Informed Consent for Online Therapy
So, I’m incredibly grateful for all of your support and kind comments in the past year, and I look forward to growing this podcast even more as we explore this incredibly dynamic and growing field. And I want to take just a moment and tell you about a new podcast that has just published, and if you like the Online Counseling Podcast, you are going to love Therapy Tech with Rob and Roy. Now, if you have done any research online in regards to technology and therapy, and how HIPAA impacts our lives, you will be familiar with two names, Roy Huggins and Rob Reinhardt. They are the go-to people for all things tech related with counseling.
CC: Now, can you imagine what it would be like if these two titans came together as a partnership and did a podcast about therapy and technology? Well, you don’t have to wonder. They actually did it, and it’s amazing. And their very first guest was another big leader in our field, Melvin Varghese of Selling the Couch. I know, It’s like almost too good to be true, but it is. So, go subscribe, go listen to this. They have three episodes so far. There’s gonna be more to come. It’s an entire series. To find them, go to their website, therapytechrobroy.com. That’s therapytechrobroy.com. You won’t be disappointed. These gentleman have incredible value. They have helped our field and our industry for years, and now they’ve come together and put together something really, really amazing. So, go check them out.
CC: Okay. A quick commercial for us. I know we have a lot of new listeners, so just want to let you know that this podcast is an extension of the Online Therapy Directory, which is modeled after Psychology Today’s directory for therapists. We are a listing service for therapists who are working online. And we have three goals. We want to help online counselors grow their practices by getting new clients. We want to help people all over the world, who are looking for psychotherapy online, find licensed and qualified providers. And finally, we want to educate therapists on the ethical and legal requirements for online counseling, and keep you updated on developments in the field. And for a small monthly fee of $24.95 a month, you can list your practice with us. It’s really fast to get set up. It takes about five minutes. And we will get everything reviewed and approved in about a day, and get you live to the site.
CC: This summer, we have been running a special annual membership level, which brings the fee down to around $12.47 a month when you pay for your year up front, and that membership will be ending, that offer will be ending on September 1st. So, if you were thinking of signing up and wanted to get in at an incredibly low price, you have only a few days left to take advantage. Just go to onlinecounseling.com and click on list My practice.
CC: Okay. On to today’s episode. I’ve been saving this interview for a special occasion and I thought the 50th episode would be perfect. And one of the biggest questions we receive is in regards to paperwork. How do I, as an online counselor, need to adjust my informed consent and other paperwork to include the needs of online counseling? A few episodes back, we had the amazing Maelisa Hall, of qaprep.com, come on the show and talk about this, and today we go even further into the general needs of informed consent, and then how it needs to be adjusted for online counseling. Our guests today are Katie Lemieux and Kate Campbell of The Private Practice Startup. These amazing therapists have a passion for helping therapists start and grow their practices, and making sure they have all the necessary tools to be successful. And one of those important tools is your informed consent. Now, upfront, I will say, this podcast had its challenges. The first time we recorded, we were cut short by jackhammering across the street from my office, not a pretty picture. Can you imagine how my therapy sessions went later that day?
CC: Anyway, Kate had to leave for a vacation the next week, so Katie was kind enough to come back today and finish the interview, and I was so grateful she did. There’s a lot of great value here. We spend the first several minutes talking about informed consent, in general. And I know I learned some things that need to be adjusted in my own paperwork. But then we went deep into the topic of online counseling and the specific needs for your informed consent when it comes to telemental health, or what Kate and Katie call, technology assisted counseling, or TAC. And be sure to stay until the end, because Katie gives away a huge freebie and a discount code for something really important. So, be sure to listen to that, and it’s gonna be in the show notes, too. Okay. Again, thanks everyone for your support, and here is Episode 50.
CC: Hello and welcome to the Online Counseling Podcast. I am so excited to speak with Kate Campbell and Katie Lemieux of The Private Practice Startup and K2 Visionaries. These two ladies have been incredibly patient with jackhammering and tech issues, and welcome to the world of telemental health. We just figure it out and keep going, don’t we?
Katie Lemieux: That’s right.
Kate Campbell: That’s exactly right.
KL: What’s up, everybody?
KC: What’s up? We’re happy to be here.
CC: Oh, I am so. Just grateful for your patience with all of our issues today, but this is gonna be great. Tell me a little bit… Today we want to talk about paperwork related to online counseling, online therapy, telemental health, whatever you wanna call it, particularly informed consent. But before we jump into that, tell us a little bit about the two of you and your Private Practice Startup.
KL: Okay, great. Kate and I have known each other since 2006. We actually initially came together during supervision, and then our paths crossed a few more times and we became president and vice president of our local chapter here, called the Broward Association for Marriage and Family Therapy. At that time, we realized we both had the same drive, leadership, mentality. And we initially started our company, as you mentioned, as K2 Visionaries, and we’ve completely transferred over into The Private Practice Startup because, last year, we decided to go global with our company. Initially, it was a statewide training-based company, we started off with the supervision course here. We also teach ethics and boundaries, laws and rules, medical errors. All those typically boring courses, we really like to make them fun. We love talking about paperwork, and our goal here is to not only make this informative but fun and for you guys to learn quite a bit.
KC: And so, as we launched The Private Practice Startup, we really specialize in working with mental health professionals who are ambitious and wanting to brand themselves and grow their dream private practices. And like Katie said, we wanted to go global so we expanded our reach and we offer the private practice coaching, private practice paperwork.
KL: Podcast, which Clay was on, Episode 18. He was on our podcast.
CC: Yes, absolutely.
KC: Exactly. Yeah. It was so great to be on the flip side here because we had such an awesome podcast with you talking about the online counseling stuff, so here we’re coming full circle.
CC: Full circle. You’re global, so you’re working with online therapists around the world, Australia, UK, it doesn’t matter, ’cause you’re essentially starting a business. And I imagine there’s some differences here and there between the different markets, but what’s it like to go global?
KL: Yeah. Our reach definitely is expanding. We had Singapore, London, and so those are people getting to know us. We’re creating relationships with them. And we’re actually going to be releasing this year more of a coaching process system to help a therapist really create their vision, their mission, their culture, as well as talk about marketing messages. I hear therapists so much are always struggling with marketing, and I said to Kate… A few months ago, I said “You know what a therapist really want?” And it’s always clients. I think any business wants clients, and I said, “Let’s shape our niche to really help therapist exactly say what they need to say to attract their ideal clients.” I think therapists jump from “I need to market,” and then just go slap some stuff somewhere,” and it’s a lot of sales pitching and, “Hey, I’m great,” or, “Hey, I have all these degrees.” And that’s not what make… That’s not why clients come in. So, we’ve done a lot of education training, ridiculous amount, and we’re really passionate about this because it’s awesome when therapists actually see and get the results that they’re looking for just by being able to connect with their client through language, through blogs, through their therapy directories and also their websites. So, that’s where we’re going, which does serve the global market.
KC: Yeah. It’s really just helping people to get very clear on their brand and then to clarify their message so that they’re able to reach their ideal clients and have their ideal clients really be attracted to wanting to work with them.
KL: And not only that, really positioned them in a different space in the field, so it’s a non-insurance-based type practice. We’re gonna position you in a way where people say, “I gotta have what you do and I don’t care what it costs.”
CC: Okay, great.
KC: That’s what we’re really passionate about.
CC: So, you’re working with people who are startup, just they are straight out beginning their practice. And I also imagine people that have been struggling for a little while, they’re not happy where they currently are with their practice and wanna take it to a more successful level. Right? Okay. Now, how many of these are also exploring the world of online counseling to expand their reach?
KL: We have therapists, from all different mixtures. We do get contacts. Actually, we get contacts about your podcast and say, “How can I connect with Clay? I wanna learn more about online counseling.” So, there’s a few therapists that do online counseling as well that we’ve come into. I know I do a hybrid more for convenience for my own practice, when either timing or travel is just not effective and efficient. Have you done some?
KC: Yes. I’ve done some as well. We both have our own private practices down here in South Florida as well, in addition to having The Private Practice Startup. We’re both involved with the online counseling. It’s a portion of what we do, and then also have coachees and members of what we call “startup nation” who are very much into the online counseling, too.
CC: Wow, that’s great. There’s a typical progression that I see with therapists who are beginning to explore this. One is, what about the state licensure issue? And once they figured that out, they’re like, “Okay, I can practice where I’m licensed. All good. Wait a minute, I can’t use Skype? What do I use?” So, they learn about Zoom, they learn about Doxy.me, they learn about VC. Great, and so they’re getting ready to get started and they go, “Whoa, wait a minute, what about my informed consent? What about my paperwork? That’s gotta be a little different, right?” So, maybe because, on the podcast, we’ve answered so many questions about the how, meaning the platform, the where, meaning where can you do this, let’s maybe delve into the paperwork questions. Where do we start?
KL: Well, I think it’s important, like you had mentioned, let’s start with informed consent overall. It’s really important. And I know sometimes therapists just move into the online counseling world and think like maybe it’s different, or something like that, but it’s not, in regards to paperwork. Informed consent obviously has a lot of things. Our informed consent is about eight pages long.
KC: Yeah. Basically we wanna talk about the ethical aspects to both informed consent and then Telehealth, also known as technology assisted counseling, online counseling. For ease of referring to it on the podcast here, we’re gonna call it “TAC.” We’re gonna talk about tips for TAC and then tips for the consent form in general, so we’re gonna give the ethical and best practices for both of those.
CC: Excellent. Okay.
KL: For us, because we do serve, like you said, all populations in regards to whether they’re just in office or online, we have our own consent, which is specific for everyone, and then we have a specific TAC consent, which then hits on the specific things that you need for tele-counseling.
CC: Okay.
KL: Okay? Number one, confidentiality, I think that’s a no-brainer. We know that we need… Confidentiality needs to be in the consent and, of course, the major issues in regards to abuse, harm to self, or harm to others. Those definitely need to be in there.
KC: And so that may differ from state to state, making sure that you’re clear on what the laws and rules are in your state, or if you’re located internationally, out of the US, being very clear on that stuff too.
KL: Of course, the benefits and risk, which is interesting, because back in… It must have been after 2012. I was getting ready for… I don’t know if I was getting ready for my supervision session, but I remember reading through my ethics, and I know that most people don’t, ’cause it’s just one of those put you to sleep at night type of thing. And I came across a place where it talks about informed consent and having the risks and benefits in your consent, and I was like, “Oh, I don’t have that.” So, really talking about the risks and benefits of therapy. And then when we talk about TAC, there’s specific benefits and limitations in regards to TAC.
KL: And then also talking about the expectations of online therapy as well, what can they expect of the process, what can they expect of you as a therapist. And then also, what do you expect of them as clients? What are your expectations of them? So, looking at that on both sides is really important.
CC: Okay, really important.
KL: Yeah. And it’s good to… Kate actually… We actually just did a paperwork launch, and one of the follow-up emails that we sent to everybody was a video on how to use the paperwork as a conversation for that initial session, which is really cool because it sets the structure of therapy. We definitely talk about cancellation policy, answer any questions they have. I know, for me, there’s maybe sometimes people cancel less than 24 hours. But overall, my client’s value our time together and my time, and so that becomes a non-issue. But it also allows a really clear structure in working together.
CC: Yeah. That’s an interesting point, because I know a lot of therapists, and even my dentist and my doctor, you show up and they go, “Okay, here’s a packet of papers, just sign these. It’s not really important, it’s just a procedural thing. We gotta jump through this hoop.” Versus, “Here’s the way we’re gonna begin the conversation. There are some things that you need to be aware of. We’re gonna set expectations, we’re gonna set some boundaries.” So, the paperwork is a guide for that, and that can be the same for online work, certainly face-to-face work.
KL: Right.
KC: Absolutely. It really gets you on the same page, and both of you know what to expect from the process, and it really helps out.
KL: So, some of the other things that need to be in your regular consent is court orders and legal issued subpoenas, how you’re gonna deal with that. Of course, talking about written release, release of information, covering that in regards to confidentiality, if clients are requesting you to involve other parties, collaborate in different ways, that’s really important.
KC: You also need to make sure that you have a clause or whatever your policy is around medical records. So, what is the process for when you provide medical records for your clients, and what is the cost associated with that? What’s the norm? What’s gonna be your process, and just being very clear about that. And then, of course, fees, fees, fees. That is actually in our ethics, that we actually have to let our clients know. I think some of the ethics don’t say it has to be written but, of course, we recommend it being written. I think I’ve heard some horror stories where therapists were kind of like, “Oh, I know this client comes from an affluent area, so I charge them more.” Like, “No, you can’t do that. It needs to be… ” Yeah, I’ve heard stories like that before.
KC: It’s funny because I remember being on LinkedIn one time, I get a little crazy when it comes to compliance, I guess. And there was someone on LinkedIn who was a registered intern, and I said something about billing insurance. And I emailed her, trying to be nice, and she never emailed me back, and I was like, “Katie, I need to stop trying to be the compliance police.” But, yeah, I’ve definitely heard crazy stories about stuff like that. But your fees really need to be laid out in your consent, it’s clear. Another thing, too, is assure that the clients get a copy of your consent. I think that’s important, if they ever need to refer back to it for any reason, or if there’s any discrepancies. You know what I’m saying?
KL: Yeah. Or questions down the line, you can say, “Okay. Well, let’s refer to the paperwork. You have a copy of that.” But coming back to fees, obviously fees for your rates, for your sessions, and also, if there’s any communication outside of session, how are you going to bill for that? Are you going to bill for that? If someone’s talking to you for 30 minutes on the phone, or you’re consulting with another provider, or you’re reading reports or evaluations, or those types of things. Or maybe you’re even writing reports and evaluations, how are you going to bill for that time?
KC: And then, of course, it’s always different with insurance-based clients. Right?
KL: Yes, of course.
KC: You need to be clear on who the client is. I just wanna make sure we’re clear on that.
KL: Of course, yes.
KC: Obviously, policies around electronic communication, so people who are doing TAC are utilizing electronic communication anyway. So, what are your basic policies and procedures? Do you take text? Do you prefer phone? Is it a HIPAA-compliant email? I know sometimes clients, they have my email and they’ll just email me books, and I always tell them, I’m like, “I will never respond to you through email. I’m always gonna call you, so I prefer that you not email me.” But sometimes they do anyway.
KL: And depending on what type of population you work with, you wanna think about some of the risks associated to communicating through text or email, and those types of things, because if… Say, you’re working with a domestic violence type of couple or individual, and they text you and say, “Hey, what time is our appointment today?” And maybe it’s actually not them, it’s their partner and they’re wanting to know, and they show up at your office, or maybe they’re actually listening on the other side, holding the computer where you can’t see the view of them, but they’re listening, and so you’re not getting the full picture from your client because their abusive partner is there. So, you just kinda wanna think about some of those things and some of the risks that can happen when you’re using forms of communication like that.
CC: Okay. Absolutely.
KC: Some other stuff are how do you schedule appointments. Do they do that with you? Do you give reminder, text, calls? Or do you have an online system where they schedule their own appointment, cancellation policy? If you are a fee-based practice, do you charge for cancellations? What’s the rules around that? And if you’re an insurance-based practice, many times obviously, you’re not able to charge clients. But maybe you have some rules about if you miss one or two sessions within X amount of time, I might have to refer you out. You just wanna be clear on your own policy and obviously stick to that for yourself.
KL: In addition to those policies, you wanna make sure in your consent form that you have a policy about your phone contacts and emergencies, what your office hours are, what your availability is outside of those office hours. Will you be available on the weekends? And also who to contact if they’re in crisis, do you want them contacting you? What happens if you’re not available? If they’re suicidal, where do they go? Who do they contact? What are those numbers, for the local resources in your area, beyond just 911? But maybe the suicide hotline, and maybe some other types of programs or resources that are in the area that you’re providing the services.
CC: Okay. Which brings up an interesting point. When you’re working with someone, telemental health, you’re not in the same town, it’s important, I would imagine, to have some kind of emergency contact and know the local police numbers or fire department numbers of where they are located. Do you have the clients provide that information?
KC: We do.
KL: Yes, we do. We do. And we’re starting with consent, with the basic consent, and like we were saying, we have the consent and then we have the TAC consent. And so in our TAC consent, we highly recommend that you not only have the emergency contacts in their area because, if you pick up 911, the call, because they call to let you know that they’re suicidal or a homicidal or something like that, and you need to call 911, it’s gonna ring in your area, not their area.
CC: Not their area, right.
KL: Yes. So, we can touch on that a little bit more when we get to TAC. Yeah, so that’s coming up. Great question.
CC: Okay. Absolutely. I’m so anxious.
[laughter]
KL: And I’m sure you’re asking questions that the listeners are thinking, so I think that’s awesome. I’m sure they’re wondering all this good stuff. Other things we talk about is the structure of therapy, just laying that out. What does that look like for you? Maybe you practice in a certain model and you have 12 sessions, so what do those sessions look like briefly? Maybe you just talk about is there intake, goal planning or treatment planning, discharge. I think it’s just nice for people to know overall the structure of therapy and what they can expect. I’m sure many people ask you, I know they ask me, one of the favorite questions is, “How long is this gonna take? How many sessions do I need?” Sometimes it’s a little hard to tell exactly, but to give people some type of range, I think that’s really helpful for them to conceptualize partaking in sessions and what that all looks like for them.
KC: Yeah. And depending on where you live, having a… Well, regardless of where you live, you’re gonna run into your clients at some point or another. We live in a pretty busy community down here in South Florida, and I run into my clients often. So, having those conversations with them, having your consent form about how you’d handle that, if you run into them. And if you’re living somewhere in a rural area, maybe you’re in Alaska, and you’re the therapist for the local butcher in town and you have to go and you wanna get some meat and that’s the place that you have to go, and talking through how you’re gonna handle these types of situations, it’s important.
KL: Right. And our ethics really talk about always trying to avoid any dual relationship. Sometimes they’re unavoidable, and then talking through that stuff is really important. With dual relationships, there’s a lot of conversation about social media. Clay, I know that when you are on our podcast, you were telling us about NASW, working on and updating their ethics. Obviously, they’re released now, so that’s exciting. And you’ll be happy to know that I combed through all 64 pages, I think it was.
CC: Oh, my word. You may be the only person. I got that, and I went, “Oh, Lord.”
[laughter]
KL: And there’s a lot of stuff on social media, which is great, and I even see people being more specific on the social media policies. And so things like you can’t look up your clients, you shouldn’t be doing that, unless there’s an issue where you’re worried about their safety. I know that I’ve actually worked… Being down here in South Florida, we have a lot of professional athletes. I’ve worked with professional athletes, and really just avoid looking them up because you just wanna be fully present with who they are in the room. That’s really important. So, having a social media policy, of course, connecting with you, encouraging clients not to obviously try to reach you on personal things, but if they also do wanna post something on your business page or your LinkedIn, and it’s public, you can’t protect their confidentiality. So, those are just some things.
KC: Let me talk about this. I’m sure you guys are wondering and thinking about your own consent form and wondering, “Oh, gosh, what do I have in there? What do I need to update? What do I need to review? How can I cross reference with what they’re talking about today? And I’m sure you guys are thinking lots about that.
KL: And that’s a cool idea, using this podcast just to check to see what you guys do have. And, of course, we’re available for questions. You can always reach out to us, and we’re happy to help too.
KC: Yeah. Another area that’s really important to talk about, speaking of coming back to fees, if there’s ever any type of a fee dispute… You guys really work really hard for your money and it’s not ideal to have to chase it. And so having a little clause in case of… Of course, you have your cancellation policy, but you have a clause if your client no shows for no apparent reason, or they just forget or whatever, and they try and dispute that with their credit card company. I actually had that happen to me with a client, a couple of clients that I was seeing a couple of years back, and at that point in time, I had my… They had signed the consent form, and they had given me their credit card information to keep on file, and so I had that stored in my credit card processor. And so I was able to bill when the individual male client didn’t show for his initial session. And he tried to dispute that with the credit card company, even though we had had that conversation, they were on the same page. And the credit card company wanted to have his consent form sent in, proving that he had agreed to the cancellation policy. So, I had him sign a release that I could do that, he agreed to have me do that, and the credit card company aired in my favor, and I ended up getting paid for that session, and we were able to work through it, and I continued working with that couple.
KC: Luckily, it didn’t damage the therapeutic relationship. But those are the types of things that happen, and that was one of the situations that happened. And Katie and I use that as an opportunity to update our forms so that there is a fee dispute clause. Because if you’re working with someone who’s… Maybe you’re taking insurance, and insurance decides not to reimburse you for the year of therapy that you did with them, how would you handle that? So, you just wanna think about what is the nature of your business, your business model, your practice, and your policies and procedures around things like this.
KL: And so we call that a bonus, and also a “Kate and Katie ninja tip.” Again, that was from experience, and we do the hashtag… I was doing the hashtag, I’m like, “Wait, we’re on a podcast. They can’t see us. So, everybody put your fingers together do a hashtag and say “ninja tip. Okay, great.” [laughter] Come to our live event and we’ll do it, do it live. So, that’s something, like he said, is we gain from experience. And another we gain from experience was your appendectomy. Sorry.
KC: Yeah. Yeah, yeah, exactly. [laughter] I’m convinced writing my dissertation killed my appendix. And just shortly after I graduated with my PhD, back in 2011, all of a sudden I have this full week of clients and my appendix decided to flake out on me, and so I had to go into the hospital for emergency appendectomy.
KL: Is that the actual medical term for that?
KC: Yeah, it totally flaked out on me.
CC: It flaked out on… Yeah. Got it.
KL: And at the time, there was no way I could call my clients. And back then, I didn’t have an assistant working for me, and so I had had luckily a colleague of mine who works at my private practice with me that was able to call my clients. And after that, we realized, “Oh, gosh, we need to be making sure that there is a clause in the paperwork so that if there’s ever a situation where you’re not capable of calling your clients, you’re not able to, maybe you’re in a car accident, something happens, who’s gonna be that next person who contacts your clients and you can make sure that they’re aware of that.”
CC: Well, we’ve learned something today, that in New York City, the construction union has a half hour lunch. [chuckle] We were hoping for an hour lunch, but the union rules just didn’t work out at the lightest negotiations, so they only get a half hour lunch and they have now returned. So, why don’t we stop the recording now and we can pick up at the appendectomy when we come back together.
[laughter]
KL: Okay, that sounds good, jackhammers and appendectomy, who thought we would be talking about those things today. Right?
CC: Absolutely. Oh, my goodness.
KL: That’s a good Facebook post. “What do jackhammers and appendectomies have in common in online counseling,” question mark.
CC: Yes. That’s gonna be part of my promo.
[chuckle]
CC: Hello and welcome back. We just had a little tiny break. This is part two recorded a few days later, because living in Manhattan right across the street from jackhammering, we didn’t wanna put our listeners through listening to jackhammers and learning about paperwork. That just seems like torture. Now, it’s Monday morning, and Kate Campbell is now on vacation. And we’re going to wrap up some of the issues about paperwork and specifically how it applies to technically assisted… Technology assisted counseling with Katie Lemieux. Katie, thank you so much for coming back and helping us wrap up this important topic.
KL: Of course. Of course. Yeah. I know we were talking about consent overall, so let’s just jump in there. I think where we left off is we were also talking about some bonuses that we offer in our consent. Some therapists take insurance, some therapists don’t, some do a hybrid. I know, too, especially now with technology assisted counseling, self-help assistance counseling, whatever we wanna call it, insurance is starting to move towards covering some of those services.
CC: I know. It’s really cool.
KL: Yeah, that’s really exciting. Of course, you need to contact your insurance company in whatever state you’re in to make sure that, if they do cover it or not, etcetera, etcetera. But Kate and I, in our consent, we have… Because we don’t take any insurance, we talk about the benefits, the pros and cons of taking insurance. And then for those who have insurance, we have a separate consent that talks about the pros and cons of insurance. So, just kind of explaining that to people so that they’re educated consumers. That’s something that we also add. Another thing that we add, and I know that we talked about this last time after we got off the podcast, but another thing too is it’s really cool nowadays… When I got into practice probably about 10 or so years ago, it’s still kind of like that, I don’t know, psychodynamic feel in the sense of just the office with the four walls. Right?
CC: Right.
KL: And online therapy has so evolved from that, and people are doing some awesome creative things. Clay, we know that you do walk and talk therapy in Manhattan, so you might be doing sessions outside or you might be doing equine therapy or some type of intensive or retreat, or you add some experiential processes. Maybe you work with… I don’t know, maybe you work with kids on the spectrum, or autistic children, and you take them actually out to do social skills engagement. So, you just wanna have a clause in your consent about that, about what does that look like, how will you protect their confidentiality, but also just creates a conversation if the client has any worry or concerns and stuff like that.
KL: And then Kate and I work with couples. We have a no secrets policy in our consent, where we talk about in regards to if they disclose any secrets. I always make a joke about it. I think that’s why I make lots of jokes about stuff and therapy, it’s a disease, that we have fun, too, so I get people laughing right away, that’s really important. But basically the no secrets policy just states to the effect that we’re gonna be working together and obviously not to share any secrets in individual session that you wouldn’t want your partner to know, because obviously that is not really why the couple is there. And then you’re caught in some type of betrayal and things like that. What I tell clients, I said, “Yeah,” and then I’ll just have to make up some really absurd way for you to fire me. “So, if one of you fires me, you might wanna be looking at the other person. If both of you fire me, I guess that’s a collective decision.” [chuckle] And then they laugh and we kind of move on.
CC: Okay. Good, good, good.
KL: Yeah. So, I think, overall, that covers consent and I know we went through a lot of stuff, I think we almost went from A to Z, probably P, around there, TUV, something like that. Kate and I always recommend, “You might have a consent already, great. If you’re listening to this podcast, awesome. Go ahead and cross-reference that.” But remember, we’re not lawyers. If you have difficulty around language and stuff like that, it’s really important to reach out to someone, an attorney in your area. They can definitely help. Of course, we’re here as a resource as well.
CC: Okay. Do you offer a packet, like some people out there will, for a fee, will give you a packet at least as a template on how you can do a general informed consent?
KL: We do. What’s really cool is we have a la carte paperwork, so we offer all of our forms a la carte and we have about 23 right now. We also offer a base package, so that’s for anyone just getting started, needing to see their initial client, so everything you would need to see your first client or a new client, I should say. And then we have our peak package, which offers all of our paperwork in a nice little package. And what’s really cool is that all of our paperwork is completely reviewed by… There were three attorneys involved in the review of our paperwork. We have family law attorneys, two family law attorneys, healthcare law attorney, and it really took Kate and I probably about a decade to perfect our paperwork before we even sent it to the attorney.
KL: Yeah, we recently just did a webinar on paperwork, and talked about certain things. And it’s crazy. We actually had three of our forms… Now, I updated the forms, reviewed them, and actually just sent them to the attorney to review. And it was $575 for a little less than three hours of his time to review that. We offer all of our paperwork less than that. The peak package is $511. The base package, I think, don’t quote me, is $299. And then a la carte, obviously people can purchase how they feel. It’s massive savings, and I think a lot of times people are getting into practice doing the hand-me-down stuff a lot of times, and I know I did this. This was my understanding and reasoning about being a therapist, I’m like, “Well, I use my mouth and I need a paper and a pen. That’s just gonna be super easy to get into practice.” Literally. I’m like, “I’m not a restaurant, I don’t need to have inventory and stuff like that.” Well, I think a lot of times therapists don’t plan. We don’t create savings for all the different expenses, and paperwork is one of those things that I know we know we all have to have, but… Kate and I teach the medical errors ethics and boundaries laws and rules, and most online therapists cover liability in their paperwork and documentation. So, guys, don’t chance it, be in the know, get educated. It’s really, really important.
CC: I would think it’s incredibly worth the cost upfront, at a pretty low cost, to be protected. And I know you and I have… I’ve talked to therapists who have had to go to court, who have said, “I am so grateful that I set things up correctly, my notes, my informed consent, everything, my confidentiality.” Everything was set up so that I was protected, and it was simple. Hopefully you will never use this, but if you need it, you really want it there. Let’s talk a little bit about specific… This is the Online Counseling Podcast, and you’re looking at technology assisted counseling, which is an interesting phrase. And I love it because there’s text, there’s email, there’s… When technology is assisting your process, your online counseling, what specific things should we be talking about with paperwork and informed consent?
KL: Good. Let’s jump into that… And before we actually jump into that, for those of you who are listening, we’re actually gonna give one of our pieces of paperwork away free and we’re gonna tell you guys how to get the TAC consent specifically at a discounted rate. So, you wanna listen to the end, and we’ll talk about that a little bit later, but let’s talk about TAC first.
KL: With TAC, one of the things that I think sometimes when we think about going into online counseling and it’s like, “Oh, cool, I can set up my computer, maybe I should have a TAC consent.” Okay, but I’m ready to go.” “But, no, you still need to have those other things. Your HIPAA, your consent, some type of bio-psych.” Clay, I know you talk about doing an assessment first, and that’s really essential, is that you definitely need to do an assessment to assure that your potential client is able to manage technology, number one, but not in some type of crisis or things like that, where they might need face-to-face or more intensive work that could be done with someone more local on site. So, those are important things just to make sure you have those basic forms for sure.
KL: One of the things seen, as we talked about, in regards to the regular consent. You wanna talk benefits and limitations. So, going over some of those benefits. And some of the cool benefits, I actually, interestingly enough, on Friday, one of my clients was awaiting surgery. He had an infection in his hand and was awaiting surgery at the hospital. He had a private room, we had a session scheduled, and he said, “Let’s do it.” My client was able to have a session because it was a private room, I had everything already set up, so the benefit is the ability for convenience. And sometimes another benefit is real-time monitoring. If your client is having difficulty… Or imagine if you do some type of parenting work, how cool would it be to actually watch your client interact with his or her child live when a tantrum is happening? So, those are just some really cool benefits. There’s many other benefits, but you wanna lay those out in your TAC.
KL: And then there’s some limitations. I know that Kate talked about this in confidentiality. Sometimes we only can see what we can see through the video, and we can’t see is there’s someone lurking in the wings. Should we be concerned? Are we working with a client that might be in a domestic violent relationship? Are they really making sure that things are confidential? One of the things we always suggest is not only for us to have headphones, but for the clients to wear headphones, because that way people can’t hear us speaking to the client on the outside. Of course, connectivity. That definitely is a limitation. I’ve had that before using one of the platforms. I was frozen, like that.
CC: Always with a weird face, too.
[chuckle]
KL: Yeah, exactly. It’s never you’re smiling. It’s like the YouTube things, when they capture, you’re like… It’s funny. Sometimes I’ll post that stuff, and I’ll write a caption because this is absolutely hysterical. And, of course, I can’t always hear them clearly sometimes. We lose things in regards to non-verbal communication or seeing the whole picture. One of the things… And I remember when we had you on our podcast, Clay, and I know you do a lot of couples work as well, I hadn’t done couples on my counseling at that time, but I did and I remember it was cool because, yeah, it was online, but I think there was a different way that the couple was being. They didn’t… It wasn’t like I was right there, so they could really interact in a different way, and I noticed that. I thought that was pretty cool.
KL: Another thing that you wanna have in your consent is logistics, who’s contacting who. Do you send a link? Do they have to sign in? Do they have to download stuff? What to do in case of a connection loss? Are you gonna be available? Are you gonna call them? Do you pick an alternate number? Those are really important things just to clarify. And again, just like with our consent, we use that as a roadmap to have a discussion with your technology, is just a counseling consent, you wanna use that as a roadmap as well. We talked about confidentiality. Again, having the consent talks about the confidentiality and just wanna remind them that. One thing that… This was an experience thing, and I haven’t seen it in the ethics. One of my friends actually works at an all-girls school, they call her the teenage whisperer, she’s pretty awesome. And one of her clients decided one day to record their session and then post it on Facebook.
CC: No.
KL: Yeah. A kid, a teenage kid. And she didn’t know, she wasn’t aware. And we really thought about that. It’s kinda scary because… Maybe the kid was obviously probably doing it to be funny or silly, kids a lot of times just love their therapists, like, “Oh, my therapist,” but who knows what could have happened in that moment? Maybe she was cracking a joke or being sarcastic as a way to engage with the client. But if one person catches this little snippet of what this one picture is, then makes an assumption, that can be really detrimental. So, in our consent, we talk about no recording. That might be different though for some people. Someone might say, “Actually, I do want you to record, so I want you to go back and see what we talked about.” But to protect the therapist and protect the confidentiality of the client, it’s just recommended that we don’t record. Again, if there are certain things in the way that you do therapy, you might. But it’s just best practice. And when we talk to the attorney and your attorney said, “Yeah, that’s a really good idea. You know why? Because we don’t want then the client to be upset or angry one day, and utilize it against a therapist.” So, that’s just really essential.
KL: Fees, again, you gotta talk about those fees and how will you do payment. We recommend definitely taking payment upfront. Do you PayPal? Do you Square up? Do you have their credit card on file? Do you send them an invoice? That all has to be taken care of. Maybe you do packages. Maybe they’re pre-paid, I’m not really sure. It just depends on what it is that’s most important for you. I know we were referencing this in our part one, when we were talking about emergency contact. Again, if your client lives in a different area than you, if you call 911…
CC: Not gonna be there, 911.
KL: Not gonna be there. So, we actually have a place in our consent that we actually have aligned for where is the client, where is the address of the client, but also what is the local emergency number, as well as resources and things like that, in that area. Of course, they gotta sign the consent and make sure that that’s done. I know that you’re also talking about email and text, and things like that, and making sure that you use some type of HIPAA-compliant platform that’s really essential, but also when are you available if you do those things. Do you have certain hours that you only do those things? What to do in a case of an emergency, what to expect. I know that we don’t… Kate and I prefer more video or phone, we don’t do the text or email, that’s just our preference. I know that people are doing that. You just have to be really clear. I know I’ve seen some sites that I looked at that just made me uncomfortable, and just stay away from some of that. I think a lot is lost in email. I don’t prefer email, just to further protect my clients’ confidentiality, and not really clearly understanding what they need and want. Those are the general stuff in regards to TAC.
CC: A question that has come up a couple of times is the electronic signature, so that you have this document and really I think it’s imagining every question that your client may have and then everything that they need to know, from payment, to how we’re gonna connect, to… It’s a lot of information to go through. You send this document to them or they download it from your website, and there’s different services out there that will allow an electronic signature. Then I’ve had some therapists say… I ask my client to print it out, sign it, scan it back into the computer and email me their scanned signature. Any thoughts on that?
KL: Personally, because I do a lot of my work anyways face-to-face, for me, what I do is I usually grab that consent face-to-face. I’m assuming, hopefully, there’s some type of protected, I don’t know, a software or stuff like that, or maybe if you have an electronic health record that they’re doing that stuff anyways, and it’s protected that way. I’m not sure what have you found, Clay…
CC: What I’ve been doing is kind of a long way, is that I have the client download and then sign it, physically sign it, scan it back into their computer and then email it to me as an attachment over HIPAA-compliant email. It’s a pain, it’s a long way. But I know that Doxy.me has embedded, they’re testing an electronic signature. So, you can upload your… You will be able to upload your informed consent, and then they’ll just click, saying, “I’m adding my signature,” and that is… ‘Cause I did that with my mortgage when I re-financed my house. I had Doxy sign the whole thing. It’s HIPAA-compliant. So, there are services out there, they’re pretty expensive. Some of the electronic medical records, like SimplePractice and TheraNest, and a few of the others, have this as an option. So, look into it. Right now, it’s a pain to… I’d have to send this to them, they print it out, they sign it, they scan it back, and then they email it. But hopefully we will be able to have a better service once Doxy.me gets tested, and up and running.
KL: Yeah. That’s interesting you say that, because we actually use a service called… Well, not a service. It’s a platform called Wufoo for a lot of our forms. I’m actually having my assistant go back and forth with them right now to see if there’s HIPAA compliance, and have them sign a PAA to see if I could actually utilize that for the meantime. But we’re trying to figure that a lot now. I’m not saying it is or isn’t. I’m just trying to figure that out. Yeah, it’s way easier doing the electronic stuff than print, sign, scan, all that stuff.
CC: Another question that came up just the other day is that one of the members of the directory got a referral, which we always like to hear, and they said, “How do I know that this person is in a state that I’m licensed in? How do I know for sure?” And we went, “That’s interesting,” because we ask the clients, when they come to the directory, “Where do you live? Do you live in New Jersey? If so, we’re only gonna show you licensed therapists from New Jersey.” But then she was like, “How do I really know that they’re in New Jersey?” So, one of the things that I’ve put into my informed consent is that we are relying on you and your honesty that you are informing us of where you reside. It’s just one of those things. This is a growing elastic document that you don’t think of, and that’s something to add in there.
KL: Good point, and that’s actually also in our consent, too. When we say something like, “I’m only allowed to practice in the state that you reside and I’m licensed in. And if you do move, you need to inform me.” And it’s interesting because actually I have a friend who is… He’s from a different state, and he was seeing a therapist there while he was living there, and he moved, and he actually didn’t tell the therapist. And I said to him, I said… And the therapist was very, very specific, and actually the therapist let him know, “I only can see if you’re here.” I was like, “You actually need to let that therapist know. You can’t be in Florida, working with a therapist that’s not licensed in Florida. You’re doing the therapist potential harm, but the therapist is unaware.” So, I think that if we’re just clear and we state that, and we let our client know…
KL: Now, what’s really cool, in the AMHCA ethics, social work in AMHCA ethics have very similar things, but in AMHCA ethics, one of the things that I really liked that it covered was… Say, for example, your client is moving out of state to a state that you’re not licensed in. And maybe you’re about to finish up sessions, maybe you need two or three more. It talks about talking to your client, the provisions of the possibility of doing a few transition sessions for certain circumstances. It’s not like, “Oh, that’s okay, you’re gonna go to Michigan. Fine. We’ll get you online counseling, no worries.” It’s more like, “We’re just finishing up. Maybe it’s two sessions, you are leaving right now. There’s just not gonna be any other way. We’ll do those two transition sessions and then we’re done.” Or maybe your client has to move for some certain reason, and maybe they are in crisis and it’s not a good time to transfer. Maybe you do a few transition sessions while you’re helping them connect to other people locally. I really like that, but again that all has to be documented and you note why you’re doing it.
KL: That’s really important because if you ever got called to court for whatever reason, they’re gonna ask you like, “What informed you of this decision?” That’s really essential. But if you wanna just go black and white, don’t practice outside the state lines that you’re not licensed in. And you can always call the Board, explain the situation, like, “This is what’s happening. What are your rules around this? Okay, I’m gonna be working with this client for three more sessions,” things like that.
CC: Yeah. And I would recommend going to your professional organizations first, because if you call on your state licensing board, you call three different times on three different days, you will get three different answers regarding anything to do with online therapy. It’s just, that’s the way in New York.
KL: You mean if you get a call back?
[chuckle]
CC: If you get a call back, or if you talk to an actual human being, these are state workers, God bless them, but they are not necessarily gonna give you the accurate information. But the guy over at NASW, or any of them, are going to be able to give you accurate information, if it’s not actually on the website. And we try to keep up with it as much as we can, like to onlinecounseling.com, but it’s hard. Okay. Any final thoughts, things that we should be thinking about for paperwork? Other things we wanna add some value to our listeners?
KL: One of the things, and I know we referenced this, but this is also in our consent, is about having that assessment first. Assessing, like you would have a consultation call with a client, 10, 15 minutes. You’re also assessing that, you wanna make sure… I know in one of the ethics, I’m not sure if it’s the NASW or AMHCA, but it talks about best practices, if available, having an initial face-to-face session with the client before you decide to do technology assisted counseling. I know your practice is a little bit different, Clay. Again, it’s just what works for you. But we always like to share best practice, best treatment ethics and laws, so we know what sandbox we can play in and what the boundaries are. Right?
CC: Yeah, that’s true.
KL: That’s one thing. No, I would love… I think the thing with the podcast, it’s like, “I wonder what everyone is thinking and wondering. What questions can we ask for them? I wish I could call that in my head right now.” [chuckle] “What would they be wondering?”
CC: Right. Yes. Send us your questions.
KL: Send us your questions, yeah. Actually you can go… I know, in our Facebook group, you’re more than welcome to post the questions, in The Private Practice Startup Facebook group. Clay and I can both respond. We can talk about that. I think one of the things is whatever… Kate and I have a rule, is always go with the highest standard. And so why did I read the 60-plus pages of NASW ethics? Number one, ’cause I teach ethics. I need to know NASW, AMHCA, ACA, AAMFT, and APA too. But the thing is, there’s a lot of information in there, and if you guys don’t know an answer, just go to the ethics first, see what’s there. And before NASW and AMHCA put out their ethics, AAMFT was the most recent at the time, back in 2015, before AMHCA put this out in October 2015. And there wasn’t much. So, whether you’re a American family therapist, or a psychologist… Psychologists have not updated theirs, go to the NASW, go to the AMHCA, if you have questions. It’s just really helpful and always going with the highest standard, I don’t think you can go wrong.
CC: Yeah, absolutely. Absolutely. And what I always tell clients… ‘Cause I get the questions all the time, “I’m thinking of doing this, but I’m scared. There’s so much to think about.” There’s really not. There’s incredible resources out there from the Zur Institute, to the therapist toolbox on the onlinecounseling.com, to your website, Katie. It’s just being informed, figuring out, and I like the old crock pot commercial, “Just set it and forget it.”
[laughter]
KL: That’s Ron Popeil, I think, right?
CC: Oh, is it? Yeah.
KL: He made the rotisserie chicken or something like that?
CC: Yes, yes.
KL: My grandmother used to watch that, or maybe it wasn’t Ron Popeil. He was the one that made gnocchis. I’m from an Italian family.
CC: Whoever it was. It’s “just set it and forget it,” so I don’t have to worry about it. And just to not be scared, be informed. Yeah, there you are.
KL: One thing, as you’re saying that, I think it’s really good to do a trial run with a friend. Use the platform. That’s another thing, is try different platforms. I tried the VC.com. I like Doxy.me better. It’s so simple. It’s like, “Here’s the link, copy/paste. Oh, you’re in the waiting room, and I’ll let you in.” For me, it’s simple. And so I did a trial run for both platforms, the VC.com and Doxy.me, and I like Doxy.me better. And another thing, too, just maybe a ninja tip for technology, sometimes if you’re worried about connection, you guys can get an ethernet cord and also plug that in right into your modem to help, if there’s connection issue or you’re noticing the first time you try it, there’s some type of connection issue, so that might be helpful too.
CC: Yeah. Good. You were mentioning a potential discount.
KL: Yes. Well, we’re gonna give you guys our HIPAA form for free. And so all of our paperwork is completely customizable, attorney-approved, so simple. Basically, we have highlighted areas where you need to change your address, location, things like that, and all of our paperwork is that way. Of course, you can customize it to however you need to. You can upload it into your EMR, you can put it into Doxy.me, when that’s all set. The website is HT, as in HIPAA TAC.gr8.com. So, it’s HT.G, as in George, R, for robot or Romeo, really, the number 8, dot com. So hipaatac.gr8.com. What you do is you get your free HIPAA, and if you just wanna stop there, awesome. If not, if you want the TAV, we’re gonna offer you that as a discounted rate. Our TAC form is regularly 49, and you guys can actually purchase it for 29. So you get the HIPAA and the TAC.
CC: That’s amazing. Do they need any kind of special code or anything?
KL: No, just go on there. And when they try to… When they go to download the HIPAA you’ll get the opportunity to purchase the TAC as well. And then, of course, if you guys have number one, any questions we’re happy to be of value to you and answer any questions that you have. You guys can always post in our Facebook group, private practice start-up, or you can just email us at the privatepracticestartup.com, that goes to both of us, and you can also go on the website, and our website is the privatepracticestartup.com. If you go to the shop tab there you’ll see all of our business, forms, the business forms are actually forms for the business but then you’ll see paperwork forms. So if you’re looking for something specific, you only need one form, or you don’t have paperwork or you wanna update your paperwork. We also offer the packages so check ’em out.
KL: Incredible value. Katie, thank you so much for your… Our multiple difficulties in trying to get through all of this, but this is incredibly valuable I think for our listeners, so thank you so much.
CC: Thank you Clay, it’s been really fun and an honor to be on the other side with you, and we really just hope that we created a lot of value for your folks today.
KL: Absolutely, have a great day.
CC: Thanks.
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