CONFIDENTIALITY: All information disclosed during sessions and the written records pertaining to those sessions are confidential and may not be revealed to anyone without the client's written permission, except where disclosure is required by law.

WHEN DISCLOSURE IS REQUIRED OR MAY BE REQUIRED BY LAW: Some of the circumstances where disclosure is required or may be required by law are: when there is a reasonable suspicion of abuse, neglect or exploitation of a child, elderly or disabled person, or when the client presents a danger to self or others. Disclosure may also be required pursuant to a legal proceeding by or against the client. In couple and family therapy, or when different family members are seen individually, even over a period of time, confidentiality and privilege do not apply between the couple or among family members, unless otherwise agreed. Dr. Blanchard will use clinical judgment when revealing such information. Dr. Blanchard will not release records to any outside party unless authorized to do so by all adult parties who were part of the family therapy, couple therapy or other treatment that involved more than one adult client.

MINORS: (under 18 years of age): Dr. Blanchard respects the confidentiality of minor clients and establishes that the child, not the parent, is the client. Parents or legal guardians have the right to view the clinical records of the minor client; however, it is advisable that for psychotherapy to be effective, trust in the therapeutic relationship is paramount. Most minors will not be willing to disclose information if they believe that it will be shared with their parents. Therefore, Dr. Blanchard will only disclose information to parents or legal guardians under the following circumstances: (1) Abuse, neglect or exploitation of a child, an elderly person or a disabled person. (2) If the minor is in eminent danger of committing suicide or homicide on an identified party. (3) Missed or unattended appointments. (4) If a referral to another professional is needed. (5) If in Dr. Blanchard's clinical opinion the child is in danger. In consideration for confidentiality and building trust, Dr. Blanchard does not routinely disclose to the parents or guardians, unless previously agreed, risky behaviors, which include, but are note limited to: sexual activity, drug use, pregnancy, vomiting, drinking, cutting, etc. Dr. Blanchard's priority to her minor client is to foster a relationship of trust while assessing their safety, and to help them meet their treatment goals. These goals may not be the same as those established by the parent or legal guardian. Dr. Blanchard respects the wishes and rights of minor clients. If a conflict of interest arises between a client and their parent(s), Dr. Blanchard may advise the parent(s) to seek separate therapeutic services.

EMERGENCY: If there is an emergency during therapy, or in the future after termination, where Dr. Tracy Blanchard becomes concerned about the client's personal safety, the possibility of the client injuring someone else, or about the client receiving proper psychiatric care, she will do whatever she can within the limits of the law to prevent the client from injuring themselves or others, and to ensure that the client receives proper medical care. For this purpose, Dr. Blanchard may also contact the person whose name the client has provided on the biographical form.

HEALTH INSURANCE & CONFIDENTIALITY OF RECORDS: As a means of protecting client confidentiality and to provide excellent service, Dr. Blanchard does not accept insurance. Clients should be aware that submitting a mental health invoice for reimbursement from an insurance company of expenses related to counseling services may pose risk to confidentiality, as well as limit the client's future ability to obtain health/life insurance, or possibly certain types of employment.

LITIGATION LIMITATION: Due to the nature of the therapeutic process and the fact that it often involves making a full disclosure with regard to many matters which may be of a confidential nature, it is agreed that should there be legal proceedings (such as, but not limited to divorce and custody disputes, injuries, lawsuits, etc.), neither the client nor their attorney, nor anyone else acting on the client's behalf will call on Dr. Tracy Blanchard to testify in court or at any other proceeding, nor will a disclosure of the psychotherapy records be requested unless otherwise agreed. Finally, if in the event that legal action is brought against Dr. Blanchard, the client understands that they waive their privilege for confidentiality and that Dr. Blanchard can use for her legal defense all information stated or implied in the client record.

CONSULTATION: In an effort to provide the best services, Dr. Blanchard consults regularly with other mental health professionals regarding her clients, and participates in peer review; however, each client's identity remains completely anonymous and confidentiality is fully maintained.

E-MAILS, CELL PHONES, COMPUTERS, AND FAXES (Except when using these modes to access the Internet portal of Dr. Tracy Blanchard, LLC): It is important to be aware that computers and unencrypted e-mail, texts, and e-fax communications can be relatively easily accessed by unauthorized people and hence can compromise the privacy and confidentiality of such communications. E-mails, texts, and e-faxes, in particular, are vulnerable to such unauthorized access due to the fact that servers or communication companies may have unlimited and direct access to all e-mails, texts and e-faxes that are transmitted through them. Dr. Blanchard's computer is password protected, the client portal is encrypted and any other written information is securely locked in cabinets. E-mails and e-faxes are not as secure and can be sent erroneously to the wrong address and computers. Dr. Blanchard's computer network is equipped with a firewall and a password, and she clears all confidential information from her computer on a regular basis. Also, clients should be aware that phone messages, although private, are not secured or encrypted. Clients should notify Dr. Blanchard if they decide to avoid or limit in any way the use of e-mail, texts, cell phone calls, phone messages or e-faxes. If a client communicates confidential or private information via unencrypted e-mail, texts, e-fax or via phone messages, Dr. Blanchard will assume that the client has made an informed decision, and will view it as the client's agreement to take the risk that such communication may be intercepted, and she will honor the client's desire to communicate in such a manner. However, she may decide to not reply to communication received via those methods, except by sending a response indicating that she received the client's message. In case of emergency, clients should not use texts, e-mail, voicemail or faxes.

RECORDS AND THE CLIENT'S RIGHT TO REVIEW THEM: Both the law and the standards of Dr. Tracy Blanchard's profession require that she keep treatment records for at least seven years. Unless otherwise agreed to be necessary, Dr. Blanchard retains clinical records only as long as is mandated by Florida law. If the client has concerns regarding the treatment records, they should discuss them with Dr. Blanchard. Clients have the right to review or receive a summary of their records at any time, except in limited legal or emergency circumstances, or when Dr. Blanchard assesses that releasing such information might be harmful in any way. In such a case, Dr. Blanchard will provide the records to an appropriate and legitimate mental health professional of the client's choice. Considering all of the above exclusions, if it is still appropriate, and upon the client's request, Dr. Blanchard will release information to any agency/person that the client specifies, in the form of a treatment summary, unless Dr. Blanchard assesses that releasing such information might be harmful in any way. As part of the treatment records, there may be clinical 
diagnoses. Diagnoses are technical terms that describe the nature of a client's problems, and an indication as to whether they are short-term or long-term in nature. Dr. Blanchard will use these diagnoses to help to drive the treatment plan. This differs from insurance company mandates for reimbursement. If Dr. Blanchard assigns a diagnosis in a client's records, and the client requests a copy of the records, Dr. Blanchard will discuss the matter with the client . All mental health-related diagnoses are included in the DSM-IV-TR.

When more than one client is involved in treatment, such as in cases of couple and family therapy, Dr. Blanchard will release records only with signed authorizations from all the adults (or all those who legally can authorize such a release) involved in the treatment.

If the client and their partner decide to have some individual sessions as part of the couples therapy, what is said in those individual sessions will be considered to be a part of the couples therapy, and may be discussed in joint sessions. Dr. Blanchard will encourage the clients to not keep secrets from one another, since trust is an essential part of all relationships.

TELEPHONE & EMERGENCY PROCEDURES: If the client needs to contact Dr. Blanchard between sessions, they should leave a message on her office number, which is (813)992-9686. Client calls will be returned as soon as possible, usually within forty-eight business hours. Dr. Blanchard checks voice messages regularly throughout business days, which are Monday through Friday 10:00 am-5:00 pm, and sets aside time to return phone calls on a daily basis. If an emergency situation arises, the client should dial 911 or have someone take them directly to the nearest emergency room. If the client is in crisis and needs to speak with someone immediately, they can contact the National Suicide HOTLINE at 1-800-273-TALK. This number is accessible 24 hours per day, 7 days per week.

PAYMENTS & FEES: Clients are expected to pay the standard fee of $195.00 for individual initial session, and $175.00 for each session thereafter. Couples rates are $195.00 for the initial session and $175.00 thereafter. Session duration is sixty minutes for individuals and couples. Sessions conducted during extended hours (7:00 PM and later during weekdays, and weekends) may be billed at the rate of $175.00. Payment is made at the beginning of each session unless other arrangements have been made. Telephone conversations, site visits, writing and reading of reports, consultation with other professionals, release of information, reading records, longer sessions, travel time, etc., will be billed a prorated amount, unless indicated and otherwise agreed. Clients should notify Dr. Blanchard if any problems arise during the course of therapy regarding the client's ability to make timely payments. If the client's account is overdue (unpaid), and there is no written agreement or payment plan, Dr. Blanchard can use legal or other means (courts, collection agencies, etc.) to obtain payment. 

MEDIATION & ARBITRATION: All disputes arising out of or in relation to this agreement to provide psychotherapy services shall first be referred to mediation before and as a pre-condition of the initiation of arbitration. The mediator shall be a neutral third party chosen by agreement of Dr. Tracy Blanchard and the client(s). The cost of such mediation shall be split equally unless otherwise agreed. In the event that mediation is unsuccessful, any unresolved controversy related to this agreement should be submitted to and settled by binding arbitration in Hillsborough County, Florida, in accordance with the rules of the American Arbitration Association, which are in effect at the time the demand for arbitration is filed. Notwithstanding the foregoing, in the event that the client's account is overdue (unpaid) and there is no agreement on a payment plan, Dr. Blanchard can use legal means (court, collection agency, etc.) to obtain payment. The prevailing party in arbitration or collection proceedings shall be entitled to recover a reasonable sum as and for attorney's fees. In the case of arbitration, the arbitrator will determine that sum.

THE PROCESS OF THERAPY/EVALUATION AND SCOPE OF PRACTICE:
Dr. Blanchard has a PhD in Clinical Sexology, earned in 2014 at The American Academy of Clinical Sexologists in Orlando, Florida. She is a board certified Clinical Sexologist by the American Board of Sexology. She has a Master's Degree in Mental Health Counseling, earned in 2012 at the CACREP-accredited Argosy University in Sarasota, Florida. Dr. Blanchard is a licensed Mental Health Counselor in Florida. Her areas of specialized training and expertise include trauma and Eye Movement Desensitization and Reprocessing (EMDR). She is a certified Humanistic Sandtray Therapist (CHST) and is trained in and uses Gottman Methods as part of couples or relational counseling. Dr. Blanchard uses an eclectic approach and a wide variety of techniques in therapy.

Participation in therapy can result in a number of benefits to the client, including improving interpersonal relationships and resolution of the specific concerns that led the client to seek therapy. Working toward these benefits, however, requires effort on the client's part. Psychotherapy requires the client's active involvement, honesty, and openness in order to change their thoughts, feelings, and/or behavior. Dr. Blanchard will ask for client's feedback and views on their therapy and its progress, and other aspects of the therapy, and will expect the client to respond openly and honestly. Sometimes more than one approach can be helpful in dealing with a certain situation. During evaluation or therapy, remembering or talking about unpleasant events, feelings or thoughts can result in the client experiencing considerable discomfort or strong feelings of anger, sadness, worry, fear, etc., or experiencing anxiety, depression, insomnia, etc. Dr. Blanchard may challenge some of the client's assumptions and perceptions or propose different ways of looking at, thinking about, or handling situations, which can cause the client to feel upset, angry, depressed, challenged or disappointed. Attempting to resolve issues that brought the client to therapy in the first place, such as personal or interpersonal relationships, may result in changes that were not originally intended. Psychotherapy may result in decisions about changing behaviors, employment, substance use, schooling, housing or relationships. Sometimes a decision that is positive for one family member may be viewed negatively by another family member. Change will sometimes be easy and swift, but more often it will be slow and even frustrating. There is no guarantee that psychotherapy will yield positive or intended results. During the course of therapy, Dr. Blanchard is likely to draw on various psychological approaches according, in part, to the problem that is being treated and her assessment of what will best benefit the client. These approaches include, but are not limited to, Behavioral, Cognitive-Behavioral, Cognitive, Psychodynamic, Eye Movement Desensitization and Repossessing (EMDR), Existential, System/Family, Developmental (adult, child, family), Humanistic or Psycho-Educational. Some of these approaches may require additional informed consent. Dr. Blanchard does not provide custody evaluation recommendation, medication recommendation or legal advice, as these activities do not fall within her scope of practice. For some mental health situations, however, a referral for a medication evaluation may be warranted. In such cases, Dr. Blanchard may refer the client to other medical or mental health professionals in an effort to maximize the client's treatment.

TREATMENT PLANS: Within a reasonable period of time after the initiation of treatment, Dr. Blanchard will discuss with the client her working understanding of the problem, treatment plan, therapeutic objectives and her view of the possible outcomes of treatment. If the client has unanswered questions about any of the procedures used in the course of therapy, their possible risks, Dr. Blanchard's expertise in employing them, or about the treatment plan, the client should not hesitate to ask. The client also has the right to ask about other treatments for their condition and their risks and benefits.

TERMINATION: As set forth above, after one or two sessions, Dr. Blanchard will determine whether she will be able to provide beneficial treatment to the client. Dr. Blanchard does not work with clients who, in her opinion, she is unable to assist. In such a case, if appropriate, she will provide the client with referral information. If at any point during psychotherapy Dr. Blanchard either assesses that she is not effective in helping the client reach the therapeutic goals, or perceives the client as non-compliant or non-responsive, she will discuss with the client the termination of treatment and will conduct pre-termination counseling. If the client requests and authorizes it in writing, Dr. Blanchard will talk to a psychotherapist of the client's choice in order to assist with the transition. The client has the right to terminate therapy and communication at any time. If the client chooses to do so, upon the client's request, and if appropriate and possible, Dr. Blanchard will provide the client with names of other qualified professionals whose services the client may prefer. If the client verbally or physically threatens or harasses Dr. Blanchard or her family, Dr. Blanchard reserves the right to terminate the client unilaterally and immediately from treatment.

DUAL RELATIONSHIPS: Therapy never involves sexual or any other dual relationship that impairs Dr. Blanchard's objectivity, clinical judgment, or one that can be exploitative in nature. Dr. Blanchard does not have social or sexual relationships with clients or former clients because this would not only be unethical and illegal, it would be an abuse of the power as a therapist.

 Outside of the office, Dr. Blanchard will never acknowledge working with a client without the client's written permission. If Dr. Blanchard sees a client outside of the office and in public, she will not acknowledge them. This is to maintain the client's confidentiality. If a dual relationship arises, Dr. Blanchard will discuss with the client the complexities and difficulties that may be involved, and how best to handle them.

SOCIAL NETWORKING AND INTERNET SEARCHES: At times, Dr. Blanchard may conduct Internet searches of client names before or during the therapeutic relationship. If the client has concerns or questions regarding this practice, they should discuss them with Dr. Blanchard. Dr. Blanchard does not accept friend requests on Internet social networking sites from current or former clients, as she believes that adding clients as friends on these sites and/or communicating via such sites can compromise their privacy and confidentiality. For these reasons Dr. Blanchard requests that clients do not communicate with her via Internet interactive or social networking web sites.

CANCELLATION: Since the scheduling of an appointment involves the reservation of time specifically for the client, a minimum of twenty-four (24) hours (one day) notice is required for re-scheduling, and forty-eight (48) hours (2 days) is required for canceling an appointment. Unless a different agreement is reached, the full fee will be charged for sessions missed without such notification.

I have read the above Office Policies & General Information Agreement and Informed Consent for Psychotherapy Services (a total of seven pages); I understand it and agree to comply with it. I may request a copy at any time.