Client Information Form - Alyse Freda-Colon, LCSW

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May I text you?(Required)
May I email you?(Required)
**Please note that email and text correspondence are not considered to be confidential forms of communication.
I understand that there is a 24-hour cancellation policy and if sufficient notice is not given, I am responsible for full payment of session.
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Welcome to my practice! This document contains important information about my professional services and business policies. Please read it carefully and discuss any questions you may have with me. This document will represent an agreement between us. Please make a copy for your records.


The appointment we schedule is your financial responsibility. I have a 24 hour cancellation policy. In order to reschedule a cancelled session you must give me a minimum of 24 hours notice, otherwise you are responsible for the full session fee. Sessions are 45 minutes; if you are late or need to stop early, those minutes are lost. Those 45 minutes are your allotted time and is not pro-rated.


My fee is $300 per 45 minute session. I do raise my fees periodically. When my fees change I will notify you in advance.


You will be expected to pay for each session at the time it is held unless we make other arrangements. I accept payment via cash or credit/debit card via Ivy Pay.


If you need to contact me between sessions you may leave a message on my voicemail. Please leave me your telephone number. If an emergency arises, please indicate this clearly in your message and if necessary call 911. You may also send me an email or a text. Please be aware that email and text are not confidential forms of communication.


Your sessions with me are confidential. With the exceptions outlined below, your identity will be kept private. The information we discuss may be shared in a confidential manner under the following circumstances:
• As part of my standard of care, I regularly seek consultation with qualified mental health professionals. If I seek consultation about your treatment, your identifying information will remain confidential.
• New York State law requires that the following exceptions be made to your right to confidentiality: a) child abuse or neglect, b) abuse of an elder or disabled individual, c) a threat to the life of another person, d) you are in imminent danger of harming yourself.
• If you become involved in legal disputes, the court can subpoena your records. In such cases, you and I will discuss how to proceed.
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Credit/Debit Card Authorization

You may keep a credit or debit card on file for payments via Ivy Pay, a credit & debit card processing service. Ivy Pay has several benefits:
• I am able to charge you for sessions without physically swiping a card.
• The service is secure and compliant with HIPAA standards for client confidentiality.
• Your credit or debit card information is stored with Ivy Pay, not in my files. I do not have access to your stored credit or debit card information.
• You can review past charges or payments on a text trail.

This service is simple to use:

• You provide a cell phone number, which I enter into an app along with a charge for the session fee.
• Ivy Pay texts you a secure link leading to a page where you enter your credit or debit card information and approve the first charge.
• For future sessions, I use Ivy Pay to charge the stored card; the app sends you a text informing you that I have done so. Charges are typically run the morning of your appointment.
• You will only be asked to enter your card information once (unless you wish to change the card) and you do not need to download an app or regularly interact with Ivy Pay.
* *note: for initial sessions, your card may be charged in advance to reserve your appointment slot.
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Telemental Health Informed Consent

I hereby consent to participate in telemental health with Alyse Freda-Colon, LCSW as part of my psychotherapy. I understand that telemental health is the practice of delivering clinical health care services via technology assisted media or other electronic means between a practitioner and a client who are in two different locations.
I understand the following with respect to telemental health:
1) I understand that there are risks, benefits and consequences associated with telemental health, including but not limited to disruption of transmission by technology failures, interruption and/or breaches of confidentiality by unauthorized persons and/or limited ability to respond to emergencies.
2) I understand that there will be no recording of any of the online sessions by either party. All information disclosed within sessions and written records pertaining to those sessions are confidential and may not be disclosed to anyone without written authorization, except where the disclosure is permitted and/or required by law.
3) I understand that the privacy laws that protect the confidentiality of my protected health information also apply to telemental health unless an exception to confidentiality applies ( i.e. mandatory reporting of child, elder or vulnerable adult abuse; danger to self or others.).
4) I understand that if I am having suicidal or homicidal thoughts, actively experiencing psychotic symptoms or experiencing a mental health crisis that cannot be resolved remotely, it may be determined that telemental health services are not appropriate and a higher level of care is required.
5) I understand that during a telemental health session, we could encounter technical difficulties resulting in service interruptions. If this occurs we will attempt to reconnect and if unsuccessful, will decide together how to proceed.
6)I understand that my therapist may need to contact my emergency contact and/or appropriate authorities in case of an emergency.

Emergency Protocols

I need to know your location in case of an emergency. You agree to inform me of the address where you are at the beginning of each session. I also need a contact person who I may contact on your behalf in a life-threatening emergency only. This person will only be contacted to go to your location or take you to the hospital in the event of an emergency.
I have read the information provided above. I understand the information in this form and all of my questions have been answered to my satisfaction.
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