This document contains important information about professional services, business policies, client rights, privacy practices, and payment expectations for therapy services with Refined Mind, PLLC. Please read it carefully and ask any questions prior to signing. Your signature indicates that you understand and agree to the information in this document.
This document is intended as a professional practice form and should be reviewed by appropriate legal, compliance, or practice-management counsel as needed for final use.
1. Your Therapist and Practice
Dr. Jasmine Allen, PhD, LCSW-S is a Licensed Clinical Social Worker-Supervisor providing mental and behavioral health services through Refined Mind, PLLC. Services may include individual therapy, couples therapy, family therapy, group therapy, clinical assessment, treatment planning, EMDR-informed care where clinically appropriate, and related therapeutic support.
Services are provided with respect for client dignity, autonomy, cultural context, privacy, and informed choice. Therapy is a collaborative process. While therapy can be meaningful and beneficial, outcomes cannot be guaranteed.
2. Nature of Therapy, Benefits, and Risks
Therapy may support insight, emotional regulation, trauma processing, healthier relationships, coping skills, improved functioning, and movement toward identified goals. Therapy may also bring up uncomfortable emotions, memories, relationship patterns, or stressors. At times, symptoms may feel more noticeable before they improve. You are encouraged to communicate openly about your needs, preferences, concerns, and pace of treatment.
You have the right to ask questions, participate in treatment planning, decline any intervention, request referrals, or discontinue services at any time. Premature termination may limit progress toward therapeutic goals.
3. EMDR and Trauma-Informed Services
When clinically appropriate and mutually agreed upon, treatment may include Eye Movement Desensitization and Reprocessing (EMDR) or EMDR-informed interventions. EMDR is a structured therapy approach often used to address trauma, distressing memories, anxiety, and related symptoms. EMDR may involve assessment, preparation, resourcing, bilateral stimulation, processing of distressing material, and follow-up. Potential temporary effects may include emotional activation, vivid dreams, fatigue, or increased awareness of memories or sensations. EMDR will be discussed with you before use, and you may pause or decline this approach at any time.
4. Confidentiality and Privacy Policy
Your privacy is important. Information shared in therapy is confidential and will not be released without your written authorization except as allowed or required by law. Protected health information may include identifying information, diagnosis, treatment plans, progress notes, billing information, appointment history, and communications related to care.
Limits of Confidentiality
Confidentiality may be limited or breached in situations including, but not limited to:
1.When there is suspected abuse, neglect, or exploitation of a child, elderly person, or person with a disability, or when reporting is otherwise required by law.
2.When there is an imminent risk of serious harm to yourself or another person, or when disclosure is clinically and legally necessary to protect safety.
3.When records are ordered by a court, subpoenaed, or otherwise required by law. Refined Mind, PLLC will make reasonable efforts to protect confidentiality to the extent permitted by law.
4.When information is necessary to obtain payment for services, address billing disputes, or process claims through an insurance or credentialing platform.
5.When you file a complaint, lawsuit, or other formal action involving services, records may be used as necessary for professional defense or response.
6.When consultation with another qualified professional is clinically appropriate. Identifying information will be minimized whenever possible, and consultants are expected to maintain confidentiality.
7.When disclosure is required by workers compensation, insurance audit, utilization review, or other applicable legal or contractual obligations.
HIPAA Notice and Privacy Rights
You have rights regarding your protected health information, including the right to request access to records, request amendments, request restrictions, request confidential communications, and receive an accounting of certain disclosures as provided by applicable law. You may request a copy of the Notice of Privacy Practices. Some records may be limited or withheld when permitted by law, including psychotherapy notes or records that could reasonably be harmful if released without appropriate review.
5. Records and Documentation
Clinical records are maintained to document services provided, support continuity of care, meet ethical and legal obligations, and assist with billing or insurance requirements when applicable. Records may include intake forms, consent forms, assessments, diagnosis, treatment plans, progress notes, communications, payment records, and other treatment-related documentation. Records are stored in a manner intended to protect confidentiality and security.
6. Insurance, Private Pay, and Headway
Refined Mind, PLLC offers private pay services and may accept select insurance plans for which Dr. Jasmine Allen is credentialed through Headway. Insurance coverage, copays, deductibles, session eligibility, and reimbursement are determined by the client’s insurance plan and the platform policies in effect at the time of service. Clients are responsible for understanding their benefits and for any amounts not covered by insurance, including deductibles, copays, coinsurance, denied claims, non-covered services, or private-pay services.
For private pay services, payment is due at the time of service unless otherwise agreed in writing.
7. Fees and Payment Agreement
Service
Fee
Initial assessment
$200
Individual follow-up therapy session
$175
Couples therapy session
$200
Family therapy session
$200
Group therapy session
$100
Court, litigation, subpoena, deposition, attorney consultation, or legally related services
$300 per hour
Accepted forms of payment include major credit cards. Clients paying privately agree to provide and maintain an active card on file. By signing this agreement, you authorize Refined Mind, PLLC, or its designated payment platform, to charge the card on file for session fees, no-show or late-cancellation fees, copays, deductibles, coinsurance, balances, or other fees specifically listed in this agreement and owed for services rendered.
If a payment is declined, the client is responsible for promptly updating payment information and resolving the balance. Ongoing services may be paused if an account remains unpaid, except where clinically or legally inappropriate to do so.
8. Cancellation, No-Show, and Late Arrival Policy
Appointments are reserved specifically for you. Cancellations must be made at least 24 hours before the scheduled appointment time. If you miss a session without notice or cancel with less than 24 hours notice, you may be charged the full session fee. Insurance generally does not pay for missed appointments, late cancellations, or no-shows; therefore, this fee may be the client’s responsibility. If you arrive late, the session may still need to end at the scheduled time, and the full session fee may apply.
9. Good Faith Estimate Notice
Clients who are not using insurance or who choose not to submit claims through insurance have the right to receive a Good Faith Estimate of expected charges for services. The estimate is not a contract and does not require you to receive services. Actual charges may vary based on the frequency, type, and duration of services provided. You may ask for an updated Good Faith Estimate at any time.
10. Telehealth Consent
Therapy may be provided by telehealth when clinically appropriate. Telehealth involves the use of electronic communication technology to provide services remotely. Benefits may include convenience and access to care. Risks may include technology failures, interruptions, privacy limitations in the client’s environment, or limitations in responding to emergencies remotely. You agree to participate from a private location, use appropriate technology, and provide your current physical location and emergency contact information when requested. Telehealth may not be appropriate for every clinical situation, and referrals or higher levels of care may be recommended if needed.
Clients must be physically located in a jurisdiction where Dr. Jasmine Allen is authorized to provide services at the time of the session, unless otherwise permitted by applicable law or temporary practice provisions.
11. Communication, Email, Texting, and Social Media
Email, text messages, website inquiries, and voicemail may be used for administrative matters such as scheduling, billing, and brief coordination. These methods may not be fully secure and should not be used for emergencies or detailed clinical content. Therapy is not provided by email, text, social media, or public messaging platforms.
To preserve confidentiality and professional boundaries, Dr. Jasmine Allen does not engage in personal social media relationships with clients. If you choose to follow, like, comment on, or engage with public professional content, you acknowledge that doing so may affect your confidentiality. Please do not use social media comments or direct messages for clinical communication.
12. Professional Boundaries
The therapeutic relationship is professional and clinical in nature. Personal, social, business, financial, or dual relationships can interfere with therapy and are not appropriate. Gifts, bartering, or service exchanges are generally not accepted.
13. Couples and Family Services
For couples or family services, the client is the relationship or family system rather than one individual. Information shared by one participant may be clinically relevant to the work with the couple or family. Secrets or private information may need to be addressed in treatment when clinically appropriate. Couples or family services are not intended for custody evaluations, forensic opinions, or litigation support. If legal proceedings are involved or anticipated, referrals to appropriate forensic or court-involved professionals may be recommended.
14. Emergencies and Crisis Situations
Refined Mind, PLLC is not a 24-hour crisis service and does not provide emergency coverage. If you are experiencing a life-threatening emergency, call 911 or go to the nearest emergency room. You may also call or text 988 for the Suicide & Crisis Lifeline. Do not use email, text, voicemail, website forms, or social media for emergencies.
15. Therapist Incapacity or Death
In the event that Dr. Jasmine Allen becomes incapacitated, dies, or is otherwise unable to continue practice, a designated licensed mental health professional or authorized practice representative may access records as necessary to notify clients, protect confidentiality, coordinate continuity of care, provide referrals, and respond to lawful record requests.
16. Grievances and Complaints
If you have concerns about therapy, you are encouraged to discuss them directly so they can be addressed with care and respect. You also have the right to file a complaint with the Texas Behavioral Health Executive Council. Contact information: Texas Behavioral Health Executive Council, 1801 Congress Ave., Ste. 7.300, Austin, Texas 78701; main phone (512) 305-7700; toll-free complaint referral system (800) 821-3205; website: bhec.texas.gov.
Consent and Payment Agreement Signature Page
Refined Mind, PLLC
Dr. Jasmine Allen, PhD, LCSW-S
Phone: 912-228-9539 | Email: dr.jasmineaallen@refinedmindpsychotherapy.com | Website: refinedmindpsychotherapy.com
I voluntarily consent to receive psychotherapy, assessment, counseling, telehealth, or related mental health services from Dr. Jasmine Allen through Refined Mind, PLLC. I understand that therapy is collaborative, outcomes are not guaranteed, and I may ask questions or discontinue services at any time.
I acknowledge that I have read, understand, and agree to the informed consent, privacy, telehealth, cancellation, no-show, payment, and card-on-file policies described in this document. I understand that I am financially responsible for fees owed under this agreement, including the full session fee for no-shows or cancellations with less than 24 hours notice.
________________________________________________
Client Printed Name
__________________
Date
________________________________________________
Client Signature
__________________
Date
HIPAA / Privacy Acknowledgment
I acknowledge that I have been offered or provided access to the Notice of Privacy Practices and understand that I may request a copy.
________________________________________________
Client Signature
__________________
Date
Automatic Card Charge Authorization
I authorize Refined Mind, PLLC, or its designated payment platform, to charge the card on file for fees and balances owed under this agreement.
________________________________________________
Client Signature
__________________
Date
Therapist Acknowledgment
________________________________________________
Dr. Jasmine Allen, PhD, LCSW-S
__________________
Date
travel experiences, designed for your enjoyment.