Patient Information and Consent to a Working Agreement with 24-7 Help
1. Please read this agreement carefully. If you are accepted as a patient of 24-7 Help, you are agreeing to be bound by the terms of this Patient Information And Consent To A Working Agreement With 24-7 Help. If you do not agree to the terms of this Patient Information And Consent To A Working Agreement With 24-7 Help, do not register to be a patient of 24-7 Help.
2. I hereby agree to begin service through 24-7 Help with James R. Lathrop, LCSW, BCD. I have reviewed and I understand the following:
- a. Notice of Privacy Practices of James R. Lathrop, LCSW, BCD.
- b. 24-7 Help Privacy Policy Disclosure and Disclaimer.
- c. 24-7 Help Policies.
- d. Straight Talk About 24-7 Help And Rational Emotive Behavior Therapy (REBT), by James R. Lathrop, LCSW, BCD.
- e. Guide to Rational Emotive Behavior Therapy by James R. Lathrop, LCSW, BCD.
3. I understand that reviewing the Albert Ellis Institute website, and reading the following, which may be obtained at that Institute, may enhance my appreciation of REBT and may assist me in efficiently utilizing the REBT model for my therapy.
- a. How to Stubbornly Refuse To Make Yourself Miserable About Anything—Yes, Anything! REVISED 2nd Edition, by Albert Ellis, Ph. D.
- b. Helping Yourself with REBT: First Steps for Clients, by Windy Dryden, Ph.D.
- c. Feeling Better, Getting Better, Staying Better, by Albert Ellis, Ph.D.
- d. A Guide to Rational Living, by Albert Ellis, Ph.D. & Robert Harper, Ph.D.
- e. I am familiar with the 24-7 Help website, www.24-7-help.com, as well as how to use it.
4. I have discussed with my therapist the operating policies and procedures of this practice setting, the role and responsibilities of my therapist, and my role and responsibilities as a Patient. I understand my rights to receive and refuse services, to privacy and confidentiality, to respectful treatment, to be informed about all aspects of my service, to read and amend my clinical record, and to file a complaint if I feel I have been unfairly or unethically or disrespectfully treated. I have asked all questions that have occurred to me.
5. I understand the purposes of this setting, the service approaches and methods used, and the qualifications of my therapist. The undersigned therapist is a licensed clinical social worker in the state of Texas engaged in private practice providing mental health care services to Patients directly. In addition, as shareholder and employee, the undersigned therapist provides all mental health services through 24-7 Help.
6. I understand that all services and records of services by 24-7 Help, including request for services, assessment(s), therapy, and termination from therapy, as well as all communications of any type in any form with staff of 24-7 Help or with the therapist, take place in the office of 24-7 Help, which is located in Nueces County Texas. This means that all online activities, including video/chat, as well as all services, including record keeping, of 24-7 Help are understood and agreed to be construed as taking place in the office of 24-7 Help, located in Nueces County Texas.
7. I understand that confidentiality includes access to my identifying data, services, records, or any communication by 24-7 Help staff, as well as by the therapist, and by the 24-7 Help Webmaster, which may be necessary in order to provide this service to me. The therapist’s discretion shall control.8. I understand that it may be advantageous or necessary for the therapist to obtain professional opinions, treatment reviews, or any service delivery review, including but not limited to those of Rational Emotive Behavior Therapists, attorneys, medical or health care professionals. I agree that the therapist may obtain any or all of these professional opinions, treatment reviews, or any service delivery review, without consultation or approval by me. The therapist’s discretion shall control.
9. I understand that the attorney(s) for 24-7 Help, or the therapist may have complete access to, as well as to take complete control of, my identifying data, services, records, or any communication I may have with 24-7 Help, or the therapist. The therapist’s discretion shall control.
10. I understand that the Information Technology Consultant for 24-7 Help, or the therapist may have "as needed" access to, as well as to take "as needed" control of, my identifying data, services, records, or any communication I may have with 24-7 Help, or the therapist. The therapist’s discretion shall control.
11. I understand that while it may not be easy to seek help from a mental health professional, it is hoped that I will be better able to understand my situation and feelings and move toward resolving my difficulties. The therapist, using his knowledge of Rational Emotive Behavior Therapy, will make observations about situations as well as suggestions for new ways to approach them. It will be important for me to explore my own feelings and thoughts and to try new approaches in order for change to occur. As this is an individual therapy format, I must attend alone.
12. I understand that therapy is the Greek word for change. I understand that I may learn things about myself that I don't like. I understand that often, change or growth cannot occur until I experience and confront issues that induce me to feel sadness, sorrow, anxiety, or pain. The success of our work together depends on the quality of the efforts on both our parts, and the realization that I am responsible for lifestyle choices/changes that may result from therapy. Specifically, I understand that, not often but sometimes, therapy can be dangerous or result in danger. I understand that it is risky business to confront the issues involved in such disturbances as depression, anxiety, or delusional thinking; or such relationship issues as child abuse or extramarital sexual encounters. I understand that sometimes as a result of these confrontations, people choose to do harm to themselves or another. I understand that 24-7 Help and my therapist are accountable for negligence, so they have developed policies, procedures, and methods to reduce these threats. I understand that first and foremost 24-7 Help and my therapist attempt to assess my problem, likely consequential reactions, resources, and coping skills. I understand that 24-7 Help and my therapist are dependent upon my open, honest, and full cooperation in this effort. I understand that 24-7 Help and my therapist can't read minds or predict the future. I understand that there may also arise some problems. After discussing the painful dysfunction of marital relations in the context of therapy, sometimes a partner chooses to dissolve the marriage; that is, opt for a divorce. An adolescent may decide during the therapy that her or his parents really are intolerably demanding so chooses to escape by running away or getting married. I understand that there can be undesirable consequences of risking the confrontations necessary to succeed at therapy.
13. I understand that I am advised to seriously consider the timing and the risks involved; Of course these are only examples of possible risks, not an all inclusive list. As I become aware of a potential risk, I am responsible for discussing it openly with my therapist.
14. I understand that, in the event the undersigned therapist becomes incapacitated or dies, it will become necessary for another therapist to take possession of my file and records. By signing this information and consent form, I give my consent to allowing another licensed mental health professional selected by the undersigned therapist to take possession of my file and records and provide me with copies upon request, or to deliver them to a therapist of my choice.
15. I understand that in the case of incapacitation or death of the therapist, the Board Chairman, Texas State Board of Social Worker Examiners shall become the executor for all 24-7-Help files and records.
16. Address:
- Board Chairman
- Texas State Board of Social Worker Examiners
- 1100 West 49th Street
- Austin, Texas 78756-3183, USA
- Email: lsw@tdh.state.tx.us
- Telephone: (512) 719-3521 or (800) 232-3162
- Fax: (512) 834-6677
17. I understand that in the case of my incapacitation or death, 24-7 Help or the therapist will disclose my file or records only upon receipt of and by direction of a court order.
18. I understand that an assessment is necessary in order to plan services or treatment. I understand that the first session, at least, with 24-7 Help or with the therapist shall be for the purpose of assessment.
19. I understand that in order to receive services, including therapy, from 24-7 Help or the therapist, I must identify myself to 24-7 Help. For this purpose, I understand that I must authorize 24-7 Help to verify that I possess a valid Texas Driver License prior to Consent To Service Plan And Service Contract With 24-7 Help. I freely permit 24-7 Help to verify my driver license from the applicable state agency.
20. I understand that for the purpose of assessment, as well as for treatment planning, I must provide, prior to Consent To Service Plan And Service Contract With 24-7 Help, to 24-7 Help or the therapist, a valid release of information regarding each and every health care appointment or therapy session I have had in the last 3 years prior to the date I request services at 24-7 Help.
21. I understand that for the purpose of assessment, as well as for treatment planning, I must provide to 24-7 Help or the therapist, a valid release of information regarding each and every health care appointment, treatment or therapy session with any other health care provider or agency during the period of that health care, until my case is closed at 24-7 Help or with the therapist. I understand that I must provide the valid release of information prior to the next session I have with 24-7 Help or with the therapist following my request for, initiation of, or receipt of other health care.
22. I understand that Consent To Service Plan And Service Contract With 24-7 Help establishes the agreement for therapy. I understand that therapy shall not begin nor shall therapy be construed to begin until Consent To Service Plan And Service Contract With 24-7 Help has been signed by me and accepted by 24-7 Help or the therapist.
23. I understand that I am accepting the terms of service offered by 24-7 Help and the therapist as stated in the Patient Information And Consent To A Working Agreement With 24-7 Help. I understand this to be a distinct and different agreement from Consent To Service Plan And Service Contract With 24-7 Help; which establishes the terms of my specific treatment.
24. I understand that after my situation is assessed, 24-7 Help or my therapist may decline to accept me as a Patient for service. The therapist’s discretion shall control.
25. I understand that if 24-7 Help or my therapist decline to accept me as a Patient for service, I may seek therapy on my own from other sources, including from the Albert Ellis Institute.
26. I understand that if 24-7 Help or my therapist decline to accept me as a Patient for service, I agree not to hold 24-7 Help or my therapist accountable for my behavior, condition, treatment, or any negative effects to me or to others, even though resulting from 24-7 Help or my therapist declining to accept me as a Patient for service. The therapist’s discretion shall control.
27. I understand that my prognosis may depend upon my receiving treatment, therapy, or other services, which I agree are my responsibility to receive, if necessary from some other source (s) than 24-7 Help or the therapist, even if 24-7 Help or the therapist decline to accept me as a Patient for service.
28. I understand that my prognosis may depend upon my receiving treatment, therapy, or other services, which I agree are my responsibility to receive, if necessary from some other source(s) than 24-7 Help or the therapist, in addition to services provided by 24-7 Help or the therapist, as well as during the period that I am being assessed or treated at 24-7 Help or by my therapist. I understand that services at 24-7 Help or by the therapist may be helpful to me, but they are not necessarily sufficient to meet all of my needs.
29. I understand that if accepted for service, my therapist and I will develop a service plan and that we will make another agreement to follow through with the service plan.
30. I understand that if accepted for service, my service plan, prognosis, and service results will largely depend upon my open, honest cooperation with 24-7 Help or my therapist.
31. Goals, Purposes and Techniques of Therapy. I understand the methods, procedures, benefits and limits of online Rational Emotive Behavior Therapy through 24-7 Help. I understand there may be alternative ways to effectively treat the problems I am experiencing. I understand that 24-7 Help and the therapist practice and advocate the Rational Emotive Behavior Model. I understand that 24-7 Help and the therapist do not recommend or refer for services delivered by agencies or practitioners of other clinical models, not because these other agencies, practitioners or other models are inferior, wrong, harmful or in any way poor; only because other models are outside the competence of 24-7 Help or the therapist. I understand that it is important for me to discuss any questions I may have regarding the treatment recommended by the therapist and to have input into setting the goals of my therapy. I understand that as therapy progresses these may change.
32. I understand that online communication through 24-7 Help is not the same as, may be more limited than, and may not provide the capabilities of a face-to-face, in person, in office experience.
33. I understand the benefits and risks of 24-7 Help therapy and/or referral, as well as alternative therapies, which were explained to me and reviewed by me with the therapist.
34. Although it is the goal of the undersigned therapist to protect the confidentiality of my records, there may be times when disclosure of my records or testimony will be compelled by law. In the event disclosure of my records or testimony is required by law, I will be responsible for and shall pay the costs involved in producing the records and the therapist's normal hourly rate for the time involved in preparing for and giving testimony. Such payments are to be made at the time or prior to the time the services are rendered by the therapist.
35. The therapist and I reviewed 24-7 Help policies, therapist license, therapist ethics, and expectations of me, and copies of those are available to me from this web site.
36. I understand that without regard to the source or to the reason, any requirement that 24-7 Help or the therapist or any requirement that an associated agent of either 24-7 Help or the therapist, acting for, or on behalf of, or because of 24-7 Help or the therapist, to submit to a court order, or to submit to a subpoena, or to appear in court, or to prepare any submission to a court, or to the Office of the Texas Attorney General or to the Office of the United States Attorney General will be billed as follows:
- a. $250.00 per hour,
- b. $50 administration fee,
- c. Transcription costs,
- d. Attorney’s fees,
- e. Information Technology Consultant fees,
- f. Administrative and secretarial assistant services,
- g. If travel over 50 miles is required, for therapist and/or each agent acting for, or on behalf of, or because of 24-7 Help: 1st class air travel, plus 1st class lodging, plus premium level rental car costs, plus maximum rental car insurance costs, plus $1,000,000 travel accident insurance costs.
- h. I understand that choice for airline, rental car company and rental car model, and lodging, and insurance carrier shall be at the sole discretion of the therapist.
- i. I understand that the choice for travel, rental car, lodging, and insurance for any agent to attend with or for 24-7 Help or with or for the therapist shall be at the sole discretion of the therapist.
- j. I understand these costs apply without regard to whether the action is required to be completed.
- k. I understand that a minimum fee of $500.00 will be billed.
- l. I understand I will be charged these fees and costs unless notice of not less than 72 hours is received from competent authority by 24-7 Help or by the therapist that the requirement is canceled or rescheduled.
37. CONFIDENTIALITY. Discussions between a therapist and a Patient are confidential. No information will be released without the Patient’s written consent unless mandated by law. Possible exceptions to confidentiality include but are not limited to the following situations: child abuse; abuse of the elderly or disabled; abuse of patients in mental health facilities; sexual exploitation; AIDS/HIV infection and possible transmission; criminal prosecutions; child custody cases; suits in which the mental health of a party is in issue; situations where the therapist has a duty to disclose, or where, in the therapist’s judgment, it is necessary to warn, notify or disclose; fee disputes between the therapist and the Patient; a negligence suit brought by the Patient against the therapist; or the filing of a complaint with a licensing board or other state or federal regulatory authority. FOR FURTHER INFORMATION REVIEW THE NOTICE OF PRIVACY PRACTICES FURNISHED TO YOU BY YOUR THERAPIST IN CONJUNCTION WITH THIS PATIENT INFORMATION AND CONSENT DOCUMENT. If you have any questions regarding confidentiality, you should bring them to the attention of the therapist when you and the therapist discuss this matter further. By signing the Patient Information and Consent to a Working Agreement with 24-7 Help, you are giving your consent to the undersigned therapist to share confidential information with all persons mandated by law and with the agency that referred you and the managed care company and/or insurance carrier responsible for providing your mental health care services and payment for those services, and you are also releasing and holding harmless the undersigned therapist from any departure from your right of confidentiality that may result. The therapist’s discretion shall control.
38. This information is to be provided at my request for use by said persons only to prevent harm to myself or another person. This authorization shall expire upon the termination of my therapy with the undersigned therapist.
39. I acknowledge that I have the right to revoke this authorization in writing at any time to the extent the undersigned therapist has not taken action in reliance on this authorization. I further acknowledge that even if I revoke this authorization, the use and disclosure of my protected health information could possibly still be permitted by law as indicated in the copy of the Notice of Privacy Practices of the undersigned therapist that I have received and reviewed.
40. I acknowledge that I have been advised by the undersigned therapist of the potential of the redisclosure of my protected health information by the authorized recipients and that it will no longer be protected by the federal Privacy Rule.
41. I further acknowledge that the treatment provided to me by the undersigned therapist was conditioned on my providing this authorization.
42. DUTY TO WARN. In the event that the undersigned therapist reasonably believes that I am a danger, physically or emotionally, to myself or another person, I specifically consent for the therapist to warn the person in danger and to contact any person in position to prevent harm to myself or another person, in addition to medical and law enforcement personnel, and the person(s) I shall identify on the Biographical Information form as my Trusted Point of Contact. The therapist’s discretion shall control.
43. I understand that my therapist and all others involved in 24-7 Help will protect my privacy and that confidential information about me will be revealed only if I give my written consent, if my safety or the safety of someone else is threatened, or if a court orders the information released.
44. I understand that I will be asked to furnish the name of someone trusted by me to be contacted in the event of an emergency. I understand that in contacting that person, my therapist will have to identify his relationship to me and my whereabouts and condition. However, I am assured that no unnecessary details of my service will be provided to that person.
45. I understand that my relationship with my therapist is now and will be in the future solely a professional relationship and that we will have no shared interests or activities outside my service.
46. I understand that my relationship with my therapist is a professional and therapeutic relationship. In order to preserve this relationship, it is imperative that the therapist not have any other type of relationship with me. I understand that personal and/or business relationships undermine the effectiveness of the therapeutic relationship. Though my therapist cares about helping me, he is not in a position to be my friend or to have a social or personal relationship with me.
47. I understand that gifts, bartering and trading services are not appropriate and should not be shared between me and the therapist.
48. I understand that I must make all contacts with 24-7 Help. 24-7 Help will be available for me to contact. I understand, that for purpose of my confidentiality, that neither 24-7 Help, nor the therapist will be required to make any attempt at any time for any reason to contact me. I understand that if I do not contact 24-7 Help after a period of 30 consecutive days from my last contact with 24-7 Help Clinic, my case will be closed and my files and record will be closed.
49. I understand that once my case is closed the therapist has no longer any responsibility to me whatsoever, including remaining available for referral or follow-up consultation, unless my therapist and I have made specific arrangements through the course of therapy for follow-up or referral after my case is closed.
50. I understand that my case will be closed 90 days after termination, in order to provide me ample time to re-consult or to request a referral. I understand that once my case is closed, I will have no direct access to 24-7 Help Clinic; however, I shall continue to have access to my records on my Patient Information Page.
51. I understand that after my case is closed, the following apply:
- a. I shall continue to have access to my Patient Information Page.
- b. However, 24-7 Help Clinic may at any time archive my records such that they, all or in part, no longer are accessible through my Patient Information Page.
- c. I shall be able to get copies of my records by contacting 24-7 Help through provisions made on my Patient Information Page for a period not to exceed 6 years from the time my case is closed.
- d. After this time, my Patient Information Page will be terminated, and I shall have no further access to my records.
52. I understand that if I am accepted by 24-7 Help for any service after my case has been closed, a new case will be opened with no reference necessarily made to my closed case material by 24-7 Help.
53. I understand that 24-7 Help or my therapist may assist me with referrals as needed, though referrals may be limited to the following: Albert Ellis Institute. The therapist’s discretion shall control.
- a. I understand that because of the limitations of 24-7 Help it may not be possible for the therapist to make any immediate, crisis, urgent, or emergency referral and it may not be possible to assist in having me involuntarily committed or placed in a restricted treatment environment.
- b. I understand that because of the limitations of 24-7 Help it may not be possible for the therapist to make adjunctive referrals for me; however, he can offer general guidance, that I may implement as I choose, but he may not be able to follow-up with me the effectiveness of his offered general guidance.
- c. I assert that if needed, I do have adequate and available resources to meet immediate, crisis, urgent, or emergency situations without assistance from or intervention by 24-7 Help or the therapist and that I am responsible for maintaining adequate and available resources to meet these needs, should I have any.
- d. I assert that if needed, I do have adequate and available resources to evaluate, undertake or implement any general guidance, in lieu of adjunctive referrals, that my therapist may offer.
- e. I assert that I am not in crisis, therefore, I do not require immediate, crisis, urgent, or emergency referral; and I do not require this therapist or 24-7 Help to provide involuntary commitment or more restrictive intervention for me.
54. I have read and understand Straight Talk About 24-7 Help And Rational Emotive Behavior Therapy (REBT), by James R. Lathrop, LCSW, BCD.
55. I agree that Straight Talk About 24-7 Help And Rational Emotive Behavior Therapy (REBT), by James R. Lathrop, LCSW, BCD, Patient Information And Consent To A Working Agreement With 24-7 Help, and Consent To Service Plan And Service Contract with 24-7 Help, are the guidance for my interactions with and service from 24-7 Help upon which the therapist’s discretion shall control.
56. I have read and understand Guide to Rational Emotive Behavior Therapy by James R. Lathrop, LCSW, BCD.
57. I have read and understand either How to Stubbornly Refuse To Make Yourself Miserable About Anything—Yes, Anything! REVISED 2nd Edition or Better, Deeper, and More Enduring Brief Therapy by Albert Ellis, Ph.D.
58. I understand the reason for and limits of 24-7 Help online intake and consent process and I freely consented to it.
59. I am competent to make personal decisions and I am able to be responsible for my behavior and my choices.
60. I agree to requested biographical information, psychological or psychosocial testing, evaluation and assessment for 24-7 Help’s purpose of determining whether to refer, whether to decline to offer treatment or services, and/or in order to guide treatment or services. The therapist’s discretion shall control.
61. I agree, if asked by my therapist, to have a physical examination with my personal physician and to request that his or her reports be sent to my therapist in this setting.
62. I understand that I have a right to copies of my entire file but acknowledge that some information may not be in my best interest to review. In the event my therapist, in the exercise of his professional judgment, determines that information in my file may be injurious to me, I waive my right to obtain such potentially injurious information and release my therapist from any and all claims, damages and causes of action that I suffer or could assert for his refusal to provide me with the information requested. The therapist’s discretion shall control.
63. I understand that 24-7 Help and the therapist have obligations to protect from disclosure proprietary tests and copyrighted material. These tests and copyrighted materials may not be revealed to me.
64. I agree not to request to be revealed to me or to anyone on my behalf the proprietary tests and copyrighted material utilized by 24-7 Help or the therapist.
65. I understand how to make complaints, especially to the Texas Board of Social Worker Examiners.
66. I was afforded a scheduled opportunity to fully discuss online through 24-7 Help with the therapist all aspects of 24-7 Help services, including referral as well as all 24-7 Help polices, procedures; all of my questions were answered to my satisfaction.
67. I accept, consent and agree to intake, ongoing psychological or psychosocial testing, evaluation and assessment, treatment or services including referral from 24-7 Help at this time.
68. I understand and agree that all activities or correspondence by any means, including over the internet or by e-mail as well as all therapy or other sessions I may have through 24-7 Help and with my therapist will be recorded by any means or methods using computer technology including audio or video media, whether 24-7 Help or my therapist may accept or decline to accept me as a Patient for service.
69. I consent for the undersigned therapist to communicate with me through 24-7 Help.
70. I understand that appointments may be made through any means selected by 24-7 Help, or the therapist, including web based appointment services. 24-7 Help, or the therapist will select any such service only after carefully reviewing and accepting the service confidentiality policy. Though 24-7 Help, or the therapist will take reasonable care to assure my confidentiality, they cannot be held in any way liable for the actions of these agents. The therapist’s discretion shall control.
71. I understand that cancellations must be received by 24-7 Help at least 24 hours before my scheduled appointment; otherwise I will be charged the full fee for that missed appointment. I am responsible for canceling or rescheduling my appointment.
72. I understand my financial responsibilities and the rules about notifying my therapist if I have to miss an appointment or be late or be interrupted, the charges for broken appointments and late arrivals or interrupted sessions without prior notification.
73. I have been made aware of the financial policies of this setting, and I understand that I will pay for each session as follows: $150.00 for each assessment session, and $120.00 for each follow-up session.
74. The undersigned therapist will look to me for full payment of my account, and I will be responsible for payment of all charges.
75. I understand that the number of sessions needed depends on many factors and will be discussed by the therapist.
76. I understand that assessment sessions are 75 minutes in length.
77. I understand that therapy sessions are 50 minutes in length.
78. I understand that if I am 10 minutes late for my appointment, it is canceled and I shall be charged the full session payment.
79. I understand that my credit card will be charged for the full payment of the session at the time I make the appointment.
80. I understand that any time I have questions about this setting, the evaluation process, or any policy or procedure, I should promptly bring my questions or concerns to my therapist.
81. I, voluntarily, agree to receive Mental Health assessment, care, treatment, or services, and authorize the undersigned therapist to provide such care, treatment, or services as are considered necessary and advisable.
82. I understand and agree that I will participate in the planning of my care, treatment, or services, and that I may stop such care, treatment, or services that I receive through the undersigned therapist at any time.
83. I understand and agree that I will not share, disclose, distribute or in any other way, make available my username and password for any reason, to anyone.
84. I understand and agree that 24-7 Help and my therapist will not be responsible for or accountable for any misuse of my username, password or resulting activities due to misuse of my username or password, including but not limited to changes to my Patient Information Page or its contents, charges to my credit card, completion or submission of homework, tests, assessments, or other forms or documents, or revelations or activities in session(s).
85. MEDIATION. I agree to resolve any disagreement, conflict or misunderstanding with 24-7 Help, or my therapist directly with them. The parties agree to attempt to resolve the disagreement, conflict or misunderstanding in good faith. The parties agree to the following procedure before pursuing any other remedy: The parties will present any disagreement, conflict or misunderstanding to the other party promptly by posting the disagreement, conflict or misunderstanding on the Patient Information Page of 24-7 Help. The presenting party will allow reasonable time for the other party to respond, but in no case more than 30 days from the date on which the complaining party posts the disagreement, conflict or misunderstanding. If, within 30 days of the posted disagreement, conflict or misunderstanding the party to whom the disagreement, conflict or misunderstanding is addressed has not responded, the matter shall be resolved through mediation with a mediator certified by the American Arbitration Association, as well as certified to practice mediation in the State of Texas, and who is acceptable to the parties.
86. Mediation shall take place in Nueces County, Texas.
87. If a response is made within the 30-day period, the parties agree to a 30-day period, from the date of response, in which to settle the disagreement, conflict or misunderstanding. If after this attempt to settle and after the 30-day period has elapsed, if either party is not satisfied with the resolution attained through negotiation, each party agrees to resolve through mediation with a mediator certified by the American Arbitration Association, as well as certified to practice mediation in the State of Texas, and who is acceptable to the parties.
88. Either party may acquire the services of the mediator, however, it is agreed by both parties that a mediator, agreeable to both parties, who is willing to accept the case, will be secured not later than 90 days following the date the disagreement, conflict or misunderstanding was first posted on 24-7 Help.
89. If services of a mediator certified by the American Arbitration Association, as well as certified to practice mediation in the State of Texas, and who is acceptable to the parties is not agreed upon within the 90-day period, then the matter shall be presented to an attorney selected by 24-7 Help, or my therapist, for referral to a mediator certified by the American Arbitration Association, as well as certified to practice mediation in the State of Texas.
90. The disputing parties agree to at least 4 hours of mediation, in accordance to the procedures or guidelines of the American Arbitration Association.
91. The costs of mediation, including the fees of the attorney selected by 24-7 Help, or my therapist, shall be borne equally by the disputing parties.
92. Once the first appointment has been agreed to with the mediator, the parties shall attempt to resolve the dispute within 30 days. If 30 days after the first agreed appointment with the appointed mediator the dispute is not resolved, it will be referred to arbitration by the mediator. If the arbitrator declines to refer the case to arbitration, an attorney selected by 24-7 Help, or my therapist will refer it. The disputing parties agree to arbitration by the arbitrator selected either by the mediator or by the attorney selected by 24-7 Help, or my therapist. The judgment upon the award rendered by the arbitrator may be entered in any court having jurisdiction.
93. If no disagreement, conflict or misunderstanding is posted on the Patient Information Page prior to the date of termination of services by 24-7 Help, or my therapist, and after 90 days have passed since termination 24-7 Help, or my therapist, neither party shall have any right to make any disagreement, conflict or misunderstanding with the other party.
94. NOTE. I understand that this is the Internet. I understand that all activities through 24-7 Help or with the therapist including communications, record keeping, appointments, referrals, as well as web links are managed through the use of secure protocols and confidentiality policy understandings. However, I understand that this is the Internet with all the risks associated. I understand that I am freely, and with considered deliberation, accepting these risks. I understand that I hold harmless 24-7 Help or the therapist from any breach of my confidentiality through any or all uses of the Internet associated with my activities or services through 24-7 Help or with the therapist.
95. Consent to electronic transmission of information: I understand that using the Internet to access my Patient Information Page, or to access any activities or services through 24-7 Help or with the therapist, involves the electronic transmission of my personal information, including my identifying data, financial information, as well as emotional, psychological, or any other personal information.
96. I understand that when I access any activities or services through 24-7 Help or with the therapist, I am consenting to electronic transmission of the information I have requested or accessed.
97. I understand that my consent is effective during the entire time that I access any activities or services through 24-7 Help or with the therapist until termination of my activities or services with 24-7 Help, or the therapist.
98. I understand that I can print a copy of this completed form, which shall serve as my printed record of this Patient Information And Consent To A Working Agreement With 24-7 Help, to which I am entitled from 24-7 Help, or the therapist.
