Note: A copy of our consent and services agreement is provided below for your convenience (updated on April 10, 2023). If you are a client, please sign the consent and services agreement that was sent to you or reach out to your provider if you aren’t sure where to locate that!
Consent and Services Agreement
Welcome to Thriveworks! This document contains important information about our professional services and business policies. When you sign this document, it will represent an agreement between you and Thriveworks to provide therapy and/or medical services, and that you acknowledge our policies. It is very important that you understand the concepts discussed below. Take your time reading it and discuss any questions you have with your clinician.
About our Services. Our goal is to offer our clients a positive, empowering, and life-enriching experience for our clients. Counseling has both benefits and risks. It 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. Risks may include experiencing uncomfortable feelings, such as sadness, guilt, anxiety, anger, frustration, loneliness, and helplessness because the process of counseling may require discussing the unpleasant aspects of your life. Counseling requires an active effort on your part. To be most successful, you will have to work on things outside of sessions that are discussed in sessions.
In addition to counseling, Thriveworks offers medication management services through our team of nurse practitioners. After an initial evaluation, our nurse practitioners may recommend medication(s), therapy, or a higher level of care. If medication is recommended, it is important to know that medication management can provide both benefits, such as a reduction in symptoms severity, frequency, and improved ease of engagement in therapy. It may also have some risks, such as side effects or allergic reactions. If you continue care at Thriveworks, our clinicians will assess the benefits and risks of your treatment at each appointment and tailor your treatment plan to meet your goals safely. Additionally, our providers can consult with any other prescribers outside of Thriveworks that you see, with your consent, to ensure the appropriateness and safety of any medications potentially prescribed. Lastly, if at any point during your treatment at Thriveworks you require a higher level of care, your clinician will not be able to continue treatment. Thriveworks is not equipped to provide a necessary higher level of care. Your clinician will supply referrals to other providers to assist you in receiving the care you need at the appropriate level.
Confidentiality. You may discuss personal information with your clinician. Confidentiality of that information and your overall privacy are extremely important to us. The Health Insurance Portability and Accountability Act of 1996 (HIPAA) and relevant state and local laws strictly govern how Thriveworks and your clinician handle your protected health information (PHI). Thriveworks is considered a “covered entity” under HIPAA, meaning we comply with HIPAA privacy rules. Generally, there are three things we can use your protected health information for – treatment, payment, and healthcare operations. Our full notice of privacy practices was provided to you in your email confirmation, and can also be found on our website: https://thriveworks.com/wp-content/uploads/2022/11/thriveworks_notice_of_privacy_practices.pdf.
As a HIPAA covered entity, Thriveworks keeps all of your Protected Health Information (PHI) (including any communications you have with your clinician) strictly confidential. However, there are exceptions to this confidence – including situations where Thriveworks must disclose information pursuant to state and federal law. The following is a list of some, but not all, exceptions:
- the client signs a written consent or authorization to use or disclose PHI;
- the client expresses serious intent to harm self or someone else;
- there is reasonable suspicion of abuse or neglect against a minor, elderly person, or dependent adult;
- for billing purposes;
- for supervision purposes;
- a subpoena or court order requires disclosure.
If you decide to participate in couples, family or group treatment (“Client Unit”), confidentiality rules become more specific. For example, in compliance with applicable ethical codes, including section 2.2. and 2.3 of the AAMFT Code of Ethics, PHI relating to the Client Unit will not be shared outside of the treatment session without a written authorization from each individual competent to execute a release, subject to any legal exceptions requiring disclosure. If you have any concerns, please ask your clinician about these policies before beginning Client Unit sessions. You agree to this policy regardless of who is listed as the ‘identified patient’ for insurance payments, as applicable.
Additionally, Thriveworks has a No Secrets Policy. This means that your clinician may, within their clinical discretion, share information within sessions with other members of the Client Unit participating in the treatment. Your clinician will always use their best clinical judgment regarding your therapeutic treatment; however, Thriveworks will not guarantee that the information provided to the clinician will be kept secret from the other members of the Client Unit. This does not include the release of medical records to any member of the Client Unit or any PHI to a third party without separate written authorization from every member.
Your clinician may live and work in the community in which treatment is being provided. If you see your clinician outside of a session, Thriveworks’ policy is that your clinician will not acknowledge you unless you acknowledge your clinician first. This is to protect your confidentiality.
Lastly, you hereby agree not to summon your clinician to court as a witness for any purpose or involve your clinician in any legal proceeding requiring them to compromise the duty of confidentiality, aside from a general records request. Should your clinician be subpoenaed upon your direction to testify or be deposed, you will be responsible for paying the clinician their hourly rate for the number of hours managing and/or attending in regards to any subpoena, plus mileage if applicable. Note insurance does not cover these costs.
Clinician-Client Relationship. Once you sign this Agreement, you become a client of Thriveworks. However, the formal client-clinician relationship is not established until such time as your clinician determines that they, and Thriveworks, are an appropriate fit for the care you require. Of course, Thriveworks values your privacy and will maintain your personal information, including PHI, in accordance with all applicable laws throughout this process whether or not you continue a relationship with a Thriveworks clinician.
Clinician Qualifications. Thriveworks employs highly qualified licensed and provisionally licensed clinicians. You acknowledge that, where not prohibited by license status or state regulation, your session may be conducted by a provisionally licensed professional under the direct active supervision of a fully licensed clinician. If you would like to learn the license status of your clinician, you can find that information in their bio on www.thriveworks.com. If you have any other questions, please email firstname.lastname@example.org.
Medical Records. We are required to keep appropriate records of the healthcare services that we provide to you. Your records are maintained in a secure electronic health record. Except in unusual circumstances involving danger to yourself, you have the right to a copy of your health records with proper authorization. Please also see the reference to Client Unit sessions explained above. For more information regarding how your electronic health records are managed, please see our full notice of privacy practices on our website. You may find more information on requesting your medical records on our website.
Electronic Communication & Online Counseling. Telephone (including text), email, and videoconference are not encrypted methods of communication, and some confidentiality risk exists with their use. Our team communicates using these methods. While we do our best to verify your email address, phone number and address at the time of intake, it is your responsibility to update your record if you would like to communicate via a different means, or if any of your contact information has changed. By signing this Consent and Services Agreement, you consent to your clinician, or someone from our team, following up with you by telephone, text or email for scheduling, billing, quality assurance, or other reasons. If you would prefer not to be contacted by email and/or text or need to update your information, you may contact us at email@example.com or 1 (855) 2-THRIVE.
If you and your clinician are participating in online counseling and/or psychiatry sessions, the clinician will abide by the laws, rules and ethical codes of their state of licensure when providing these services. While a growing base of research has shown that online counseling and/or psychiatry services can be effective, such services are relatively new in comparison to traditional in-person counseling, which has a much longer track record of positive outcomes. Online counseling may not be appropriate for some clients and for the treatment of some mental health issues.
Conflicts. We work hard to ensure that you have a positive experience. If you don’t have a great experience, please tell us and we will try to make it right by contacting firstname.lastname@example.org or 1 (855) 2-THRIVE. If a conflict occurs, it is agreed that any disputes shall be negotiated directly between the parties. If these negotiations are not satisfactory, then the parties agree to mediate any differences. Litigation shall be considered only if these methods are given a good faith effort.
Emergency Contacts. Your clinician will establish emergency contacts for you, such as a family member. These contacts may be used if your clinician perceives a need. If you are actively suicidal, or have been hospitalized for a mental health reason in the past 90 days prior to signing this Agreement, please inform our support staff by calling 1 (855) 2-THRIVE. If you are in crisis, please go to your nearest emergency room or call the hotline emergency number by dialing 988. See additional help here: https://thriveworks.com/immediate-help.
Inactive Clients. If you, as the client, fail to attend a session within 30 days of your last counseling session, or within 180 days of your last psychiatry session, Thriveworks will assume you have concluded your relationship with your current clinician unless other arrangements are made. At any time after you have concluded your relationship with your clinician, you may contact Thriveworks to schedule an appointment with your former clinician or a new clinician. You agree that Thriveworks may contact you when you become an inactive client for feedback or other purposes. You may opt out by contacting us at email@example.com or 1 (855) 2-THRIVE.
Minors. To provide services to clients younger than 18 years old, Thriveworks requires written consent from parent(s), legal guardian(s), or other individual(s) legally authorized to provide consent, who legally must provide consent pursuant to state law or court order, including custody agreements. Note, however, that in certain circumstances Thriveworks’ policies may be more strict than what is legally required in order to protect a minor client’s interests. We will use reasonable efforts to determine who has the legal authority to consent to treatment of a minor. If the parents of a minor are separated or divorced, a copy of the divorce decree or custody agreement must be provided, if available. If you are signing this consent on behalf of a minor and are aware that consent of additional individuals is required prior to treatment, it is your responsibility to provide Thriveworks with that information.
Coordination of Care. Thriveworks believes in integrated health care. Therefore, we ask that you provide your clinician with your primary care physician’s (PCP) name and contact information shortly after your initial appointment. Your clinician will also request a Release of Information (ROI) form be completed so that they may coordinate your care with your PCP or other relevant stakeholders such as schools or therapy programs, to ensure the best possible outcome.
Psychiatry Program. At Thriveworks, we offer well-rounded treatment by providing our clients the ability to obtain psychiatry services through our clinicians qualified to prescribe and manage prescription medication. If you choose to utilize these services, you understand and give consent for Thriveworks to retrieve your prescription history as part of your participation in the program. Thriveworks uses a Prescription Monitoring Program which serves as a registry to track prescriptions for controlled substances. When you sign up for these services, you will receive information on how the service works, client-facing policies, and how to obtain prescriptions. Make sure to read and review these carefully.
Billing. You agree that Thriveworks may bill any insurance through the information you provide. Thriveworks will attempt to verify benefits on your behalf. However, benefits are not a guarantee of full or partial payment by your insurance company. You will be responsible for any co-pays or other non-covered fees or costs. Additionally, your employer may be responsible for co-pays or other non-covered fees or costs that may be owed to Thriveworks. In the event your insurance and/or your employer does not cover costs, you will be responsible for any co-pays, deductibles, or other non-covered fees or costs. If your insurance has termed or is unable to be verified, our team will reach out to you to remedy the issue. If the issue cannot be remedied, you will be responsible for the self-pay rate of any sessions that may occur. As described above, there may be situations in which you are responsible for the entire cost of services (e.g. an unmet deductible) and we may be contractually obligated to charge you more than our advertised self-pay rate. If your insurance has termed or is unable to be verified, our team will reach out to attempt to remedy the issue. If the issue cannot be remedied, you will be responsible for the self-pay rate of any sessions that may occur. As described above, there may be situations in which you are responsible for the entire cost of services (e.g. an unmet deductible) and we may be contractually obligated to charge you more than our advertised self-pay rate. If you have further questions about your insurance coverage, please contact your insurer directly.
Self-pay Clients. If you are a self-pay client, meaning you do not have insurance or you choose not to use your insurance, you have the right to request a Good Faith Estimate (GFE) explaining how much your therapy or psychiatry services are likely to cost. This includes the total expected cost of any non-emergency item or service such as those offered at Thriveworks. We will provide you with a GFE upon request at least one (1) business day before your scheduled session. You can request your GFE by emailing firstname.lastname@example.org. If you receive a bill for at least $400 more than your GFE, you can dispute the bill by visiting https://www.cms.gov/nosurprises/consumers/medical-bill-disagreements-if-you-are-uninsured. Make sure to save a copy of your GFE. Questions on your rights can be directed to www.cms.gov/nosurprises or call 1-800-958-3059.
Fees and Cancellation. You consent to Thriveworks securely retaining the credit card information you provide. You are responsible for paying all amounts not covered by insurance and ensuring your payment information is up-to-date. Costs may include a copayment, cost share, deductible, or other fees, which will be charged to the card on file as soon as possible after your insurance company provides Thriveworks with your explanation of benefits. Any balance owed will be charged on a weekly basis. Payment must be made by credit or debit card; we are not able to accept cash or checks. To change your method of payment, you may contact email@example.com. If you refuse to pay your debt, we reserve the right to use an attorney or collection agency to secure payment. Please note that we may be required to provide limited information about you and your treatment to a third party who is associated with your payment method (e.g., if you utilize a parent’s or spouse’s credit card), but that disclosure will be limited to the information necessary to resolve the applicable billing issue.
If you miss a session without canceling or cancel with less than 48-hours’ notice, our policy is to charge you a cancellation fee of $135 (see policy below), if applicable. Insurance companies do not provide reimbursement for canceled sessions and you will be responsible for the cancellation fee. You may schedule a new appointment by contacting firstname.lastname@example.org or 1 (855) 2-THRIVE. We will keep your credit card information on file, and you agree for it to be used to collect these fees.
Thriveworks charges for other professional services that you may require, such as producing your medical records to you or third parties, report or summary writing, or the time required to perform any other service which you may request of your clinician.
Thriveworks Policies: Any Thriveworks policy mentioned in this Consent and Services Agreement, on the Thriveworks website, or any other Thriveworks policy is subject to change at any time without prior notice.
Law: This Consent and Services Agreement is governed by the laws of the state in which you are located when receiving services. Where this Consent and Services Agreement differs from relevant state or federal laws, those laws will govern.
State Specific Addenda:
California: NOTICE TO CLIENTS The Board of Behavioral Sciences receives and responds to complaints regarding services provided within the scope of practice of marriage and family therapists, licensed educational psychologists, clinical social workers, and professional clinical counselors. You may contact the board online at www.bbs.ca.gov, or by calling (916) 574-7830.
Oregon: The Board of Licensed Professional Counselors and Therapists receives and responds to complaints regarding services provided within the scope of practice of marriage and family therapists and professional counselors. You may contact the board online at www.oregon.gov/oblpct, or by calling (503) 378-5499.
Texas: The Texas Behavioral Health Executive Council receives and responds to complaints regarding services provided within the scope of practice of marriage and family therapists, professional counselors, psychologists, and social workers. You may contact the council online at www.bhec.texas.gov, or by calling (800) 821-3205.
48-hour Cancellation Policy
At Thriveworks, we aim to provide mental healthcare access within seven days not seven weeks, unlike much of the mental health industry. Our high-quality, licensed clinicians are in high demand, and their time is carefully booked out in advance. Therefore, we have a strict cancellation policy to ensure our clinicians can manage their schedule, as their time is our most valuable commodity.
Please note this Policy may be changed at any time by Thriveworks without prior notice. Further, your employer, if applicable, may cover these costs.
If you cancel your appointment less than forty-eight (48) hours prior to your scheduled appointment time, you will be charged a $135 cancellation fee. You may schedule a new appointment at any time.
If you do not show up for your appointment and have not canceled more than forty-eight (48) hours prior to the scheduled time, you will be charged a $135 cancellation fee. You may schedule a new appointment at any time.
Note that the fees mentioned above are not reimbursable by insurance providers, and will be charged to the credit card on file. All cancellation fees are subject to rules and restrictions that may be governed by any state or federal law.