RO-DBT Therapy, Eating Disorders, Pregnancy & Postpartum Counseling in San Antonio
Informed Consent, Practice Policies & Privacy Practices
Becca Allen Counseling, PLLC
Combined Informed Consent, Practice Policies & Privacy Practices
Effective: March 10, 2025
CLIENT-COUNSELOR SERVICE AGREEMENT
This document outlines the business policies, professional services, and privacy practices at Becca Allen Counseling, PLLC. It includes a summary of HIPAA (Health Insurance Portability and Accountability Act) guidelines regarding your rights and privacy protections related to your Protected Health Information (PHI).
GOALS OF COUNSELING
Counseling goals are defined collaboratively. They may include both long-term objectives (e.g., improving quality of life and relationships) and short-term goals (e.g., reducing anxiety or depression). Your therapist may offer recommendations, but you ultimately choose your goals.
RISKS AND BENEFITS OF COUNSELING
Counseling may evoke difficult emotions and memories. While it can lead to significant personal growth, progress is not always linear. Active participation is essential. Benefits may include improved coping skills, emotional regulation, and overall well-being.
APPOINTMENTS
Sessions are 50 minutes in length and typically held weekly. Cancellations must be made at least 24 hours in advance to avoid a full-session charge. If more than 15 minutes late, the session may be canceled and charged as a no-show. Zoom sessions must be arranged in advance, not used as a last-minute substitute.
CONFIDENTIALITY
Your information is kept private with certain legal exceptions:
1. Risk of harm to self or others
2. Child or elder abuse
3. Court orders/subpoenas
Consultations with other professionals may occur for your benefit but without revealing identifying details.
Group Therapy
Confidentiality cannot be guaranteed in group settings, though efforts will be made to uphold it.
Technology Use
Using Zoom or other electronic communications carries some privacy risks. Clients should take precautions with personal devices and accounts.
Social Media
To protect confidentiality, we do not accept friend or contact requests from clients on social media.
RECORD KEEPING
Session notes and treatment plans are maintained securely for at least 7 years. Clients may request a release of records with proper authorization.
ELECTRONIC COMMUNICATION
Text and email are acceptable for scheduling only. Therapy-related matters should not be discussed via these methods. Telehealth sessions comply with Texas regulations and involve specific risks and benefits.
CONSENT FOR TELEHEALTH CONSULTATION
I understand that my health care provider wishes me to engage in a telehealth consultation.
My health care provider explained to me how the video conferencing technology that will be used to affect such a consultation will not be the same as a direct client/health care provider visit due to the fact that I will not be in the same room as my provider.
I understand that a telehealth consultation has potential benefits including easier access to care and the convenience of meeting from a location of my choosing.
I understand there are potential risks to this technology, including interruptions, unauthorized access, and technical difficulties.
I understand that my health care provider or I can discontinue the telehealth consult/visit if it is felt that the video-conferencing connections are not adequate for the situation.
I have had a direct conversation with my provider, during which I had the opportunity to ask questions in regard to this procedure. My questions have been answered and the risks, benefits and any practical alternatives have been discussed with me in a language in which I understand.
By signing this form, I certify:
> That I have read or had this form read and/or had this form explained to me.
> That I fully understand its contents including the risks and benefits of the procedure(s).
> That I have been given ample opportunity to ask questions and that any questions have been answered to my satisfaction.
BY CLICKING ON THE CHECKBOX BELOW I AM AGREEING THAT I HAVE READ, UNDERSTOOD AND AGREE TO THE ITEMS CONTAINED IN THIS DOCUMENT.
MINORS
Minors’ parents/legal guardians may be entitled to certain information. Confidentiality specifics will be discussed on a case-by-case basis.
TREATMENT TEAM MEETINGS
Time spent coordinating care with other providers will be billed accordingly. Email or text updates between providers will not incur charges.
PROFESSIONAL FEES
Individual Session (50 min): $200
Intake Assessment (60 min): $250
Payments are due at the time of service. A credit card is required on file when a third party is responsible for payment. Unpaid balances may be sent to collections.
INSURANCE
Becca Allen Counseling, PLLC is an out-of-network provider. Superbills for insurance reimbursement are available through the client portal. We do not correspond with insurance companies directly.
CONTACT & EMERGENCIES
Non-urgent messages will be returned within 24 hours. For emergencies, call 911 or visit the nearest emergency room. Coaching calls (when applicable) exceeding 15 minutes will be billed per minute.
TERMINATION
Termination will be discussed when appropriate. Failure to attend three consecutive scheduled appointments without prior arrangement may be considered discontinuation of services.
CONSUMER COMPLAINTS
To file a complaint, contact the Texas Board of Examiners of Professional Counselors at 1-800-942-5540 or visit www.dshs.state.tx.us/counselor.
NOTICE OF PRIVACY PRACTICES (HIPAA)
We are committed to safeguarding your PHI and are legally required to:
1. Maintain the privacy of your PHI
2. Provide you with this Notice
3. Abide by its terms
How We May Use Your PHI:
> For treatment, payment, and healthcare operations
> For legal proceedings with proper orders/subpoenas
Uses That Require Authorization:
> Use of psychotherapy notes (with exceptions)
> Marketing or sale of PHI
Permitted Disclosures Without Authorization:
> Required by law
> Public health and safety
> Law enforcement
> Research (under strict conditions)
> Workers' compensation
> Appointment reminders
You Have the Right To:
> Request limits on how your PHI is used
> Request confidential communication methods
> Access and copy your PHI
> Request an accounting of disclosures
> Request corrections to your PHI
> Receive a paper or electronic copy of this notice
Effective Date: January 4, 2021
ACKNOWLEDGMENT
By signing or checking the box on your intake form, you confirm that you have read, understood, and agreed to the terms outlined in this combined Informed Consent, Practice Policies, and Privacy Practices document.
CONTACT US
If you have questions or requests regarding this Notice, please contact Becca Allen Counseling.
Address: 4940 Broadway, Suite 223, San Antonio, Texas 78209
Email: info@beccaallencounseling.com
Phone: 210-436-6555
RO-DBT Therapy, Eating Disorders, Pregnancy & Postpartum Counseling in San Antonio
Informed Consent, Practice Policies & Privacy Practices
Becca Allen Counseling, PLLC
Combined Informed Consent, Practice Policies & Privacy Practices
Effective: March 10, 2025
CLIENT-COUNSELOR SERVICE AGREEMENT
This document outlines the business policies, professional services, and privacy practices at Becca Allen Counseling, PLLC. It includes a summary of HIPAA (Health Insurance Portability and Accountability Act) guidelines regarding your rights and privacy protections related to your Protected Health Information (PHI).
GOALS OF COUNSELING
Counseling goals are defined collaboratively. They may include both long-term objectives (e.g., improving quality of life and relationships) and short-term goals (e.g., reducing anxiety or depression). Your therapist may offer recommendations, but you ultimately choose your goals.
RISKS AND BENEFITS OF COUNSELING
Counseling may evoke difficult emotions and memories. While it can lead to significant personal growth, progress is not always linear. Active participation is essential. Benefits may include improved coping skills, emotional regulation, and overall well-being.
APPOINTMENTS
Sessions are 50 minutes in length and typically held weekly. Cancellations must be made at least 24 hours in advance to avoid a full-session charge. If more than 15 minutes late, the session may be canceled and charged as a no-show. Zoom sessions must be arranged in advance, not used as a last-minute substitute.
CONFIDENTIALITY
Your information is kept private with certain legal exceptions:
1. Risk of harm to self or others
2. Child or elder abuse
3. Court orders/subpoenas
Consultations with other professionals may occur for your benefit but without revealing identifying details.
Group Therapy
Confidentiality cannot be guaranteed in group settings, though efforts will be made to uphold it.
Technology Use
Using Zoom or other electronic communications carries some privacy risks. Clients should take precautions with personal devices and accounts.
Social Media
To protect confidentiality, we do not accept friend or contact requests from clients on social media.
RECORD KEEPING
Session notes and treatment plans are maintained securely for at least 7 years. Clients may request a release of records with proper authorization.
ELECTRONIC COMMUNICATION
Text and email are acceptable for scheduling only. Therapy-related matters should not be discussed via these methods. Telehealth sessions comply with Texas regulations and involve specific risks and benefits.
CONSENT FOR TELEHEALTH CONSULTATION
I understand that my health care provider wishes me to engage in a telehealth consultation.
My health care provider explained to me how the video conferencing technology that will be used to affect such a consultation will not be the same as a direct client/health care provider visit due to the fact that I will not be in the same room as my provider.
I understand that a telehealth consultation has potential benefits including easier access to care and the convenience of meeting from a location of my choosing.
I understand there are potential risks to this technology, including interruptions, unauthorized access, and technical difficulties.
I understand that my health care provider or I can discontinue the telehealth consult/visit if it is felt that the video-conferencing connections are not adequate for the situation.
I have had a direct conversation with my provider, during which I had the opportunity to ask questions in regard to this procedure. My questions have been answered and the risks, benefits and any practical alternatives have been discussed with me in a language in which I understand.
By signing this form, I certify:
> That I have read or had this form read and/or had this form explained to me.
> That I fully understand its contents including the risks and benefits of the procedure(s).
> That I have been given ample opportunity to ask questions and that any questions have been answered to my satisfaction.
BY CLICKING ON THE CHECKBOX BELOW I AM AGREEING THAT I HAVE READ, UNDERSTOOD AND AGREE TO THE ITEMS CONTAINED IN THIS DOCUMENT.
MINORS
Minors’ parents/legal guardians may be entitled to certain information. Confidentiality specifics will be discussed on a case-by-case basis.
TREATMENT TEAM MEETINGS
Time spent coordinating care with other providers will be billed accordingly. Email or text updates between providers will not incur charges.
PROFESSIONAL FEES
Individual Session (50 min): $200
Intake Assessment (60 min): $250
Payments are due at the time of service. A credit card is required on file when a third party is responsible for payment. Unpaid balances may be sent to collections.
INSURANCE
Becca Allen Counseling, PLLC is an out-of-network provider. Superbills for insurance reimbursement are available through the client portal. We do not correspond with insurance companies directly.
CONTACT & EMERGENCIES
Non-urgent messages will be returned within 24 hours. For emergencies, call 911 or visit the nearest emergency room. Coaching calls (when applicable) exceeding 15 minutes will be billed per minute.
TERMINATION
Termination will be discussed when appropriate. Failure to attend three consecutive scheduled appointments without prior arrangement may be considered discontinuation of services.
CONSUMER COMPLAINTS
To file a complaint, contact the Texas Board of Examiners of Professional Counselors at 1-800-942-5540 or visit www.dshs.state.tx.us/counselor.
NOTICE OF PRIVACY PRACTICES (HIPAA)
We are committed to safeguarding your PHI and are legally required to:
1. Maintain the privacy of your PHI
2. Provide you with this Notice
3. Abide by its terms
How We May Use Your PHI:
> For treatment, payment, and healthcare operations
> For legal proceedings with proper orders/subpoenas
Uses That Require Authorization:
> Use of psychotherapy notes (with exceptions)
> Marketing or sale of PHI
Permitted Disclosures Without Authorization:
> Required by law
> Public health and safety
> Law enforcement
> Research (under strict conditions)
> Workers' compensation
> Appointment reminders
You Have the Right To:
> Request limits on how your PHI is used
> Request confidential communication methods
> Access and copy your PHI
> Request an accounting of disclosures
> Request corrections to your PHI
> Receive a paper or electronic copy of this notice
Effective Date: January 4, 2021
ACKNOWLEDGMENT
By signing or checking the box on your intake form, you confirm that you have read, understood, and agreed to the terms outlined in this combined Informed Consent, Practice Policies, and Privacy Practices document.
CONTACT US
If you have questions or requests regarding this Notice, please contact Becca Allen Counseling.
Address: 4940 Broadway, Suite 223, San Antonio, Texas 78209
Email: info@beccaallencounseling.com
Phone: 210-436-6555
Copyright 2025. Becca Allen Counseling. All Rights Reserved.