This Client Service Agreement (the “Agreement”) between GearingUP Counseling Centers, Inc., a Texas corporation, (“GearingUP”) and the Client or the parent, guardian, or other legally responsible party on behalf of the Client (the “Client”) is entered into as of the date of signature on Client’s initial Agreement. By signing this Agreement and receiving services from GearingUP, Client represents that they have reviewed and agreed to all of GearingUP’s Terms of Service. Client may find GearingUP’s Terms of Service listed in full on GearingUP’s website at any time or request a copy from GearingUP’s offices as well. Additionally GearingUP may update the Terms of Service and Agreement from time to time. While GearingUP may give notice to Client of updated Terms of Service pursuant to the Agreement, Client agrees that they are solely responsible for regularly reviewing the most recently published Terms of Service as a part of continuing to receive services from GearingUP. If Client continues to receive services from GearingUP, Client agrees to any updated Terms of Service in perpetuity as a part of this Agreement. GearingUP and the Client, after a careful review of the terms set forth in this Agreement and an opportunity to discuss it with their respective attorneys, agree as follows:
GearingUP provides assessment, counseling, and therapy services to children, adolescents, and adults who are seeking assistance in solving life problems, a better understanding of themselves, addressing relationship difficulties, better functioning as an individual, and more. GearingUP also provides consultations for many mental health issues including anxiety, depression, stress, personality disorders, mood disorders, child and adolescent issues, eating disorders, trauma recovery, grief and loss, divorce and separation, obsessive compulsive disorder, learning differences, anger management, attention deficit disorder, psychological testing, and much more. For a full list of Services GearingUP provides, please contact our offices or consult GearingUP’s website for more information (www.GearingUP.com).
Services are provided by GearingUP’s clinical staff who are professionally trained and licensed therapists who may hold one or multiple therapist license types including licensed clinical psychologists, professional counselors, marriage and family therapists, social workers, psychological associates, and other licensed therapists and appropriately credentialed professionals. Our professional staff have met all necessary licensing requirements as determined by state law in addition to completing rigorous academic study and professional training. Many of GearingUP’s clinicians have completed additional trainings, certifications, and / or licenses in related areas including various new professional therapy systems or approaches, further specializations and expertise with specific diagnoses, additional specialty licenses such as Licensed Chemical Dependency Counselor, and more. Please consult each clinician’s professional background on GearingUP’s website for more information.
Typically, the first session of therapy is an “initial client interview session.” The clinician will discuss your current lifestyle and relationships, review your history, and try to understand your current challenges that you would like to address in therapy. The following few sessions often include additional interviews to collect more information such as any history of other therapy treatment, current functioning and resources, possible challenges for therapy, and more. Psychological testing may be recommended to assist your therapist in treatment planning. After your initial therapy assessments have been completed, you and your therapist will finalize the goals for your treatment, discuss therapeutic strategies to address those goals, and finalize a treatment plan to begin your therapy journey.
Different clients work with therapists in different ways. Some clients may only engage in therapy for a few months and stop once they feel they have met their initial goals, while others may choose to identify new therapeutic goals and possibly work with their therapist for multiple years. While there is no guarantee that all therapy goals will be met, your therapist is committed to applying their professional training, prodigious experience, and GearingUP’s community of experts to your challenges. Every GearingUP therapist is dedicated to working with you in good faith to achieve your identified treatment goals. Your therapist will discuss the relevant aspects of the suggested services to be provided so that you can make an informed decision about whether to proceed with therapy services. Relevant aspects include information such as therapy methods and procedures, treatment goals, fees, confidentiality, and use of the information obtained. Ultimately, the most successful therapeutic outcomes are achieved by a collaborative relationship between you and your therapist.
Simply completing and submitting any paperwork to GearingUP does not constitute the creation of any type of Therapist-Client relationship and should not be viewed as implied consent by GearingUP to provide services to you. The Therapist-Client relationship is formed in collaboration by both parties. The agreement to provide therapy services can be made only after the initial session with your therapist, the completion and submission of the required patient paperwork, and the payment of any and all amounts due to GearingUP as detailed herein. GearingUP reserves the right to refuse the acceptance of any Client for any reason until an initial treatment plan has been finalized and approved by both GearingUP and Client.
In order for your professional relationship with the therapist to be helpful and supportive, it must be free of any complications that might influence objectivity or take unfair advantage of either party. For these reasons, business, personal, or other outside relationships between the therapist and Client are not permitted.The professional boundaries with your therapist must be maintained to insure their professional perspective on your issues. This policy is in accordance with state and federal law, professional ethics, and the American Psychological Association’s Code of Ethics. Please ask your therapist if you have any questions or concerns regarding this policy.
Therapy functions based on a collaborative relationship between the therapist and you, the Client. If you feel that you are not meeting your goals or have issues with how your therapy is delivered, please discuss these concerns in your sessions with your therapist or contact our offices. While therapy can elicit difficult thoughts and emotions, Client understands and agrees to remain as collaborative and respectful as possible with their therapist and GearingUP staff. GearingUP therapists and staff may end a session or terminate treatment if they deem, in their sole judgment, that the collaborative relationship has been breached or broken or is no longer possible. Client may also request a transfer to a different therapist if they feel that they are no longer able to work in a productive and collaborative manner with their current GearingUP therapist.
It is vital to remember that psychological services can sometimes generate strong emotions or feelings such as anxiety or depression. Counseling may alter your view of an important relationship, and you may alter your attitudes toward important issues and aspects of your life. Such outcomes are possible when people are in psychotherapy, and these changes are to be processed during the sessions with your therapist. These thoughts and emotions can be challenging, and we encourage all GearingUP clients to discuss any such challenges with their therapist. Additional support, resources, or extra sessions may be recommended to help support you during these challenging times.
While GearingUP and the clinicians will do their best to alter and customize therapy to your desires and needs, GearingUP must also follow and abide by professional ethics, legal requirements, and other codes of professional conduct. GearingUP may be forced to alter or terminate treatment due to such ethical, legal, or other reasons and reserves the right to do so at any time. GearingUP also reserves the right to terminate treatment at any time if Client refuses to comply with requirements for treatment. GearingUP may specify the conditions under which therapy will be offered through GearingUP, and GearingUP reserves the sole authority to determine the requirements for offering treatment of any kind.
Client agrees to participate in therapy sessions in conditions conducive to therapeutic progress. Client agrees to not ingest or imbibe any mind altering substances immediately before a therapy session that may alter their state of mind or may cause them to be “under the influence” of mind altering substances, except for what has been prescribed by a medical professional and allows them to retain attention and focus during their session. Client agrees to disclose any prescription medications or health conditions that may impact their ability to focus in the therapy session. The use of illegal drugs or alcohol will not be permitted or tolerated at any time either immediately before or during therapy sessions. Therapy sessions may be denied or ended if the therapist determines that the client is not able to continue the session due to the influence of a mind altering substance. GearingUP and the therapist staff reserve sole discretion to make such determinations to terminate sessions based on Client’s state of mind. Therapy sessions that do not meet these requirements may be immediately terminated, and Client may be responsible for fees or payments to GearingUP due to noncompliance.
GearingUP may offer “telecommunication therapy sessions” or “telehealth sessions” to Client as a part of their therapy treatment. Telehealth sessions are therapy sessions delivered through various telecommunication methods including live video conference sessions, telephone sessions, and more for Client to complete their therapy sessions with their therapist from a separate remote location. While GearingUP offers telehealth sessions, not all insurance plans may cover telehealth services. Client is solely responsible for confirming coverage of telehealth services by their insurance benefits through their insurance company or third party payer.
GearingUP requires that all telehealth services must meet certain basic requirements. Client must be in a secure, private, and quiet location to receive telehealth services. Client is solely responsible for providing means to connect to a telehealth session including internet access, telephone access, or other similar means. Client must also be within the state lines of Texas to receive telehealth services in Texas. Due to the licensing requirements of other states and state laws, GearingUP would have to be licensed in the state where the Client is currently receiving telehealth services. Exceptions cannot be made to this policy for temporary travel due to ethical and legal requirements. Client is solely responsible for informing GearingUP that they will be outside of the boundaries of the state of Texas at the time of their session. GearingUP and the therapist staff reserve the sole authority to determine if Client does not meet these requirements for a telehealth session. Therapy sessions that do not meet these requirements may be immediately terminated, and Client may be responsible for fees or payments to GearingUP due to noncompliance.
GearingUP approaches therapy in a holistic manner where all of Client’s interactions with GearingUP including clinicians, staff, other clients, and more are a part of the Client’s therapy treatment. Therapy often includes considerations for effective self-regulation, meeting responsibilities, and a general collaborative attitude. Client is responsible for appropriate conduct at all times and following through with their responsibilities for treatment including prompt payment of therapy fees, returning calls or messages and completing reasonable requests from GearingUP staff, and working collaboratively with all people at GearingUP. The therapist may discuss issues concerning client responsibility and behavior during your sessions as a part of your therapy. GearingUP reserves the right to alter or terminate treatment based upon Client not meeting the standards and basic requirements of responsible behavior at GearingUP. Certain issues, such as nonpayment of therapy fees, may result in immediate termination of Client’s therapy services at the sole discretion of GearingUP.
GearingUP does not advertise or offer any medical administrative services such as coordination of disability services, administrative social services, external clinician consultations, school visits or consultations, or any other external medical paperwork, reports, coordination of care, or similar service. If GearingUP agrees to participate in or complete a non-advertised medical administrative service, Client agrees to pay out-of-pocket self-pay hourly rates for any and all administrative paperwork not required by state or federal law or contractual obligations with their insurance company or third party payer. GearingUP also reserves the right to refuse any Client administrative requests without cause and in its sole judgment, unless required by state or federal law.
In an effort to deliver the best care possible, GearingUP recommends Coordination of Care with other healthcare professionals you may be working with for ongoing treatment related to your therapy. GearingUP may request authorization to speak with other relevant healthcare providers including, but not limited to, Client’s primary care physician, family physician, psychiatrist, pediatrician, nutritionist, dietician, OB/GYN, internist, or others. Please inform our office if you have been prescribed any psychotropic medications related to your mental health such as antidepressants or mood stabilizers so GearingUP may coordinate with your prescriber. Coordinating treatment with your related healthcare professionals is an important aspect of your treatment at GearingUP, and it allows your entire healthcare team to work most effectively on your behalf. Please inform our office of any relevant healthcare professionals our office should coordinate with, and we can initiate the Coordination of Care process to contact them.
During your therapy services, you may interact with other clients in common areas such as a waiting room or in therapy services with multiple clients such as group therapy or skills classes. GearingUP asks all Clients to respect confidentiality for others that they may see or interact with during their time at GearingUP. In an effort to protect the confidentiality of all GearingUP clients, it is recommended to not share personal information beyond Client’s first name. Further, it is not recommended for clients to engage in personal relationships that began by meeting at GearingUP. Pre-existing relationships may be considered appropriate, but relationships of any kind with another GearingUP Client should be discussed with your therapist. GearingUP reserves the right to terminate treatment if Client conduct is deemed inappropriate for any reason including engaging in inappropriate personal relationships with other GearingUP clients. If you have any questions or concerns, please do not hesitate to discuss them with your therapist or contact our offices.
Client agrees to treat all people at GearingUP with respect and dignity, including all of GearingUP’s clinicians, employees, owners, contractors, staff, other patients, or anyone else they may come into contact with at GearingUP. While therapy may lead to challenging thoughts and emotions to arise, excessively disrespectful, demanding, or threatening behavior will not be tolerated towards any GearingUP clinician, staff, or client. Violation of this policy may be grounds for immediate termination of services in compliance with state and federal law.
GearingUP is a safe space for people of all backgrounds seeking therapy services. Client acknowledges and agrees to GearingUP’s policy not to discriminate against any GearingUP clinician, staff, client, or any other person at GearingUP on the basis of race, ethnicity, gender, age, sexual orientation, disability, religion, color, national origin, or other personal characteristic. Any discrimination, determined at the sole discretion of GearingUP, against any GearingUP clinician, staff, client, or any other person at GearingUP could violate this policy, and may be grounds for immediate termination of services. Further, Client agrees that, should his or her conduct result in any action being taken against GearingUP for any harassment or discrimination, Client shall indemnify GearingUP and hold it harmless for all judgements, damages, costs, attorney fees, or any other legal expenses GearingUP is required to pay in any such legal action.
Please ask any questions to any GearingUP staff member or clinician at any time concerning any information in this Agreement, the services provided, or any other matter related to your care at GearingUP. Your welfare is our top priority, and GearingUP is dedicated to serving your mental health needs to the best of our ability. As previously mentioned, therapy services are most effective with a collaborative working relationship, and we work very hard to earn your satisfaction. This Agreement is prepared with that collaborative relationship in mind. Your therapist will happily answer any questions regarding your treatment during your sessions, and they will work diligently to meet your therapy needs including potentially altering treatment plans, goals, or other treatment considerations based on your needs. If you have any other questions or concerns, please do not hesitate to contact our offices.
Our office administrative staff are happy to assist you with anything you may need outside of your sessions with your therapist. They are available to help with all business or administrative issues including scheduling, billing, insurance information, and more. Please understand that our administrative staff service hundreds of clients at GearingUP, and they will address your questions or concerns as quickly as possible in a timely manner. The answers to many common or basic questions can be found on GearingUP’s website including informative web pages, help articles, frequently asked questions, and more. However, do not hesitate to contact our office for any question.
GearingUP’s administrative staff assists hundreds of clients every week with their administrative needs including scheduling, billing, and more. Our administrative staff strive to address all client needs quickly and efficiently with the vast majority of interactions likely only requiring a few minutes. In an effort to maintain availability, efficiency, and accessibility for all GearingUP clients, GearingUP administrative staff may limit the amount of time they dedicate to each client interaction or request. While they are happy to assist you with your needs, GearingUP’s administrative staff are not available for excessive amounts of time without additional charges for their time. GearingUP reserves the right to charge for any meeting, phone call, session, communication, written question, support request, report, account audit, or any other administrative time dedicated solely to Client or their account for either live meetings or customized administrative work on behalf of client lasting longer than 15 minutes at $200 per hour billed in 15 minute increments. These fees will only be waived as required by state or federal law or at the sole discretion of GearingUP. While our office is happy to provide you with any documentation or records for your needs such as itemized billing statements, a list of scheduled appointments, or other helpful documentation, GearingUP administrative staff cannot spend excessive amounts of time assisting only one client. If you would like to schedule an appointment with an administrative staff person or manager to review issues or concerns in more depth, please contact our office to make arrangements or explore other options to avoid any charges. The answers to many common or basic questions can be found on GearingUP’s website including informative web pages, help articles, frequently asked questions, and more.
Outside of scheduled therapy sessions, GearingUP does not supervise children or minors in the building or office common areas (e.g., waiting room, public restrooms, etc.) and cannot be responsible for any unattended children in its common areas. Parents or guardians are solely responsible for supervising their child or minor at all times including before and after any clinical sessions if the child or minor is receiving therapy services. GearingUP may be forced to cancel or reschedule services for other clients to monitor the child or minor if they are left unattended by their parent or guardian. If a child or minor Client is unattended for more than five (5) minutes after the conclusion of their scheduled session, GearingUP reserves the right to bill Client for child or minor supervision at its full hourly rate.
GearingUP does not actively monitor or secure the common areas in the buildings or offices where therapy services are delivered. Please make sure to secure and monitor all personal property when visiting GearingUP offices. If you need assistance, please speak with the building staff and managers.
GearingUP reserves the right to bill Client for any property destroyed, damaged, stolen, or altered by Client or any of their dependents or associates. In the case of destroyed, damaged, stolen, or other altered states of GearingUP property of any kind, Client agrees to indemnify GearingUP for any loss or legal action caused by their actions or the actions of their children, dependents, or other associates.
GearingUP offers therapy services to Clients by appointment only. Please contact GearingUP’s offices to schedule an appointment or ask any further questions regarding appointment scheduling. Client may also find the answers to many common or basic questions on GearingUP’s website including informative web pages, help articles, frequently asked questions, and more.
Therapy services and sessions may be conducted either in-person at GearingUP’s offices, remotely through telecommunication technology (also known as “telehealth sessions” utilizing online video conference software, telephone calls, and more), or other potential venues or means as described and defined by professional ethics and state and federal laws. If Client intends to use their insurance or a third party payer to pay for therapy services, Client is solely responsible for confirming their benefits include coverage for other methods of therapy services beyond in-person office sessions. If Client’s benefits do not cover service method alternatives to in-person office therapy, Client is solely responsible for any charges incurred for alternative service delivery methods.
Therapy service appointment lengths are determined primarily by the service type. If you have any questions about the length of each appointment or appointment types, please contact our office for more information or you may be able to find information on GearingUP’s website as well. While your therapist makes every effort to be on time for your scheduled appointment time, please be patient if they are a few minutes late. GearingUP therapists deliver services and care for many patients and their families throughout the day, and other clients may be in crisis or require additional time to appropriately end their session. Your therapist reserves the sole right to make such determinations, and they may make similar decisions about your sessions from time to time as well. If you need to reschedule, have any questions, or would like to speak with someone regarding your appointments, please contact our offices and we will be happy to assist you.
GearingUP is unable to predict the expected length or duration of therapy services due to a number of factors outside of GearingUP’s control. To maximize the effectiveness of Client’s therapy, GearingUP recommends Client complete all recommended sessions at the pace and frequency recommended by GearingUP. Further, the goals of treatment may shift, expand, or evolve over time during therapy. Any alterations to the treatment plan and goals can be made at any time and will be agreed upon by both the therapist and Client. Alterations to the treatment plan or therapy goals may extend or shorten the duration of treatment accordingly. If finances, insurance coverage, or other restrictions may influence treatment decisions, please discuss this with your therapist. Such restrictions or considerations may impact the duration of therapy services or the accomplishment of treatment goals. Modifications to treatment regularity must be approved by either the therapist or the clinical team before treatment considerations such as session frequency will be altered.
GearingUP administrative staff are available during business hours to assist you with any scheduling needs or questions. All appointment scheduling is centralized through GearingUP’s administrative offices, and GearingUP clinicians and therapists are not responsible for and cannot complete any schedule changes on behalf of Client. Client is solely responsible for communicating all scheduling requests including scheduling appointments, rescheduling, canceling, terminating treatment, or other scheduling needs. GearingUP requires communication with Client by telephone calls or telephone voicemails for scheduling requests to verify Client’s identity and process scheduling requests as quickly as possible depending on availability, treatment plan, and other factors. Secured patient portal messages may not monitored regularly by GearingUP staff during business hours or after our Offices have closed which may lead to delays in processing requests.
Other methods of communication such as text message, email, or other alternatives are not considered fully secure and may be viewed, accessed, or used by other members of Client household. GearingUP reserves the right to not acknowledge or respond to any messages from Client or other sources by text message, email, or other unsecured communication methods. Further, unauthorized access could be used to make unauthorized schedule changes impacting Client’s treatment, account charges, or relationship with the therapist or GearingUP. GearingUP will make all reasonable efforts to make appointment scheduling as efficient, convenient, and pleasant as possible for Client, however there may be certain limiting factors such as high phone call and message volume, therapist availability, GearingUP policy considerations, treatment plan requirements, and more. GearingUP thanks you for your understanding and patience.
GearingUP will offer Client options for standing recurring appointments with a GearingUP therapist. Final appointment frequency decisions will be made solely by the therapist and/or clinical therapy team at GearingUP. Appointment frequency may vary depending on multiple factors including severity of clinical issues, recommended treatments, client goals, and more. Please discuss appointment frequency with your therapist if you have further questions or concerns. GearingUP administrative staff will only implement appointment frequency alterations with clinician approval since administrative staff are not allowed to alter clinical treatment. Due to the scheduled appointment time being reserved solely for you and your therapist to meet, please follow all cancellation and rescheduling policies from GearingUP. Failure to appear, properly cancel, or reschedule appointments may result in GearingUP charging Client for the reserved time. Please review and be mindful of all scheduling and cancellation policies listed in this Agreement including any fees associated or that may be assessed for failing to follow the scheduling and cancellation policies.
GearingUP will make every effort to offer Client emergency sessions with their regular therapist if Client feels they are in crisis or need additional support. Depending on particular circumstances such as the severity of the crisis, clinician availability, or other considerations, GearingUP reserves the right to schedule emergency sessions with any GearingUP clinician. GearingUP does not guarantee availability for emergency sessions at all times or when is convenient for Client. GearingUP may also offer additional resources for Client use during mild crisis. If Client is experiencing a severe crisis requiring immediate attention, Client agrees to immediately go to the nearest hospital emergency room or dial 911.
If Client is experiencing a crisis during normal GearingUP business hours, GearingUP may be able to offer either an emergency session or schedule an emergency phone call with one of GearingUP’s clinicians for remote support, consultation, or other assistance. Emergency sessions and phone calls will be offered at the sole discretion of GearingUP. GearingUP may, in their sole discretion, recommend that Client proceed immediately to the nearest hospital emergency room or dial 911 immediately. If Client is experiencing a crisis outside of normal business hours, Client should either contact one of the emergency resources listed on GearingUP’s website for support, proceed to the nearest hospital emergency room, or dial 911.
GearingUP has partnered with Blueprint (https://www.blueprint-health.com/) to offer our clients easy access to regular psychological assessments, homework, journaling, and other useful tools for therapy at GearingUP. Blueprint meets all HIPAA required security protocols, respects the privacy of all users, and will never sell any personally identifiable data. You own your data at all times and can always request your data and account to be deleted by sending an email to support@blueprint-health.com with the subject “Account Deletion.” You can view Blueprint’s privacy policy in detail at www.blueprint-health.com/privacy.
Measuring your progress through Blueprint may be considered a billable service by your provider towards your insurance plan and in some situations, may result in additional co-payments, amounts applied to deductibles, and other amounts that may be deemed the responsibility of the patient as required by contract with the insurance plan and state regulations. Please contact GearingUP’s offices if you have any further questions.
GearingUP has opted to use Blueprint’s note-taking software system as part of their effort to provide excellent care to clients. Blueprint’s note-taker software temporarily records Client sessions and uses this recording to automatically generate a written progress note summary (a required form of clinical documentation) for the therapist’s clinical records. The final progress note from your therapist may or may not include some or all portions of Blueprint’s note-taking software generated written summaries. After a progress note summary is generated, the recording is automatically deleted from Blueprint’s servers and database. No recordings, written summaries, or any other session data is stored by Blueprint or GearingUP after the therapist closes out the session in Blueprint.
Use of this software allows your therapist to be more fully present during your sessions, without having to slow down to take notes or trying to remember important information during or after the session. This allows them to focus more of their attention on your care. All of the final progress notes for your sessions prepared by your therapist will be available in your clinical chart.
Blueprint’s software is HIPAA compliant and SOC 2 Type 2 certified, which means an external third-party auditor reviews Blueprint’s systems, policies, and processes on an ongoing annual basis to ensure Blueprint meets certain data privacy and security standards.
By signing this Agreement and attending sessions with your therapist at GearingUP, you are agreeing to allow your therapist and GearingUP to use Blueprint’s note-taking software to record your sessions and utilize software to assist them in generating progress notes to document these encounters. You may opt out at any time by speaking with your therapist or contacting GearingUP’s office.
GearingUP may offer Client automatic courtesy reminders of their scheduled appointments by phone, text, email, or other method. GearingUP does not guarantee these courtesy reminders for reliability, accuracy, or other considerations, and Client not receiving an appointment reminder does not excuse Client of their responsibility to attend scheduled sessions or be subject to fees or charges such as a No Show or Late Cancellation fee for scheduled sessions.
Client is free to cancel any session or terminate treatment at any time. Due to Client security concerns, all cancellations must be made by telephone call or voicemail. GearingUP will not accept written cancellations of any kind. Client also agrees to be subject to the scheduling policies of GearingUP, and they may be subject to No Show and Late Cancellation fees in accordance with GearingUP’s written policy depending on when and how they cancel appointments.
Client acknowledges and agrees that GearingUP’s clinical services and fees are based upon time spent with Clients. All services delivered at GearingUP are by appointment only, and GearingUP does not accept “walk in” appointments for clinical services. If a session time is reserved for Client, then GearingUP cannot reasonably schedule a session with another Client with less than the requested cancellation notice. Client agrees to pay any No Show or Late Cancellation fees, as applicable, before Client’s next session will be scheduled, or, if it is already scheduled, Client understands that such scheduled session (including future sessions) may be canceled until Client pays the No Show / Late Cancellation fees, as applicable.
Client understands and agrees that Client will be charged a “No Show Fee” each time Client fails to appear (“no shows”) or provides notice of cancellation with less than 48 hours before scheduled appointment (“late cancel”). Further, Client agrees to the “No Show Fee” charge of $120.00 or the expected payment amount for the session (based on the provider, Client’s insurance rates or self-pay arrangement, or other factors), whichever is greater,
For appointments scheduled the day after GearingUP’s offices are temporarily closed (e.g., Monday appointments, holidays, or other similar circumstances), Client understands and agrees that they will be charged a “No Show Fee” if they fail to provide notice of cancellation at least 72 hours before the session or by 12 noon of the last business day before GearingUP’s temporary closure (whichever is greater) for any scheduled appointment. This additional time allows GearingUP staff to attempt to reschedule with other clients before GearingUP’s offices are temporarily closed.
In addition, Client understands and agrees that they will be charged a “No Show Fee” if they fail to provide at least 72 hours notice of cancellation for any appointment requiring additional resources or multiple hours to complete (e.g., testing appointments, psychological assessments, autism spectrum testing, etc.) and/or multiple clinicians to be present (e.g., parent conferences, certain test feedback sessions, treatment planning meetings, etc.).
Additionally, Client understands and agrees that Client will be charged the full “No Show Fee” if the Client is more than 10 minutes late to any scheduled appointment. Due to contractual obligations, insurance regulations, and state law requirements, GearingUP can only bill for a “completed session” where the Client is present for the preponderance of the session time allotted.
GearingUP’s offices prefer all client scheduling requests and cancellations to be done by telephone call or voicemail. GearingUP reserves the right to not acknowledge any unsecured means of communication (e.g., text message, email, etc.) to our office for scheduling requests or cancellation notice. Unsecured messages will not be considered appropriate “notice of cancellation” for the aforementioned “No Show Fee” policy.
Secured patient portal messages may not be regularly monitored by GearingUP staff during business hours or after our offices have temporarily closed which may lead to delays in processing requests. Due to these considerations, all secured patient portal messages regarding scheduling requests or cancellations must be sent with one (1) week notice of cancellation for any scheduled appointment. Client understands and agrees that they may be charged a “No Show Fee” if a secured patient portal message to cancel an appointment is sent with less than one week notice of cancellation.
GearingUP reserves the right, in its sole discretion, to waive these fees, but GearingUP will generally only do so in cases involving extreme emergencies such as car accidents, extreme illness, or similar unexpected emergencies or “life-or-death” circumstances. GearingUP may request evidence of these emergencies if necessary (e.g., a doctor’s note, a police report, etc.). Work, school, and extracurricular activity related demands are NOT considered emergencies.
In addition, Client agrees to attend sessions in accordance with all other written policies and requirements for sessions in GearingUP’s Terms of Service. The GearingUP therapist in the session may immediately terminate the session, in their sole discretion, if Client is not in compliance with GearingUP’s written policies. GearingUP reserves the right to charge the Client a “No Show Fee” for these terminated sessions. GearingUP reserves the right to specify any other necessary conditions for appropriate clinical session requirements as specified by GearingUP’s clinical team, insurance regulations, or state and federal law.
For effective clinical treatment, Client must follow the treatment plan as determined by their therapist and GearingUP’s clinical team. If Client misses two or more consecutive scheduled sessions without good cause, as deemed in the sole discretion of GearingUP, the patient will be considered to have given their notice of termination of therapy. A patient who does not reschedule within 14 days following their last therapy session may be considered to have terminated therapy and ended the Professional Therapeutic Relationship.
GearingUP recognizes that Clients may need to suspend treatment temporarily due to various circumstances such as long work trips out of state, sabbaticals, extended vacations, or other reasons. If Client must miss more than two regularly scheduled appointments, Client must inform GearingUP’s office and their therapist to remain an active client. Client may be considered voluntarily suspending treatment and will be considered “inactive” at GearingUP. If Client is gone longer than 45-60 days, GearingUP will consider the client as temporarily terminating treatment until they resume active therapy with GearingUP. While Client is free to cancel, terminate, or suspend treatment at any time, GearingUP cannot guarantee availability of Client’s previous therapist, session time, in-person office, or other factors when Client returns to treatment.
Treatment usually ends “successfully” when the therapist and Client agree that all therapy goals have been achieved, the Client has no other treatment areas they would like to address, and that progress is no longer being made. However, Client is free to terminate treatment at any time by contacting GearingUP’s office. If Client is considering premature termination or has complaints about the services at GearingUP, Client should discuss their concerns with their therapist or GearingUP management. The therapist or GearingUP may also terminate services under certain conditions such as nonpayment, noncompliance with treatment recommendations, lack of collaborative working relationship, breach of GearingUP’s Terms of Service, or other considerations. GearingUP is dedicated to serving your goals. However, we will happily provide Client with a list of referrals for other licensed therapists.
GearingUP now offers telehealth services to select Clients on a case-by-case basis. Individual sessions, group therapy, skills classes, or other services may be offered by telehealth to Clients within the state of Texas who qualify. Telehealth services will require an email address and Client provided access method such as a smart phone or computer with a video camera and microphone for video conferencing. In emergency circumstances, telehealth services may be offered by telephone session at the sole discretion of GearingUP. All telehealth services will follow the same policies and requirements as any other appointment type at GearingUP. GearingUP may require prepayment for Telehealth services, and GearingUP reserves the right to refuse telehealth services to any Client for any reason. Client is solely responsible for confirming if their insurance benefits cover telehealth sessions.
If enrolled in a therapeutic program requiring group or class participation, GearingUP requires any missed sessions must be made up within a reasonable amount of time. Due to groups and classes following strict curriculum to teach specific skills and theory during each session, presenters will not be able to review previous session materials in future presentations. These make up sessions will require a GearingUP therapist to review the presented material in an individual session with Client. The make up session will be billed as an individual session to Client’s account. It is the Client’s sole responsibility to schedule a make-up session for the missed material so as not to slow down, confuse, or impede the progress of the group or class in which they are enrolled.
GearingUP therapists may return Client calls if Client is in acute crisis. If the therapist is unavailable or determines Client is in severe crisis, Client agrees to proceed to the nearest emergency room or dial 911. GearingUP may also recommend an emergency session with a GearingUP therapist scheduled in the immediate future. However if GearingUP determines a Client’s emergency call to not be a “crisis” or emergency situation, GearingUP reserves the right to charge Client for the clinician’s time speaking with the Client at GearingUP’s self-pay hourly rates (billed in 15 minute increments). This service is not covered by most insurance policies, and Client agrees to pay for therapist’s time at self-pay hourly rates out-of-pocket.
Client hereby assigns all medical benefits, which include major medical benefits, to which Client is entitled including private carrier and other health plans to GearingUP. This assignment shall remain in effect until revoked by Client in writing. A photocopy of this assignment is to be as valid as the original.
Please refer to GearingUP’s website for the most up to date information regarding GearingUP’s listed rates and fees for services. You may also contact GearingUP’s office at any time and request a complete list of rates.
Non-Guarantee of Insurance Payment
Client understands that pre-certification, pre-authorization, or other verifications for services by Client’s insurance company does not guarantee payment for services rendered. Client understands that they are financially responsible for all charges whether paid or not by any insurance carrier. Client hereby authorizes GearingUP to release all information necessary to secure the payment for services rendered. Client understands that their personal information may be released to the appropriate agency (e.g., collections agency, law firm, credit bureau, etc.) if they do not pay all fees for services rendered. Client gives full permission to GearingUP to release all necessary information to third parties to collect all fees incurred for services rendered or any agreed upon fees or charges in this Agreement in accordance with state and federal laws.
Insurance Coverage Responsibility & Benefits Disclaimer
Client is solely responsible for confirming their insurance information and benefits at all times. Any insurance benefits verified, quoted, or presented to GearingUP by your insurance company are temporary verifications that are subject to immediate change. Information quoted by insurance is sometimes incorrect due to the ever-changing nature of EOB’s, deductible payments, etc. that are being processed by Client’s insurance carrier. Client understands and agrees to be financially responsible for all charges incurred over the course of treatment, and Client further agrees to pay for any such services as are denied or incorrectly quoted by their insurance carrier. In addition, GearingUP reserves the right to collect on any balance from Client due to new information from an Explanation of Benefits (“EOB”) or revised EOB on previously covered services from their insurance carrier.
Client acknowledges and agrees to GearingUP’s publicly listed fees prior to initiating psychological services. If Client is using their insurance benefits, Client recognizes and agrees that Client will be responsible for all fees not covered by or not paid by their insurance plan. All fees are due at the time of service. THERE ARE NO EXCEPTIONS TO THIS POLICY. Failure to pay for your treatment may result in cancellation of future appointments until you pay your bill in full. GearingUP may escalate to further action to collect on unpaid balances. GearingUP requires a credit card be kept on file with our office to assist in collection of payments for delivered services. Cash or checks are also accepted under certain circumstances.
Client is ultimately responsible for 100% of charges incurred in our office. Client understands that pre-certification, pre-authorization, or other verification of services by their insurance company does not guarantee the insurance company will pay for delivered services. If Client’s insurance benefits do not pay for delivered services, Client agrees to make immediate payment for all services rendered by GearingUP. If Client’s insurance benefits, employer, or any other third party refuses to pay for services, Client is responsible to pay for delivered charges incurred.
Please note that GearingUP will work with only one financially responsible party and is not responsible for managing payments between friends or family members, parents of adult clients, divorced parents, or other situations. The Client signing the patient forms (either the person receiving clinical services or the person financially responsible for a dependent or minor) is the identified responsible party and is fully and solely responsible for all fees incurred for GearingUP’s services and charges.
Any services not covered, denied, or unpaid by Client’s insurance for any reason will revert to GearingUP’s full self-pay pricing rates by default. Any non-covered services requested by Client that are not billable to their insurance will be billed hourly at GearingUP’s self-pay pricing with a one hour minimum. Examples of non-covered or non-billable services include but are not limited to: school consultations, home visits, consultations with other offices or treatment professionals, phone coaching, behavioral contract plan writing, and more. If Client has any questions about billable services or what is covered by their insurance benefits, please call GearingUP’s office for more information.
The fees paid by Client to GearingUP under this Agreement contemplates only the therapy services advertised by GearingUP. Client may request services from GearingUP that, while they may be related to their treatment, are not direct delivery of therapy services or may not be billable to their insurance benefits. Client acknowledges and agrees that any administrative work related to clinical services, except for required documentation based on state and federal laws, that is not billable to their insurance benefits will be billed to Client at GearingUP’s self-pay rates on an hourly basis. Examples of such non-covered administrative or clinical paperwork include but are not limited to the following: private insurance disability paperwork, correspondence with a third party on behalf of Client, emotional support animal paperwork, parent-child behavioral contracts, specialized non-standard reports, specific formatting requests for clinical reports, summaries of services for third parties, and more.
Client understands that Client is required to pay the necessary payment for services at the time of service and that failure to pay in accordance with this policy will release GearingUP of any obligation to schedule any future appointments until all amounts due are paid in full.
While Client may choose other forms of payment at the time of service such as cash or check, GearingUP requires ALL Clients to have a valid form of payment on file. Due to the number and variety of services GearingUP now offers our Clientele across the state of Texas including remote telehealth therapy services, payment information must be on file with GearingUP even if Client believes they have no deductible or copay from their insurance plan.
Please choose one of the following options:
GearingUP will charge any and all fees incurred over the course of treatment to the payment method(s) selected by Client. If you wish to change the information you have on file, please contact our administrative staff. GearingUP reserves the right to refuse treatment and/or immediately cancel all services if Client does not provide sufficient payment method information.
Due to the administrative burden of servicing hundreds of therapy clients per week, GearingUP’s administrative staff may collect the necessary session payment in advance of the therapy session. If necessary, GearingUP reserves the right to collect the necessary payment for an upcoming session multiple days in advance of the session to confirm payment at the time of service delivery. Please contact GearingUP’s office with any questions or concerns.
While not intentional, Client account credits and refunds may occur from time-to-time for various reasons. If Client believes they are owed a refund, GearingUP may take up to 30 days to investigate Client’s charges, contact insurance, apply payments, resolve transactions, etc. to confirm a refund is owed to Client. Once confirmed, GearingUP may take up to an additional 30 days to process the refund back to Client through the original payment method. GearingUP may also require Client to sign a refund agreement to confirm the amount of the refund, confirm that the refund resolves all of their concerns, and Client agrees to withdraw any credit card disputes or other disputes or complaints in addition to other terms. Any change in refund amount, refund method, or other substantive change to refund agreement may cause additional delays or fees to be incurred.
Client agrees that any returned payments of any form including returned checks, credit card chargebacks, or other forms of returned payment will be subject to a $100.00 fee per instance of returned payment. GearingUP may charge additional and reasonable fees if required by GearingUP’s bank, financial institution, credit card processor, or other entity. These fees are to cover any penalties or losses or necessary administrative time incurred by GearingUP due to Client’s returned payment.
In the event of chargeback to GearingUP of any kind due to intentional action of Client such as credit card disputes, fraud or security issues, canceled check, stop payment, credit card inquiries, or other intentional denial or removal of funds from GearingUP due to no fault of GearingUP, Client agrees to pay $500.00 per instance or $300 per hour of necessary administrative time, whichever is greater, to GearingUP in addition to any necessary attorney’s fees and costs or other legal expenses incurred. Responding to improper payment disputes requires GearingUP to assemble evidence and prepare written responses to any and all claims alleged by Client. Client agrees that these fees are reasonable and necessary for GearingUP due to the time expenditure required by senior staff for responding to such disputes due to no fault of GearingUP. GearingUP may waive these fees in its sole discretion, but generally only does so due to an error committed by GearingUP, state or federal laws, or other mitigating circumstances. Payment of these administrative fees will be due immediately and may be referred for further collections activity, legal filings, and may be referred to credit bureaus in certain cases. While “credit card disputes” or private organizations such as the “Better Business Bureau” may make a temporary decision in Client’s favor, Client recognizes that financial institutions, private business organizations, and credit card companies are not legal authorities in the state of Texas. These decisions from private organizations do not relieve Client of any financial burden to GearingUP including penalties, damages, legal fees, or other amounts. GearingUP reserves the right to pursue Client through all legal means to collect these fees such as filing suit or other legal remedies even if a financial institution, private business organization, or other private non-governmental body may have made a decision in Client’s favor previously.
If Client engages GearingUP for treatment and opts to “self-pay,” does not have insurance benefits, or establishes an out-of-pocket payment arrangement, GearingUP will assume that Client does not have or has decided not to use their insurance benefits. GearingUP will not retroactively bill sessions to an insurance plan after fifteen (15) days after the date of service. GearingUP will not refund or reprocess any self-pay sessions after this fifteen (15) day probationary period has concluded.
If Client loses insurance coverage for any reason, any previously delivered service will immediately be transferred to Client responsibility and may be subject to immediate charges or collections activities. If Client’s insurance coverage changes for any reason (e.g., terminates, switches to another carrier, etc.), it is the sole responsibility of Client to inform GearingUP of the change in their insurance coverage. Client agrees to give GearingUP thirty (30) days of notice before the change in coverage so that GearingUP may verify benefits and properly bill for services rendered. If Client fails to disclose a new insurance policy to GearingUP, GearingUP reserves the right to refuse to resubmit claims to insurance after fifteen (15) days after the date of service. These delivered sessions may be charged and collected from Client immediately after the fifteen (15) day period has elapsed.
Payment for all GearingUP services is due at the time of service. If payments are missed or prearranged payment agreements such as payment plans are not paid as agreed, charges and accounts may be considered past due. GearingUP will attempt to contact Client regarding past due balances through standard means such as phone calls, billing statements, and other forms of communication. However Client agrees to additional charges due to delinquent or past due balances including, but not limited to, the following:
Client agrees that all self-pay charges not related to direct clinical service, such as No Show Fees, administrative fees, or other similar fees, to Client’s account will not be reconsidered after thirty (30) days of being charged. GearingUP cannot reconsider every charge to Client’s account in perpetuity, and GearingUP may not be able to access records to discuss certain relevant facts such as if Client attempted to cancel a session “on time” to avoid a No Show Fee. Any non-clinical charges to Client’s account will not be altered after 30 days of charge.
You have the right to receive a “Good Faith Estimate” explaining how much your medical care will cost. Under the law, health care providers need to give patients who don’t have insurance or who are not using insurance an estimate of the bill for medical items and services. You have the right to receive a Good Faith Estimate for the total expected cost of any non-emergency items or services. This includes related costs like medical tests, prescription drugs, equipment, and hospital fees. Make sure your health care provider gives you a Good Faith Estimate in writing at least 1 business day before your medical service or item. You can also ask your health care provider, and any other provider you choose, for a Good Faith Estimate before you schedule an item or service. If you receive a bill that is at least $400 more than your Good Faith Estimate, you can dispute the bill. Make sure to save a copy or picture of your Good Faith Estimate. For questions or more information about your right to a Good Faith Estimate, visit www.cms.gov/nosurprises or call the No Surprises Help Desk at 1-800-985-3059.
GearingUP may offer Client a payment plan for services to make charges more affordable or spread out payments for services. Please contact GearingUP’s offices to discuss payment plan options and request a written payment plan agreement or Promissory Note.
Based on the Texas Insurance Code Sec. 843.338 and Sec 1301.103, Client’s insurance company must pay any “clean claim” within 30 days of electronic submission or 45 days of non electronic format. The Texas Insurance Code imposes strict penalties upon insurers for noncompliance with these policies as detailed in Texas Insurance Code Sec. 1301.137. Based on these Claim Payment Requirements standards, GearingUP reasonably expects payment from Client’s insurer within 30 days of submitting an electronic “clean claim” or 45 days of submitting a nonelectronic “clean claim” to Client’s insurer. If Client’s insurance has not paid a claim within these time limits, GearingUP may treat the claim as having been denied by Client’s insurance. GearingUP reserves the right to immediately collect on past due, delinquent, or denied claims from Client or their insurance company including any applicable penalties or interest as determined under state and federal law.
Client’s insurer may deny claims for delivered services from GearingUP for many reasons. However, denials due to no fault of GearingUP will immediately be transferred to patient responsibility and subject to immediate collection from Client. GearingUP may appeal the insurance company’s decision on behalf of Client, but GearingUP does not guarantee or represent that any appeal will be successful. GearingUP will only make one appeal attempt before finalizing charges and pursuing payment from Client.
While GearingUP’s staff will happily assist client with verifying their insurance benefits and coverage, Client retains sole responsibility for understanding and confirming benefits at all times. GearingUP does not guarantee that any information provided by Client’s insurer will be accurate or complete, and GearingUP does not waive any rights to payment or pursuit of payment based on inaccurate or incorrect information regarding Client insurance benefits from insurer or Client.
GearingUP reserves the right to terminate treatment and relationship with Client at any time due to nonpayment of agreed upon fees and financial policies of GearingUP. GearingUP will provide referrals for Client at any time including to low cost or no cost providers if requested.
The fees paid by Client to GearingUP under this Agreement contemplates only the therapy services advertised by GearingUP. GearingUP reserves the right, in GearingUP’s sole discretion, to decline to provide any services to Client in any fashion or venue apart from a regularly scheduled therapy service. Client understands and agrees that GearingUP only offers the therapy services as specifically listed in GearingUP’s paperwork, advertising, or on its website. This Agreement does not contemplate any additional services beyond what is listed, and GearingUP does not represent or offer any additional services to the public. If Client would like to see the most up to date list of GearingUP’s services, please call GearingUP’s offices or visit GearingUP’s website (www.GearingUP.com).
Client agrees to pay for any legal expenses or attorney’s fees GearingUP incurs of any kind on behalf of or in relation to Client or labor related to Client’s account except as required under state or federal law. This provision includes any consultation, retainer, court appearance, deposition, preparation, document review, or other legal services GearingUP may require due to Client or related to Client’s account. Client agrees to pay for these legal services within fifteen (15) days of GearingUP presenting Client an official invoice from its attorney. Exceptions will only be made for required services per state or federal law.
Attorneys’ Fees in the Event of Breach
Client agrees that should GearingUP be forced to pursue legal action against Client for a breach of any provision of this Agreement, GearingUP shall be entitled to recover its reasonable attorneys’ fees and costs of court.
Due to insurance reimbursement restrictions, to the extent Client wishes to secure GearingUP’s services for any reason outside of the parameters of an advertised service, including any and all matters compelled by lawful subpoena, court order, or other official or legal notice pertaining to Client matters, Client must pay, in full and in advance, for such requested services according to the terms of this Agreement. To the extent any such additional services are reimbursed or covered by Client’s insurance, it is the Client’s sole responsibility to file any required or necessary paperwork to recover any fees charged by GearingUP in this manner. Non-Standard Services include, but are not limited to, the following:
For any forensic or litigation-related services (whether in anticipation of a lawsuit or after the commencement of one), Client agrees to pay each GearingUP employee or contractor at the rate of $500 per hour for any GearingUP clinicians or staff (applied in quarter-hour increments, with a minimum three-hour commitment required), including any time reasonably required for travel from and back to GearingUP’s offices. Client agrees that these Forensic Work Agreement fees are separate from additional Attorney’s Fees necessary on behalf of Client. Client agrees to advance funds to GearingUP for any and all reasonably necessary costs of travel. To the extent possible, Client also agrees to give GearingUP 28 days’ advance notice of any event requiring GearingUP’s attendance. Furthermore, should GearingUP be required to reschedule existing appointments to comply with a subpoena or court order pertaining to Client matters or to accommodate Client’s request for non-standard services away from the office and the event is subsequently canceled through no fault of GearingUP, Client agrees to pay GearingUP’s minimum three-hour requirement. Client understands, agrees, and consents that GearingUP may disclose Client’s confidential information in the possession of GearingUP as reasonably necessary to comply with the requirements of any lawful subpoena or court order. If Client is involved in litigation, please contact GearingUP’s office immediately to inform our staff. Please note that it is Client’s sole responsibility to inform GearingUP if Client enters into litigation of any kind.
Child Custody Agreements
If Client is separated, divorced, or the legal guardian of a child who is receiving therapy at GearingUP, Client is solely responsible for informing GearingUP and providing GearingUP a copy of any relevant court orders, child custody agreements, or legal documents proving Client’s authority to seek treatment for Client’s child. If Client’s child is being treated and Client is currently married, the authorization to treat a minor must be signed by both parents before treatment of a minor can proceed.
Client understands and agrees that all of GearingUP’s services rely upon Intellectual Property either developed internally by GearingUP or licensed to GearingUP by external developers through properly accredited training sessions, professional continuing education programs, and/or professional training materials. GearingUP’s services and presentations are GearingUP’s Intellectual Property, and Client agrees to never attempt to recreate, sell, share, post, or distribute in any way GearingUP’s Intellectual Property beyond their personal individual use without express written permission from the owners of GearingUP. Violations of this policy may violate state and federal laws and may be open to prosecution in certain cases.
Client agrees to hold all information presented to them by GearingUP in strictest confidence and, unless GearingUP gives Client prior written consent to do so, not to disclose or use any such Information external to GearingUP, except as required by state or federal law, either during treatment at GearingUP or after termination of Client’s treatment.
GearingUP does not authorize any form of transcription or video, audio, or recordings of any kind during sessions, groups, classes, telehealth sessions, or any other GearingUP service without express written permission from the owners of GearingUP. GearingUP does allow Clients to take handwritten notes only for their personal use, however transcription software, services, or similar “word for word” transcription methods are not authorized. Please contact GearingUP’s office if you have any accessibility issues or require specific accommodations or exceptions to this policy, as may be applicable by state or federal law. Any violations of this policy may violate state and federal laws, and GearingUP may refer any such violations to law enforcement for further action.
The information Client shares in session with their therapist will be kept confidential in compliance with professional ethics and legal requirements including HIPAA regulations except as may be necessary according to State and Federal laws. Parents or legal guardians have a right to the records of their minor children or those under their legal guardianship. When the therapist is working with a minor, information is also considered confidential to the extent allowed by law. Parents will be informed if the child appears dangerous to themselves or others. However, the child’s confidentiality will be observed with parents while allowing for periodic updates concerning progress, completed goals, and other treatment updates. If Client consents to services provided by a therapist who is under supervision, or services provided by a treatment team, relevant treatment information may be shared with the supervisor and/or treatment team. GearingUP therapists may consult with each other from time to time regarding clinical care or concerns, and GearingUP may need to share information with administrative staff in the course of their professional work. All of GearingUP’s clinical and administrative staff are bound by HIPAA regulations to maintain confidentiality. Client may give written consent to release information to another treatment professional or other party external to GearingUP at any time. Please be aware that there are important exceptions to this privileged communication, and Client should discuss any questions or concerns with their therapist.
The therapist creates and maintains a record of each of Client’s counseling sessions, reports or records of any testing, and other materials relevant to Client’s treatment at GearingUP. Testing records may only consist of a report instead of the full testing “raw data” due to the technical nature of these records as well as copyright concerns for test forms, testing records, and other materials. Client clinical and treatment records are subject to state and federal confidentiality laws and HIPAA regulations, except under certain exceptions. Client may request a copy of their treatment records at any time.
While GearingUP follows all professional standards and legal requirements regarding HIPAA regulations and confidentiality, GearingUP cannot guarantee complete confidentiality at all times due to circumstances beyond their control. In some cases, psychological services involve a group, a class, a couple, a family, or other group of people. HIPAA regulations and state and federal confidentiality requirements apply to the clinicians and staff of GearingUP in this context to the extent allowed by law. However, GearingUP cannot guarantee that other people in the family, couple, class, group, or group of people will keep such information confidential. While GearingUP asks all Clients in these situations to maintain confidentiality and privacy of others, GearingUP has no ability to enforce those requests. In addition, GearingUP cannot control if you or a family member are seen at or near GearingUP such as entering our offices, in our waiting room, in common areas such as hallways or bathrooms, or other similar situations. By signing this Agreement and receiving services from GearingUP, you understand and agree to these limits of confidentiality.
If Client is using insurance benefits or their psychological services are paid in part or in full by a third party, they authorize GearingUP to submit any necessary information required to collect payment for services in compliance with state and federal law. Client should discuss with GearingUP any concerns about the exact information the third party payer requires. Your contractual agreement with your insurance company or third party payer should address the privacy and confidentiality policies of your insurance company or third party payer, examples of required information for paying providers, and payment policies for your services. In addition to basic demographic or identifying information, your insurance company or third party payer may require the release of clinical information in order to access your benefits and pay for your services. By signing this Agreement and providing GearingUP your insurance or third party information, you understand and agree to these exceptions to patient confidentiality.
If your therapist believes, in their sole discretion, Client (or their minor) may be dangerous to themselves or others, GearingUP may release this information to the appropriate people (for example, emergency contacts, spouses, parents, law enforcement, etc.) without your consent in an effort to keep you and other people safe in compliance with state and federal law. Mental health information is also required to be released pursuant to the terms of a court order or a valid subpoena. Any and all occurrences of abuse of a minor, the disabled, or the elderly must be reported to law enforcement officials. This law is mandated by state law and there are no exceptions to this policy.
Client acknowledges and understands the foregoing exceptions to patient confidentiality and how those exceptions apply to them (or their minor). Furthermore, because of their understanding, Client consents to treatment for themselves (or their minor) by GearingUP with these exceptions in mind. Finally, even if Client fails to sign these policies, by agreeing to meet with a GearingUP therapist for themselves (or their minor), they waive all claims, demands, causes of action, suits, rights, counter-claims of any kind, whether known or unknown, against GearingUP, for any disclosure of their confidential information pursuant to the exceptions outlined hereinabove or other exceptions as permissible or required by applicable federal and state law and regulations. This provision is not intended as a waiver of your (or your minor’s) rights under any federal or state law, including information governed by the Health Insurance Portability and Accountability Act of 1996 (“HIPAA”), 42 U.S.C. 1320d and 45 C.F.R. 160-164, subject to the exceptions (both required and permissible) outlined therein.
Notice to Clients – The Texas Behavioral Health Executive Council investigates and prosecutes professional misconduct committed by marriage and family therapists, professional counselors, psychologists, psychological associates, social workers, and licensed specialists in school psychology. Although not every complaint against or dispute with a licensee involves
professional misconduct, the Executive Council will provide you with information about how to file a complaint. Please call 1-800-821-3205 for more information. They can also be reached by mail at Texas Behavioral Health Executive Council, George H.W. Bush State Office Building, 1801 Congress Ave., Ste. 7.300, Austin, Texas 78701 or the main phone number of (512) 305-7700.
Please note, if a complaint is determined to be false, misleading, or used for any inappropriate purpose such as harassment, you may be personally and legally liable for fees and damages incurred to defend such complaints. This may include full recovery of any attorney fees, legal fees, expenses incurred, lost wages, or other damages to GearingUP as determined in a court of law.
Client agrees not to make any demonstrably false or misleading statements, written or verbal, or cause or encourage others to make any such statements, written or verbal, that defame, disparage, or in any way criticize the personal or business reputation, practices, or conduct of GearingUP, its employees, or its principals. Client acknowledges and agrees that this prohibition extends to statements, orally or in writing (including text messages, emails, social media, online reviews, Better Business Bureau (“BBB”) complaints, credit card disputes, and more), made to anyone, including but not limited to, government officials, regulatory authorities, competitors, strategic partners, vendors, employees (past and present), and current and potential clients. Any breach of this policy may violate state and federal law. GearingUP takes false or misleading statements in an effort to damage GearingUP’s reputation extremely seriously, and GearingUP reserves the right to take legal action in response to such false or misleading statements. If a public statement is determined to be false, misleading, or used for any inappropriate purpose such as harassment or defamation, you may be personally and legally liable for legal fees and damages incurred to address and correct such statements. This may include full restitution of any attorney fees, legal fees, expenses incurred, lost wages, or other damages as determined in a court of law.
GearingUP is not an enrolled provider in Medicare and has no current plans to become an enrolled provider in Medicare. Please call GearingUP’s office or check our website for the most up-to-date information regarding insurance and payment information for GearingUP. If Client (or their minor) are eligible or become eligible during the course of your sessions for enrollment in Medicare or other government program, you must inform GearingUP of your eligibility no later than your first or next, as applicable, scheduled appointment. It will be necessary for Client to sign a separate agreement acknowledging that GearingUP is not an enrolled provider in Medicare and that you assume full financial responsibility for the services rendered to Client (or their minor) by GearingUP and agreeing to refrain from submitting any invoices for services rendered to Medicare for reimbursement. Failing to inform GearingUP of Client’s (or their minor’s) eligibility for Medicare does not in any way reduce Client’s personal liability for payment of services rendered.
Client acknowledges that they have received a copy of GearingUP’s HIPAA disclosure and regulations. Client may request an electronic or printed copy at any time, or Client may access them on GearingUP’s website at any time. By signing this agreement and proceeding with services at GearingUP, you acknowledge that you have received and been fully informed of GearingUP’s HIPAA policies and Privacy Practices.
The provisions of this Agreement are severable. The invalidity or unenforceability of any provision shall not affect the validity and enforceability of the other provisions. If any provision of this Agreement is unenforceable for any reason, such provision shall be appropriately limited and given effect to extent that it may be enforceable.
This Agreement contains the entire understanding between the parties with respect to the subjects covered in such Agreement, and supersedes all prior agreements and understandings between the parties, both written and oral.
Any alterations or exceptions to the Terms of Service or GearingUP policy listed in this Agreement must be made in writing and either signed or sent by authorized method of transmission by an authorized representative of GearingUP. GearingUP may update this Agreement and included Terms of Service and policies from time to time. GearingUP agrees to notify Client of updates to the Terms of Service. If Client fails to provide GearingUP a signature or written affirmation after written notice from GearingUP, Client will consent to all updated terms by continuing to receive services at GearingUP at their next scheduled appointment.
The interpretation and construction of this Agreement, and all matters relating hereto, shall be governed by the laws of the State of Texas. Any action or other proceeding arising out of or related to this Agreement shall be instituted and maintained exclusively in the state courts of Texas or the United States District Court in Collin County, Texas, and each party hereto (i) irrevocably accepts, generally and unconditionally, the jurisdiction of such courts and any related appellate court, and (ii) irrevocably waives any objections as to venue of any such action or proceeding brought in such court or that such court is an inconvenient forum. The parties agree personal hand-delivery service (i.e., of any demand letter, notice of breach, petition, complaint, or initiation of a lawsuit) is not required. All notices and other communications required or permitted under this Agreement must be in writing and will be deemed delivered when sent.