is not being requested.
A valid email and telephone number is required for the licensed clinician to contact you for the necessary counseling sessions.
Telephone/Online counseling sessions are included at no additional charge.
A Treatment/ ESA Recommendation Letter is Not Guaranteed
Although this service includes both the disability assessment AND a treatment recommendation letter for an Emotional Support Animal (ESA), purchase of these services does NOT guarantee a client will qualify as disabled. The assessment and treatment recommendation letter for an ESA is valid for 12 months, at which time a new assessment and treatment recommendation letter are required.
The online assessment uses 128-bit encryption to keep your responses private. The findings of our assessment, along with the DSM-5 diagnosis are included in the formal clinical report we prepare and send to you.
Verification Form Completion Service (Add on Service and is an additional $25 per form)
Most landlords and many airline companies now require a licensed mental health professional to complete a 3rd Party Verification Form to confirm you are legally eligible for no pet housing or to be accompanied by your ESA in the cabin of an aircraft. If you seek approval for housing or wish to fly with your ESA, the Verification Form Completion service should be added. This service can be used only once and is valid for 12 months following the date it is ordered. After the single use, it must be reordered to use the service again.
UNITED AIRLINES NOW REQUIRES THIS FORM TO BE COMPLETED FOR ALL PASSENGERS FLYING WITH AN ESA.
If a client meets criteria and qualifies as disabled, these documents will be emailed the afternoon the documents are mailed to the landlord or airline.
1) Test scores, raw data, test questions/answers, and subjective results of interview questions, and counseling session notes are not available to clients or other inquirers. Only the specific services purchased will be provided.
2) Tina C. Christian cannot guarantee a property manager or airline company will not inadvertently or intentionally violate law by discriminating against you, despite possessing a valid treatment recommendation letter.
3) You are paying to be assessed using an online client intake diagnostic and evaluation assessment, and counseling sessions with Tina C. Christian, LPC, NCC. Once you have completed the assessment and spoken to Tina C. Christian, LPC, NCC, refund for services will not be warranted.
4) By ordering and paying for these services from Tina C. Christian, LPC, NCC , the client/purchaser acknowledges and accepts the above terms.
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256 -BIT ENCRYPTION DATA TRANSMISSION
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