Leslie J Wondra LLC

                                                                                   NOTICE OF PRIVACY PRACTICES

HIPAA is a federal law that provides privacy protections and assures patient rights with regard to the use and disclosure of your Protected Health Information (PHI) used for the purpose of treatment, payment, and health care operations.

I am required by law to maintain the privacy of your health information.  I am also required to give you this Notice about my privacy practices, legal obligations, and your rights concerning your health information ("Protected Health Information" or "PHI").  I will follow the privacy practices that are described in this Notice.  If I amend this Notice, I will provide you with the amended Notice for your information and signature. We can discuss any questions that you may have about the procedures outlined in the HIPAA Notice.

I.  Uses and Disclosures for Treatment, Payment, and Health Care Operations

I may use or disclose your protected health information (PHI), for treatment, payment, and health care operations purposes with your consent.

-        For Treatment. Your PHI may be used and disclosed by those who are involved in your care for the purpose of providing, coordinating, or managing your health care treatment and related services. This includes consultation with other treatment team members. I may disclose PHI to any other consultant only with your authorization.

-         For Payment. I may use and disclose PHI so that I can receive payment for the treatment services provided to you. This will only be done with your authorization. Examples of payment-related activities are: making a determination of eligibility or coverage for insurance benefits, processing claims with your insurance company, reviewing services provided to you to determine medical necessity, or undertaking utilization review activities. If it becomes necessary to use collection processes due to lack of payment for services, I will only disclose the minimum amount of PHI necessary for purposes of collection.

-        For Health Care Operations. I may use or disclose, as needed, your PHI in order to support my business activities including, but not limited to, quality assessment activities, employee review activities, licensing, and conducting or arranging for other business activities. For example, I may share your PHI with third parties that perform various business activities (e.g., billing or typing services) provided I have a written contract with the business that requires it to safeguard the privacy of your PHI. For training or teaching purposes PHI will be disclosed only with your authorization.

-        For EHR and electronic records information: I use the electronic health records system CounSol for all paperwork and record keeping. CounSol is a privacy compliant software that safeguards your information.

II. Uses and Disclosures Requiring Authorization

I may use or disclose PHI for purposes outside of treatment, payment, or health care operations when your appropriate authorization is obtained. An "authorization" is written permission above and beyond the general consent that permits only specific disclosures. In those instances when I am asked for information for purposes outside of treatment, payment or health care operations, I will obtain an authorization from you before releasing this information. You may revoke all such authorizations at any time, provided each revocation is in writing. You may not revoke an authorization to the extent that (1) I have relied on that authorization; or (2) if the authorization was obtained as a condition of obtaining insurance coverage, law provides the insurer the right to contest the claim under the policy.

III. Permissible Uses and Disclosures That May Be Made Without My Authorization, But For Which You Have An Opportunity to Object.

-        Fundraising:  I may use your PHI to contact you in an effort to offer you new services.  I may also disclose PHI to any foundation with which I am connected so that the foundation may contact you in an effort to raise money for its operations.  Any fundraising communications with you will include a description of how you may opt out of receiving any further fundraising communications. 

-        Family and Other Persons Involved in Your Care.  I may use or disclose your PHI to notify, or assist in the notification of (including identifying or locating) your personal representative, or another person responsible for your care, location, general condition, or death.  If you are present, then I will provide you with an opportunity to object prior to such uses or disclosures.  In the event of your incapacity or emergency circumstances, I will disclose your PHI consistent with your prior expressed preference, and in your best interest as determined by my professional judgment. I will also use my professional judgment and my experience to make reasonable inferences of your best interest in allowing another person access to your PHI regarding your treatment with me.

-        Disaster Relief Efforts.  I may use or disclose your PHI to a public or private entity authorized by law or its charter to assist in disaster relief efforts for the purpose of coordinating notification of family members of your location, general condition, or death. 

IV. Uses and Disclosures Requiring Your Written Authorization.  

-        Psychotherapy Notes.  I will not disclose the records of our work that I keep separate from the medical record for my personal use, known as psychotherapy notes, except as permitted by law. 

-        Marketing Communications; Sale of PHI.  I must obtain your written authorization prior to using or disclosing your PHI for marketing or the sale of your PHI, consistent with the related definitions and exceptions set forth in HIPAA.    

-        Other Uses and Disclosures.  Uses and disclosures other than those described in this Notice will only be made with your written authorization.  For example, you will need to sign an authorization form before I can send your PHI to your life insurance company or to your attorney.  You may revoke any such authorization at any time by providing me with written notification of such revocation.

V.  Uses and Disclosures with Neither Consent nor Authorization

As a social worker licensed in this state and as a member of the National Association of Social Workers, it is our practice to adhere to more stringent privacy requirements for disclosures without an authorization. The following language addresses these categories to the extent consistent with the NASW Code of Ethics and HIPAA. I may use or disclose PHI without your consent or authorization in the following circumstances:

-         Serious Threat to Health or Safety - If I determine, or pursuant to the standards of my profession should determine, that you present a serious danger of violence to yourself or another, I may disclose information in order to provide protection against such danger for you or the intended victim.

-        Child Abuse or Neglect. We may disclose your PHI to a state or local agency that is authorized by law to receive reports of child abuse or neglect.

-        Adult and Domestic Abuse - If I have reasonable cause to believe that a disabled adult or elder person has had a physical injury or injuries inflicted upon such disabled adult or elder person, other than by accidental means, or has been neglected or exploited, I must report that belief to the appropriate authority.

-        Judicial or Administrative Proceedings - If you are involved in a court proceeding and a request is made about the professional services I provided you or the records thereof, such information is privileged under state law, and I will not release information without your written consent or a court order. The privilege does not apply when you are being evaluated for a third party or where the evaluation is court ordered. You will be informed in advance if this is the case.

-        Deceased Patients. I may disclose PHI regarding deceased patients as mandated by state law, or to a family member or friend that was involved in your care or payment for care prior to death, based on your prior consent. A release of information regarding deceased patients may be limited to an executor or administrator of a deceased person's estate or the person identified as next-of-kin. PHI of persons that have been deceased for more than fifty (50) years is not protected under HIPAA

-        Medical Emergencies. I may use or disclose your PHI in a medical emergency situation to medical personnel only in order to prevent serious harm. I will try to provide you a copy of this notice as soon as reasonably practicable after the resolution of the emergency.

-        Health Oversight. If required, I may disclose PHI to a health oversight agency for activities authorized by law, such as audits, investigations, and inspections. Oversight agencies seeking this information include government agencies and organizations that provide financial assistance to the program (such as third-party payors based on your prior consent) and peer review organizations performing utilization and quality control.

-        Law Enforcement. I may disclose PHI to a law enforcement official as required by law, in compliance with a subpoena (with your written consent), court order, administrative order or similar document, for the purpose of identifying a suspect, material witness or missing person, in connection with the victim of a crime, in connection with a deceased person, in connection with the reporting of a crime in an emergency, or in connection with a crime on the premises.

-        Specialized Government Functions. I may review requests from U.S. military command authorities if you have served as a member of the armed forces, authorized officials for national security and intelligence reasons and to the Department of State for medical suitability determinations, and disclose your PHI based on your written consent, mandatory disclosure laws and the need to prevent serious harm.

-        Public Health. If required, we may use or disclose your PHI for mandatory public health activities to a public health authority authorized by law to collect or receive such information for the purpose of preventing or controlling disease, injury, or disability, or if directed by a public health authority, to a government agency that is collaborating with that public health authority.

-        Public Safety. I may disclose your PHI if necessary to prevent or lessen a serious and imminent threat to the health or safety of a person or the public. If information is disclosed to prevent or lessen a serious threat it will be disclosed to a person or persons reasonably able to prevent or lessen the threat, including the target of the threat. Research. PHI may only be disclosed after a special approval process or with your authorization.

-        Verbal Permission. I may also use or disclose your information to family members that are directly involved in your treatment with your verbal permission.

VI. Patient's Rights and Therapist's Duties

-        Right to Request Restrictions-  You have the right to request a restriction on your PHI that I use or disclose for treatment, payment or health care operations.  You must request any such restriction in writing addressed to Leslie J Wondra LLC.  I am not required to agree to any such restriction you may request, except if your request is to restrict disclosing your PHI to a health plan for the purpose of carrying out payment or health care operations, the disclosure is not otherwise required by law, and the PHI pertains solely to a health care item or service which has been paid in full by you or another person or entity on your behalf.   

-        Right to Receive Confidential Communications by Alternative Means and at Alternative Locations You have the right to request that I communicate with you about health matters in a certain way or at a certain location. I will accommodate reasonable requests. I may require information regarding how payment will be handled or specification of an alternative address or other method of contact as a condition for accommodating your request. I will not ask you for an explanation of why you are making the request.

-        Right to Inspect and Copy - You have the right, which may be restricted only in exceptional circumstances, to inspect and copy PHI that is maintained in a "designated record set". A designated record set contains mental health/medical and billing records and any other records that are used to make decisions about your care. Your right to inspect and copy PHI will be restricted only in those situations where there is compelling evidence that access would cause serious harm to you or if the information is contained in separately maintained psychotherapy notes. I may charge a reasonable, cost-based fee for copies. If your records are maintained electronically, you may also request an electronic copy of your PHI. You may also request that a copy of your PHI be provided to another person.

-        Right to Amend - If you feel that the PHI we have about you is incorrect or incomplete, you may ask us to amend the information although we are not required to agree to the amendment. If I deny your request for amendment, you have the right to file a statement of disagreement with me. I may prepare a rebuttal to your statement and will provide you with a copy. Please contact the Privacy Officer if you have any questions.

-        Right to Accounting of Disclosures.  Upon written request, You have the right to request an accounting of certain of the disclosures that I make of your PHI. I may charge you a reasonable fee if you request more than one accounting in any 12-month period.. 

-         Right to Obtain Notice.  You have the right to obtain a paper copy of this Notice by submitting a request to Leslie J Wondra LLC at any time.  

-        Right to Receive Notification of a Breach.  If there is a breach of unsecured PHI concerning you, I may be required to notify you of this breach, including what happened and what you can do to protect yourself.

VII. Complaints

If you believe I have violated your privacy rights, you have the right to file a complaint in writing with Privacy Officer Agency for Health Care Administration and/or Secretary of the Department of Health and Human Services at the addresses below. I will not retaliate against you for filing a complaint.

Privacy Officer                                                Secretary of the U.S. Department of Health and Human Services.

Agency for Health Care Administration              200 Independence Avenue, S.W.

2727 Mahan Drive, Mail Stop 4                             Washington, D.C. 20201

Tallahassee, Florida 32308                                      (800) 368-1019

(850) 412-3960

VIII. Client Consent for Services and the HIPAA Notice Signature Page

I have read, understand, and agree to abide by the terms and conditions set forth in the Consent for Services, and do hereby consent to participation in the treatment as described in the consent agreement. I also understand that my participation is entirely voluntary, and that I may withdraw my consent and terminate treatment at any time.

IX. EFFECTIVE DATE AND CHANGES TO THIS NOTICE

Effective Date.  This Notice is effective on March 25, 2021 

Changes to this Notice.  I may change the terms of this Notice at any time.  If I change this Notice, I may make the new notice terms effective for all PHI that I maintain, including any information created or received prior to issuing the new notice.  If I change this Notice, I will post the revised notice in the waiting area of my office and on my website at lesliewondratherapy.com.  You may also obtain any revised notice by asking me directly. 

                                                                 Patient's Bill of Rights and Responsibilities

                                                                         Section 381.026, Florida Statutes

A PATIENT HAS THE RIGHT TO:

           - Be treated with courtesy and respect, with appreciation of his or her dignity, and with protection of privacy.

           - Receive a prompt and reasonable response to questions and requests.

           - Know who is providing medical services and is responsible for his or her care.

           - Know what patient support services are available, including if an interpreter is available if the patient does not speak English.

           - Know what rules and regulations apply to his or her conduct.

           - Be given by the health care provider information such as diagnosis, planned course of treatment, alternatives, risks, and prognosis.

           - Refuse any treatment, except as otherwise provided by law.

           - Be given full information and necessary counseling on the availability of known financial resources for care.

           - Know whether the health care provider or facility accepts the Medicare assignment rate, if the patient is covered by Medicare.

           - Receive prior to treatment, a reasonable estimate of charges for medical care.

           - Receive a copy of an understandable itemized bill and, if requested, to have the charges explained.

           - Receive medical treatment or accommodations, regardless of race, national origin, religion, handicap, or source of payment.

           - Receive treatment for any emergency medical condition that will deteriorate from failure to provide treatment.

           - Know if medical treatment is for purposes of experimental research and to give his or her consent or refusal to participate in such research.

           - Express complaints regarding any violation of his or her rights.

A PATIENT IS RESPONSIBLE FOR:

           - Giving the health care provider accurate information about present complaints, past illnesses, hospitalizations, medications, and other information about his or her health.

           - Reporting unexpected changes in his or her condition to the health care provider.

           - Reporting to the health care provider whether he or she understands a planned course of action and what is expected of him or her.

           - Following the treatment plan recommended by the health care provider.

           - Keeping appointments and, when unable to do so, notifying the health care provider or facility.

           - His or her actions if treatment is refused or if the patient does not follow the health care provider's instructions.

           - Making sure financial responsibilities are carried out.

           - Following health care facility conduct rules and regulations.

Leslie J Wondra LLC

PRACTICE POLICIES, INFORMED CONSENT, SERVICE AGREEMENT

THERAPIST-CLIENT SERVICE AGREEMENT

Welcome to my practice and thank you for allowing me to be part of your journey. This document contains important information about my professional services and business policies. Your signature on this document represents an agreement between us. I am happy to discuss any questions you have or at any time in the future.

THERAPIST QUALIFICATION

My name is Leslie Wondra, I currently hold an LCSW in Florida from the State of Florida Board of Clinical Social Work, Marriage and Family Therapy and Mental health Counseling, SW 17111 and Wyoming from the Mental Health Professions Licensing Board, LCSW-1003. I earned my Bachelor of Arts in Sociology from University of North Carolina-Chapel Hill in 2007. I earned my Master of Social Work from the University of Pennsylvania in 2012 and have been in practice for over eight years.

THERAPEUTIC SERVICES

Therapy is a relationship between people that works in part because of clearly defined rights and responsibilities held by each person. As a client in psychotherapy, you have certain rights and responsibilities that are important for you to understand. There are also legal limitations to those rights that you should be aware of. I, as your therapist, have corresponding responsibilities to you. These rights and responsibilities are described in the following sections.

Psychotherapy has both benefits and risks. Risks may include experiencing uncomfortable feelings, such as sadness, guilt, anxiety, anger, frustration, loneliness, and helplessness; because the process of psychotherapy often requires discussing the unpleasant aspects of your life. However, psychotherapy has been shown to have numerous benefits for individuals who undertake it. Therapy often leads to a significant reduction in feelings of distress, increased satisfaction in interpersonal relationships, greater personal awareness and insight, increased skills for managing stress, and resolutions to specific problems. But there are no guarantees about what will happen. Psychotherapy requires a very active effort on your part. In order to maximize your success, you will have to work outside of sessions on things we discuss in the session. I find that the more committed a client is outside of session, faster progress can be made and goals can be achieved.

The first few sessions will involve a comprehensive evaluation of your needs. By the end of the evaluation, I will be able to offer you some initial impressions of what our work might include. At that point, we will discuss your treatment goals and create an initial treatment plan. You should evaluate this information and make your own assessment about whether you feel comfortable working with me. If you have questions about my procedures, we should discuss them when they arise. If your doubts persist, I would be happy to refer out to another mental health professional for a second opinion.

APPOINTMENTS AND CANCELLATION POLICIES

All therapy sessions are by appointment only and can be scheduled via the client portal on my website https://lesliewondratherapy.com. Appointments will ordinarily be 45 minutes in duration, after your initial intake appointment but there is an option for an extended individual session for 60 minutes. The time scheduled for your appointment is assigned to you and you alone. Cancellations must be made at least 24 hours in advance. If you miss a session without canceling (No Show), my policy is to collect the full amount of the reserved session. If you cancel with less than 24-hour notice, my policy is to collect $100. Your credit card on file will be automatically charged for no-shows and late cancellations. Additionally, you are responsible for coming to your session on time; if you are late, your appointment will still end at the originally scheduled time. It is understandable that you may occasionally need to cancel or miss an appointment due to illness or emergency. However, your appointment time has been reserved especially for you. If you are more than 15 minutes late, I will determine if continuing with the remaining time is beneficial or will need to be rescheduled and will be considered a late cancellation and charged accordingly. Also, I cannot do therapy with you while you are driving as it could be dangerously distracting. Therefore, if you join our session while driving, your session will need to be rescheduled and you will be considered a late cancellation.  Frequent cancellations, missed appointments, late payments, or non-payment could result in the need to discontinue your treatment.

PROFESSIONAL FEES

The fee for the initial intake is $160.00, 60 minutes extended individual session is $150 and 45-minute standard individual session is $135.00. You are responsible for paying at the time of your session unless prior arrangements have been made. Payment must be made by credit card. If you refuse to pay your debt, I reserve the right to use an attorney or collection agency to secure payment. In addition to weekly appointments, it is my practice to charge $135 on a prorated basis for other professional services that you may require such as report writing, non-therapeutic telephone conversations that last longer then 15 minutes, attendance at meetings or consultations which you have requested, or the time required to perform any other service which you may request of me. These services will be billable in 15 min increments, meaning you will be charged per quarter-hour and will be rounded to the nearest quarter-hour. Additional specifics can be found in your "Financial Agreement and Consent to Services" form. Furthermore, I reserve the right to terminate our counseling relationship if 2 consecutive sessions are missed without proper notification.

TRIAL, COURT-ORDERED APPEARANCES, LITIGATION

If you anticipate becoming involved in a court case, I recommend that we discuss this fully before you waive your right to confidentiality. Often, it is not helpful to participate in a legal process concerning any therapy that may have been given. Therefore, I will decline if asked to participate in any legal or court hearings. If your case requires my participation, you will be expected to pay for all the professional time required even if another party compels me to testify. I charge for professional services I am asked or required to perform in relation to your legal matter, which will include travel to and from the courthouse, time in court, waiting for the court hearing, preparation for documents, etc. A proposed invoice will be drawn up and you will be required to pay prior to the appearance. Additional specifics can be found in your "Financial Agreement and Consent to Services" form.

BILLING AND PAYMENTS

You will be expected to pay for each session at the time it is held unless we agree otherwise. Payment schedules for other professional services will be agreed to when such services are requested. I do not carry over session balances from week to week, please be prepared to pay the entire balance on the day of your scheduled session. A credit card will be required to remain on file and is stored in an electronic health record system that is a password-protected and encrypted system. I charge clients on the day of their session, including for no-shows and late cancellations.

Fee Disputes: In the case of a credit card dispute, I reserve the right to provide the needed and adequate documentation that covers the cancellation policy to your bank or credit card company should you dispute a charge that you are financially responsible for.  

INSURANCE

I am in-network with Optum, Aetna, United HealthCare and Oscar Health. Any services that insurance fails to pay for; the client will be responsible for the full amount of each service. I use Alma and Headway to manage my insurance credentialing, billing and administration work so I can place all of my focus on our work together. 

For all other insurance companies, I am not a participating provider. Upon request, I will supply you with a receipt for services, which you can submit to your insurance company for reimbursement. Some or all your fees may be covered by your health insurance if you have outpatient mental health coverage. However, insurance companies do not reimburse all conditions that may be the focus of psychotherapy. It is your responsibility to verify the specifics of your coverage. Please remember that my services are provided and charged to you, not your insurance company, so you are responsible for payment. You are responsible for determining if any health care benefits are available to you. The receipt provided contains the necessary information you need to file for reimbursement. You are responsible for sending in your claim to the insurance company. Please note, your insurance company may request additional documentation from me and I am responsible for sending in those treatment reports. 

LETTERS

Leslie J Wondra LLC does not provide disability letters, companion pet letters, letters regarding your ability to work, or letters regarding FMLA. You must discuss these needs with your medical or primary care provider. If a letter is required attesting the client's needs, I will provide it for a fee of $15 per letter. Letters are only provided to clients who have been seen for 6 sessions or longer.

PROFESSIONAL RECORDS

I am required to keep appropriate records of the therapeutic services that I provide. I keep brief records noting that you were here, your reasons for seeking therapy, the goals and the progress we set for treatment, your diagnosis, topics we discussed, your medical history, social history, treatment history, records I receive from other providers, copies of records I send to others, and your billing records. Except in unusual circumstances that involve danger to yourself, you have the right to a copy of your file. Because these are professional records, they may be misinterpreted and/or upsetting to untrained readers. For this reason, I recommend that you allow me to provide you with a treatment summary instead. If you wish to review your Clinical record, I recommend we do so together so that we can discuss the specific contents in detail. You should be aware that this will be treated in the same manner as any other professional services, thus you will be billed accordingly. 

MINORS

If you are under 18 years of age, please be aware that the law may provide your parents, or legal guardians, with the right to examine your treatment records. Normally, I will provide them only with general information on how your treatment is proceeding. If, however, I feel that there is a high risk that you will seriously harm yourself or another, I will notify them of my concern. Before giving them any information, I will try to discuss the matter with you and will do the best I can to resolve any objections you might have about what I am prepared to discuss.

CONSULTATION 

I consult regularly with other professionals regarding my clients; however the client's name or other identifying information is never disclosed. The clients' identity remains completely anonymous and confidentiality is fully maintained.  

CONFIDENTIALITY

In general, the privacy of all communications between a client and a therapist is protected by law, and I can only release information about our work to others with your written permission. However, there are a few exceptions. In most legal proceedings, you have the right to prevent me from providing any information about your treatment. In some legal proceedings, a judge may order my testimony if they determine that the issues demand it, and I must comply with that court order. 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. Additional potential limitations of confidentiality are outlined below: 

- If a client threatens or attempts to commit suicide or otherwise conducts themself in a manner in which there is a substantial risk of incurring serious bodily harm.

- If a client threatens grave bodily harm or death to another person.

- If the therapist has a reasonable suspicion that a client or other named victim is the perpetrator, observer of, or actual victim of physical, emotional, or sexual abuse of child(ren) under the age of 18 years.

- Suspicions as stated above in the case of an elderly person who may be subjected to these abuses.

- Suspected neglect.

- If a court of law issues a legitimate subpoena for information stated on the subpoena.

- If a client is in therapy or being treated by order of a court of law, or if the information is obtained for the purpose of rendering an expert's report to an attorney.

My policies about confidentiality, as well as other information about your privacy rights, are fully described in a separate document entitled Notice of Privacy Practices. You have been provided with a copy of that document. 

Dual Relationships & Public Settings: 

Not all dual relationships are unethical or avoidable. However sexual involvement between therapist and client is never part of the therapy process, nor are any other actions or dual relationship situations that might impair your clinician's objectivity, clinical judgment, or therapeutic effectiveness, nor that could be exploitive in nature. 

My relationship with you is strictly professional. In order to preserve this relationship, it is imperative that we do not have any relationship outside the counseling relationship such as a friendship, business, or social relationship. If we have contact in a public setting, I will not acknowledge you in any way that would jeopardize your confidentiality. Should you choose to acknowledge me, I may not be able to protect your confidentiality.  

In some instances, even with permission, the clinician may choose to preserve the integrity of the therapy relationship. For this reason, your clinician will not accept any invitations via social networking sites, nor will he/she respond to blogs written by clients. Your clinician will not build a relationship with you outside of sessions, which means that outside of session communications will be limited to scheduling purposes.   

COMMUNICATION

Counsol email, chat, and video exchanges as well as Hushmail and Phone.com are secure HIPPA compliant platforms. By signing this document, you agree to work with the platforms outlined. For communication between sessions, I only use email communication and text messaging with your permission and only for administrative purposes unless we have made another agreement. This means that email exchanges and text messages should be limited to administrative matters. This includes things like setting and changing appointments, billing matters, and other related issues. I am often not immediately available by telephone. Client communication regarding clinical issues or concerns via email (or texting) should be avoided as the delivery of any electronic communication can be intercepted, misdirected, or delayed.  

 I do not answer my phone when I am with clients or otherwise unavailable. At these times, you may leave a message on my confidential voicemail and your call will be returned as soon as possible, but it may take a business day or two for non-urgent matters. If, for any number of unseen reasons, you do not hear from me or I am unable to reach you, and you feel you cannot wait for a return call or if you feel unable to keep yourself safe 1) go to your Local Hospital Emergency Room OR 2) call 911 and ask to speak to the mental health worker on call. I will make every attempt to inform you in advance of planned absences. If you feel you will require frequent between-session contact, we need to discuss whether or not I will be the best therapist for you. 

SOCIAL MEDIA/TELECOMMUNICATION

I do not communicate with, or contact, any of my clients through social media platforms such as Twitter and Facebook. In addition, if I discover that I have accidentally established an online relationship with you, I will cancel that relationship. This is because these types of casual social contacts can create significant security risks for you. I participate on various social networks, but not in my professional capacity. If you have an online social media presence, there is a possibility that you may encounter me by accident. If that occurs, please discuss it with me during our time together. I believe that any communication with clients online through social media platforms has a high potential to compromise the professional relationship. Additionally, please do not try to contact me in this way. I will not respond and will terminate any online social media contact no matter how accidental.

Websites: I have a website that you are free to access, lesliewondratherapy.com. I use it for professional reasons to provide information to others about me and my practice. You are welcome to access and review the information that I have on my website. If you have questions about this, we should discuss them during your therapy sessions.

Web Searches: I will not use web searches to gather information about you without your permission. I believe that this violates your privacy rights. However, I understand that you might choose to gather information about me in this way. In this day and age there is an incredible amount of information available about individuals on the internet, much of which may actually, be known to that person and some of which may be inaccurate or unknown. If you encounter any information about me through web searches, or in any other fashion for that matter, please discuss this with me during our time together so that we can deal with it and its potential impact on your treatment. 

Recently it has become fashionable for clients to review their health care provider on various websites. Unfortunately, mental health professionals cannot respond to such comments and related errors because of confidentiality restrictions. If you encounter such reviews of me or any professional with whom you are working, please share them with me so we can discuss them and its potential impact on your therapy. Please do not rate my work with you while we are in treatment together on any of these websites. This is because it has a significant potential to damage our ability to work together.

COMMUNICATION BY EMAIL, TEXT MESSAGE, AND OTHER NON-SECURE MEANS 

It may become useful during the course of treatment to communicate by email, text message (e.g. "SMS"), or other electronic methods of communication. Be informed that these methods, in their typical form, are not confidential means of communication. If you use these methods to communicate with Leslie J Wondra of Leslie J Wondra LLC, there is a reasonable chance that a third party may be able to intercept and eavesdrop on those messages. The kinds of parties that may intercept these messages include, but are not limited to:

- People in your home or other environments who can access your phone, computer, or other devices that you use to read and write messages

- Your employer, if you use your work email to communicate with Leslie J Wondra

- Third parties on the Internet such as server administrators and others who monitor Internet traffic

If there are people in your life that you don't want accessing these communications, please talk with Leslie J Wondra about ways to keep your communications safe and confidential.

OTHER RIGHTS

If you are unhappy with what is happening in therapy, I hope you will talk with me so that I can respond to your concerns and we can work through this together. Such comments will be taken seriously and handled with care and respect. You may also request that I refer you to another therapist and are free to end therapy at any time. You have the right to considerate, safe, and respectful care; without discrimination as to race, ethnicity, color, gender, sexual orientation, age, religion, national origin, or source of payment. You have the right to ask questions about any aspects of therapy and about my specific training and experience. You have the right to expect that I will not have social or sexual relationships with clients or with former clients.

TERMINATION OF TREATMENT

Should you fail to schedule an appointment for 60 days, unless other arrangements have been made in advance, for legal and ethical reasons, I must consider the professional relationship discontinued. Should you fail to appear for two consecutive appointments, unless other arrangements have been made in advance, it is at my discretion to consider the professional relationship discontinued, to which you will be notified. To reinstate, please call the office at 954-787-9869 and schedule an appointment or via the client portal. 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. As long as it is safe for both of us, I will make an effort to discuss terminating therapy with you. Optimally, we mutually agree to end therapy. For the most part, you can decide when you want to terminate. You can end therapy at any time and you do not need a reason. At the same time, the decision to end therapy can also be mine. If during the course of treatment, I determine that our continuing therapy may not be good for either one or both of us, I have an ethical responsibility to let you know, work with you to find an appropriate referral, and end therapy. Should this course of action need to happen, it will take place after consultation with other professionals and careful consideration, but all of this can occur outside of your knowledge. 

CHANGES IN SERVICES AND FEES 

Leslie J Wondra LLC reserves the right to change the policies, practices, procedures, and fees described in this document. You will be notified within 30 days of any such changes.

Your signature below indicates that you have read this Agreement and the Notice of Privacy Practices and agree to their terms and consent to treatment.

Revised 5/21

Parts adapted from Dr. Amber Lyda

FINANCIAL AGREEMENT AND CONSENT TO SERVICES

To facilitate clear financial agreements, I find it helpful to clearly outline policies regarding payments and appointment scheduling. It is very important to me that business matters do not impact our therapeutic relationship. This also gives you an opportunity to ask any questions you might have. This way we can begin our relationship with a clear understanding of expectations.

FEE SCHEDULE

For your information, this section lists the fees for services offered. Leslie J Wondra LLC, is a fee for service provider. This means the service fee is the client's responsibility to pay at the time of service. Changes to the fees may be made by this therapist but will be done with notice and discussion.

Services

Initial Intake: $160

Extended Individual Session (60 minutes): $150

Standard Individual Session (45 minutes): $135

No Shows: Based on the full session fee of reserved time scheduled (45 min or 60 min)

Late Cancellation (less than 24-hour notice): $100

Phone calls (over 15 minutes) These calls are not therapeutic sessions: Prorated $135

                    - 8 min-22 min: $33.75

                    - 23 min-37 min: $67.50

                    - 38 min-52 min: $101.25

                    - 53 min-60 min: $135

Letters (not disability letters, companion pet letters, letters regarding your ability to work, or FMLA, as I do not provide those services.) $15

Court Appearance

       - Preparation time $220/hr billable in 15 min increments

       - Phone calls $220/hr billable in 15 min increments

       - Deposition $250/hr

       - Time required giving testimony $250/hr

       - Mileage $0.56/mile (IRS standard mileage rate)

       - Filing documents with court $100 plus court fees

       - Attorney fees TBD

       - Minimum charge for court appearance $1500

COURT ACTION POLICY AND FEES

Clients are discouraged from having Leslie J Wondra LLC subpoenaed for the purpose of litigation. I have not been trained forensically or with the expertise to appear in court. I am unable to guarantee that any testimony that I am required by law to give will be solely in your favor. I can only testify to the facts of the case and my professional opinion. I request a minimum of 72-hour notice of any court appearance so that schedule changes for my clients can be made within a reasonable time frame. If a subpoena is received without a minimum of 72-hour notice, there will be an additional $250 express charge. As a general policy, I cannot be available "on-call," as being called to come to court at the last minute in that fashion is too disruptive to my practice, and not fair to my clients that otherwise would be scheduled that day. All fees are doubled if the therapist has to postpone or interrupt plans to go out of town. Bills for court related services are presented to clients on a weekly basis and payment is expected upon receipt. A zero balance must be kept at all times.  

Court action fees are as follows:

          - Preparation Time (including submission of records): $220 per hour (billable in 15-minute increments)

          - Phone Calls/Email Exchanges: $220 per hour (billable in 15-minute increments)

          - Deposition: $250 per hour

          - Time Required in Giving Testimony: $250 per hour

          - Mileage: $0.56/mile (IRS standard mileage rate)

          - Time Away from Office Due to Deposition or Testimony: $220 per hour

          - Filing Document with Court: $100 (plus court fees)

          - Attorney Fees: The client agrees to pay all attorney fees and costs incurred as a result of any court action.

          - Minimum Charge for Court Appearance: $1500 and due at least 72 hours before the scheduled appearance. This fee is NON-REFUNDABLE and is in addition to expenses incurred for court related services.

CONSENT FOR TREATMENT

- I agree to engage in a therapeutic relationship with Leslie Wondra of Leslie J Wondra LLC to provide counseling services to me, the client. I know that I can stop at any time and that I can refuse any requests or suggestions made to me.

- I understand my rights and responsibilities as a client and my therapist's responsibilities to me.

HIPPA/PRIVACY PRACTICES

- I have read and received a copy of Leslie J Wondra LLC's Notice of Privacy Practices and agree to the terms within.

- I understand and agree to the Social Media policy.

- I agree to respect the boundaries of contact between sessions and understand emails and text messaging are not an appropriate way to process what should be discussed in session.

FEES

- I understand that Leslie J Wondra LLC is only contracted with Aetna, Optum, United Healthcare and Oscar Health (in-network status is specific to state) and out of network with all other insurance companies.

- I understand, Leslie J Wondra LLC will utilize Headway/Alma for billing and sending insurance claims to insurance companies in network with. 

- I understand that my insurance company will not pay for missed appointments and that I must pay the full fees for services rendered as stated in the above Fee Schedule. 

- I understand that if I do not have insurance or Leslie J Wondra LLC does not participate with my insurance plan, I agree to pay full session fee of services rendered as stated in the above Fee Schedule.

- I agree to honor the 24-hr cancellation policy and understand that I will be charged the full fee for no shows and $100 for late cancellations.

- I understand that I am financially responsible for charges and fees incurred and expected at time of visit. I agree to pay the agreed upon fee at time of service. 

- I understand a credit card will need to remain active on file and will be charged same day services rendered as well as for additional charges acrued, no-shows and late cancellations.

YOUR SIGNATURE BELOW INDICATES THAT YOU HAVE READ THE INFORMATION IN THIS DOCUMENT AND FULLY UNDERSTAND THE PRACTICE POLICIES, INFORMED CONSENT AND SERVICE AGREEMENT DOCUMENT AND AGREE TO ABIDE BY ITS TERMS DURING THE PROFESSIONAL RELATIONSHIP. I UNDERSTAND THAT ANY FEES OR CHARGES INCURRED ARE MY RESPONSIBILITY IN FULL.

Cancellation / No-Show / Late Arrival Policies

Please understand that Leslie J Wondra LLC does not over book her schedule to cover for clients cancelling at the last minute or not showing up. I reserve your appointment time for you specifically. If you cancel short notice, do not show up, or show up very late (more than 15 minutes late) - that is lost opportunity that another patient could have used to be treated and lost revenue for the practice. I understand unanticipated events happen occasionally in everyone's life, but in my desire to be fair to all clients and maintain a viable practice the following policies must be honored.

Cancellations

At least 24-hour advanced notice is required when cancelling any appointment. This allows the opportunity for someone else to schedule an appointment. If you are unable to give me 24-hour advance notice you will be charged $100. This amount will be collected on the day of the scheduled appointment via the credit card on file.

No-Shows

Anyone who either forgets or consciously chooses to forgo their appointment, regardless of reason, will be considered a "No-Show" and will be charged the full amount for their missed appointment. This amount will be collected on the day of the scheduled appointment via the credit card on file. If you have not called and have not arrived 15 minutes after your scheduled appointment time, I will consider you a "no show" and may not be available for any of the remaining scheduled time.

Late Arrivals

If you happen to arrive late for an appointment, your visit will be shortened as it will end at the originally scheduled time in order to accommodate other clients whose appointments follow yours. Insurance companies can only be billed for the time spent in session with the provider. If you are "self-pay" you will be billed for the time scheduled regardless of your arrival time. If you are more than 15 minutes late, I will determine if continuing with remaining time is beneficial or will need to be rescheduled and will be considered a late cancellation and charged accordingly.