Thank you for choosing me to help with your concerns. While we work together, I promise to walk with you every step of the way of your journey of understanding, exploration and growth. I will provide you with tools and techniques that will help you achieve the change you desire.Please take a moment to read what is asked of you and what is required from you before we begin our work together. I look forward to working with you!

What is Asked of You:• A Completed Registration

• A Completed Biography

After you registered, you may have seen the prompt that asked if you wanted to complete thebiography. Completing the biography is important because it provides me with information that helps me to help you. If you have not already completed it, please take a few moments to do so.

• Identification

Driver's LicenseInsurance Card (Only applicable if you are using your insurance)

7171 Hwy 6 N. Suite 105. Houston, TX 77095

Website: houstoncounselor.me

Sherell Hebert, MA, LPC

Sherell Hebert, MA, LPC

• Informed Consent Form and Teletherapy Consent if applicable

Teletherapy Clients must submit these documents prior to the visit. Office clients may elect to submit before the visit or in the office at the time of the visit.

Phone: 832-356-8549 FAX: 281-254-7979 Email: sherell@houstoncounselor.me

If you have not already done so, please register at therapydate.com.

Please sign the consent form(s) that are included in this packet.

A copy of this packet can be found at houstoncounselor.me/1 .

! ! !

Copperfield Counseling & Psychotherapy Sherell Hebert, MA, LPC-S

! !IMPORTANT INFORMATION AND CLIENT CONSENT: Please read and sign in the designated areas stating that you have fully read and understand the information below. !CLIENT/THERAPIST RELATIONSHIP: You and your therapist have a professional relationship existing exclusively for therapeutic treatment. The relationship between therapist and client is much different from any other relationship you may have with other health care professionals. Because therapy is not only about tools and techniques, but also about the genuine human connection, it is a important to understand that the therapeutic relationship works when the key ingredients, honesty and respect, are present.

!RISKS AND BENEFITS: Counseling and psychotherapy are beneficial, but as with any treatment, there are inherent risks. During counseling, you will have discussions about personal issues which may bring to the surface uncomfortable emotions such as anger, guilt, and sadness. The benefits of counseling can far outweigh any discomfort encountered during the process, however. Some of the possible benefits are improved personal relationships, reduced feelings of emotional distress, and specific problem solving. We cannot guarantee these benefits, of course. It is our desire, however, to work with you to attain your personal goals for counseling and/or psychotherapy. !COUNSELING: We provide short-term counseling designed to address many of the issues our clients are dealing with. Your first visit will be an assessment session in which you and your therapist will determine your concerns, and if both agree that Sherell Hebert, LPC can meet your therapeutic needs, develop a plan of treatment. Should you choose not to follow the plan of treatment provided to you by your therapist, services to you may be terminated. !The goal of Sherell Hebert, LPC is to provide the most effective therapeutic experience available to you. If at any time you feel that you and your current therapist are not a good fit, please discuss this matter with your therapist to determine if transferring to a more suitable therapist is right for you. If you and your therapist decide that other services would be more appropriate, we will assist you in finding a provider to meet your needs. !Wellness is more than the absence of disease; it is a state of optimal well-being. It goes beyond the curing of illness to achieving health. Through the on-going integration of our physical, emotional, mental, and spiritual self, each person has the opportunity to create and preserve a whole and happy life. Our services are designed to provide our clients an integrated solution for their mind, body, spirit, and life to enhance their lives and resolve issues. !APPOINTMENTS: Appointments are typically scheduled on a weekly basis and are approximately 45 minutes long. More frequent sessions or intensive outpatient schedules are available if determined appropriate by your therapist.

Sherell Hebert, MA, LPC

If you must cancel, or reschedule your appointment, we ask that you do so at least 24 hours in advance. Failure to cancel without giving appropriate notice, will result in a no-show fee of $75 which will be automatically billed to

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AVAILABLE SERVICES: Sherell Hebert specializes in anxiety and stress related disorders. She also works with mild/moderate depression, adjustment disorders, adolescent issues, and pet grief. Sherell Hebert provides individual counseling, group counseling and family counseling (if it is determined that family counseling will benefit the client who is already been seen for individual counseling).

!FEE SCHEDULE: All sessions listed below are 45-50 minutes unless otherwise indicated. Cash and credit cards are the only forms of payment accepted. Checks are not accepted.

!

PAYMENT/INSURANCE FILING: Payment of fees, including any required co-pays, is expected at the time of each appointment. We request that payment be made before your session begins. If you are using insurance benefits, Sherell Hebert, LPC will file counseling insurance claims for you, and will honor any contractual agreements with managed health care companies that have specific reimbursement restrictions and claim requirements. If your plan includes a pre-existing waiting period, you must submit for reimbursement on your own. Your contractual rate will be honored and full payment of that rate is expected at the time of service. If your insurance company denies the claim, you are responsible for the cost. Any claims unpaid by the insurance company within 90 days are the client/parent’s responsibility.

I understand that I am responsible for claims that are unpaid by the insurance company. I hereby authorize the release of necessary medical information for insurance reimbursement purposes.

____________________________________________________________

Client (Parent’s Signature if Client is under 18) Date

$140$125$125 $30-$60

Standard Non-Insurance Covered ServicesLife Coaching $125 Hypnotherapy $125Photocopied Records $.60/pageLetters written on your behalf $60Summary Reports $75Court Appearance (Retainer required 72 hrs in advance.) $1500/day Retainer *Please ask your therapist to provide you with a copy of the fees associated with litigation issues.

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*The Difference Between Canceling and Re-Scheduling*

Diagnostic & Evaluation Session (1st visit)Regular Office Visit (Individual Therapy)Teletherapy/Virtual VisitsGroup Therapy (Depends upon group and duration)

Patter ns of canceling or re-scheduling may be viewed as non-compliance with the therapeutic treatment plan ag reed upon. If this occurs, your therapist may discuss with you other options for treatment which may include the “same day only scheduling” or ending therapy. If you are on a state funded plan that does not require payment for ser vices and you miss an appointment without canceling, you will not be charged. You may, however, be asked to sign a document agreeing to miss no more sessions within a 90 day period.

Re-scheduling occurs when one cancels the reser ved appointment at least 24 hours in advance and then schedules an appointment at another time. A cancellation occurs when one cancels an appointment with less than 24 hours notice reg ardless if another appointment is scheduled.

the credit card on file at the close of the business day of your missed appointment. You may cancel your appointment by calling 832-356-8549, by emailing sherell@houstoncounselor.me or by going to the website at www.houstoncounselor.me and clicking the “schedule an appointment” link. This link will take you to the client portal where you can cancel your appointment. Canceling via the client por tal is the prefer red method for canceling appointments because it provides a digital record of the cancellation, thereby preventing any confusion regarding whether cancelation infor mation was received.

!CONFIDENTIALITY: Sherell Hebert, LPC follows all ethical standards prescribed by state and federal law. We are required by practice guidelines and standards of care to keep records of your counseling. These records are confidential with the exceptions noted below and in the Notice of Privacy Practices provided to you.

DUTY TO WARN/DUTY TO PROTECT: If my therapist believes that I am in any physical or emotional danger to myself or another human being, I hereby specifically give consent to my therapist to contact any person who is in a position to prevent harm to me or another, including, but not limited to, the person in danger. I also give consent to my therapist to contact the following person(s) in addition to any medical or law enforcement personnel deemed appropriate:

Name and Phone Number of Individual To Be Contacted:

_____________________________________________________________________________________

!CONSENT TO TREATMENT: By signing this Client Information and Consent Form as the client or guardian of said client, I acknowledge that I have read, understand, and agree to the terms and conditions contained in this form. I have been given appropriate opportunity to address any questions or request clarification for anything that is unclear to me. I am voluntarily agreeing to receiving mental health assessment, treatment and services for me (or my child if said child is the client), and I understand that I may stop such treatment or services at any time.

NOTE: If you are consenting to treatment of a minor child, and a court order has been entered with respect to the conservatorship of said child, or impacting your rights with respect to consent to the child’s mental health care and treatment, Sherell Hebert, LPC will not render services to your child until the therapist has received and reviewed a copy of the most recent applicable court order.

____________________________________________________________

Client (Parent’s Signature if Client is under 18) Date

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EMERGENCIES: You may encounter a personal emergency which will require prompt attention. In this event, please contact our office regarding the nature and urgency of the circumstances. We will make every attempt to schedule you as soon as possible or to offer other options. Because clients may be scheduled back-to-back, it is not always possible to return a call immediately. However, we will make every effort to respond to your emergency in a timely manner. If your emergency arises after hours or on a weekend, please contact your therapist via email. If you are experiencing a life-threatening emergency, call 911 or have someone take you to the nearest emergency room for help. When your therapist is out of town, you will be advised and given the name of an on-call therapist.

Discussions between a therapist and a client are confidential. No information will be released without the client’s written consent unless mandated by law. Possible exceptions to confidentiality include but are not limited to the following situations: child abuse; abuse of the elderly or disabled; abuse of patients in mental health facilities; sexualexploitation; AIDS/HIV infection and possible transmission; criminal prosecutions; child custody cases; suits in which the mental health of a party is in issue; situations where the therapist has a duty to disclose, or where, in the therapist’s judgment, it is necessary to warn or disclose; fee disputes between the therapist and the client; a negligence suit brought by the client against the therapist; or the filing of a complaint with the licensing or certifying board. If you have any questions regarding confidentiality, you should bring them to the attention of the therapist so that these concerns can be discussed further. By signing this Information and Consent Form, you are giving consent to the undersigned therapist to share confidential information with all persons mandated by law, and with the agency that referred you, and the insurance carrier responsible for providing your mental health care services and payment for those services. You are also releasing and holding harmless the undersigned therapist from any departure from your right of confidentiality that may result.

We may use and share your information as we: Treat you Run our organization Bill for your services Help with public health and safety issues Do research Comply with the law Respond to organ and tissue donation requests Work with a medical examiner or funeral director Address workers’ compensation, law enforcement, and other government requests

Respond to lawsuits and legal actions

³�See pages 3 and 4 for more information on these uses and disclosures

You have the right to: Get a copy of your paper or electronic medical recordCorrect your paper or electronic medical recordRequest confidential communicationAsk us to limit the information we shareGet a list of those with whom we’ve shared your informationGet a copy of this privacy noticeChoose someone to act for youFile a complaint if you believe your privacy rights have been violated

³�See page 2 for more information on these rights and how to exercise them

Our Uses and

Disclosures

Your Rights

³�See page 3 for more information on these choices and how to exercise them

You have some choices in the way that we use and share information as we:

Tell family and friends about your conditionProvide disaster reliefInclude you in a hospital directoryProvide mental health careMarket our services and sell your informationRaise funds

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.

Your Information. Your Rights.Our Responsibilities.

Your Choices

10694 Jones Road Suite 220

Houston, TX 77065

www.houstoncounselor.me

sherell@houstoncounselor.me

7062A Lakeview Haven Dr., Suite 105

77095

When it comes to your health information, you have certain rights. This section explains your rights and some of our responsibilities to help you.

Your Rights

Get an electronic or paper copy of your medical record

You can ask to see or get an electronic or paper copy of your medical record and other health information we have about you. Ask us how to do this.

We will provide a copy or a summary of your health information, usually within 30 days of your request. We may charge a reasonable, cost-based fee.

Ask us to correct your medical record

You can ask us to correct health information about you that you think is incorrect or incomplete. Ask us how to do this.

We may say “no” to your request, but we’ll tell you why in writing within 60 days.

Request confidential communications

You can ask us to contact you in a specific way (for example, home or office phone) or to send mail to a different address.

We will say “yes” to all reasonable requests.

Ask us to limit what we use or share

You can ask us not to use or share certain health information for treatment, payment, or our operations. We are not required to agree to your request, and we may say “no” if it would affect your care.

If you pay for a service or health care item out-of-pocket in full, you can ask us not to share that information for the purpose of payment or our operations with your health insurer. We will say “yes” unless a law requires us to share that information.

Get a list of those with whom we’ve shared information

You can ask for a list (accounting) of the times we’ve shared your health information for six years prior to the date you ask, who we shared it with, and why.

We will include all the disclosures except for those about treatment, payment, and health care operations, and certain other disclosures (such as any you asked us to make). We’ll provide one accounting a year for free but will charge a reasonable,

Get a copy of this privacy notice

You can ask for a paper copy of this notice at any time, even if you have agreed to receive the notice electronically. We will provide you with a paper copy promptly.

Choose someone to act for you

If you have given someone medical power of attorney or if someone is your legal guardian, that person can exercise your rights and make choices about your health information.

We will make sure the person has this authority and can act for you before we take any action.

File a complaint if you feel your rights are violated

You can complain if you feel we have violated your rights by contacting us using the

You can file a complaint with the U.S. Department of Health and Human Services

www.hhs.gov/ocr/privacy/hipaa/complaints/.

We will not retaliate against you for filing a complaint.

In these cases, you have both the right and choice to tell us to:

Share information with your family, close friends, or others involved in your care

Share information in a disaster relief situation

Include your information in a hospital directory

If you are not able to tell us your preference, for example if you are unconscious, we may go ahead and share your information if we believe it is in your best interest. We may also share your information when needed to lessen a serious and imminent threat to health or safety.

In these cases we never share your information unless you give us written permission:

Marketing purposes

Sale of your information

Most sharing of psychotherapy notes

In the case of fundraising: We may contact you for fundraising efforts, but you can tell us not to contact you again.

For certain health information, you can tell us your choices about what we share. If you have a clear preference for how we share your information in the situations described below, talk to us. Tell us what you want us to do, and we will follow your instructions.

Your Choices

Treat you We can use your health information and share it with other professionals who are treating you.

Example: A doctor treating you for an injury asks another doctor about your overall health condition.

Run our organization

We can use and share your health information to run our practice, improve your care, and contact you when necessary.

Example: We use health information about you to manage your treatment and services.

Bill for your services

We can use and share your health information to bill and get payment from health plans or other entities.

Example: We give information about you to your health insurance plan so it will pay for your services.

How do we typically use or share your health information? We typically use or share your health information in the following ways.

Our Uses and

Disclosures

continued on next page

Help with public health and safety issues

We can share health information about you for certain situations such as: Preventing disease Helping with product recalls Reporting adverse reactions to medications Reporting suspected abuse, neglect, or domestic violence Preventing or reducing a serious threat to anyone’s health or safety

Do research We can use or share your information for health research.

Comply with the law We will share information about you if state or federal laws require it, including with the Department of Health and Human Services if it wants to see that we’re complying with federal privacy law.

Respond to organ and tissue donation requests

We can share health information about you with organ procurement organizations.

Work with a medical examiner or funeral director

We can share health information with a coroner, medical examiner, or funeral director when an individual dies.

Address workers’ compensation, law enforcement, and other government requests

We can use or share health information about you: For workers’ compensation claims For law enforcement purposes or with a law enforcement official With health oversight agencies for activities authorized by law For special government functions such as military, national security, and presidential protective services

Respond to lawsuits and legal actions

We can share health information about you in response to a court or administrative order, or in response to a subpoena.

How else can we use or share your health information? We are allowed or required to share your information in other ways – usually in ways that contribute to the public good, such as public health and research. We have to meet many conditions in the law before we can share your information for these purposes. For more information see: www.hhs.gov/ocr/privacy/hipaa/understanding/consumers/index.html.

Our Responsibilities

We are required by law to maintain the privacy and security of your protected health information.

We will let you know promptly if a breach occurs that may have compromised the privacy or security of your information.

We must follow the duties and privacy practices described in this notice and give you a copy of it.

We will not use or share your information other than as described here unless you tell us we can in writing. If you tell us we can, you may change your mind at any time. Let us know in writing if you change your mind.

For more information see: www.hhs.gov/ocr/privacy/hipaa/understanding/consumers/noticepp.html.

Changes to the Terms of this NoticeWe can change the terms of this notice, and the changes will apply to all information we have about you. The new notice will be available upon request, in our office, and on our web site.

This Notice of Privacy Practices applies to the following organizations.

www.houstoncounselor.me

I have been provided with a copy of the HIPPA Notice of Privacy Practices by Sherell Hebert, MA, LPC-S.

My signature below indicates receipt of this document.

Please print your name, or if the client is a child, print his/her name.

_____________________________________

Please sign your name if you are the adult client or the parent.

________________________________________________Today's Date ____________________

Sherell Hebert, MA, LPC-S !

!Release of PHI Authorization Form !!

Name of Client: _____________________________ Date of Birth: _____________________ !Address: _________________________________________________________________________ !Phone: _____________________________________ This is a ( ) cell phone ( ) home phone !This form, when completed and signed by you, permits me to release and/or receive protected health information (PHI) from your clinical record to/from a person/entity that you designate. !I authorize Sherell Hebert, LPC: ( ) To disclose information ( ) To receive information ( ) To speak with !Name, address and phone number to whom information will be released/received: !Name: __________________________________________________________________________ ! Address: ________________________________________________________________________ !Phone: _____________________________________ Fax: ________________________________ !Sherell Hebert, LPC may release or receive the following information: ( ) No restrictions- Any information she deems as clinically appropriate ( ) Case History ( ) Current Medical or Psychiatric Information ( ) Diagnosis ( ) Medications ( ) Psychological Evaluations ( ) Attendance Dates !This information is being requested or released for the following reason(s). ( ) To help with diagnosis and treatment ( ) Coordination of Care ( ) Other ________________________________________________________________________ !You have the right to revoke this authorization at any by submitting your request in writing to Sherell Hebert, LPC. However, your revocation will not be effective to the extent that I have taken in reliance on this authorization. !

______________________________________ ______________ Client (Parent’s Signature if Client is under 18) Date

TELETHERAPY INFORMED CONSENTTeletherapy is a means by which you can receive counseling or psychotherapy from an experienced psychotherapist. It is also a process of creating, over time, a trusting and collaborative relationship. In our collaboration, you retain the right to determine which topics we cover and the depth of consideration each receives. In other words, you are free to contribute or withhold any information you choose. We work at your pace. Though all interventions suggested are clinically based, you are not obligated to to apply them.

While I hope that you will find our exchange useful in your efforts to improve your life, it is not possible to guarantee that; despite the ever growing positive feedback from Teletherapy clients. Teletherapy is relatively new, therefore it is considered experimental until its' efficacy has been validated scientifically over time.

The process of Teletherapy itself is utilizes electronic transmissions to treat the needs of a client through video and/or audio communication. Therefore the practice of healthcare delivery, diagnosis, consultation, treatment, transfer of medical data, and education is conducted via interactive audio, video or data communications.

The risks involved with Teletherapy include the potential release of private information due to the complexities and abnormalities involved with the internet. Viruses, Trojans and other other involuntary intrusions have the ability to grab and release information you may desire to keep private. Furthermore, there is the risk of being overheard by anyone in your environment if you donot place yourself in a private area. The advantages of Teletherapy include the benefit of continuity of care in the absence of your therapist as well as the ability to be treated from any location in Texas at any time. It is YOUR responsibility to create a an environment on your end ofthe Teletherapy transmission that is not subject to unexpected or unauthorized intrusion of your personal information. It is MY responsibility to do the same.

2. Unless we explicitly agree, our Teletherapy sessions are confidential. Any information you disclose to me is held in the strictest confidence. Just as with my face-to-face clients, I will not release your information to anyone without your prior approval, or unless I am required to do so by law. If there is a risk of eminent danger to anyone, I have an ethical obligation to take necessary steps to prevent such danger. I am bound by law to report suspicion or evidence of abuse involving children, the elderly or individuals with disabilities.

3. Helping you build the life you want is what our exchange is all about. We should not continue any process that is counter-productive with respect to that. Either of us is free to terminate our relationship at any time and for any reason. In the unlikely event that I become convinced that Teletherapy is not in your best interests, I will explain this to you and suggest alternative that are better suited for your needs.

4. While Teletherapy is a great way to get help with many of life's problems, overwhelming or potentially dangerous challenges are best met with face-to-face professional support. Teletherapyis not a universal substitute, nor is it the same as face-to face psychotherapy treatment. It is also important to understand that Teltherapy does not provide emergency services. If you are

1. I am licensed in the states of Texas and Louisiana. I can only provide Teletherapy to individuals who are in Texas or Louisiana at the time services are rendered.

Sherell Hebert, MA, LPC

Phone: 832-356-8549 FAX: 281-254-7979 Email: sherell@houstoncounselor.me

7171 Hwy 6 N. Suite 105 Houston, TX 77095 Website: houstoncounselor.me

experiencing an emergency situation, you should exercise one or more of the following options: call 911, proceed to the nearest hospital emergency room for help, contact your psychiatrist. If you are having suicidal thoughts, contact the National Suicide Prevention Line at: 1-800-273-8255.

5. You are responsible for information security on your computer. If you decide to keep copies of our emails or other communication on your computer, it is up to you to keep that information secure. I can not guarantee the security of emails as they travel between our computers, but VSee is encrpted and confidential. All messages exchanged between you and I in the client portal are also HIPPA compliant. If you choose to send emails to me from your personal email, you may want to consider encrypting them.

6. Teletherapy sessions are conducted via VSee, a HIPAA-Compliant Videoconferencing platform. VSee provides encryption, and protects patient data, which is why it is chosen over Skype or other alternatives. You can download VSee at https://vsee.com. If for some reason we are disconnected and can not be reconnected, I will call you by phone at the number you have provided. We will discuss how/when to proceed.

Services and Fees

Insurance

It is up to you to decide whether or not you want to use your insurance. All providers requesting payment from insurance companies must submit the following personal information on each insurance claim: your identifying information (name, date of birth, address and insurance id), diagnosis and dates of service. Your insurance company also has a right to request treatment plans and progress notes.

By signing this form, you agree to have read, understand and agree to the information presented above.

_______________________________ _____________________

Client/Parent Signature Date

_______________________________ _____________________ Therapist Signature Date

Sherell Hebert, MA, LPC

Phone: 832-356-8549 FAX: 281-254-7979 Email: sherell@houstoncounselor.me

Each session is 50 minutes. The fee is $125 per session. Payments are made prior to or at the beginning of each sessions. If you schedule a session but are unable to attend, please cancel within 24 hours. If you fail to give notice 24 hours prior to your session, your credit card will be billed for the missed appointment at the end of the business day.

Your insurance company may cover or reimburse the cost of the session. If it has been determined that your insurance will pay for this service, you will only be billed for the co-payment and/or co-insurance. If for some reason your insurance does not pay, you are responsible for the payment at the contracted rate. It is required that a credit card be kept on file.

7171 Hwy 6 N. Suite 105 Houston, TX 77095 Website: houstoncounselor.me

A copy of this packet can be found at houstoncounselor.me/1 .