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Please complete the following information in order to register for Kiley Counseling and Consulting.

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Terms and Policy

SOCIAL MEDIA POLICY

Kiley Consulting and Counseling's  Private Practice Social Media Policy

This document outlines Kiley Consulting and Counseling's policies related to use of Social Media. Please read it to understand how we conduct ourselves on the Internet as a mental health professional and how you can expect us to respond to various interactions that may occur between us on the Internet. If you have any questions about anything within this document, I encourage you to bring them up when we meet. As new technology develops and the Internet changes, there may be times when we need to update this policy.  Such updates will be made available to you on my website.

FRIENDING

I do not accept friend or contact requests from current or former clients on any social networking site (Facebook, Instagram, Twitter, LinkedIn, etc). I believe that adding clients as friends or contacts on these sites can compromise your confidentiality and our respective privacy. It may also blur the boundaries of our therapeutic relationship. If you have questions about this, please bring them up when we meet and we can talk more about it.

FANNING

I may keep a Facebook Page for my professional practice to allow people to share my blog posts and practice updates with other Facebook users. You are welcome to view my Facebook Page and read or share articles posted there, but I do not accept clients as Fans of this Page. I believe having clients as Facebook Fans creates a greater likelihood of compromised client confidentiality and I feel it is best to be explicit to all who may view my list of Fans to know that they will not find client names on that list. Note that you should be able to subscribe to the page via RSS without becoming a Fan and without creating a visible, public link to my Page. You are more than welcome to do this.

FOLLOWING

I may publish a blog on my website or elsewhere online.  I may use other social media sites to share information related to my professional field and practice. I have no expectation that you as a client will want to follow my blog or postings. However, if you use an easily recognizable name on such an account and I happen to notice that you've followed me there, we may briefly discuss it and its potential impact on our working relationship. My primary concern is your privacy. If you share this concern, there are more private ways to follow me online(such as using an RSS feed or a locked Twitter list), which would eliminate your having a public link to my content. You are welcome to use your own discretion in choosing whether to follow me. Note that I will not follow you back. My reasoning is that I believe casual viewing of clients' online content outside of the therapy hour can create confusion in regard to whether it's being done as a part of your treatment or to satisfy my personal curiosity. In addition, viewing your online activities without your consent and without our explicit arrangement towards a specific purpose could potentially have a negative influence on our working relationship. If there are things from your online life that you wish to share with me, please bring them into our sessions where we can view and explore them together, during the therapy appointment.

TEXTING and ONLINE MESSAGING

Please do not use texting or messaging on Social Networking sites such as Twitter, Facebook, or LinkedIn to contact me. These sites are not secure and I may not read these messages in a timely fashion. Do not use Wall postings, @replies, or other means of engaging with me in public online if we have an already established client/therapist relationship. Engaging with me this way could compromise your confidentiality. It may also create the possibility that these exchanges become a part of your legal medical record and will need to be documented and archived in your chart. If you need to contact me between sessions, the best way to do so is by phone or email. Direct email is also a great option for quick, administrative issues such as changing appointment times. See the email section below for more information regarding email interactions.

USE OF SEARCH ENGINES

It is NOT a regular part of my practice to search for clients on Google or Facebook or other search engines. Extremely rare exceptions may be made during times of crisis. If I have a reason to suspect that you are in danger and you have not been in touch with me via our usual means (coming to appointments, phone, or email) there might be an instance in which using a search engine (to find you, find someone close to you, or to check on your recent status updates / check-ins) becomes necessary as part of ensuring your welfare. These are unusual situations and if I ever resort to such means, I will fully document it and discuss it with you when we next meet.  Such searches would be used only as a last resort after exhausting other known options, including your emergency contact person.

GOOGLE READER

I do not follow current or former clients on Google Reader and I do not use Google Reader to share articles. If there are things you want to share with me that you feel are relevant to your treatment whether they are news items or things you have created, I encourage you to bring these items of interest into our sessions.

BUSINESS REVIEW SITES

You may find my practice on sites such as Yelp, Healthgrades, Yahoo Local, Bing, or other places which list businesses. Some of these sites include forums in which users rate their providers and add reviews. Many of these sites comb search engines for business listings and automatically add listings regardless of whether the business has added itself to the site. If you should find my listing on any of these sites, please know that my listing is NOT a request for a testimonial, rating, or endorsement from you as my client. Of course, you have a right to express yourself on any site you wish. But due to confidentiality, I cannot respond to any review on any of these sites whether it is positive or negative. I urge you to take your own privacy as seriously as I take my commitment of confidentiality to you. You should also be aware that if you are using these sites to communicate indirectly with me about your feelings about our work, there is a good possibility that I may never see it. If we are working together, I hope that you will bring your feelings and reactions to our work directly into the therapy process. This can be an important part of therapy, even if you decide we are not a good fit. None of this is meant to keep you from sharing that you are in therapy with me wherever and with whomever you like. Confidentiality means that I cannot tell people that you are my client and my Ethics Code prohibits me from requesting testimonials. But you are more than welcome to tell anyone you wish that I'm your therapist or how you feel about the treatment I provided to you, in any forum of your choosing. If you do choose to write something on a business review site, I hope you will keep in mind that you may be sharing personally revealing information in a public forum. I urge you to create a pseudonym that is not linked to your regular email address or friend networks for your own privacy and protection. If you feel I have done something harmful or unethical and you do not feel comfortable discussing it with me, you can always contact the US Department of Health and Human Services 200 Independence Avenue S.W., Washington, D.C. 20201.

LOCATION-BASED SERVICES

If you used location-based services on your mobile phone, you may wish to be aware of the privacy issues related to using these services. I do not place my practice as a check-in location on various sites such as Foursquare, Gowalla, Loopt, etc. However, if you have GPS tracking enabled on your device, it is possible that others may surmise that you are a therapy client due to regular check-ins at my office on a weekly basis. Please be aware of this risk if you are intentionally "checking in," from my office or if you have a passive LBS app enabled on your phone.

EMAIL

To arrange or modify appointments please contact me through the portal or via: KileyCC2020@gmailcom. Please be aware that if you email me content related to your therapy sessions, email is not completely secure or confidential. If you choose to communicate with me by email, be aware that all emails are retained in the logs of your and my Internet service providers. While it is unlikely that someone will be looking at these logs, they are, in theory, available to be read by the system administrator(s) of the Internet service provider. You should also know that any emails I receive from you and any responses that I send to you become a part of your legal record.  You can email me securely by logging into your account on the patient log in link to the electronic medical record system on my webpage. 

CONCLUSION

Thank you for taking the time to review my Social Media Policy. If you have questions or concerns about any of these policies and procedures or regarding our potential interactions on the Internet, do bring them to my attention so that we can discuss them.

In summary, if you wish to contact me, please call the office at (317)663-9802 or email me at the appropriate email address listed above.  Any other attempts to contact me online or via texting will receive no response.  Thank you.


****This form's original author is Keely Kolmes, Psy.D. and has been modified to address specific matters related to Kiley Consulting and Counseling***

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COVID 19 Policy and Procedure

Kiley Consulting and Counseling COVID 19 Policies and Practice

INFORMED CONSENT FOR IN-PERSON SERVICES DURING COVID-19 PUBLIC HEALTH CRISIS


This document contains important information about our decision (yours and mine) to resume in-person services in light of the COVID-19 public health crisis. Please read this carefully and let me know if you have any questions. When you sign this document, it will be an official agreement between us.

Decision to Meet Face-to-Face

We have agreed to meet in person for some or all future sessions. If there is a resurgence of the pandemic or if other health concerns arise, however, I may require that we meet via telehealth. If you have concerns about meeting through telehealth, we will talk about it first and try to address any issues. You understand that, if I believe it is necessary, I may determine that we return to telehealth for everyone's well-being.

If you decide at any time that you would feel safer staying with, or returning to, telehealth services, I will respect that decision, as long as it is feasible and clinically appropriate.Reimbursement for telehealth services, however, is also determined by the insurance companies and applicable law, so that is an issue we may also need to discuss.

Risks of Opting for In-Person Services

You understand that by coming to the office, you are assuming the risk of exposure to the coronavirus (or other public health risk). This risk may increase if you travel by public transportation, cab, or ridesharing service.

Your Responsibility to Minimize Your Exposure

To obtain services in person, you agree to take certain precautions which will help keep everyone (you, me, and our families, [my other staff] and other patients) safer from exposure, sickness and possible death. If you do not adhere to these safeguards, it may result in our starting / returning to a telehealth arrangement.

You agree to the following prevention actions steps:

         You will only keep your in-person appointment if you are symptom free.

         You will take your temperature before coming to each appointment. If it is elevated (100 Fahrenheit or more), or if you have other symptoms of the coronavirus, you agree to cancel the appointment or proceed using telehealth.  If you wish to cancel for this reason, there will be no charge for late cancellation fee.

         You will wait in your car or outside in the waiting area until I text that it is time to come in.

         You will wash your hands or use alcohol-based hand sanitizer when you enter the building.

         You will adhere to the safe distancing precautions we have set up in the waiting room and testing/therapy room. For example, you won't move chairs or sit where we have signs asking you not to sit.

         You will wear a mask in all areas of the office (I [and my staff] will too).

         You will keep a distance of 6 feet and there will be no physical contact (e.g. no shaking hands) with me [or staff].

         You will try not to touch your face or eyes with your hands. If you do, you will immediately wash or sanitize your hands.

         If you are bringing your child, you will make sure that your child follows all of these sanitation and distancing protocols.

         You will take steps between appointments to minimize your exposure to COVID.

         If you have a job that exposes you to other people who are infected, you will immediately let me [and my staff] know.

         If your commute or other responsibilities or activities put you in close contact with others (beyond your family), you will let me [and my staff] know.

         If a resident of your home tests positive for the infection, you will immediately let me [and my staff] know and we will then [begin] resume treatment via telehealth.

I may change the above precautions if additional local, state or federal orders or guidelines are published. If that happens, we will talk about any necessary changes.

My Commitment to Minimize Exposure

My practice has taken steps to reduce the risk of spreading the coronavirus within the office. We will clean between clients and provide, masks, face shields and gloves during sessions. We will ask all clients to sign and agree with the practice protocols of Kiley Consulting and Counseling.

Please let me know if you have questions about these efforts.

 Minimizing Exposure During Play Therapy:

         Clients are required to wear masks or face shields.

         Clients will be required to hand sanitize in the playroom.

         Toys will be removed and cleaned after one client use for protection of others.

         Youth clients will have a limit of toys available to them during COVID 19 in office sessions.

         It is likely not possible to remain at a social distance of 6 feet through the entire play session, parents understand and will make every effort to maintain best practice for prevention in other environments.

         If children exhibit symptoms (fever, sore throat, cough, etc) or are ill they should remain at home.

         Teleplay sessions are available

If You or I Are Sick

You understand that I am committed to keeping you, me, [my staff] and all of our families safe from the spread of this virus. If you show up for an appointment and I [or my office staff] believe that you have a fever or other symptoms, or believe you have been exposed, I will have to require you to leave the office immediately. We can follow up with services by telehealth as appropriate.

If I [or my staff] test positive for the coronavirus, I will notify you so that you can take appropriate precautions.

Your Confidentiality in the Case of Infection

If you have tested positive for the coronavirus, I may be required to notify local health authorities that you have been in the office. If I have to report this, I will only provide the minimum information necessary for their data collection and will not go into any details about the reason(s) for our visits.  By signing this form, you are agreeing that I may do so without an additional signed release.

Informed Consent

This agreement supplements the general informed consent/business agreement that we agreed to at the start of our work together.

Your signature below shows that you agree that you understand the risks of possible transmission of illness during in- office visits and accept these terms and conditions.

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Patient/Client                                                                          Date

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Therapist                                                                     Date


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