Melissa Hansen, MS, LPC

Training: I received my Bachelor of Arts in Social Work degree from Gordon College in Wenham, MA in 2000. In 2012 I received my Master of Science in Mental Health Counseling degree from Capella University in Minneapolis, MN. I completed a Practicum, Internship, and Residency through Capella in conjunction with VPCC.

General Information About Psychotherapy Services: You have the right to information about the methods of therapy, techniques used, length of therapy when possible, and the fee structure. The process of counseling can raise a variety of difficult emotions. Please be aware that is often a necessary part of healing but you can also talk with me about how to work through those feelings.

You have the right to seek a second opinion and to terminate therapy at any time.

I offer psychotherapy services to individuals, couples, youth, families, and groups. I do not prescribe or dispense medications or offer legal services. I will refer you to other professionals when indicated for your welfare. Few clinical approaches match perfectly with a stated theoretical orientation. My approach fits most consistently with an existential, psychodynamic, pastoral framework. My work encompasses a wide variety of mental health issues and I also pay attention to spiritual concerns. I begin by working with the struggle in the present and often give attention, which is sometimes extensive, to historical relationships that continue to affects styles of relating today.

In a professional relationship, sexual/romantic intimacy between a therapist and client is never appropriate. Dual relationships are also inappropriate and therefore my primary role is that of counselor. This prevents me from any kind of intentional social contact outside the counseling office including any social media or other social contact.

Confidentiality of Client Records: The confidentiality of therapy sessions and client records are protected by State and Federal Law. Generally, the practitioner may not disclose to any person that you are receiving treatment or disclose any information identifying a person as a client unless:

1.       The client consents in writing

2.       The disclosure is permitted by a court order

3.       The disclosure is required to prevent clear and imminent danger to the client or others

4.       I am made aware of potential or actual occurrence(s) of physical or sexual abuse or neglect of minors, disabled persons, or elder abuse

5.       The disclosure is made to medical personnel in a medical emergency or to qualified personnel for research, audit or program evaluation.

Counselors often consult with one another on cases to think through issues and in order to hone their skills and offer the highest quality counseling they can. Any consideration is done confidentially and no identifying information is given.

Please note that confidentiality is less clear in marital and family work and individual confidentiality usually cannot be guaranteed. Please see VPCC Privacy Policy Notice Section 3 for additional information.

Incapacitation or Termination of Practice: As per the ACA Code of Ethics, C.2.h, in the case of my incapacitation due to health or other factors, or in the event of the termination of my clinical practice, the custodian of my records will be C. Alan Melton, DMin., LPC at Valley Pastoral Counseling Center.

Fees: Effective January 1, 2024, fees are as listed unless we have arranged otherwise:

Initial Assessment Sessions - $150 (These sessions can be billed once per year)

Individual sessions that are "hour-long" (53 or more minutes) - $130

Individual sessions that are 45 minutes - $100

Couple/Family sessions that are "hour-long" minutes - $130

Individual 25-minute sessions - $65

Crisis Sessions - $160 (I always charge this for late-evening or weekend sessions)

Self-Pay without use of the Client Assistance Fund - $100

Our agreed upon payment is $____ per session. Payment may be made by check, cash, or credit card. Please make checks payable to VPCC. All fees or co-pays should be made at the time of the session.

A late fee of 2.0% may be assessed on balances over 60 days and accounts older than 120 days will be turned over to a collection agency unless you make alternate arrangements with me. If your account is turned over to a collection agency you will be responsible for all associated fees.

Under certain circumstances additional fees may be assessed for other services rendered, which will include, but are not limited to: Professional consultations, preparation time for court or school appearances, inpatient hospital care and sessions, extended telephone consultations (more than 5 minutes), travel time to and from services rendered outside the office.

Cancellation and Rescheduling Policy: Due to the nature of this work, it is important that you regularly schedule and attend sessions as scheduled. If you need to reschedule your appointment, please call me at least 24 hours in advance at my direct number - 540-932-1471.

If you do not show up or call 24 hours in advance, please be aware that you will be charged a $50 fee.

Some insurance providers do not allow me to charge a late cancel fee. Therefore, after 3 late-cancels or missed appointments, I will no longer be able to continue working with you, as I need to consider my other clients, and will refer you to another provider. Thank you for your understanding and your consideration of my time, of the needs of other clients, and for working with me to attend all sessions as scheduled.

In case of an emergency the following person(s) may be contacted:

_____________________________________________________________________________________

Name                                                                                       Phone                                                  

_____________________________________________________________________________________

Name                                                                                       Phone                                                  

o   I have been given the opportunity to review a copy of the VPCC Notice of Privacy Practices (on display in the waiting room).

o   I have read and understand the cancellation and rescheduling policy

o   I am aware that telemental health services are available and have signed for that if I would like to utilize them.

I have read and understand the information presented in this form and consent to treatment within the aforementioned guidelines:

_____________________________________________________________________________________

Client/Guardian Signature                                                                                              Date

_____________________________________________________________________________________

Therapist Signature                                                                                                        Date

Updated as of 1/1/2024

Melissa Hansen, MS, LPC

Psychotherapy and Counseling Services International, LLC

www.pcsi.securepatientarea.com

Informed Consent for TeleMental Health Services

The following information is provided to clients who are seeking TeleMental health therapy. Please note that you must also read and sign my general informed consent document.

TeleMental Health Defined: TeleMental health means the remote delivery of health care services via technology-assisted media. This includes a wide array of clinical services and various forms of technology. The delivery method must be secured by two-way encryption to be considered secure. Synchronous (at the same time) secure video conferencing is the preferred method of service delivery.

Limitations of TeleMental Health Therapy Services: While TeleMental health offers several advantages such as convenience and flexibility. It is an alternative form of therapy or adjunct to therapy and thus may involve disadvantages and limitations. For example, there may be a disruption to the service (e.g., phone gets cut off or video drops). This can be frustrating and interrupt the normal flow of personal interaction. Primarily, there is a risk of misunderstanding one another when communication lacks visual or auditory cues. As the therapist, I will take every precaution to insure a technologically secure and environmentally private psychotherapy sessions. As the client, you are responsible for finding a private quiet location where the sessions may be conducted. Consider using a "do not disturb" sign/note on the door. The virtual sessions must be conducted on a wifi connection for the best connection and to minimize disruption.

*Please note: There is to be no recording of any teletherapy sessions, or part of a session, by either the psychotherapist or the client.

In Case of Technology Failure: I understand that during a TeleMental health session we could encounter a technological failure. If something occurs to prevent or disrupt any scheduled appointment due to technical complications and the session cannot be completed via online video conferencing, please call the therapist back at: 434.409.0778. Please make sure you have a phone with you, and I have that phone number. We may also reschedule if there are problems with connectivity.

Text and Email: Email is not a secure means of communication and may compromise your confidentiality. Please also refrain from sending text messages. Please send me messages through my secure, two-way encrypted website: pcsi.securepatientarea.com

Structure and Cost of Sessions: I offer face-to-face psychotherapy when appropriate and available. However, based on your ability to make in-person sessions and my availability, I may provide virtual psychotherapy if your treatment needs determine that TeleMental health services are appropriate for you. If appropriate, you may engage in either face-to-face sessions, TeleMental health, or both. We will discuss what is best for you. Please remember that your insurance company may or may not cover therapy via phone or video. We are both responsible for understanding your mental health benefits. Please contact your insurance provider to verify coverage via TeleMental health. The structure and cost of TeleMental health sessions are exactly the same as face-to-face sessions described in my general "Informed Consent" form.

I strongly suggest that you only communicate through a device that you know is safe and technologically secure (e.g., has a firewall, anti-virus software installed, is password protected, not accessing the internet through a public wireless network, etc.). I agree to take full responsibility for the security of any communications or treatment on my own computer or electronic device and in my own physical location. I understand I am solely responsible for maintaining the strict confidentiality of my user ID, password, and/or connectivity link. I shall not allow another person to use my user ID or connectivity link to access the services. I also understand that I am responsible for using this technology in a secure and private location so that others cannot hear my conversation. I understand that there will be no recording of any of the online session and that all information disclosed within sessions and the written records pertaining to those sessions are confidential and may not be revealed to anyone without my written permission, except where disclosure is required by law.

*Please refrain from driving, eating, or drinking during sessions.

In case of an emergency, please write the name and phone number of your local hospital.

1.       Hospital Name and Location:_______________________________________________________

2.       Hospital Telephone Number:_______________________________________________________

Consent to Treatment: I, voluntarily agree to receive telehealth therapy services under the guidelines outlined above.

Signature                                                                                                             Date

Website Instructions:

www.pcsi.securepatientarea.com

Go to the website and select the session.

Click the "Start Video Session" button.

Please be prepared at least 5 minutes prior to our scheduled session and if we are doing a video session be logged in and make sure your video, speaker or headphones and space are set up.

Otherwise, please go to doxy.me/mhansenpcsi