Trailhead Informed Consent and Practice Policies

Informed Consent

 

Therapy Services Risks and Benefits
At Trailhead Treatment Center, we aim to assist you with challenges related to relationships,
addictions, trauma, depression, anxiety, grief, and other emotional issues. Therapy involves
discussing difficult aspects of your life, which can lead to uncomfortable feelings such as
sadness, guilt, shame, anger, or frustration. Your therapeutic journey may impact important
relationships and might lead to healthier ones. The therapy process may help with finding
solutions to problems and reducing feelings of distress, anxiety, and depression. If you have
concerns about your therapy process, discuss them with your therapist or one of Trailhead’s
owners, Jimmy Hill, LPC-MHSP, or Logan Mahan, LCSW.

For all emergencies, call 911.

Termination of Therapy
Therapy is unique to each client. Some issues may be resolved in a short period (10-20
sessions), while others may take longer. You and your therapist will create a treatment plan
and set goals during or after your first visit. Discuss any questions regarding the length of
treatment with your therapist at any point.

Confidentiality
Therapy is best experienced in an atmosphere of trust. Thus, all therapy services are strictly
confidential and may not be revealed to anyone without your written permission. There are
exceptions to confidentiality where disclosure is required by law (explained further ahead).
There may be occasions where your therapist may consult with other clinicians at Trailhead 
in order to discuss aspects of your sessions to best support your process.Because of this, we
ask that you sign a release for all Trailhead Clinicians. If you’re uncomfortable with this,
please let your clinicians know during your intake appointment. Should you desire that your
therapist speak with another professional or person (i.e. doctors, former therapists,, family,
or anyone else outside the therapy room), you must first provide your signed written
consent,  after which your therapist will determine if such communication is in the best
interest of supporting your therapeutic process and progress.

Legal Exceptions to Confidentiality
Confidentiality is fundamental to our practice, but there are legal exceptions to protect your
safety and others. Therapists are mandated reporters and must act if there is a reasonable
suspicion of abuse or a threat of harm. Legal exceptions include:

1. Child Abuse: Reasonable suspicion or reported physical, sexual, or neglect of a minor
(under 18).
2. Elder or Dependent Adult Abuse: Reasonable suspicion or reported abuse or neglect of
an elderly or dependent adult.
3. Suicide:  If you are suicidal, confidentiality may be broken to prevent harm.
4. Threats of Harm to Others: If you threaten to harm others, your therapist will take
necessary steps to prevent harm, including contacting 911 and warning potential victims.
5. Court Orders: If a court mandates the release of records, such as in divorce or custody
hearings, your therapist must comply and may be required to testify truthfully under oath.
These exceptions are in place to ensure safety and comply with legal obligations.

Confidential Electronic Data Storage and Email Transmission
Your confidentiality is paramount. Trailhead Treatment Center securely stores and protects
your clinical information using robust systems, including Simple Practice and Blueprint. 
These applications comply with HIPAA regulations (45 C.F.R., Part 164, Subpart C). If you
choose to communicate Patient Identifiable Information via email correspondence, you are
consenting to the associated email risks. Please note email is not a secure form of
communication, and we cannot guarantee that information transmitted will remain
confidential.

AI-Enhanced Documentation
We leverage artificial intelligence (AI) to enhance our mandated progress note-taking
process. This involves real-time transcription of live audio from therapy sessions,
immediately generating a comprehensive progress note. By utilizing AI to generate
immediate progress notes during sessions, we can improve our ability to capture the most
important details of your therapy sessions, which, in turn, can lead to a therapy experience
that is more comprehensive and accurately tailored to your needs.

Our AI system is deliberately designed to operate in an "air-gapped" environment,
completely isolated from live internet access during our sessions. This choice prioritizes your
confidentiality, safeguarding your personal information from external access.
Crucially, no audio recordings of your sessions are saved. The AI system generates a
progress note from the audio data, after which the audio data is promptly deleted.

​

Practice Policies

Therapy Sessions
Therapy sessions are generally scheduled on a weekly or bi-weekly basis, and are scheduled
in advance. Standard sessions are 53-minutes in length and begin and end on time. Therapy
can be conducted in office or  via telehealth if you are out of town, ill or cannot make it into
the office for any other reason. Please note that, in order to participate in telehealth
appointments, you must physically be located in Tennessee at the time of the appointment.
It is understandable that occasionally you may be late. If you are late to your session, please
understand that the session will not extend past your 53-minutes, nor will the time be made
up at future sessions, as this will impact other clients.

At the start of therapy, your therapist may extend your first few sessions past the 53
minutes. However, unless your therapist chooses to extend this time, we ask that you please
respect your 53-minute session time. If your therapist finds that your session tends to run
longer, they will discuss this in session in order to maintain healthy boundaries around
starting and ending on time.

Non-Discrimination Policy
We respect and welcome people representing a broad diversity of belief systems, sexual
orientations, genders, ethnicities, cultures, neuro-differences and physical disabilities.
While our gender, ethnicity, orientation or spirituality may be different, we are open to
discussing any concerns or questions you may have in working with a therapist who is either
a different race, ethnicity, religion, orientation or gender than you. Having an open
discussion on any of these topics can lead to a greater level of trust and rapport. If you have
any questions regarding your therapist’s therapeutic approach and style or our nondiscrimination policies, please feel free to discuss this with your therapist now and/or in the future.

Court Reports or Letters
Therapists at Trailhead Treatment Center do not recommend clients request legal letters
nor do Trailhead Treatment Center clinicians voluntarily provide legal letters or court
reports for divorce, custody, or other legal matters.

In special circumstances where a court order legally requires a letter, written consent is
needed, and a fee of $35.00 per page plus your therapist’s hourly rate will be charged.

We do not recommend requesting clinical letters if you are involved in a lawsuit, as it places
us in a dual role, crossing therapeutic boundaries. Involving your mental health in legal
proceedings may not be advisable as it could compromise your confidentiality, and clinical
files may be requested. Additionally, therapists must speak honestly if under oath and will
not act as your advocate in court.

You acknowledge that if your therapist is subpoenaed or court-ordered, your therapist has
permission to consult their legal counsel and share the necessary client information to
respond to the subpoena or court order.

Court Fees
If your therapist's participation is required in your legal proceedings, you must cover the
cost of all the associated professional time by your therapist, including preparation and
travel, even if your therapist is called to testify by another party connected to you. The rate
is $250 per hour for time out of practice, preparation, travel, and court attendance.

A $1000 retainer is due two weeks before the hearing and is refundable only if the hearing is
canceled at least one week in advance. If other client sessions must be canceled due to the
legal proceedings, you will be billed for those sessions at their regular rates.

Court fees can be very expensive. By signing this document, you acknowledge your financial
responsibility for these expenses if your therapist is mandated to attend court for your legal
issue. Note that a therapist is required to speak truthfully under oath and is not a court
advocate or friend.

Healthcare/Managed Care Insurance Policy
In order for the therapist to be reimbursed by an insurance company, a diagnosis must be
made and submitted to the insurance carrier. Sometimes information on the presenting
problem and symptoms the client is experiencing from the client’s private therapy records
are also required by the insurance company. This information once released becomes part
of the client’s medical records and may impact confidentiality. Please note that it is at the
discretion of each therapist at Trailhead Treatment Center whether or not to choose to work
with Managed Care Health Insurance programs  Some Trailhead Treatment Center
therapists may be on certain insurance panels, and others are not.

If your therapist is not paneled with your insurance program, we are glad to provide a
superbill receipt on a monthly basis that you may submit to your insurance company if you
wish to seek out-of-network reimbursement. However, Trailhead Treatment Center will not
fill out forms or work directly with or on your behalf with your insurance company for
insurance reimbursements.

Additionally, it is important that you also understand that there is no guarantee that your
insurance company will cover your therapy sessions. We ask that clients carefully consider
this before we begin our work together. If you choose to work with Trailhead Treatment
Center therapists, our policy is a fee-for-service policy as described in the following section.
You understand and agree to respect this policy around health insurance, and will honor
this agreement now and in the future.

Payment
Therapy sessions are paid via credit or debit card and are automatically charged the evening
of the appointment. Please fill out the credit card form included in this packet. This
information is stored securely and is password protected. Some clients prefer to pay by cash
for confidential reasons. Please bring the exact cash amount for your session fee.
We can make arrangements to bill a third party after we have confirmed the agreement with
the billing party you’ve listed. If payment from the third party is not received, you will be
responsible for your balance and any fees that are applied.

We do not “carry over” session payments from week to week, or extend credit as this could
constitute as an unethical “debtor/creditor” dual relationship and ultimately impact the
therapeutic relationship.

If your account becomes past due, your therapist may need to temporarily postpone future
sessions until your balance has been paid.  If this happens, your therapist will work with you
to identify a plan for repayment or continued treatment with another provider.

Release for Third-Party Payers
If your therapy services are being paid for by a third party such as a parent, employer or
religious organization, you are required to sign a limited release of your presence in
treatment for that third party. This release allows us to send the third-party invoices
reflecting the amount charged, the service rendered, and any charges for late cancels, late reschedules, or no-shows. The third-party payer will also be sent a copy of your signed agreement to our payment policy.

Fee Increases
Fees are reviewed each year, and may increase periodically. Every consideration to a client’s
current finances will be made. The increase will be discussed with the client, and a 30-day
notice will be given prior to the increase. Please understand that you have the right to
terminate therapy at any point.

Cancellation Policy
To cancel or reschedule an appointment, please notify us at least one full business day
(24 hours) in advance, during customer support hours or by using the client portal. For
Monday appointments, cancellation must occur by the preceding Friday. Late cancellations
(less than one business day) and no-shows will incur the full session fee, charged on the
morning of the missed session.

You can manage appointments through the secure Client Portal, which provides reminders
for upcoming sessions. However, keeping track of and attending appointments is ultimately
your responsibility.

For clients using insurance or third-party payers, any late cancellations or no-shows will be
billed at the therapist’s full amount for the session directly to the card on file. For further
information about this, refer to the Payment Agreement.

Clients on reduced or scholarship rates will be charged the negotiated rate for no-shows.

Repeated no-shows or late cancellations may result in dismissal from the clinician’s
caseload, with three referrals provided.

If your schedule can no longer accommodate your recurring appointment time, please
discuss this with your therapist. We will try to find an alternative time of the week or utilize
virtual sessions to accommodate.

Continual cancellations, frequent reschedules, no-shows, or late payments will prompt a
discussion with your therapist. If the issue persists despite exploring other options, we may
need to release your reserved recurring appointment time and move you to the waitlist. If
you prefer not to be on the waitlist, we can provide three therapy referrals and/or terminate
services.

Bad Weather
For instances of weather preventing you from attending your appointment in person, we ask
that you meet with your therapist virtually via video conference. Missed appointments that
have not been canceled or rescheduled more than 24 business hours before the time of the
scheduled session will be charged the full amount on the day of the session.

Professional Boundaries Policy
While the therapeutic relationship includes a mutual sense of friendliness and care, it
remains a professional one with solid boundaries intended to help keep you, the client, safe.
It is unethical for a therapist to invite you into business ventures, ask for personal favors, or
engage in a social, romantic, or sexual relationship with you. These "dual relationships"
can negatively impact the therapeutic relationship, but client confidentiality at risk, and
cause psychological harm.

In order to further protect your confidentiality and the therapeutic relationship, your
therapist may not acknowledge you or your relationship to them, if you see each other in
public. In such an event, your therapist will be discreet, maintain confidentiality, and follow
your lead as to whether or not to acknowledge the encounter. If you choose not to, your
therapist will respect your decision.

Health Policy
To maintain a safe and healthy environment, we ask that clients who are ill conduct their
sessions via telehealth until fully recovered. This includes any stage of illness, such as flu or
COVID symptoms, colds, pink eye, contagious rashes, scabies, lice, chicken pox, or any other
potentially contagious illnesses, no matter how mild.

Please inform a Trailhead Treatment Center representative or your therapist if you are ill
and reschedule your session or switch to a telehealth session. Your therapist will do the
same if they are unwell.

For couples therapy, please cancel in advance or request the appointment be switched to telehealth if either partner is ill.