Welcome to Stonehouse Associates. We are a group of independent mental health professionals under the name of Stonehouse Associates. This document is specifically for clients being treated by Michelle Turbide, LICSW. This document is to help clarify important aspects of your treatment and to represent an agreement between us. Your signature at the end of this document indicates your agreement and understanding of these disclosures and policies. I hope this will help clarify my procedures to help you feel comfortable with this process.

Disclosure of Information

As part of my introduction I will be fulfilling professional obligations as outlined by the State of Vermont Office of Professional Regulations. These obligations are:

Each licensed clinical social worker who provides psychotherapy services shall disclose to each client the following information, printed or typed in easily readable format:
(1) The licensed clinical social worker’s professional qualifications and experience, including (A) all relevant graduate programs attended and all graduate degrees and certificates earned, including the full legal name of the granting institution, and (B) a brief description of any special qualifications and areas of practice.

(2) A copy of the statutory definition of unprofessional conduct (26 V.S.A. ‘ 3210).
(3) Information on the process for filing a complaint with, or making a consumer inquiry to, the Director.

Qualifications and Experiences:

I am licensed by the State of Vermont as a licensed independent clinical social worker. License # 089.0001226. I received a Bachelors of Science in Social Work (BSW) in 1995 from the University of Vermont. I received my Master’s of Social Work with a focus on children and families from the University of Vermont in 2002. I provide psychotherapy services for children, adolescents, families, and adults. I have received graduate credit and continuing education in treating trauma with children and families, attachment issues and disorders, treating multi-stressed families, trauma and substance abuse, solution focused family therapy, cognitive behavioral therapy, expressive therapy, play therapy, brief therapy, narrative therapy, Self Compassion, treating sexual abuse survivors and their families, as well as extensive training in child abuse and neglect. I attended a 70 hour Expressive Arts Facilitator II program in May of 2013.

Disputes or Complaints:

Please discuss any concerns you may have regarding your counseling or related issues directly with me at any time. I will make every reasonable effort to resolve disputes or conflicts in a satisfactory manner. You have the right to lodge a formal complain with:

Vermont Secretary of State Office of Professional Regulation National Life Bldg,
North FL2, Montpelier, VT 05620 (802) 828-1505.

Following are the Vermont State Statues for unprofessional conduct.

§ 3210. Unprofessional conduct

Michelle Turbide, LICSW
27 Rye Circle
South Burlington, VT 05403
802.654.7607 michelle.turbide@yahoo.com

(a) The following conduct and the conduct set forth in section 129a of Title 3 by a licensed social worker constitutes unprofessional conduct. When that conduct is by an applicant or a person who later becomes an applicant, it may constitute grounds for denial of a license:

  1. failing to use a correct title in professional activity;
  2. conduct which evidences unfitness to practice clinical social work;
  3. engaging in any sexual conduct with a client, or with the immediate family member of a client, with whom the licensee has had a professional relationship within the previous two years;
  4. harassing, intimidating, or abusing a client or patient;
  5. practicing outside or beyond a clinical social worker’s area of training, experience or competence without appropriate supervision;
  6. engaging in conflicts of interest that interfere with the exercise of the clinical social worker’s professional discretion and impartial judgment;
  7. failing to inform a client when a real or potential conflict of interest arises and to take reasonable steps to resolve the issue in a manner that makes the client’s interest primary and protects the client’s interest to the greatest extent possible;
  8. taking unfair advantage of any professional relationship or exploiting others to further the clinical social worker’s personal, religious, political or business interests;
  9. engaging in dual or multiple relationships with a client or former client in which there is a risk of exploitation or potential harm to the client;
  10. failing to take steps to protect a client and to set clear, appropriate and culturally sensitive boundaries, in instances where dual or multiple relationships are unavoidable;
  11. failing to clarify with all parties which individuals will be considered clients and the nature of the clinical social worker’s professional obligations to the various individuals who are receiving services, when a clinical social worker provides services to two or more people who have a spousal, familial or other relationship with each other;
  12. failing to clarify the clinical social worker’s role with the parties involved and to take appropriate action to minimize any conflicts of interest, when the clinical social worker anticipates a conflict of interest among the individuals receiving services or anticipates having to perform in conflicting roles such as testifying in a child custody dispute or divorce proceedings involving clients.

(b) After hearing, and upon a finding of unprofessional conduct, an administrative hearing officer may take disciplinary action against a licensed clinical social worker or applicant. (Added 1985, No. 253 (Adj. Sess.), § 1; amended 1989, No. 250 (Adj. Sess.), § 4(b); 1993, No. 98, § 30; 1993, No. 222 (Adj. Sess.), § 6; 1997, No. 40, § 36; 1997, No. 145 (Adj. Sess.), § 52; 1999, No. 133 (Adj. Sess.), § 29.)

Michelle Turbide, LICSW
27 Rye Circle
South Burlington, VT 05403
802.654.7607 michelle.turbide@yahoo.com

Communication and Appointments:

Practice Policies

Please direct all non-emergency calls to my office voice mail at 802.654.7607 x6. If I am unavailable at the time of your call please leave a message and I will return your call as soon as possible. (Usually within the next 1-2 business days, however it may be longer during holidays and vacations). During non- work hours, please leave a message on my voice mail and I will return your call.

You may also contact me for email for rescheduling appointments. Please do not contact me by email for emergencies or clinical discussions or content.

Social Media Policy

In the age of social media (Facebook, websites, Blogs, YouTube, Instagram, Google, Pinterest, Flikr, tumblr, email, texting, and other venues) it is important to clarify my policy of such media.

These policies are in place for several reasons. My primary concern will be how it relates to your own privacy and our therapeutic relationship. In addition, there are risks that social media present in the therapeutic relationships. These risks include but are not limited to: compromising confidentiality, blurring the boundaries of therapeutic relationships, miscommunication, misunderstandings, loss of emails, timeliness of response, and the fact that emails and other social media are not safe, secure or confidential. I reserve the right to make further decisions about social media usage that I feel are in the best interest of your privacy and our therapeutic relationship. These policies include but are not limited to:

  • ✦  Clients have a right to privacy other than what is discussed in session. I will not directly pursue information about a client outside of sessions via any social media technology.
  • ✦  If clients choose to share information with me about something on their social media venues for therapeutic purposes, we can view it together in session.
  • ✦  In return, I ask that you respect my privacy and not directly seek out personal information about myself or my family and friends.
  • ✦  If I believe that you are in danger to harm yourself and someone else, I may use the internet to locate your whereabouts or get in touch with your immediate family to inform them of my concern for your safety. These cases are rare and if it does occur we will discuss it at our next session.
  • ✦  I do not follow, friend, text, comment, or fan any current or former client’s social media venues.
  • ✦  I am not responsible for any confidential information that you post, email, or provide in social


  • ✦  I maintain several social media pages, some of which is public. Please be advised that if you

    choose to follow these sites publicly, you are doing so at your own discretion and your name will

    be associated with my sites in a public forum.

  • ✦  Information posted on my public sites should not be taken as clinical advice or part of our

    therapeutic relationship.

  • ✦  I will not necessarily be aware that you are following my public sites. If you discover or choose

    to follow, please discuss this with me so that we may explore how/if this might affect our

    therapeutic relationship.

  • ✦  Please note that you may be able to view any public content without becoming a fan by

    subscribing via RSS or email without creating a visible, public link to my Page.

Michelle Turbide, LICSW
27 Rye Circle
South Burlington, VT 05403
802.654.7607 michelle.turbide@yahoo.com

  • ✦  If I find that you comment or post on any of my public sites and that communication in any way violates your confidentiality, I will delete these comments and bring it up with you at our next session.
  • ✦  Social Media, including email, is not a form of communication to use in the case of an emergency or to connect with me outside of session.
  • ✦  Email is for scheduling and non therapeutic discussions only.
  • ✦  I cannot respond to any clinical questions or information via email. Please contact me by phone

    or make an appointment to discuss any clinical information or issues.

  • ✦  I check email daily, however cannot always respond right away. Please allow up to two working

    days for me to return emails. It may take longer due to vacations and holidays.

  • ✦  You should also know that any email I receive from you (beyond scheduling), and any responses

    that I send to you, will be printed out by me and kept in your treatment record, including everything you forward to me.

    If you have questions or concerns about any of these policies, please feel free to bring it up during our next session.

    Many parents and clients have requested an email to confirm appointments. If you would like this type of notification, then please review and sign the attached waiver.


    During work or after hours, if you have a clinical emergency (i.e., extreme behavioral situation, risk of suicide, or bodily harm to you or another person) call 802.654.7607 to be forwarded to my answering service or contact the answering service directly at 350.8921. They will attempt to contact me or the clinician covering in my absence. (keep in mind that during the day I am in sessions and not available at all times)

    If you feel the nature of the emergency cannot wait or you cannot reach me within a short timeframe then please go to the nearest emergency room for evaluation, dial 911, or call the community service in your area. Here are the numbers for Chittenden County:

First Call- CRISIS Chittenden county Domestic Abuse Hotline
Department for Children and Families

802.488.7777 802.658.1996 802.863.7370

Agreement of Financial Responsibility for Clients:
My initial evaluation fee is $130 for the first session. Follow up visits, which last 45-50 minutes, are $120 per sessions. Sessions that last longer than 50 minutes are billed at $140.

It should be noted that as of 1/1/13 there has been a change in billing codes for psychotherapy. Sessions that last longer than 50 minutes are billed at a different code and rate. Some insurances require pre- authorizations for these longer sessions and may include a larger copay or copayment. If you would like to arrange for more than 50 minute sessions, please discuss this so that we can determine if it is medically necessary and accommodate for this in the schedule and with your insurance carrier.

Michelle Turbide, LICSW
27 Rye Circle
South Burlington, VT 05403
802.654.7607 michelle.turbide@yahoo.com

I am a participating provider in a number of insurance provider panels. In those cases, insurances are billed directly and the client is responsible for any deductibles, co-payments, or self-pay; which are due at the time of service.

Telephone consultations that exceed 15 minutes may be billed to the client at the regular rate. If you have clinical issues or concerns that will take more than 15 minutes your insurance does not reimburse for telephone consultations. Please make an appointment for a session to allow you the time to explore these clinical issues.

All insurance plans vary, and you are responsible for finding out the details of your plan. Some require pre-authorization by your primary care provider or by the insurance company directly before they will pay for services. Some plans authorize a set number of sessions. You are responsible for tracking this information. Many insurance companies require that I provide verbal or written up-dates of your treatment on a periodic basis in order for services to be covered. I will provide these updates with your signature on the disclosure and consent form.

Please inform me ahead of time of any changes in your insurance coverage or plan information. If you have VHAP or Dr Dinosaur, please make sure your premium is paid. If you do not inform me of any insurance changes, you will be responsible for the fees of any rejected claims.

Checks are payable to Michelle Turbide, not Stonehouse Associates. Canceled Appointments

24-hour notification of canceled appointments is required, and with advance notification, no fee will be charged. Notice for Monday cancelations is due by Friday.

My preference is for 48 hours of notice so that I may be accommodate schedules for other clients. I appreciate if clients can give me as much notice as possible and I thank you in advance for this consideration.

Missed or late canceled appointments are not billable to insurance and clients are responsible for the fees. In order to be fair and equal to clients and my schedule, policies are consistent for ALL clients.

Sessions are considered missed if 24 hours notice is not given and are are billed at $60 for the first three and subsequently billed at the usual and customary rate for insurance sessions (rates vary between insurances).

If you have three appointments missed/canceled without 24-hour notice, I reserve the right to discontinue services and provide you with information and referrals for other clinicians who might better be able to meet your needs.

In the case of inclement weather, please contact me and discuss whether it is safe to come in to the office for your appointment. Inclement weather would be weather that causes the roads to be unsafe for driving such as closure of school and other area community events.

If you or your child are sick and cannot make an appointment. Please contact me by 8:00 am.

Michelle Turbide, LICSW
27 Rye Circle
South Burlington, VT 05403
802.654.7607 michelle.turbide@yahoo.com


Your psychotherapy services and records are confidential, however, limits to this confidentiality do exist and include minors or other persons with a legal guardian (information may be released to the legal guardian). I am a mandated reported and I am under legal obligation to report any of the following to the authorities:

  • ·  Danger to yourself or to others.
  • ·  Actual or suspected child abuse or neglect involving children, persons with a disability, and the


  • ·  Respond to a court-ordered subpoena to testify or to provide records.
  • ·  Situations which directly affect the health and safety of others.

    If you have signed a release with the insurer, the insurer may request such information as diagnosis, treatment plan, and general course of treatment. However, it is important to note that some insurers may request release of more detailed or sensitive information. Please discuss with me any concerns you may have about such disclosures.

    I may at other times find it helpful to consult with other professionals about a case. During a consultation I make every effort to avoid revealing the identity of my client. The consultant is also legally bound to keep the information confidential.


    Effective January 1, 2011

    The Health Insurance Portability & Accountability Act of 1996 (HIPAA) is a federal program that requires that all medical records and other individually identifiable health information used or disclosed by us in any form, whether electronically, on paper, or orally, are kept properly confidential. For Clinical Social Workers this requires little change from the practice of confidentiality that has been required of our profession prior to HIPAA. In general, the HIPAA Act gives you, the client or patient, significant new rights to understand and control how your health care information is used. HIPAA provides penalties for covered entities that misuse personal health information.

    As required by HIPAA, I have prepared this explanation of how I am required to maintain the privacy of your health information and how I may use and disclose your health information. Please note that, for the practice of psychotherapy, these HIPAA requirements compliment rather than add any significant change to our normal and usual practice as regards record keeping and confidentiality.

    This notice describes how medical information about you may be used and disclosed and how you can get access to this information. Please review it carefully.

    My pledge regarding health information.

    I understand that health information about you and your health is personal. I am committed to protecting your privacy and health information about you. As a psychotherapy client you own the privilege of confidentiality, and no information, including your presence in therapy or the fact that you are a client, will be disclosed without your specific written permission in a release of information request. I create a record of the care and services that you receive. I need this record to provide you with quality care and to comply with certain legal requirements. This notice applies to all of the records of your care generated by me.

Michelle Turbide, LICSW
27 Rye Circle
South Burlington, VT 05403
802.654.7607 michelle.turbide@yahoo.com

This notice will tell you about the ways in which I use and disclose health information about you. I describe your rights and certain obligations I have regarding the use and disclosure of health information.

I am required by law to:
· Make sure that health information that identifies you is kept private,
· Give you this notice of my legal duties and privacy practices with respect to health information

about you; and
· Follow the terms and notices that are currently in effect.

How I may use and disclose health information about you.

The following categories describe different ways that I use and disclose health information. For each category of uses or disclosures I will explain what is meant and try to give some examples. Not every use or disclosure in a category is listed.

Treatment means providing, coordinating, or managing health care and related services by one or more health care providers. An example of this would be making a referral to another health care provider for additional evaluation or treatment. Coordination of services with other professionals involved in your health care will require you (or your legal guardian) to sign a release of information. You may revoke such authorization in writing and I am required to honor and abide by that written request, except to the extent that I have already taken actions relying on your prior written authorization to take such actions.

Payment means such activities as obtaining reimbursement services, confirming insurance coverage, billing or collection activities, and utilization review for managed care coverage and approval and/or at the request of a third party payer for your treatment (your insurance company). An example of this would be sending a bill for your psychotherapy visit to your insurance company, or telephonically, by mail, or by fax, sending the necessary clinical information for your insurance company to approve more sessions for coverage for you.

Health care operations includes the business aspects of running our practice, such as conducting quality assessment and improvement activities, auditing functions, cost-management analysis, and customer service. An example would be an internal quality assessment review.

Other uses of health information:

I may contact you to provide appointment reminders or information about treatment alternatives or other health related benefits and services that might be requested by or is of interest to you.

I may use or disclose health information about you without your prior authorization for several other reasons. Subject to certain requirements, I may give out health information about you without prior authorization for:

  • ·  Abuse or neglect reporting of a child or a vulnerable adult.
  • ·  Health oversight audits or inspections
  • ·  Emergencies.
  • ·  To prevent a serious threat to your health or the health and safety of the public or another person.
  • ·  Public health purposes.
  • ·  To notify an individual who may have been exposed to a disease or may be at risk for contracting or spreading a disease or condition.
  • ·  When a child under the age of sixteen is a victim of a crime.
  • ·  Legal proceedings or law enforcement.

Michelle Turbide, LICSW
27 Rye Circle
South Burlington, VT 05403
802.654.7607 michelle.turbide@yahoo.com

  • ·  Workers’ compensation purposes.
  • ·  Firearm related injuries.
  • ·  To report reaction to medications or problems with a product.
  • ·  Funeral arrangements and organ donation.
  • ·  Research purposes.
  • ·  Military activity or National Security.

    I may also disclose health information when required by law, or in response to valid judicial or administrative purposes.

    In any other situation not covered by this notice, I will ask for your written authorization before using or disclosing health information about you. If you choose to authorize use or disclosure, you can later revoke that authorization by notifying me in writing of your decision. I am required to honor and abide by that written request, except to the extent that I have already taken actions relying on your prior written authorization to take such actions.

    Court Subpoena

    In cases when I have been served a legal subpoena to appear in court, I am legally compelled to appear at court at a specific date and time. A subpoena itself does not release me of my duty to protect your health information. I cannot release health information without client permission or a court order. It is my duty to protect the confidentiality of clients during legal proceedings to the extent permitted by law.

    In cases where I have been served a legal subpoena, I will need to have a discussion with you before court to discuss the risks associates with any testimony on my part and the disclosure of your private health care information and/or records in a court process. You will then need to decide if you want to sign a release of authorization for me speak to any attorneys and/or answer questions under testimony to the court. If you are not available to sign a waiver or choose not to sign a release, I will do everything legally possible to protect your health information, however under court order I may be required to release information. (Please note that an attorney asking for information in or out of court is not the same things as a court order.)

    Due to my role as a psychotherapist and a licensed clinical social worker, I am precluded from having a dual relationship with clients. This includes a dual relationship as a therapist and a court advocate. My clinical relationship with clients does not allow me to write letters, testify on your behalf, or advocate for you in court. It should be noted that if your attorney serves me with a legal subpoena on your behalf, I will proceed with my duty to protect your confidentiality as stated above. In addition, I have the right to proceed with a court motion to quash the subpoena.

    Your rights regarding health information about you.

    In most cases, you have the right to look at or get a copy of health information that I use to make decisions about your care, when you submit a written request. If you request copies, I may charge a fee for the cost of copying, mailing, or other related supplies. If I deny your request to review or obtain a copy, you may submit a written request for a review of that decision.

    If you believe that information in your record is incorrect or if important information is missing, you have the right to request that I correct the records, by submitting a request in writing that provides your reason for requesting the amendment. I could deny your request to amend a record if the information was not created by me; if it is not part of the medical information maintained by me; or if I determine that the record is accurate. You may appeal, in writing, a decision by me not to amend a record.

Michelle Turbide, LICSW
27 Rye Circle
South Burlington, VT 05403
802.654.7607 michelle.turbide@yahoo.com

You have the right to a list of those instances where I have disclosed health information about you, other than for treatment, payment, health care operations or where you specifically authorized a disclosure, when you submit a written request. The request must state the time period desired for the accounting, which must be less than a 6-year period. You may receive the list in paper or electronic form.

You have the right to request that health information about you be communicated to you in a confidential manner. You also may request, in writing, that I not use or disclose medical information about you for treatment, payment or healthcare operations or to persons involved in your care except when specifically authorized by you, when required by law, or in an emergency. I will consider your request, but are not legally required to accept it. I will inform you of my decision on your request.

If you are concerned that your privacy rights may have been violated, you can file a complaint with me or

with the:

Office for Civil Rights
U.S. Department of Health and Human Services Government Center
J.F. Kennedy Federal Building – Room 1875 Boston, MA 02203
Voice phone (617)565-1340
FAX (617)565-3809

Under no circumstances will you be penalized or retaliated against for filing a complaint.


I may change my policies at any time. Changes will apply to medical information that I already hold, as well as new information after the change occurs. However, before I make a significant change in my policies, I will change my notice and post the new notice. You can receive a copy of the current notice at any time by request or on my website. The effective date is listed on the notice.