Mind Form Personal Development (Mind Form) is committed to earning and keeping the trust and confidence of the clients we serve and that of the other members of our community. As an organization founded to reduce suffering and increase well-being and functionality in fellow human beings, we first want to do no harm. This statement demonstrates our dedication to respecting and protecting the information members of the community share with us and the privacy of our clients and contacts.
We obtain and possess certain personal contact information from members of the community at the point when they submit one of our website forms or call us requesting information about our programs. We then add this information to our confidential and private contact list and return their inquiry. We retain this information in order to let potentially interested parties know of upcoming events at Mind Form. We also use contact information in order to stay in touch with current program participants and to contact former program participants in order to evaluate our programs after they have been completed.
Please see below for further details about our policies on how we interact with individuals' contact information in different situations. All information provided to Mind Form by an interested party through email, phone inquiries, Mind Form's website, or through any other means is provided with the understanding that unless otherwise directed it may be used in the manners listed below. Mind Form collects and uses personal information by:
Keeping a private and passworded list of our contacts – The people who have shared their interest in our organization by contacting us through our web forms, calling us, or otherwise engaging us are on our contact list. We simply use this information to email or call them back and provide the information they have requested. After providing initial information we ask if they want to remain on our list and receive additional information about upcoming programs and events. If they say no, we remove them from our contacts. If they say yes we keep them on our contact list and they may receive future email messages or phone calls about upcoming programming at Mind Form. Contacts may request to be removed from our list at any time and we will promptly do so.
Contacting current members of our programs – We keep in touch with members of our programs throughout their enrollment via email and phone messages. In cases of members' participation in one of our groups or classes, members may be asked if they want to share their contact information. Group members will be asked to keep this contact information strictly confidential.
Evaluating members’ experiences by administering surveys – we may contact individuals who have participated in our programs in order to evaluate program effectiveness and client satisfaction.
Changes to this Statement
This statement may be updated or changed at any time. Should our practices change the updated notice will be posted on our website.
Questions / Comments
Should you have any questions or concerns about our contact information privacy statement or our website, or if you would like your information removed from our contact list, please email change(at)mindform.net or call 919.526.0735
This statement was written March 13, 2014.
This statement was reviewed December 4, 2014.
OUTLINE OF CLINICAL PRACTICE
Type of Service/Treatment
Anticipated Length of Service/Treatment
Participant Choice and Consent for Treatment
I acknowledge that information has been provided to me regarding the alleged benefits and potential risks of receiving treatment services from Mind Form Personal Development. A representative of Mind Form Personal Development has explained to me the anticipated course of treatment. I understand that there are other available treatment providers and that I have the choice of selecting other providers to address my needs. By signing this form I acknowledge that I choose to receive the above noted services through Mind Form Personal Development. I further understand that this consent is valid for one year and may be withdrawn at any time.
The Therapist will work out a session schedule with you. Please schedule any additional or emergency appointments by texting, emailing or calling the Therapist.
- Both members of the couple are requested to attend all scheduled appointments. Please text or email the Therapist to inform her of any expected lateness or absence as soon as it is known.
- Mind Form Personal Development requires 36 hours notice for cancellation of scheduled services. Appointments can be cancelled by texting, calling or emailing the Therapist/Consultant and receiving confirmation of cancellation. Participants are responsible for the full price of services not cancelled more than 36 hours in advance. Once an appointment has been booked, there is a $3.95 cancellation fee regardless of notice given.
- Within 6 months, if 2 appointments are cancelled without notice to the Therapist, no further services will be scheduled.
All clients must pay in full and payment is due at the start of each session.
In order to create a safe environment representatives of Mind Form Personal Development maintain Client privacy and confidentiality. You are asked to do the same by not disclosing the identity of any clients you see or interact with at Mind Form or any information about them you acquired through joint participation in an event. The Therapist will not keep confidential any information that involves keeping you or others alive. The Therapist is also required by law to report any instances of abuse or neglect of children or disabled adults. Also there is no guarantee of confidentiality for information that is sent to insurance companies. In light of this, you may want to consider whether or under what conditions you use insurance versus paying for therapy on your own.
If you need to talk with the Therapist at any time other than your scheduled appointment time, you may call 919.526.0735 between the hours of 10:00 am and 10:00 pm. If the Therapist is available she will answer or return your call. The first 10 minutes are free. Additional time will be charged at the rate of her hourly fee. You may leave voice mail for the Therapist. The voice mail box is confidential; it is passworded and voice mails are erased after being listened to by the Therapist.
For some clients, writing can be an important part of recovery. If you would like to email your Therapist between sessions in the spirit of journaling and sharing your thoughts, feelings, and experiences via email, the Therapist will attempt to read your email(s) before your next appointment and come prepared to discuss what you have shared. The Therapist will rarely email you back, but will talk with you about what you wrote in the session.
The Therapist spends about 1 hour/week of time outside each session for every 1 hour of time spent in session with Clients. This is about the ratio that is necessary to maintain North Carolina licensing, attend mandatory and relevant continuing Therapist training sessions, compile post-session Client case notes, perform case conceptualizations, perform weekly scheduling and administrative duties related to case load, staff cases with colleagues as is clinically appropriate, etc. – all in the interest of providing quality services to Clients. The Therapist’s hourly fee for Client sessions is $64. Family sessions are scheduled for 1.25 - 1.5 hours and are $79.
I have read the Outline of Clinical Practice and I accept responsibility for the financial agreement, attendance policy, and issues of confidentiality.
This statement was written March 25, 2014.