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This policy is meant to protect your privacy and clarify how we can communicate outside of sessions.
Email & Text Messaging
Email and text are convenient, but they are not secure forms of communication.
These methods should be used for administrative purposes such as scheduling, appointment reminders, or sharing forms.
Please do not use email or text for urgent concerns or for sharing sensitive clinical information.
Messages may not be read immediately. For emergencies, call 911 or the crisis lines listed in the Policies & Procedures document.
Phone Calls & Voicemail
You are welcome to call and leave a voicemail. I will return calls as soon as I am able, generally within 1–2 business days.
Please keep voicemail messages brief and administrative in nature.
Social Media
To protect your privacy and keep professional boundaries clear, I do not accept friend or follow requests from current or former clients on personal social media accounts.
I do not engage in therapy-related communication through social media platforms (such as Facebook, Instagram, or Twitter).
If you see my professional page online, you are welcome to follow or view it, but please be aware that doing so may compromise your confidentiality.
Online Reviews & Testimonials
Ethical guidelines prevent me from soliciting or requesting testimonials from clients.
You are free to share your experiences on public sites if you choose, but I will not respond to reviews to protect your confidentiality.
Telehealth
If we meet virtually, we will use a secure, HIPAA-compliant platform.
I encourage you to choose a private, quiet location for sessions and to use headphones when possible to protect your privacy.
Boundaries & Safety
I will not use electronic communication to provide therapy outside of scheduled sessions.
If you send sensitive information electronically, please understand the risks and limitations of privacy.
For time-sensitive or emergency needs, please use phone or crisis resources instead of electronic communication.
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Purpose of Treatment
I understand that I am eligible to receive a range of counseling services. The type and extent of services will be determined after an initial assessment and discussion with my provider. The goal of this process is to identify the best course of treatment for me.
Treatment is typically provided over the course of several weeks or longer, depending on my needs.
My Rights as a Client
I have the right to ask questions at any time about my treatment.
I may request an outside consultation if I wish.
I can consent to or refuse specific treatment recommendations.
My progress will be reviewed regularly, and I will be included in these discussions.
I may stop treatment at any time. If I choose to do so, I agree to first discuss this decision with my provider.
I understand that no guarantees can be made about specific treatment outcomes.
Confidentiality
I understand that what I share in counseling is confidential and will not be released without my written permission, except in the following circumstances:
1. Safety Concerns – If I am at risk of harming myself or someone else, my provider is required to take steps to keep everyone safe.
2. Abuse or Neglect – If there is suspected abuse or neglect of a child, elder, or vulnerable adult, my provider is legally required to report this to the proper authorities.
3. Court Orders – If a valid court order is issued for records, my provider must comply with the law.
I also understand that once information is shared with an insurance company or other third party, my provider cannot guarantee that it will remain confidential.
For a detailed explanation of my privacy rights, I have been provided with a Notice of Privacy Practices and encouraged to discuss any questions with my provider.
Consent to Treatment
By signing below, I voluntarily consent to participate in counseling services with Allison Etchison, LCSW. I understand that:
Counseling may involve a variety of approaches and techniques.
The practice of counseling is not an exact science, and outcomes cannot be guaranteed.
I have had the opportunity to ask questions about my treatment and this consent form.
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This notice describes how medical information about you may be used and disclosed. It also describes how you can get access to this information. Please review it carefully.
In order to provide you care, Allison Etchison (your “Provider”) must collect, create and maintain health information about you, which includes any individually identifiable information that we obtain from you or others that relates to your past, present or future physical or mental health, the health care you have received, or payment for your health care. Your Provider is required by law to maintain the privacy of this information. This Notice of Privacy Practices (this “Notice”) describes how your health information may be used and disclosed, and explains certain rights you have regarding this information. Your Provider is required by law to provide you with this Notice, and will comply with the terms as stated.
How Provider Uses and Discloses Your Health Information
Your Provider protects your health information from inappropriate use and disclosure, and will use and disclose your health information for only the purposes listed below:
Uses and Disclosures for Treatment, Payment and Health Care Operations. Your Provider may use and disclose your protected health information in order to provide your care or treatment, obtain payment for services provided to you and in order to conduct our health care operations as detailed below.
Treatment and Care Management. We may use and disclose health information about you to facilitate treatment, and coordinate and manage your care with other health care providers.
Payment. We may use and disclose health information about you for our own payment purposes and to assist in the payment activities of other health care providers. Our payment activities include, without limitation, determining your eligibility for benefits and obtaining payment from insurers that may be responsible for providing coverage to you, including Federal and State entities.
Health Care Operations. We may use and disclose health information about you to support health care functions related to treatment and payment, which include, without limitation, care management, quality improvement activities, evaluating our own performance and resolving any complaints or grievances you may have. We may also use and disclose your health information to assist other health care providers in performing health care operations.
Uses and Disclosures Without Your Consent or Authorization. We may use and disclose your health information without your specific written authorization for the following purposes:
As required by law. We may use and disclose your health information as required by state, federal and local law.
Public health activities. We may disclose your health information to public authorities or other agencies and organizations conducting public health activities, such as preventing or controlling disease, injury or disability, reporting births, deaths, child abuse or neglect, domestic violence, potential problems with products regulated by the Food and Drug Administration or communicable diseases.
Victims of abuse, neglect or domestic violence. We may disclose your health information to an appropriate government agency if we believe you are a victim of abuse, neglect, domestic violence and you agree to the disclosure or the disclosure is required or permitted by law. We will let you know if we disclose your health information for this purpose unless we believe that advising you or your caregiver would place you or another person at risk of serious harm.
Health oversight activities. We may disclose your health information to federal or state health oversight agencies for activities authorized by law such as audits, investigations, inspections and licensing surveys.
Judicial and administrative proceedings. We may disclose your health information in the course of any judicial or administrative proceeding in response to an appropriate order of a court or administrative body.
Law enforcement purposes. We may disclose your health information to a law enforcement agency to respond to a court order, warrant, summons or similar process, to help identify or locate a suspect or missing person, to provide information about a victim of a crime, a death that may be the result of criminal activity, or criminal conduct on our premises, or, in emergency situations, to report a crime, the location of the crime or the victims, or the identity, location or description of the person who committed the crime.
Deceased individuals. We may disclose your health information to a coroner, medical examiner or a funeral director as necessary and as authorized by law.
Organ or tissue donations. We may disclose your health information to organ procurement organizations and similar entities.
For research. We may use or disclose your health information for research purposes. We will use or disclose your health information for research purposes only with the approval of our Institutional Review Board, which must follow a special approval process. When required, we will obtain a written authorization from you prior to using your health information for research.
Health or safety. We may use or disclose your health information to prevent or lessen a threat to the health or safety of you or the general public. We may also disclose your health information to public or private disaster relief organizations such as the Red Cross or other organizations participating in bio-terrorism countermeasures.
Specialized government functions. We may use or disclose your health information to provide assistance for certain types of government activities. If you are a member of the armed forces of the United States or a foreign country, we may disclose your health information to appropriate military authority as is deemed necessary. We may also disclose your health information to federal officials for lawful intelligence or national security activities.
Workers’ compensation. We may use or disclose your health information as permitted by the laws governing the workers’ compensation program or similar programs that provide benefits for work-related injuries or illnesses.
Individuals involved in your care. We may disclose your health information to a family member, other relative or close personal friend assisting you in receiving health care services. If you are available, we will give you an opportunity to object to these disclosures, and we will not make these disclosures if you object. If you are not available, we will determine whether a disclosure to your family or friends is in your best interest, taking into account the circumstances and based upon our professional judgment.
Appointments, Information and Services. We may contact you to provide appointment reminders or information about treatment alternatives or other health-related services that may be of interest to you.
Incidental Uses and Disclosures. Incidental uses and disclosures of your health information sometimes occur and are not considered to be a violation of your rights. Incidental uses and disclosures are by-products of otherwise permitted uses or disclosures which are limited in nature and cannot be reasonably prevented.
Special Treatment of Certain Records. HIV related information, genetic information, alcohol and/or substance abuse records, mental health records related to services provided by a New York Article 31 mental health clinic and other specially protected health information may enjoy certain special confidentiality protections (that are more restrictive than those outlined above) under applicable state and federal law. Any disclosures of these types of records will be subject to these special protections.
Obtaining Your Authorization for Other Uses and Disclosures. Certain uses and disclosures of your health information will be made only with your written authorization, including uses and/or disclosures: (a) of psychotherapy notes (where appropriate); (b) for marketing purposes; and (c) that constitute a sale of health information under the Privacy Rule. Your Provider will not use or disclose your health information for any purpose not specified in this Notice unless we obtain your express written authorization or the authorization of your legally appointed representative. If you give us your authorization, you may revoke it at any time, in which case we will no longer use or disclose your health information for the purpose you authorized, except to the extent we have relied on your authorization to provide your care.
Your Rights Regarding Your Health Information
You have the following rights regarding your health information:
Right to Inspect or Get a Copy of Your Medical Record. You have the right to inspect or request a copy of health information about you that we maintain. Your request should describe the information you want to review and the format in which you wish to review it. We may refuse to allow you to inspect or obtain copies of this information in certain limited cases. We may charge you a fee of up to $.75 per page for copies or the rate established by the Department of Health. We may also deny a request for access to health information under certain circumstances if there is a potential for harm to yourself or others. If we deny a request for access for this purpose, you have the right to have our denial reviewed in accordance with the requirements of applicable law.
Right to Request Changes to Your Medical Record. You have the right to request changes to any health information we maintain about you if you state a reason why this information is incorrect or incomplete. Your Provider might not agree to make the changes you request. If we do not agree with the requested changes we will notify you in writing and inform you how to have your objection included in our records.
Right to an Accounting of Disclosures. You have the right to receive a list of all disclosures we have made of your health information. The list will not include disclosures made for certain purposes including, without limitation, disclosures for treatment, payment or health care operations or disclosures you authorized in writing. Your request should specify the time period covered by your request, which cannot exceed six years. The first time you request a list of disclosures in any 12-month period, it will be provided at no cost. If you request additional lists within the 12-month period, we may charge you a nominal fee.
Right to Request Restrictions. You have the right to request restrictions on the ways which we use and disclose your health information for treatment, payment and health care operations, or disclose this information to disaster relief organizations or individuals who are involved in your care. We are required to comply with your request if it relates to a disclosure to your health plan regarding health care items or services for which you have paid the bill in full, though in other instances, we may not agree to the restrictions you request.
Right to Request Confidential Communications. You have the right to ask us to send health information to you in a different way or at a different location. Your request for an alternate form of communication should also specify where and/or how we should contact you.
Right to Receive Notification of Breach. You have the right to receive a notification, in the event that there is a breach of your unsecured health information, which requires notification under the Privacy Rule.
Right to Paper Copy of Notice. You have the right to receive a paper copy of this Notice of Privacy Practices at any time.
To make a request as described in any of the above, please contact your Provider.
Right to File Complaints
If you believe your privacy rights have been violated you may file a complaint with your Provider or with the Secretary of the U.S. Department of Health and Human Services. You will not be penalized or retaliated against by your Provider for filing a complaint.
Changes to this Notice
Your Provider may change the terms of this Notice of Privacy Practices at any time. If the terms of the Notice are changed, the new terms will apply to all of your health information, whether created or received by your Provider before or after the date on which the Notice is changed. Any updates to the Notice will be provided to you.
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What is Telehealth?
Telehealth is the delivery of counseling or healthcare services using technology instead of an in-person visit. Services may include therapy, consultation, follow-up, education, and sharing of health information via:
Video conferencing
Telephone
Secure messaging or patient portals
Other electronic communications
Consent to Participate
I consent to participate in telehealth sessions with Allison Etchison, LCSW, as part of my care. I understand that telehealth involves providing services while the client and provider are in separate locations.
My Rights
I may withdraw my consent to telehealth at any time without affecting my future access to care.
I have the right to ask questions about telehealth services at any time.
Risks and Limitations
I understand that telehealth carries some risks, including but not limited to:
Technology failures or service interruptions
Delays in communication or information transmission
Potential breaches of confidentiality by unauthorized persons
Limited ability to respond to emergencies remotely
I understand that telehealth may not be appropriate for crises such as:
Suicidal or homicidal thoughts
Severe psychotic symptoms
Other urgent mental health emergencies
If such situations occur, my provider may recommend a higher level of care.
Privacy and Confidentiality
Sessions will not be recorded by either party.
All information shared is confidential, except as required by law (e.g., danger to self/others, abuse of a child, elder, or vulnerable adult, or legal requirements).
The same privacy laws that protect my health information in-person also apply to telehealth sessions.
Electronic Communication
Sensitive health information (e.g., mental health, HIV/AIDS, substance use) may be communicated electronically, but risks remain.
Electronic communication should never be used for emergencies. For urgent concerns, call 911 or your local crisis line.
Technical Issues
If a session is disrupted, end the session and restart.
If we cannot reconnect within ten minutes, please call or email to reschedule.
Emergency Protocol
In the event of an emergency, my provider may contact my emergency contact or appropriate authorities.
Acknowledgment of Risks
I understand that:
Telehealth carries inherent risks due to electronic transmission.
There are no guarantees regarding outcomes of treatment.
To the extent allowed by law, I release my provider and practice from liability related to telehealth services.Item description
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Welcome, and thank you for choosing me to support your counseling needs. As we begin our work together, I want you to know what to expect so that our sessions can feel safe, supportive, and effective.
Session Times
Each session is scheduled for 53 minutes. This time is reserved exclusively for you and allows us to focus on meaningful work together as well as coordinating future appointments.
Cancellations, No-Shows, and Cancellation
Because your appointment time is held just for you, I ask that you provide at least 24 hours’ notice for cancellations or rescheduling.
Sessions canceled with less than 24 hours’ notice or missed without notice will be charged a $75 fee to the card on file.
This fee cannot be billed to insurance.
To schedule, cancel, or reschedule, please contact me by email. The time stamp of your message will be honored.
Late Arrival
If you arrive more than 15 minutes late, the session will be considered a missed appointment and the $75 fee will apply.
If you notify me in advance and at least 30 minutes remain, we can proceed with the session. Please note that frequent late arrivals may impact your progress.
Payment and Billing
To ensure smooth billing, all clients are required to use Auto Pay through Alma’s secure portal.
Your card on file will be used to cover:
Copays (if using insurance) or full session fees (if paying privately)
Late cancellation or no-show fees
Outstanding balances must be paid in full before additional sessions can be scheduled.
School and Work Notes
Notes for school or work are available upon request when you reschedule an appointment.
Release of Information
Your privacy is very important. I require a signed Release of Information form before sharing any details about your care with schools, physicians, or other parties.
Emergency Contacts
For emergencies outside of session hours, please call:
911
988 (National Suicide & Crisis Lifeline)
Tarrant County Crisis Line: (817) 335-3022 (24/7, free of charge)
If you live outside Tarrant County, please let me know during your first session so I can help connect you with local resources.
Continued Care
If two consecutive appointments are missed without at least 24 hours’ notice, you may be considered inactive and referred to other counseling resources.
Limits of Confidentiality
What you share in counseling is confidential and will not be released without your written consent, except in situations where disclosure is legally or ethically required. These include:
Mandatory Reporting
Suspected abuse or neglect of children, elderly adults, or individuals with disabilities
Abuse of patients in mental health facilities
Sexual exploitation
Legal / Court-Related Situations
Court orders or custody disputes where mental health is relevant
Criminal investigations or prosecutions
Legal cases in which your mental health is a key issue
Professional Responsibilities
Fee disputes between client and therapist
Negligence claims or malpractice suits
Complaints filed with licensing or certification boards
Safety Concerns
If there is an immediate risk of harm to yourself or others
Please feel free to ask me about confidentiality at any time.
Consent to Treatment
I voluntarily agree to participate in counseling services with Allison Etchison, LCSW. I understand that:
I have the right to participate in planning my care and treatment.
I may ask questions about my care at any time.
I may stop counseling at any time.
By signing below, I confirm that I have read and understood the Policies & Procedures and Consent to Treatment. I have had the opportunity to ask questions and receive clarification as needed.