PRACTICE EXPECTATIONS & CLIENT RESPONSIBILITIES

This policy outlines expectations for participation in services, appropriate conduct, financial responsibility, and the therapeutic fit for care provided by our practice. These expectations support a safe, respectful, and effective therapeutic environment.

Fit for Therapy and Level of Care
Our practice provides outpatient, low-acuity mental health services. Services are appropriate for clients who can participate in scheduled therapy and do not require intensive, crisis-level, or 24-hour care. Services are not appropriate for inpatient or residential treatment, partial hospitalization or intensive outpatient programs, ongoing crisis stabilization, court-ordered or forensic evaluations, or primary treatment for active psychosis, unmanaged mania, or severe substance dependence. If a higher level of care becomes clinically indicated, referrals will be discussed.

Client Participation Expectations
Clients are expected to attend scheduled sessions consistently, arrive on time and prepared to engage, communicate openly and honestly, participate in treatment planning, and notify the practice in advance when unable to attend appointments.

Respectful Conduct
All interactions with clinicians, staff, and other clients must be respectful. Verbal abuse, harassment, discriminatory language, threatening or intimidating behavior, physical aggression, repeated boundary violations, or disruptive behavior that interferes with care delivery are not permitted.

Communication Expectations
Clients are expected to use approved communication channels and allow reasonable response times during business hours. Messaging is not appropriate for emergencies or crisis situations.

Safety and Prohibited Items
Weapons, illegal substances, and alcohol are not permitted on premises or during sessions. Clients should not attend sessions while intoxicated or impaired.

Attendance and Reliability
Consistent attendance is essential for therapeutic progress. Repeated missed appointments, late cancellations, or inconsistent participation may impact the ability to continue services. Attendance expectations are further detailed in the Financial Policy.

Financial Responsibility and Failure to Pay
Clients are expected to comply with the Financial Policy, including payment for services rendered, cancellation fees, and outstanding balances. Failure to maintain payment or unresolved balances may result in suspension or termination of services.

Boundaries and Professional Relationship
Therapy is a professional relationship. Clinicians do not engage in social or dual relationships with clients. Social media connections are not permitted. Clinicians will not identify clients in public settings.

Technology and Telehealth Participation
Clients participating in telehealth are expected to join sessions from a private, secure location, maintain appropriate technology, and minimize distractions. Sessions may be ended or rescheduled if privacy or safety cannot be maintained.

Discharge and Termination of Services
The practice reserves the right to discharge or terminate services at any time, with or without cause, when continuation of services is not clinically appropriate, safe, or feasible. Reasons may include services no longer being appropriate, client needs exceeding the level of care provided, violation of practice expectations, repeated non-attendance, or failure to pay. When clinically appropriate, referrals and transition planning will be provided.

Client Questions and Concerns
Clients are encouraged to discuss questions or concerns with their therapist or practice leadership.

Good Faith Estimate Notice

Under the No Surprises Act, you have the right to receive a Good Faith Estimate explaining how much your mental health care may cost if you are uninsured or choosing to pay out of pocket.

A Good Faith Estimate shows the expected cost of services reasonably anticipated for your care based on information known at the time the estimate is provided.

Who Can Receive a Good Faith Estimate

You are entitled to a Good Faith Estimate if you:

• Do not have insurance, or

• Choose not to use your insurance and plan to self-pay

You may request a Good Faith Estimate at any time.

What the Estimate Includes

Your Good Faith Estimate will include:

• The expected cost of psychotherapy services provided by our practice

• An estimate of services reasonably expected as part of your care

This estimate is not a guarantee of final charges.

Changes to the Estimate

Actual charges may differ from the estimate based on:

• The number of sessions

• Changes to the treatment plan

• Clinical needs identified during treatment

You are responsible for payment for services actually provided.

Your Right to Dispute Charges

If you receive a bill that is $400 or more higher than your Good Faith Estimate, you may have the right to dispute the bill through the Patient-Provider Dispute Resolution (PPDR) process.

You must initiate the dispute within 120 days of receiving the bill.

More information is available at:
www.cms.gov/nosurprises
or by calling 1-800-985-3059

Insurance Notice

If you choose to use insurance, insurance companies make the final determination regarding coverage and payment. This Good Faith Estimate applies only to uninsured or self-pay services.

Questions or Requests

To request a Good Faith Estimate or ask questions, please contact:

Ashé Counseling & Coaching
Phone: 773-377-5577
Email: operations@ashecc.com

NOTICE OF PRIVACY PRACTICES (HIPAA)

This Notice describes how medical and mental health information about you may be used and disclosed, and how you can get access to this information. Please review it carefully.

Our Legal Duty

We are required by law to:

• Maintain the privacy of your Protected Health Information (PHI)

• Provide you with this Notice of Privacy Practices

• Follow the terms of this Notice currently in effect

Protected Health Information includes information that identifies you and relates to your mental or physical health, healthcare services, or payment for those services.

How We May Use and Disclose Your Information

We may use or disclose your Protected Health Information without your written authorization for the following purposes.

Treatment

We may use your information to provide, coordinate, or manage your mental health care. This includes consultation with other healthcare providers, supervision of clinicians and interns, referrals, and treatment planning.

Payment

We may use or disclose your information to bill and collect payment from insurance companies, managed care organizations, or you. This may include eligibility verification, authorization requests, claims processing, and payment collection.

Healthcare Operations

We may use your information for practice operations such as quality improvement, supervision, training, auditing, accreditation, compliance, licensing, legal review, and administrative activities.

Disclosures Required or Permitted by Law

We may disclose your information without your authorization when required or permitted by law, including:

• Suspected abuse or neglect of a child, elder, or dependent adult

• Serious risk of imminent harm to you or others, including duty to warn or protect

• Medical emergencies

• Court orders, subpoenas, or legal proceedings

• Health oversight activities such as audits, investigations, or licensure reviews

• Law enforcement purposes when legally required

Only the minimum necessary information will be disclosed.

Supervision, Training, and Workforce

Your information may be reviewed as part of supervision, consultation, training, or quality assurance activities. Provisionally licensed clinicians and graduate interns provide services under supervision, and supervisors are bound by the same confidentiality and privacy requirements.

Use of Technology and Artificial Intelligence (AI)

We may use technology tools, including artificial intelligence (AI)–assisted systems, to support administrative, operational, and clinical workflows such as scheduling, intake, documentation support, quality assurance, analytics, and communication.

Important points regarding AI use:

• AI tools are used to assist, not replace, licensed clinical judgment

• Diagnosis, treatment planning, and clinical decisions are made by licensed clinicians or supervised trainees

• Access to information is limited to what is necessary for the intended purpose

• AI tools are not used to provide independent therapy or clinical decision-making without human review

Uses and Disclosures Requiring Your Authorization

We will obtain your written authorization before using or disclosing your Protected Health Information for purposes not described in this Notice.

You may revoke an authorization at any time in writing, except where action has already been taken in reliance on the authorization.

Your Rights Regarding Your Health Information

You have the right to:

Access Your Records

Inspect or obtain a copy of your health records, subject to legal limitations.

Request Amendments

Request corrections to your records if you believe information is incorrect or incomplete.

Request Restrictions

Request limits on how your information is used or disclosed. We are not required to agree to all requests.

Request Confidential Communications

Request that we contact you in a specific way or at a specific location.

Accounting of Disclosures

Receive a list of certain disclosures made of your information.

Right to Restrict Information When Paying Out of Pocket

If you pay for a service in full out of pocket, you may request that we not share information about that service with your health plan for payment or operations purposes, as allowed by law.

Receive a Copy of This Notice

Request a paper or electronic copy of this Notice at any time.

Electronic Communication

We use electronic systems for scheduling, documentation, billing, reminders, and communication. While safeguards are in place, electronic communication carries some privacy risk.

Email and text messaging are used for administrative purposes only and should not be used for emergencies or urgent clinical matters.

Telehealth Services

Telehealth services involve electronic communication and may present additional privacy risks. We take reasonable measures to protect your information, and you are responsible for participating from a private and secure location.

Record Retention

Your records are retained for the period required by federal and state law, which may extend beyond seven years and longer for minors.

Breach Notification

We will notify you if a breach occurs that compromises the privacy or security of your unsecured Protected Health Information, as required by law.

Changes to This Notice

We reserve the right to change this Notice. Any changes will apply to all Protected Health Information we maintain. Updated Notices will be made available upon request and posted where services are provided.

Complaints

If you believe your privacy rights have been violated, you may file a complaint with us or with the U.S. Department of Health and Human Services. Filing a complaint will not affect your care.

Practice Contact for Privacy Concerns:
Phone: 773-377-5577
Email: operations@ashecc.com

U.S. Department of Health and Human Services
Office for Civil Rights
www.hhs.gov/ocr

Financial Policy

Ashé Counseling & Coaching is committed to transparent and straightforward billing practices. Please review the information below.

Payment Responsibility
Clients are responsible for payment for services received, including copayments, coinsurance, deductibles, cancellation fees, and any balances not covered by insurance. Payment is due at the time of service unless otherwise arranged.

Accepted Payments
We accept major credit cards and HSA/FSA cards. A valid credit or debit card is required to be kept on file. Charges are processed to the card on file the day after your appointment.

Insurance
If we are in network with your insurance, we will submit claims as a courtesy. We may provide an estimate of your out-of-pocket cost; however, insurance companies make the final determination of coverage and payment. Clients are responsible for any remaining balance after insurance processes the claim.

Self-Pay and Good Faith Estimates
Uninsured or self-pay clients are entitled to receive a Good Faith Estimate of expected charges under the No Surprises Act. Estimates are not guarantees of final charges.

Cancellation and No-Show Policy
We require 24 hours notice to cancel or change an appointment. Appointments cancelled with less than 24 hours notice or missed appointments will be charged a $99.00 fee, billed to the card on file. Insurance does not cover missed or late-cancelled appointments.

Medicaid Clients
Medicaid clients are not charged a no-show or late cancellation fee. However, two consecutive missed appointments or a pattern of excessive late cancellations or no-shows may result in discharge from services.

Late Arrivals
Late arrivals may result in a shortened session. The full session fee still applies.

Non-Payment
Failure to maintain payment or unresolved balances may result in suspension or termination of services.

For questions regarding billing or to request a Good Faith Estimate, please contact us at 773-377-5577 or operations@ashecc.com.