I am very pleased that you have selected me to be your therapist, and I am sincerely looking forward to assisting you. This document is designed to inform you about what you can expect from me regarding confidentiality, emergencies, and several other details regarding your treatment. Although providing this document is part of an ethical obligation to my profession, more importantly, it is part of my commitment to you to keep you fully informed of every part of your therapeutic experience. Please know that your relationship with me is a collaborative one, and I welcome any questions, comments, or suggestions regarding your course of therapy at any time.

Background Information

The following information regarding my educational background and experience as a therapist is
an ethical requirement of my profession. If you have any questions, please feel free to ask.

I am a Licensed Psychologist in the state of Georgia. I have a Doctoral Degree in Psychology from Alfred University and a Bachelor's Degree in Human Development and Family Studies from Cornell University. I am an inducted member of Psy Chi, a psychology academic honor society. I am also an active member of the American Psychological Association (APA), the National Association of School Psychologists (NASP), and the Georgia Psychological Association (GPA). I have rich experience in providing psychotherapy services to children, adolescents, adults, and families. I have been providing services in private practice since 2004 and worked as a School Psychologist from 1994 to 2004. I am the Owner of D. Craig Kerley, Psy.D. LLC, (aka Roswell Counseling for Children and Adults) a limited liability company established to provide counseling and psychotherapy services. Overall, I approach counseling from an integrative perspective. I draw heavily from Cognitive Behavioral Therapy (CBT) and family systems therapies as deemed appropriate based on the age, needs, and collaboratively determined treatment goals of each individual client and family.

Theoretical Views & Client Participation

It is my belief that as people become more aware and accepting of themselves, they are more capable of finding a sense of peace and contentment in their lives. However, self-awareness and self-acceptance are goals that may take a long time to achieve. Some clients need only a few sessions to achieve these goals, whereas others may require months or even years of therapy. As a client, you are in complete control, and you may end your relationship with me at any point.
In order for therapy to be most successful, it is important for you to take an active role. This means working on the things you and I talk about both during and between sessions. This also means avoiding any mind-altering substances like alcohol or non-prescription drugs for at least eight hours prior to your therapy sessions. Generally, the more of yourself you are willing to invest, the greater the return.
Furthermore, it is my policy to only see clients who I believe have the capacity to resolve their own problems with my assistance. It is my intention to empower you in your growth process to the degree that you are capable of facing life's challenges in the future without me. I also don't believe in creating dependency or prolonging therapy if the therapeutic intervention does not seem to be helping. If this is the case, I will direct you to other resources that will be of assistance to you. Your personal development is my number one priority. I encourage you to let me know if you feel that terminating therapy or transferring to another therapist is necessary at any time. My goal is to facilitate healing and growth, and I am very committed to helping you in whatever way seems to produce maximum benefit. I truly hope we can talk about any of these decisions. If at any point you are unable to keep your appointments or I don't hear from you for one month, I will need to close your chart. However, as long as I still have space in my schedule, reopening your chart and resuming treatment is always an option.

Confidentiality & Records

Your communications with me will become part of a clinical record of treatment, and it is referred to as Protected Health Information (PHI). The PHI will be stored electronically with Counsol.com, a secure storage company who has signed a HIPAA Business Associate Agreement (BAA). The BAA ensures that they will maintain the confidentiality of the PHI in a HIPAA compatible secure format using point-to-point, Federally approved encryption. Additionally, I will always keep everything you say to me completely confidential, with the following exceptions: (1) you direct me to tell someone else and you sign a "Release of Information" form; (2) I determine that you are a danger to yourself or to others; (3) you report information about the abuse of a child, an elderly person, or a disabled individual who may require protection; or (4) I am ordered by a judge to disclose information. In the latter case, my license does provide me with the ability to uphold what is legally termed "privileged communication." Privileged communication is your right as a client to have a confidential relationship with a therapist. This state has a very good track record in respecting this legal right. If for some unusual reason a judge were to order the disclosure of your private information, this order can be appealed. I cannot guarantee that the appeal will be sustained, but I will do everything in my power to keep what you say confidential. Please note that in couple's counseling, I do not agree to keep secrets. Information revealed in any context may be discussed with either partner.
During professional supervision or consultation with fellow licensed therapists, information may be shared about cases or clients (without revealing names or identity) for the purpose of gaining further perspective and ideas for how to best serve my clients. In the case of my death or major medical incapacitation, all of my records will be accessed by Susan Kerley, LPC, Clinical Director of Marietta Counseling and Roswell Counseling.

Release of Records

Clients or their legal guardians often request that I obtain or provide information to other healthcare or mental health professionals, schools, insurance companies, and other relevant parties. For clients over 18, a signed authorization form must be filled out by the client to allow me to speak to anyone regarding their care, even parents. For children and teens, parents or legal guardians must fill out an authorization form before I can even acknowledge knowing the client.

Pursuant to HIPAA, I keep information about clients in a collection of professional records, known as your clinical record. You may receive a copy of your clinical record if requested in writing. Because these are clinical records, they are easily misinterpreted by untrained readers. For this reason, I recommend reviewing them together within a scheduled session or have them forwarded to another mental health professional so you can discuss the contents. There is an administrative fee of $35 for copying and mailing the record for release.

Initial Interview, Assessment, and Possible Referral

The first appointment is an assessment interview in which your needs and expectations are discussed and a preliminary determination is made as to what services would be most beneficial to you. On occasion, this may require more than one interview. If the services provided by Dr. Kerley do not meet your needs, he will refer you to a more appropriate resource. Full payment is expected at the time of this service.

Structure and Cost of Sessions

I agree to provide psychotherapy for the fee of $225 per 45-50 minute session and $250 for the same length sessions on weekends. This rate and structure also applies to Live Video Sessions. Preparation of summaries of treatment or letters at the request of the client are prorated at session rate based on amount of preparation time needed. Court related services are billed at $250.00 per hour and are applicable to preparation, consultation, waiting at the courthouse, and travel time. School observations and/or meetings are billed at the psychotherapy session rate, including travel time from my office location. While I do provide HIPPA compliant secure email through Counsol.com, I generally do not provide therapy services via email. Unless otherwise stated, emails addressing therapy issues will be filed and addressed during the next scheduled psychotherapy session. Emails that require a response prior to the next psychotherapy session, and are not specifically related to scheduling, are considered Priority Emails, and should include the word PRIORITY in the subject line. Priority Email responses that exceed 10 minutes in duration to read and respond will be billed at $4.50 per minute. Doing psychotherapy by telephone is not ideal, and needing to talk to me between sessions may indicate that you need extra support. If this is the case, you and I will need to explore adding sessions or developing other resources you have available to help you. Telephone calls that exceed 10 minutes in duration will be billed at $4.50 per minute. The fee for each session will be due at the conclusion of the session. Cash, personal checks, Visa, MasterCard, Discover, or American Express are acceptable for payment, and I will provide you with a receipt of payment. The receipt of payment may also be used as a statement for insurance if applicable to you. Please note that there is a $30 fee for any returned checks.
Insurance companies have many rules and requirements specific to certain plans. Unless otherwise negotiated, it is your responsibility to find out your insurance company's policies and to file for insurance reimbursement. I will be glad to provide you with a statement for your insurance company and to assist you with any questions you may have in this area.

Cancellation Policy

In the event that you are unable to keep an appointment, you must notify me at least 24 hours in advance. If such advance notice is not received, you will be financially responsible for the session you missed. If there is a true, unavoidable emergency or if serious or contagious illness, please call me as soon as possible and I will work with you to reschedule within the same week when possible. Please note that insurance companies do not reimburse for missed sessions.

In Case of an Emergency

My practice is considered to be an outpatient facility, and I am set up to accommodate individuals who are reasonably safe and resourceful. I do not carry a beeper nor am I available at all times. If at any time this does not feel like sufficient support, please inform me, and we can discuss additional resources or transfer your case to a therapist or clinic with 24-hour availability. Generally, I will return phone calls within 24-48 hours. If you have a mental health emergency, I encourage you not to wait for a call back, but to do one or more of the following:

- Call Behavioral Health Link/GCAL: 800-715-4225
- Call Ridgeview Institute at 770.434.4567
- Call Peachford Hospital at 770.454.5589
- Call Lifeline at (800) 273-8255 (National Crisis Line)
- Call 911.
- Go to the emergency room of your choice.

Professional Relationship

Psychotherapy is a professional service I will provide to you. Because of the nature of therapy, our relationship has to be different from most relationships. It may differ in how long it lasts, the objectives, or the topics discussed. It must also be limited to only the relationship of therapist and client. If you and I were to interact in any other way, we would then have a "dual relationship," which could prove to be harmful to you in the long run and is, therefore, unethical in the mental health profession. Dual relationships can set up conflicts between the therapist's interests and the client's interests, and then the client's (your) interests might not be put first. In order to offer all of my clients the best care, my judgment needs to be unselfish and purely focused on your needs. This is why your relationship with me must remain professional in nature.
Additionally, there are important differences between therapy and friendship. Friends may see your position only from their personal viewpoints and experiences. Friends may want to find quick and easy solutions to your problems so that they can feel helpful. These short-term solutions may not be in your long-term best interest. Friends do not usually follow up on their advice to see whether it was useful. They may need to have you do what they advise. A therapist offers you choices and helps you choose what is best for you. A therapist helps you learn how to solve problems better and make better decisions. A therapist's responses to your situation are based on tested theories and methods of change.
You should also know that therapists are required to keep the identity of their clients confidential. For your confidentiality, I will not address you in public unless you speak to me first. I must also decline any invitation to attend gatherings with your family or friends. Lastly, when your therapy is completed, I will not be able to be a friend to you like your other friends. In sum, it is my ethical duty as a therapist to always maintain a professional role. Please note that these guidelines are not meant to be discourteous in any way, they are strictly for your long-term protection.

Statement Regarding Ethics, Client Welfare & Safety

I assure you that my services will be rendered in a professional manner consistent with the ethical standards of the American Psychological Association. If at any time you feel that I am not performing in an ethical or professional manner, I ask that you please let me know immediately. If we are unable to resolve your concern, I will provide you with information to contact the professional licensing board that governs my profession.
Due to the very nature of psychotherapy, as much as I would like to guarantee specific results regarding your therapeutic goals, I am unable to do so. However, with your participation, we will work to achieve the best possible results for you. Please also be aware that changes made in therapy may affect other people in your life. For example, an increase in your assertiveness may not always be welcomed by others. It is my intention to help you manage changes in your interpersonal relationships as they arise, but it is important for you to be aware of this possibility nonetheless.
Additionally, at times people find that they feel somewhat worse when they first start therapy before they begin to feel better. This may occur as you begin discussing certain sensitive areas of your life. However, a topic usually isn't sensitive unless it needs attention. Therefore, discovering the discomfort is actually a success. Once you and I are able to target your specific treatment needs and the particular modalities that work the best for you, help is generally on the way.

Technology Statement

In our ever-changing technological society, there are several ways we could potentially communicate and/or follow each other electronically. It is of utmost importance to me that I maintain your confidentiality, respect your boundaries, and ascertain that our relationship remains professional. Therefore, I've developed the following policies:
Cell phones: It is important for you to know that cell phones may not be completely secure or confidential. However, I realize that most people have and utilize a cell phone. I may also use a cell phone to contact you. If this is a problem, please feel free to discuss this with me.
Text Messaging and Nonsecured Email: Both text messaging and emailing are not secure means of communication and may compromise your confidentiality. I realize that many people prefer to text and/or email because it is a quick way to convey information. However, please know that it is my policy to utilize these means of communication strictly for appointment confirmations (nothing that could be inferred as therapy). Please do not bring up any therapeutic content via text or nonsecured email to prevent compromising confidentiality. If you do, please know that I will not respond. However, I do provide email communication via Counsol.com, a secure storage company who has signed a HIPAA Business Associate Agreement (BAA). This email server is fully HIPPA compliant and may be used to discuss therapeutic issues. You also need to know that I am required to keep a summary or a copy of all emails and texts as part of your clinical record that address anything related to therapy.
Facebook, LinkedIn, Instagram, Pinterest, Twitter, Etc: It is my policy not to accept requests from any current or former clients on social networking sites such as Facebook, LinkedIn, Instagram, Pinterest, etc. because it may compromise your confidentiality. I have a professional Facebook page. You are welcome to follow me on any of these pages. However, please do so only if you are comfortable with the general public being aware of the fact that your name is attached to mine. Please refrain from making contact with me using social media messaging systems such as Facebook Messenger or Twitter Direct Message. These methods have insufficient security, and I do not watch them closely. I would not want to miss an important message from you.
Google, Bing, etc.: It is my policy not to search for my clients on Google or any other search engine. I respect your privacy and make it a policy to allow you to share information about yourself to me as you feel appropriate. If there is content on the Internet that you would like to share with me for therapeutic reasons, please print this material, and bring it to your session.
Blog: I may post psychology information on my professional blog. If you have an interest in following my blog, you are welcome to. However, please do so only if you are comfortable with the general public being aware of the fact that your name is attached to mine.
Faxing Medical Records:
If you authorize me (in writing) via a "Release of Information" form to send your medical records or any form of protected health information (PHI) to another entity for any reason, I may need to fax that information to the authorized entity. It is my responsibility to let you know that fax machines may not be a secure form of transmitting information. Additionally, information that has been faxed may also remain in the hard drive of my fax machine. However, my fax machine is kept behind two locks in my office. And, when my fax machine needs to be replaced, I will destroy the hard drive in a manner that makes future access to information on that device inaccessible.
Recommendations to Websites or Applications (Apps):
During the course of treatment, I may recommend that you visit certain websites for pertinent information or self-help. I may also recommend certain apps that could be of assistance to you and enhance your treatment. Please be aware that websites and apps may have tracking devices that allow automated software or other entities to know that you've visited these sites or applications. They may even utilize your information to attempt to sell you other products. Additionally, anyone who has access to the device you used to visit these sites and/or apps, may be able to see that you have been to these sites by viewing the history on your device. Therefore, it is your responsibility to decide and communicate to me if you would like this information as adjunct to treatment or if you prefer that I do not make these recommendations.
Counsol.com Online Counseling Solutions and Practice Management: I provide online counseling services and practice management exclusively through Counsol.com, a secure practice management company who has signed a HIPAA Business Associate Agreement (BAA). The BAA ensures that they will maintain the confidentiality of the PHI in a HIPAA compatible secure format using point-to-point, Federally approved encryption. Counsol.com allows me to not only manage forms and notes with HIPPA compliant levels of security, but also allows increased access to my practice. The following formats can be utilized through Counsol.com:
Secure Email Messaging: Counsol.com allows my practice to send and receive HIPPA compliant secure emails. Clients must login to their secure client site to view their emails rather than having emails being sent to a personal email address. Their secure email system helps prevent any other persons from reading personal information communicated between client and counselor.
Scheduling and Appointment Reminders: Counsol.com allows you to schedule, reschedule, and cancel appointments online. Additionally, you will be able to opt-in for appointment reminders via email, text, or phone.
Secure Live Video Session: Counsol.com provides a HIPPA compliant gateway for live video conferencing. While face-to-face sessions are the ideal method for psychotherapy, video sessions can provide additional access to therapy when clients are unable to make it to the office.
Client Journals: Clients can login to their secure account and write in their personal journal at any time. Client journals are private. The client does have the option to share their journal entries with their therapist through the secured site.
In summary, technology is constantly changing, and there are implications to all of the above that we may not realize at this time. Please feel free to ask questions, and know that I am open to any feelings or thoughts you have about these and other modalities of communication.

Our Agreement to Enter into a Therapeutic Relationship

I am sincerely looking forward to facilitating you on your journey toward healing and growth. If you have any questions about any part of this document, please ask.

Please date, and sign your name below indicating that you have read and understand the contents of this "Information, Authorization and Consent to Treatment". Your signature also indicates that you agree to the policies of your relationship with me.

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

Our Commitment to Your Privacy

Our practice is dedicated to maintaining the privacy of your protected health information. I am required by law to do this and must provide you with this important information. The information presented here is a shorter version of the full, legally required Notice of Privacy Practices (NPP), which is located in the binder in the waiting area. Please refer to the NPP for more information. Also, feel free to take a personal copy from the binder. Since we cannot cover all possible situations, please talk with me about any questions or problems.

I will use the information about your health that I get from you or from others, mainly to provide you or your child with treatment, to arrange payment for services, or for other business activities, which are called in the law “healthcare operations”. After you have read this NPP, I will ask you to sign a consent form to let me use and share this information. If you do not consent and sign, I cannot treat you or your child.

Of course, I will keep your health information private, but there are times when the laws require me to use or share it, such as the following:

1) When there is a serious threat to you or your child’s health and/or safety, or the health and/or safety of another individual and/or the public. I will only share information with a person or organization who is able to help prevent or reduce the threat.
2) Some lawsuits and legal or court proceedings.
3) If a law enforcement official legally requires me to do so.
4) For workers compensation and similar benefit programs.

There are some other situations like these that do not happen very often. They are described in the long version of NPP.

Your Rights Regarding Your Health Information
1) You can ask me to communicate with you about your health and related issues in a particular way or at a certain place. For example, you can ask me to call you at home, and not at work, to schedule or cancel an appointment.
2) You have the right to ask me to limit what I tell certain individuals involved in you or your child’s care, or in the payment of your care, such as family members and friends. While I do not have to agree to your request, if I do agree, I will keep our agreement except if it is against the law or in an emergency, or when the information is necessary to treat you or your child.
3) You have the right to a copy of this notice. If I change this NPP, I will post it in the waiting area and you can always get a copy of the NPP from me.
4) You have a right to file a complaint if you believe your privacy rights have been violated. You can file a complaint with me and with the Secretary of the Department of Health and Human Services. All complaints must be in writing. Filing a complaint will not change the health care I provide to you in any way.
5) If you have any questions regarding this notice or our health information privacy policies, please let me know.

The effective date of this notice is July 1, 2012.

I have received and read the Notice of Privacy Policies.

I have read or had read to me and understand all the information in the above terms. I have had a chance to review and ask questions and have all questions answered to my satisfaction. I agree to abide by all the policies outlined herein. By signing this agreement, I am consenting to treatment and understand all the benefits and risks of counseling. I also hereby acknowledge that I have received the Notice of Privacy Policies.

Every time I schedule an appointment with D. Craig Kerley, Psy.D. (Psychologist), I understand that I am entering into a contract with D. Craig Kerley, Psy.D., LLC (also known as Roswell Counseling for Children and Adults), and for the professional time and services of the therapist. I recognize that professional services are not only provided during my appointment time, but also during the 24 hours prior to my appointment time. I understand that these services include preparation for my scheduled session, case review, case notes, and confidential consultations with other professionals as agreed in writing. I understand therapist's professional fees as outlined. At this time, therapist and I have agreed to the fee for sessions will be $225 for each 45-50 minute session, except on weekends when the rate is $250, and I agree to pay this fee at the time of each session. Cancelled appointments paid in advance are not reimbursable, but any such fees may be credited to your account and applied to future services provided.

I understand the cancellation policy requires 24 hours advance notice in order to be released from the contract for time and services of preparation for my session. I agree that if I fail to cancel my appointment within the 24 hour time frame prior to my session, I will be charged a full session fee for the appointment. I hereby authorize D. Craig Kerley, Psy.D, to charge my credit card if I indeed fail to observe this cancellation policy. I also understand if there is an emergency situation or sudden onset of contagious illness, I can discuss this with Dr. Kerley directly and request a waiver of this policy but I understand Dr. Kerley is not bound to grant that waiver and may by this contract proceed with charging my credit card as agreed herein.