Welcome to the Telehealth Practice of Michelle Turbide, LICSW. This document is to help clarify important aspects of your treatment and to represent an agreement between us. Your signature on the separate CLIENT CONSENT form 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, Internal Family Systems model, Self Compassion, treating sexual abuse survivors and their families, and various integrative behavioral therapy models. I attended a 70 hour Expressive Arts Facilitator II program in May of 2013. In 2021/2022 I underwent training for EMDR therapy.
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
Following are the Vermont State Statues for unprofessional conduct.
§ 3210. Unprofessional conduct
(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:
- failing to use a correct title in professional activity;
- conduct which evidences unfitness to practice clinical social work;
- 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;
- harassing, intimidating, or abusing a client or patient;
- practicing outside or beyond a clinical social worker’s area of training, experience or competence without appropriate supervision;
- engaging in conflicts of interest that interfere with the exercise of the clinical social worker’s professional discretion and impartial judgment;
- 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;
- taking unfair advantage of any professional relationship or exploiting others to further the clinical social worker’s personal, religious, political or business interests;
- 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.)
Communication and Appointments:
Please direct all non-emergency calls to my office voice mail at 802.881.9001. 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.
Once invited into my Jituzu portal you can access the HIPPA secure messaging system. This is my preferred method of communication.
All written documents, file uploads, and messages should be done in the portal. Please note that you can only upload files from a computer/web browser not in the mobile App.
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 media.
- 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.
- 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) you can call my work phone at 802.881.9001. You can also message me through Jituzu and if you click ‘urgent’ I will be notified by text in 15 minutes that I have an urgent message.
Keep in mind that during the day I am in sessions and not available at all times. I do my best to respond to urgent/emergency situations when I receive the message. However, in the age of technology they are not always reliable and there are times I am unavailable or out of range.
If you feel the nature of the emergency cannot wait or you cannot reach me within a short timeframe (15-30 min) then please go to the nearest emergency room for evaluation, dial 911, or call the community service emergency team in your area.
Here are the numbers for Chittenden County, VT:
First Call- CRISIS Chittenden county 802.488.7777
Domestic Abuse Hotline 802.658.1996
Department for Children and Families 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.
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 including your deductible, copay or co-insurance.
Please inform me ahead of time of any changes in your insurance coverage or plan information. 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.
All credit card payments processed through the Jituzu portal will be listed on your credit/debit account as “medical billing” and will not have identifying information. (The exact identifier is subject to change). Please keep track of your payment dates/amounts so that you can recognize them on your banking statements. Any fees associated with reversal of payments will be the responsibility of the client.
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 or you do not show for your designated appointment time. Cancelations fees are $30 for the first missed session and the usual and customary rate of session reimbursement thereafter (which can vary based on insurance).
For clients whose insurance does not allow for missed session fees per contract there will be the same 3 missed session policy.
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.
If you are sick and cannot make an appointment. Please contact me by 8:00 am.
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 elderly.
- 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.
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
- 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.
- 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.
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.
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
Under no circumstances will you be penalized or retaliated against for filing a complaint.
Telemedicine and Portal Policy
I have opted to work with Jituzu.com as a way of streamlining, convenience, and assisting you in a HIPAA approved encrypted client portal. Through this portal I can schedule our sessions as a telemedicine appointment and we can engage in live video/audio conferencing on a HIPAA compliant connection.
What you will need and directions for how to connect to Telemedicine sessions:
- A private place in order to teleconference with me. (I cannot be responsible for anything that is heard on your end. Please have a private room/space available for sessions where you feel safe, private, comfortable, and secure.)
- High speed internet or reliable cell service.
- A working web camera and microphone.
- Familiarity with the Jituzu app or website in order to navigate to connect at the time of our appointment. Please check to make sure your camera, microphone, and internet browser works properly before we begin sessions.
- I cannot log into your side of the portal. If you loose/forget your username or password, I believe there is a recovery option. However, if you can’t log in please notify me. I can disconnect you form the portal and you can sign up again (but you will need to select a different user name and password.)
- You can either download the app for your mobile device (android, tablet or smart phone) or you can log in with an internet browser on a computer. (The computer must have a functioning web camera and microphone to work for telemedicine.)
- Video conferencing does not work with the Safari web browser, but does work with Chrome and firefox. It may also work with other browsers. You will have to determine if your browser will support this connection. Please make sure that this works before any scheduled sessions.
- In the portal, in the left menu, you can click on ‘video conferencing checklist’ to verify that your audio and video are connected.
- I am only licensed in the state of Vermont. You will need to be physically in the state in order for me to provide services. I cannot meet with you via video conference if either of us are on vacation or traveling out of state.
- A few minutes before the beginning of the session log into Jituzu.
- In the app you will see an appointment under the calendar section with the video symbol. click on this and it will begin to connect you to the session. If it’s the first tele-session, You may need to approve that the app can use your camera and microphone. Click yes.
- After this you will have to click on “connect” in order to join the session.
- If you are using a web browser on your computer, click on the “appointments” button on the left menu bar. Under scheduled appointments, you see the current scheduled appointment click on the video symbol to begin connecting to the session.
- If you have trouble connecting it is best to ‘reboot’ by exiting the app/website and attempting to connect again.
- If I am not connected, please wait until I join. I should never be more than 5 minutes later than the scheduled time. If I am please check your messages and email in case there is an issue on my end.
- Once we are both connected, we proceed with your 45-60 minutes session as scheduled.
Portal and Telemedicine Guidelines and Policies
Here are my guidelines around telemedicine and use of the portal (which includes but is not limited to the following).
- If you do not show for a tele session I will wait 15 minutes. If you have not contacted me or connected, I will assume that you have missed the session.
- If you are having difficulty connecting, please contact me through the portal or via email. You can also call my work phone 802.881.9001. Again, please check your connections prior to the time of appointment so that you do not miss session time.
- This portal is an encrypted site, which means that information on the server is safeguarded against outside breaches. However, as you know there are no 100% guarantees with any technology. If you use the portal on your computer or an app on your phone please take precaution. Use a password that only you know and cannot be detected, close the applications after use, and take every precaution not to expose any of your protected health information (PMI).
- Under no circumstances can you record or capture our video sessions (audio or video). This is a breach of your private health care records. If I find that you are are recording any sessions, it could lead to an immediate termination of services.
- Neither I nor Jituzu are responsible for any breaches that occur on your end. So please take precaution and read my policies and Jituzu’s policies thoroughly when you click that you agree as you sign up. Always make sure you are comfortable with the use of this technology before you use it.
- Portals are for scheduling, video conferences, and messaging only. It does not grant you or anyone else access to your file, client notes, or insurance information. Those files are held on my HIPAA approved encrypted account through MyClientsPlus. I am the only accessor of those records as I am a sole practitioner.
- Messaging through the portal is encrypted, but there are still risks of breach of PMI, particularly if you have a breach on your end.
- You may email clinical information, upload files, and relay sensitive information about your PMI through the portal. However, this is up to your discretion, comfort level, and knowledge that nothing is ever 100% secure due to user error.
- I will always ask your permission before I send any uploads to you through messaging.
- 10. If you decide to forward/relay any information from the portal outside of the Portal, I am not responsible for breaches of PMI in those cases. Again, please play it safe, ask questions, and do not use electronic communication if you are concerned.
- 11. Messaging is not for dire emergencies and is not a replacement for in person or video sessions. Messaging, just like email, is open to interpretation, subjectivity, and miscommunication. Messages should continue to be for scheduling, quick questions, relaying information, and some clarifications. It is not meant to be an ongoing clinical conversation. If I find that messaging is posing an issue or a concern, we will discuss the use of this service and determine what is most clinically appropriate for our therapeutic relationship.
- 12. All tele-sessions are scheduled in advance. Any emergencies should follow my emergency protocol.
- 13. Statements and bills can be paid via the portal. If you are using an HSA, Debit, or credit card this is my preferred method of payment. All credit card payments processed through the Jituzu portal will be listed on your credit/debit account as “medical billing” and will not have identifying information. (The exact identifier is subject to change). Please keep track of your payment dates/amounts so that you can recognize them on your banking statements. Any fees associated with reversal of payments will be the responsibility of the client.
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.
I can be contacted during working hours at 802.881.9001 or messaging through the portal. I look forward to our work together,
Michelle Turbide, LICSW