Insurances Accepted:
BCBS Texas · BCBS Massachusetts · Quest (TX) · Carelon (TX) · Cigna (TX) · Aetna (TX) · Optum · Medicare & Advantage Plans

Message to the Plan Member, Spouse and/or Dependent regarding Personal Information: Personal information that we collect and disclose about you, and if applicable, your spouse and/or dependents, is used by the insurer and/or plan administrator and their service provider(s) for the purposes of assessing your claims, underwriting, investigating, auditing and administering the group benefits plan, including the investigation of fraud and/or plan abuse. Authorization and Consent I authorize my healthcare provider to collect, use and disclose personal information concerning any claims submitted on my behalf with the insurer and/or plan administrator and their service provider(s) for the above purposes.

I authorize the insurer and/or plan administrator and their service provider(s) to:
• Use my personal information for the above purposes.
• Exchange personal information with any individual or organization, including healthcare professionals, investigative agencies, insurers and reinsurers, and administrators of government benefits or other benefits programs when relevant for the above purposes.
• Exchange personal information concerning any claims submitted with the plan member or a person acting on behalf of the plan member.
• Exchange personal information for the above purposes electronically or in any other manner.

I understand that personal information may be subject to disclosure to those authorized under applicable law. I agree that a photocopy or electronic version of this authorization shall be as valid as the original, and may remain in effect for the continued administration of the group benefits plan. Additional Consent Applicable to Plan Members Only I confirm that I am authorized by my spouse and/or dependents, if any, to disclose personal information about them to the insurer and/or plan administrator and their service provider(s). I confirm that my spouse and/or dependents also authorize the insurer and/or plan administrator and their service provider(s) to disclose information about their claims to me, for the purposes of assessing and paying a benefit, if any, and managing the group benefits plan.

In the event there is suspicion and/or evidence of fraud and/or plan abuse concerning claims submitted, I acknowledge and agree that the insurer and/or plan administrator and their service provider(s) may use and disclose relevant personal information to any relevant organization including law enforcement bodies, regulatory bodies, government organizations, medical suppliers and other insurers for the purposes of investigation and prevention of fraud and/or plan abuse.

If there is an overpayment, I authorize the recovery of the full amount of the overpayment from any amount payable under the group benefits plan, and the exchange of personal information with other persons or organizations, including credit agencies, for that purpose.

I hereby assign benefits payable for the eligible claims to the Provider responsible for submitting my claims electronically to the group benefits plan and I authorize the insurer/plan administrator to issue payment directly to the Provider. In the event my claim(s) are declined by the insurer/plan administrator, I understand that I remain responsible for payment to the Provider for any services rendered and/or supplies provided.

I acknowledge and agree that the insurer/plan administrator is under no obligation to accept this Assignment, that any benefit payment made in accordance with this Assignment will discharge the insurer/plan administrator of its obligations with respect to that benefit payment, and that in the event the benefit payment is made to me, the insurer/plan administrator will also be discharged of its obligation with respect to that benefit payment.

I understand that this Assignment will apply to all eligible claims submitted electronically by the Provider and that I may revoke it at any time by providing written notice to the insurer/plan administrator. If I am a spouse or dependent, I confirm that I am authorized by the plan member to execute an assignment of benefit payments to the Provider.

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Rooted In Hope Therapy, PLLC

5330 Griggs Rd, Houston, TX 77021 · 612.389.0270 · doreatha@rootedinhopetherapy.com

PART 2 — Limitation to Confidentiality, Service Agreement & Consents

• Blue Cross Blue Shield Texas
• Blue Cross Blue Shield of Massachusetts (in Texas)
• Quest Behavioral Health (in Texas)
• Carelon Behavioral Health (in Texas)
• Cigna (in Texas)
• Aetna (in Texas)
• Optum
• Medicare and Advantage Plans

Welcome to my practice. I am a Licensed Professional Counselor, Lic# 92035. I completed a Master of Arts Degree in Clinical Mental Health Counseling from the University of the Cumberlands.

This document contains important information about my professional services and business policies. When you sign this document, it represents an agreement between us. We can discuss any questions you have during your first session or at any time in the future.

I may choose to facilitate virtual counseling sessions (via video/phone) through Rooted In Hope Therapy, Doreatha L. Page, Licensed Professional Counselor, Lic# 92035. I understand that I must be at least 16 years old to consent to online or in-person therapy/counseling. If I am under the age of 16, my parent/legal guardian will need to consent for me.

All sessions should be treated like in-office sessions. No outside distractions: please turn off cell phones not in use for therapy and close other computer programs. No third parties will be in or near the session at any time without the therapist's knowledge. Please ensure that you have a private space away from others for your session.

Technical problems may occur. If the call is disrupted, the counselor will call you back shortly. If reconnection cannot occur, the session will be rescheduled at no additional fee.

If I am in crisis or an emergency situation, I will call 911 or immediately go to the nearest hospital emergency room. If I am unable to do this and my counselor/therapist considers me to be of high risk, I understand that they will contact the appropriate service on my behalf.

I understand that if I choose to use my cell phone or land line for my session, I am completely responsible for any breaches of confidentiality, as phones are not considered sufficiently private for this purpose.

In an emergency: Call 911 if life-threatening · Mental Health Help Line: 1-877-303-2642 · Dial 988

Counselor: Doreatha L. Page, M.A., LPC, NCC — License #92035

The personal information you disclose to me will be kept confidential and will not be released without your written consent. However, I will need to break confidentiality if any of the following circumstances arise:

• If there is suspicion of abuse or neglect to a child or a vulnerable adult
• If there is suspicion of serious and imminent risk of harm or death to yourself or others
• If you disclose you have been sexually abused by another regulated health professional
• If there is a court order or subpoena requesting your personal information

Note on Electronic Communication: Email is not considered fully secure and should be limited to scheduling and basic non-clinical matters. All emails are retained by the internet provider. Please do not send sensitive health information via email. Rooted In Hope Therapy does not use text messaging for clinical communication — texts are used for appointment reminders only.

Counseling is an intensely personal process which can bring unpleasant memories or emotions to the surface. There are no guarantees that counseling will work for you. Clients can make improvements and also experience setbacks. Progress may happen slowly. Counseling requires a very active effort on your part — you will need to work on things we discuss outside of sessions.

The benefits you may gain include greater awareness of your thoughts, feelings, and behaviors, healthier relationships, and new ways of coping with challenges. Counseling can be a safe place to express emotions and discuss difficult experiences.

There are also risks: you may experience temporary emotional distress from discussing your experiences and may find it difficult to adjust to changes. I will do my best to ensure a safe space. At the end of each session, we will do a closing exercise if needed to ensure you do not leave with significant emotional distress.

Counseling is a relationship between people that works in part because of clearly defined rights and responsibilities. As a client, you have certain rights and responsibilities that are important to understand, as well as legal limitations to those rights.

Once you agree to attend sessions, you are entering into a professional relationship — not a personal one. Although sessions can be emotionally and psychologically intimate, contact is limited to paid session time. You are not able to invite your counselor to social gatherings, give gifts, or relate to them outside of the professional relationship.

For clients who are dependents (under 18), it is important that parents/guardians understand the nature of the therapeutic activities. Parents/guardians have the right and responsibility to question and understand progress, and to be part of the therapeutic process.

• Sessions are 60 minutes in length per visit, at a time agreed upon by both of us
• Sessions can be scheduled by email and online
• The first few sessions involve assessment of your needs and goal setting
• Together, we will create a framework on which to proceed with therapy
• If you have any questions regarding the process, my qualifications, or anything else, we can discuss them at any time

Cancellation:
• If you miss a session without canceling, or cancel with less than 24 hours' notice, you will be charged a $65 fee to the card on file (unless we mutually agree the absence was due to circumstances beyond your control).

Be On Time:
• You are responsible for coming to your session on time. If you are late, your appointment will still end on time.
• If the previous session runs late, your session length will not be affected.

No Show:
• Failure to arrive for a scheduled appointment will result in a $10 charge to the card on file.

When you book an online therapy appointment, a reminder email or text message is sent 24 hours prior and again 2 hours prior to your appointment.

Email: Email may be used for non-emergency communication such as scheduling, billing inquiries, and appointment confirmations. Email is not secure and should not be used to share sensitive personal health information. Rooted In Hope Therapy uses a secure encrypted email account but email will not be used for clinical counseling purposes.

Please be aware:
• Privacy and security of email cannot be fully guaranteed
• Emails can be misdirected to unintended recipients
• Email is not an acceptable substitute for clinical conversations
• Email may not be checked regularly — follow up if you have not received a response
• Do not use email for crisis or emergency situations — call 911 or 988

Text Messages: Rooted In Hope Therapy does not use text messaging for clinical communication. Texts are used for appointment reminders only.

Session Fees:
• Individual session fee: $130.00 (with insurance)
• Individual session fee: $70.00 (private pay)

Sliding Scale:
• Sliding scale fees can be discussed and agreed upon prior to the initial session
• You will be notified prior to any increase in sliding scale fees
• Payments can only be made by credit card

Credit Card Processing:
• Session co-pays are received via credit card
• A receipt will be sent to your email once payment is received
• You will be required to have a credit card on file
• Your credit card will be processed at the time of session, or in the case of a late cancellation/no-show

Other Services:
• Medical or legal reports will be billed at an hourly rate of $110.00, due at time of production
• Court case involvement: please discuss with your therapist before waiving confidentiality rights

I understand that I am responsible for payment of counseling fees at the end of each session.

By your electronic signature of this form, you authorize charges to your credit card through your practice's secure payment processor for services rendered. These charges will appear on your bank/credit card statement as Rooted In Hope Therapy. You have the right to request a paper copy of this document.

I authorize Rooted In Hope Therapy to charge my credit card for services rendered. I also agree that my credit card can be charged the applicable no-show/late cancellation fee for any session not cancelled at least 24 hours prior to the scheduled session.

I understand that this authorization will remain in effect until I cancel it in writing, and I agree to notify Rooted In Hope Therapy in writing of any changes in my account information or termination of this authorization. I certify that I am an authorized user of this credit card and will not dispute these scheduled transactions with my bank or credit card company as long as the transactions correspond to the terms indicated in this authorization form.

Rooted In Hope Therapy conducts telehealth sessions via VSee Clinic, a HIPAA-compliant, secure (encrypted) video conferencing system. It is virtually impossible for anyone to intercept and decrypt the video and/or audio transmission between two people. However, as with all forms of internet communication, if someone has access to your login details or has installed a virus on your computer, transmissions could potentially be compromised. Your therapist is not responsible for compromised communication due to client-side security issues.

It is very important that you keep your login details secure and private, and routinely check your computer system for viruses and trojans. If all exceptions to confidentiality are extremely rare, it is important for you to be aware of these limitations. If you choose to use a landline or cell phone, please contact your provider for security information.

• Brief records of our sessions and progress will be maintained
• Records will note your presence, interventions used, and general topics discussed
• You are entitled to a copy of your records or to review them at any time
• You have the right to request corrections if you see fit
• Your records will be stored in a secure location
• Your personal information will not be used for any purpose other than delivering counseling services to you

There can be many goals for the counseling relationship. Some may be long-term, such as:
• Improving the quality of your life
• Learning to live with mindfulness
• Self-actualization

Others may be more immediate, such as:
• Decreasing anxiety and depression symptoms
• Developing healthy relationships
• Changing behavior
• Managing pain

Whatever the goals, they will be set by you according to what you want to work on. Your counselor may make suggestions on how to reach your goals, but you decide where you want to go.

Recording of Rooted In Hope Therapy sessions is a violation of our confidentiality agreement and is strictly prohibited. Rooted In Hope Therapy reserves the right to suspend all therapy services to any client who records or re-transmits any part of a counseling session.

Sessions can only be recorded with the consent of both parties, and for supervision purposes only.

The decision to end counseling may be made by either myself or my therapist. Reasons may include:
• The goals of counseling have been met
• Lack of progress
• There is a conflict of interest

If a conflict of interest arises, attempts will be made to resolve it by discussing solutions together. If there is no contact with the therapist for 3 months from your last attended appointment, it will be assumed that counseling services are no longer required. Services may be resumed by mutual agreement.

In the event of my unexpected death or incapacity, another assigned therapist will take possession of files and records, which will be safeguarded, stored, and disposed of appropriately.