Informed Consent for Treatment


I. General Information

The therapeutic relationship is unique in that it is a highly personal and at the same time, a contractual agreement. Given this, it is important for us to reach a clear understanding about how our relationship will work, and what each of us can expect. This consent will provide a clear framework for our work together. Feel free to discuss any of this with me. Please read and indicate that you have reviewed this information and agree to it by filling in the checkbox at the end of this document.

II. The Therapeutic Process

You have taken a very positive step by deciding to seek therapy. The outcome of your treatment depends largely on your willingness to engage in this process, which may, at times, result in considerable discomfort. Remembering unpleasant events and becoming aware of feelings attached to those events can bring on strong feelings of anger, depression, anxiety, etc. There are no miracle cures. I cannot promise that your behavior or circumstance will change. I can promise to support you and do my very best to understand you and repeating patterns, as well as to help you clarify what it is that you want for yourself.

III. Jurisdiction for Treatment

Nova Telemental Health LLC and its owner, Kelly Cipera, LCSW are licensed to operate in Virginia only. For the purposes of your telehealth sessions, you must be in Virginia at the time of services. This is non-negotiable and subject to Virginia law, not the clinician’s discretion. If you are outside of your home address, you will need to provide your clinician with your current address, or if parked in your care, the nearest address to you. If you are in your car, you clinician will ask you for the make, model, and license plate and nearest cross street.


IV. Privacy Practices

Our Pledge Regarding Health Information

I understand that health information about you and your health care is personal. I am committed to protecting health information about you. I create a record of the care and services you receive from me. 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 this mental health care practice. This notice will tell you about the ways in which I may use and disclose health information about you. I also describe your rights to the health information I keep about you and describe certain obligations I have regarding the use and disclosure of your health information. I am required by law to:

  • Make sure that protected health information (“PHI”) that identifies you is kept private.

  • Give you this notice of my legal duties and privacy practices with respect to health information.

  • Follow the terms of the notice that is currently in effect.

  • I can change the terms of this Notice, and such changes will apply to all information I have about you. The new Notice will be available upon request, in my office, and on my website.


How I May Use and Disclose 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 I mean and try to give some examples. Not every use or disclosure in a category will be listed. However, all the ways I am permitted to use and disclose information will fall within one of the categories.

  1. For Treatment Payment, or Health Care Operations: Federal privacy rules (regulations) allow health care providers who have direct treatment relationship with the patient/client to use or disclose the patient/client’s personal health information without the patient’s written authorization, to carry out the health care provider’s own treatment, payment or health care operations. I may also disclose your protected health information for the treatment activities of any health care provider. This too can be done without your written authorization. For example, if a clinician were to consult with another licensed health care provider about your condition, we would be permitted to use and disclose your person health information, which is otherwise confidential, to assist the clinician in diagnosis and treatment of your mental health condition.

  2. Disclosures for treatment purposes are not limited to the minimum necessary standard. Therapists and other health care providers need access to the full record and/or full and complete information to provide quality care. The word “treatment” includes, among other things, the coordination and management of health care providers with a third party, consultations between health care providers and referrals of a patient for health care from one health care provider to another.

  3. Lawsuits and Disputes: If you are involved in a lawsuit, I may disclose health information in response to a court or administrative order. I may also disclose health information about your child in response to a subpoena, discovery request, or other lawful process by someone else involved in the dispute, but only if efforts have been made to tell you about the request or to obtain an order protecting the information requested.


Certain Uses and Disclosures Require Your Authorization

  1. Psychotherapy Notes. I do keep “psychotherapy notes” as that term is defined in 45 CFR § 164.501, and any use or disclosure of such notes requires your Authorization unless the use or disclosure is:

    • For my use in treating you.

    • For my use in training or supervising mental health practitioners to help them improve their skills in group, joint, family, or individual counseling or therapy.

    • For my use in defending myself in legal proceedings instituted by you.

    • For use by the Secretary of Health and Human Services to investigate my compliance with HIPAA.

    • Required by law and the use or disclosure is limited to the requirements of such law.

    • Required by law for certain health oversight activities pertaining to the originator of the psychotherapy notes.

    • Required by a coroner who is performing duties authorized by law.

    • Required to help avert a serious threat to the health and safety of others.

  2. Marketing Purposes. As a psychotherapist, I will not use or disclose your PHI for marketing purposes.

  3. Sale of PHI. As a psychotherapist, I will not sell your PHI in the regular course of my business.


Certain Uses and Disclosures Do Not Require Your Authorization

Subject to certain limitations in the law, I can use and disclose your PHI without your Authorization for the following reasons:

  1. When disclosure is required by state or federal law, and the use or disclosure complies with and is limited to the relevant requirements of such law.

  2. For public health activities, including reporting suspected child, elder, or dependent adult abuse, or preventing or reducing a serious threat to anyone’s health or safety.

  3. For health oversight activities, including audits and investigations.

  4. For judicial and administrative proceedings, including responding to a court or administrative order, although my preference is to obtain an Authorization from you before doing so.

  5. For law enforcement purposes, including reporting crimes occurring on my premises.

  6. To coroners or medical examiners when such individuals are performing duties authorized by law.

  7. For research purposes, including studying and comparing the mental health of patients who received one form of therapy versus those who received another form of therapy for the same condition.

  8. Specialized government functions, including, ensuring the proper execution of military missions; protecting the President of the United States; conducting intelligence or counter-intelligence operations; or, helping to ensure the safety of those working within or housed in correctional institutions.

  9. For workers' compensation purposes. Although my preference is to obtain an Authorization from you, I may provide your PHI to comply with workers' compensation laws.

  10. Appointment reminders and health related benefits or services. I may use and disclose your PHI to contact you to remind you that you have an appointment with me. I may also use and disclose your PHI to tell you about treatment alternatives, or other health care services or benefits that I offer.


Certain Uses and Disclosures Require You to Have the Opportunity to Object

Disclosures to family, friends, or others. I may provide your PHI to a family member, friend, or other person that you indicate is involved in your care or the payment for your health care, unless you object in whole or in part. The opportunity to consent may be obtained retroactively in emergency situations.


You Have the Following Rights with Respect to Your PHI

  1. The Right to Request Limits on Uses and Disclosures of Your PHI. You have the right to ask me not to use or disclose certain PHI for treatment, payment, or health care operations purposes. I am not required to agree to your request, and I may say “no” if I believe it would affect your health care.

  2. The Right to Request Restrictions for Out-of-Pocket Expenses Paid for In Full. You have the right to request restrictions on disclosures of your PHI to health plans for payment or health care operations purposes if the PHI pertains solely to a health care item or a health care service that you have paid for out-of-pocket in full.

  3. The Right to Choose How I Send PHI to You. You have the right to ask me to contact you in a specific way (for example, home or office phone) or to send mail to a different address, and I will agree to all reasonable requests.

  4. The Right to See and Get Copies of Your PHI. Other than “psychotherapy notes,” you have the right to get an electronic or paper copy of your medical record and other information that I have about you. I will provide you with a copy of your record, or a summary of it, if you agree to receive a summary, within 30 days of receiving your written request, and I may charge a reasonable, cost-based fee for doing so.

  5. The Right to Get a List of the Disclosures I Have Made. You have the right to request a list of instances in which I have disclosed your PHI for purposes other than treatment, payment, or health care operations, or for which you provided me with an Authorization. I will respond to your request for an accounting of disclosures within 60 days of receiving your request. The list I will give you will include disclosures made in the last six years unless you request a shorter time. I will provide the list to you at no charge, but if you make more than one request in the same year, I will charge you a reasonable cost-based fee for each additional request.

  6. The Right to Correct or Update Your PHI. If you believe that there is a mistake in your PHI, or that a piece of important information is missing from your PHI, you have the right to request that I correct the existing information or add the missing information. I may say “no” to your request, but I will tell you why in writing within 60 days of receiving your request.

  7. The Right to Get a Paper or Electronic Copy of this Notice. You have the right get a paper copy of this Notice, and you have the right to get a copy of this notice by e-mail. And, even if you have agreed to receive this Notice via e-mail, you also have the right to request a paper copy of it.


Practice Policies to maintain HIPAA Compliance

  1. Simple Practice: Contains medical records, scheduling, insurance processing, credit card process, secure documentation and HIPAA compliant messaging and client portal.  Nova Telemental Health LLC maintains a Business Associate Agreement.

  2. Iplum: HIPAA Compliant Online Fax service, Nova Telemental Health LLC maintains a Business Associate Agreement.

  3. Psychology Today: Client referral services. Nova Telemental Health LLC maintains a Business Associate Agreement.

  4. Doxy: HIPAA Compliant Video Conferencing Platform, each clinician maintains their own Business Associate Agreement.

  5. Zoom: Any clinician using HIPAA Compliant Zoom maintains their own Business Associate Agreement.

  6. Google Workplace: Nova Telemental Health LLC maintains a Business Associate Agreement.

  7. Virtru: Additional protection including end to end email encryption overlaid with Google Workplace/Email/Drive. Nova Telemental Health LLC maintains a Business Associate Agreement.


Consent for Telemental Health Consultation and Sessions

I understand that:

  1. My Clinician plans on conducting therapy session over a HIPAA Compliant audio and visual telemedicine platform (Zoom, Doxy, Simple Practice).

  2. The laws that protect the confidentiality of my medical information also apply to telemedicine. As such, I understand that the information disclosed by me during my therapy is generally confidential. However, there are both mandatory and permissive exceptions to confidentiality, including, but not limited to reporting child, elder, and dependent adult abuse; expressed threats of violence towards an ascertainable victim; and where I make my mental or emotional state an issue in a legal proceeding.

  3. Telehealth therapy session has potential benefits including easier access to care and the convenience of meeting from a location of my choosing. In addition, confidentiality cannot be maintained if you participate in therapy in public spaces using telehealth services.

  4. There are risks and consequences from telememental health, including, but not limited to: the possibility, despite reasonable efforts on the part of my psychotherapist, that: the transmission of my medical information could be disrupted or distorted by technical failures; the transmission of my medical information could be interrupted by unauthorized persons; and/or the electronic storage of my medical information could be accessed by unauthorized persons.

  5. I have had a direct conversation with my provider, during which I had the opportunity to ask questions regarding this procedure. My questions have been answered and the risks, benefits and any practical alternatives have been discussed with me in a language in which I understand.

  6. I have the right to withhold or withdraw consent at any time without affecting my right to future care or treatment nor risking the loss or withdrawal of any program benefits to which I would otherwise be entitled.


Specific Policies and Considerations with Telehealth

  • A telememental health appointment should be conducted as an in-person appointment.  Both parties will be expected to be dressed in appropriate, professional attire.

  • If during an appointment a client behaves in an inappropriate manner, the client will be terminated immediately and/or reported to authorities.

  • There will be no recording of any of the online sessions by either party. All information disclosed within sessions and written records pertaining to those sessions are confidential and may not be disclosed to anyone without written authorization, except where the disclosure is permitted and/or required by law.

  • If you are having suicidal or homicidal thoughts, actively experiencing psychotic symptoms, or experiencing a mental health crisis that cannot be resolved remotely, it may be determined that telemental health services are not appropriate and a higher level of care is required.

  • I understand that my therapist may need to contact my emergency contact and/or appropriate authorities in case of an emergency.

    • Your therapist will need to know your location in case of an emergency.

    • You agree to inform your therapist of the address where you are at the beginning of each session.

    • You will need to provide two emergency contacts within the state of Virginia, who may be contacted on your behalf in a life- threatening emergency only. This person will only be contacted to go to your location or take you to the hospital in the event of an emergency.

    • You will also need to indicate the closest Emergency Room to your home location, and nearest police department’s non-emergency local number.

    • If you are in a different location than usual, this will need to be determined at the beginning of your session.

  • I understand that safety during telemental health sessions is important and certain behaviors are not considered safe during our sessions such as driving, walking in public, riding bicycles, or other activities where you may be distracted during session.


Practice Policies


  1. The initial appointment is generally a 60-minute appointment, please be prepared to spend the hour with your therapist.

  2. Appointment times will be determined between you and your individual therapist.  Standard appointment increments are 30 minutes, 45 minutes, 60 minutes, and 90 minutes.

  3. Crisis appointments or appointments made outside of normally scheduled hours may incur additional costs associated with copayments, coinsurance, or deductibles, the client agrees to be responsible for these costs.

  4. Crisis appointments are defined by this practice as: Any appointment made outside of normal scheduled time, that would require your Clinician to add or modify their schedule to see you.

  5. Nova Telemental Health LLC and its clinicians are not considered crisis services, your therapist may refer you to emergency services after a crisis appointment is initiated.

  6. In the event of a medical or mental health emergency, do not wait for your scheduled appointment but call 9-1-1, or go to your nearest emergency room for immediate services.


Client Initiated Cancellations

  1. Please remember to cancel or reschedule 24 hours in advance.

  2. Cancellations and failure to show to a session will be subject to a fee of $75.

  3. Arriving Late will reduce your appointment time, or beyond 15 minutes late will be considered a no-show appointment, fees will apply.

  4. In the event of an emergency, clinician can provide a professional courtesy and waive the fee, this is up to the individual clinician’s discretion.

  5. Excessive cancellations (general threshold is 3 missed appointments) can result in losing your appointment time or being discharged from services.

  6. Reinitiating services is at the discretion of the clinician.  Your clinician may work with you to create a written plan to address late cancellations or failing to show for appointments, but this is at their discretion based on the concerns being addressed in therapy.

  7. The practice policy is to immediately discharge/terminate treatment at the third missed appointment without sufficient notice and to provide a minimum of 3 referrals.


Clinician Initiated Cancellations

  1. Your clinician will make every effort to afford you the same courtesy of canceling an appointment with 24-hour notice when possible.  Just as we understand you will have emergencies from time to time, or other issues arise we will do our best to communicate as soon as possible.

  2. Discuss with your clinician their policy for days that have school closures, government closures, holidays, etc.  Each clinician is at their discretion for how they will handle these times off.



  1. Copayment/Coinsurance/Deductible payments are due at time of service.  If there is an insurance-based adjustment, refunds are processed the day of the adjustment or underpayments will be collected at time of notice.

  2. Clients will be fully responsible for all copayments, coinsurance payments, or deductible payments. While we make every attempt verify your insurance benefits ahead of time, we encourage you to call your mental health benefits, from the number that is usually found on the back of your insurance card to verify for yourself.

  3. Nova Telemental Health LLC requires a credit card to be kept on file.  Exceptions will be made on a case-by-case basis and must be reviewed with practice owner.

  4. Nova Telemental Health LLC’s policy is that all client balances must be paid at the time of service. If you have a balance of $100 or more, that balance must be paid before meeting with your therapist again.

  5. Nova Telemental Health LLC will make every effort to collect on any unpaid balance to help you avoid accruing a large balance and reserves the right to cancel your future appointments until that balance is paid.



  1. Nova Telemental Health LLC reserves the right to increase its fees at any time, and reasonable notice will be given to you.

  2. Private “cash” Based Fees are provided on the company website and will be collected at time of appointment.'

    • If you choose to pay out of pocket and you have insurance, you will be asked to complete an “Insurance Opt-Out” form.

    • Sliding Scale fees are available on a case-by-case basis and are ultimately at the discretion of the individual clinician.

  3. We ask that if you have insurance, we first evaluate your costs based on our negotiated rates with your insurance.  There may be more benefit in doing a shorter session while paying down your deductible rather than opting out of using insurance.

  4. If it is determined that Sliding Scale is appropriate, you will be asked to sign a “Sliding Scale Agreement” to activate the current sliding scale rates.

  5. Our sliding scale rates are meant to be temporary and should be re-evaluated at regular intervals with your therapist or if your financial situation changes/new insurance is obtained.  It is not meant to be permanent, if possible.

    • No-Show/Late Cancellation Fees are $75 unless the individual clinician as waived the fee.

    • Letter Writing Fee: $25 per 15 Minutes

      • Examples of Letters or Forms include: School Accommodation Letters, Social Security Disability Forms, Letters to Insurance Companies, Health Providers (outside normal PCP Care Coordination Letters), etc.

    • Phone Calls over 15 minutes: $25 per 15 minutes.

    • Attendance at Meetings outside Therapy (virtual or in person): $150 per hour.

    • Full Medical Records Request: $25. If you are requesting your complete medical record, which will take time to prepare we ask for 7 calendar days to complete the request.  If you are requesting a summary, diagnosis, letter, discuss with your therapist.

    • Court Appearance: Clients are discouraged from having the therapist subpoenaed. Though the client’s attorney, who initiates the subpoena request is responsible for the court appearance and testimony fees, it does not mean that the therapist's testimony will be solely in in the client's favor. The Therapist will only testify their professional opinion and to the facts of the case. The following fees apply for court appearances:

      • Preparation time (including submission of records) $220/hour

      • Phone calls $220/hour

      • Depositions $250/hour

      • Email or written letters $200/hour

      • Time required in giving testimony $250/hour

      • Mileage $0.56/mile (mileage based on annual recommendations)

      • Time away from office due to depositions or testimony $220/hour

      • Filing a document with the court $100 (Plus court fees)

      • The minimum charge for a court appearance $3000

      • Any and all legal fees and costs incurred by the therapist as a result of the legal action.

      • PLEASE NOTE: A retainer of $3000 is due in advance. If a subpoena or notice to meet attorney(s) is received without a minimum of 48-hour notice, there will be an additional $250 “express” charge. If the case is reset with notice of less than 72 business-hours, the client will be charged $500 (in addition to the retainer of $1500). All fees are doubled if the therapist has to postpone or interrupt plans to go out of town.



  1. Telehealth Sessions: Each clinician within this practice maintains their own HIPAA Compliant audio and visual conferencing platform.  The practice maintains all necessary Business Associate Agreements in compliance with telehealth standards.

  2. Email Communication: Your Clinician has a company email with the ending These emails are protected with additional encryption through Google Workplace and Virtru.  While our email meets the qualifications for HIPAA it is not a replacement for attending your regularly scheduled sessions.

  3. Sharing Documents and Forms: The Simple Practice Platform has a Client Portal which can be accessed using this link: Within the portal you may access invoices, signed paperwork, your upcoming schedule with your clinician, upload documents to your client chart, and securely message your Clinician in a secure, HIPAA compliant system.

  4. Telephone Access to Clinician: Please leave a voice mail requesting a call back.  This practice does not have an on-call or administrative service to answer calls on behalf of your clinician.

    • Phone calls and voicemail are not suitable alternatives to therapy sessions and any phone calls or voicemails that include therapeutic information will be noted within the client’s medical record.

    • Excessive phone calls, or length of calls will incur a fee, as outlined in the Fees section of this agreement.

  5. Emergency Situations:

    • In the event of a medical or mental health emergency, please dial 9-1-1 or go to your local emergency room.  Your clinician is not considered a crisis counselor and is not “on-call” for emergencies.

    • Emergency Contacts: Clients are required to complete a form for Telemental Health Emergency contacts prior to the first appointment.  This form will include two local to the client contacts in the event of an emergency during a telemental health appointment, the closes hospital with phone number, and the local police department and phone number.  This helps ensure client safety and access to emergency services if needed.


Social Media

  1. This practice participates in LinkedIn, Psychology Today, and Google Business.  It may engage in other forms of social media in the future.  Social Media is not an acceptable replacement for therapy services.  All interactions on social media by this company are for informational or marketing purposes. 

  2. This practice will never identify clients, the family of clients, or anyone known to be an associate of a client on these social media platforms.

  3. You clinician will not accept “friend requests” on any social media platform.  You clinician will not search for you, accept messages from your, or engage on any social media platform.  This protects your privacy and reduces the chance for dual relationships.

  4. If you identify yourself as a client of this practice or of a specific clinician, you are doing that of your own volition and will never be asked to participate in reviews, testimonials, or to join any social media on behalf of this practice.  You may provide reviews or testimonials if you wish, but you accept the risks and benefits of identifying yourself as a client.

  5. If you have questions, you can bring them to session with your clinician.


Minors in Treatment

If you are a minor, your parents may be legally entitled to some information about your therapy. I will discuss with you and your parents what information is appropriate for them to receive and which issues are more appropriately kept confidential.

Termination/Discharge from Treatment

Ending relationships can be difficult. Therefore, it is important to have a termination process to achieve some closure. The appropriate length of the termination depends on the length and intensity of the treatment.


Reasons for Termination/Discharge from Treatment:

  1. After appropriate discussion with you with referrals to any additional supportive services. I will not terminate the therapeutic relationship without first discussing and exploring the reasons and purpose of terminating.

  2. If you require a higher level of care as evidenced by self-report, clinical interview, or behavior evidenced in sessions.  Appropriate referrals and supports will be provided to client at this time.

  3. Therapy is only effective if you attend and are willing to work, if it is determined that the psychotherapy is not being effectively used or if there is a clear pattern of late-cancellations or failure to show for the scheduled session, you may be discharged with referrals.  The practice policy is after three no-show appointments you can be discharged from services.  Your clinician may alter this policy, but this will require written consent and a plan between you and your therapist to reduce future occurrences of missed appointments.

  4. If you are in default on payment treatment can be paused or terminated.  Efforts will be made to collect owed payments before sessions can resume.

  5. Therapy can be terminated by client for any reason, or you request another therapist, I will provide you with a list of qualified psychotherapists to treat you. You may also choose someone on your own or from another referral source.

  6. If you are in a suicidal crisis, treatment will not be terminated even for failure to pay.  Once the crisis has resolved, clinician and client will have to determine correctness of fit, need for additional or higher levels of care.