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Terms and Policy

Practice Polices, Counseling Agreement and Informed Consent

Entering into Counseling: Welcome to my private practice; I am happy to be given the opportunity to work with you. Whether your unique challenges come from loss, trauma, internal conflict, and relationship conflict, career or life transitions, counseling offers a safe place to begin to explore and heal these issues. I strive to develop a collaborative counseling relationship with you that is governed by respect and adherence to professional ethics and standards. Participating in psychotherapy can result in various benefits to you, including: developing personal insight; reducing emotional distress; increasing your capacity for intimacy; and resolving other specific concerns. Psychotherapy can have risks as well. During the course of therapy you may experience uncomfortable feelings or you may experience unexpected consequences. Psychotherapy requires openness and your active involvement. You are encouraged to give me feedback and input about the course of your therapy as it proceeds. Hopefully our work together will help to minimize your overall distress, you will gain insight, and learn more effective coping skills and problem-solving strategies, which will open up new possibilities for personal growth and change. If during our work together I decide that I am not able to help you reach your counseling goals, I will talk with you about my concerns and possibly develop a plan for terminating our work together and referring you to another counselor.

Confidentiality: Our counseling relationship, as well as the storage and disposal of records, will be kept confidential within legal and ethical limitations. Professional ethics practices outlined by the professional licensing board, federal and state law, insurance, and managed care companies require me to maintain clinical records and to safeguard them. Your clear consent, generally signed and written, is necessary for me to discuss your case or to release records. If you would like me to confer with another healthcare professional, you will need to sign a "release of information" form. You can revoke this permission at any time.

I may find it helpful to consult with other mental health professionals about your case. During a consultation, I make every effort to protect your identity. If you choose to file insurance claims, the company will require a diagnosis and may ask for additional treatment details.

Everything discussed in our sessions is strictly confidential. Information may be released without your written consent in the following circumstances:

1. You indicate that there is a serious danger of hurting yourself or another identified victim.

2. If I suspect or have been informed that child abuse or neglect has occurred, I will file a report with Child Protective Services. If I suspect or have been informed that abuse or neglect of an elderly or disabled adult has occurred, I will file a report with Adult Protective Services.
3. You are under the age of 16 and have been sexually or physically abused, raped, or the victim of another crime.
4. The information is ordered by a court subpoena or parole officer.
5. You require hospitalization.

If I am working with family members who are present in sessions with me, or when working with partners in couple's therapy, information shared with me by one family member is not necessarily confidential from others in treatment unless so discussed and specified.

Parental Disclosure:
When working with adolescents younger than age 18, parents have a legal right to know the nature of the therapeutic work. However, in order for treatment to be effective, like adults, teenage clients need to feel a sense of trust, safety, and confidentiality within the therapeutic relationship. Therefore, by and large, therapy is strictly between the client and the therapist. I encourage parents to participate in the treatment planning and I will invite parents into sessions from time to time. I primarily work to help the adolescent to relate necessary or pertinent information to parents (both in and outside of sessions). If I believe an adolescent is at risk, I will work with this client to help him/her to inform parents in an appropriate and timely manner. In the event that risky information is not being communicated from adolescent to parent, then I will directly communicate this to parents.

Services and Fees: Our counseling sessions will generally last for 55 minutes unless otherwise arranged. The initial intake session fee is $160. The cost for the following 50-minute individual psychotherapy sessions is currently $140. While there is not a charge for check-in by phone, there is a charge for extended telephone consultations at my discretion. Payment will be collected at the end of each session, and you may pay by cash, check or credit card. Checks should be made payable to Heather McMillen, LPC. Receipts are available on the patient portal. The patient portal can also store your credit card for easy payment each week. Your signature on this form is an agreement for charging your appointment and no-show fees to that card.

The $140 hourly fee is applied to other professional services such as consultations with other professionals (when requested and authorized by you), writing reports, preparation of records and treatment summaries.

Preparation time for letters or court documents will be charged at my hourly rate of $140. Please know that I do not go willingly to court. However, if I am subpoenaed and must appear, my fees for court appearances (including depositions) are $1500 per day, due 10 days prior to court (this includes travel, preparation time and missed work hours). If court is cancelled with a five-day notice, $750 will be refunded.

Health Insurance Plan Participation: I am not in network with insurance companies. Receipts are available on the patient portal with all the necessary information for you to obtain payment from your insurance company directly.

No-Show and Cancellation Policy: Your appointment hour is reserved exclusively for you. Please notify me as soon as possible if you do not expect to attend your appointment. I require a 24-hour notice of cancellation excluding unforeseen circumstances. Monday appointments should be canceled no later than the previous Friday. Appointments missed or cancelled with less than 24 hours notice will be charged for the full session fee. Please note that health insurance companies do not reimburse for missed sessions and you are responsible for the full fee for that missed session. Clients with a card on file will be charged the session fee at the time of the late cancellation or no show.

Telephone and Email Procedures: I check my messages regularly Monday through Friday and will return your call as soon as possible. You may email or text for scheduling issues only.  Please be aware that any communication by email or text is not considered private. The most secure form of communication is the online messaging system through

Emergencies: In the event of a psychiatric emergency, I very much would want to hear from you. you are unable to reach me, you should call a local Mental Health Hotline or the police (911) or go to the nearest Emergency Room of your nearest hospital. Hotline numbers include 202-673-9300 (Washington, D.C.), 703-573-5679 (Fairfax County), and 703-228-4256 (Arlington County).

Do not use email to inform me of an emergency. In the event of a planned extended absence (e.g., vacation), I may arrange backup clinical coverage.


I look forward to working with you and I hope that you find our professional relationship to be supportive and enriching. Please feel free to discuss any questions or concerns you have with me at any time during our counseling sessions and professional relationship.

Your signature below indicates that you have read, understood, had the opportunity to ask questions, and you agree to the above conditions and policies.

( Type Full Name )
Heather McMillen, LPC
Licensed Professional Counselor

Notice of Therapists' Policies and Practices to Protect the Privacy of
Your Health Information


I. Uses and Disclosures for Treatment, Payment, and Health Care Operations

I may use or disclose your protected health information (PHI), for treatment, payment, and health care operations purposes with your consent. To help clarify these terms, here are some definitions:

• "PHI" refers to information in your health record that could identify you.

• "Treatment, Payment and Health Care Operations" Treatment is when I provide, coordinate or manage your health care and other services related to your health care. An example of treatment would be when I consult with another health care provider, such as your family physician or another therapist. Payment is when I obtain reimbursement for your healthcare. Examples of payment are when I disclose your PHI to your health insurer to obtain reimbursement for your health care or to determine eligibility or coverage. Health Care Operations are activities that relate to the performance and operation of my practice. Examples of health care operations are quality assessment and improvement activities, business related matters such as audits and administrative services, and case management and care coordination.

• "Use" applies only to activities within my [office, clinic, practice group, etc.] such as sharing, employing, applying, utilizing, examining, and analyzing information that identifies you.

• "Disclosure" applies to activities outside of my [office, clinic, practice group, etc.], such as releasing, transferring, or providing access to information about you to other parties.

II. Uses and Disclosures Requiring, Authorization

I may use or disclose PHI for purposes outside of treatment, payment, and health care operations when your appropriate authorization is obtained. An "authorization" is written permission above and beyond the general consent that permits only specific disclosures. In those instances when I am asked for information for purposes outside of treatment, payment and health care operations, I will obtain an authorization from you before releasing this information. I will also need to obtain an authorization before releasing your psychotherapy notes. "Psychotherapy notes" are notes I have made about our conversation during a private, group, joint, or family counseling session, which I have kept separate from the rest of your medical record. These notes are given a greater degree of protection than PHI.

You may revoke all such authorizations (of PHI or psychotherapy notes) at any time, provided each revocation is in writing. You may not revoke an authorization to the extent that (1) 1 have relied on that authorization; or (2) if the authorization was obtained as a condition of obtaining insurance coverage, and the law provides the insurer the right to contest the claim under the policy.

III. Uses and Disclosures with Neither Consent nor Authorization

I may use or disclose PHI without your consent or authorization in the following circumstances:

• Child Abuse: If I have reason to suspect that a child is abused or neglected, I am required by law to report the matter immediately to the Virginia Department of Social Services.

• Adult and Domestic Abuse: If I have reason to suspect that an adult is abused, neglected or exploited, I am required by law to immediately make a report and provide relevant information to the Virginia Department of Social Services.

• Health Oversight: The Virginia Board of Counseling has the power, when necessary, to subpoena relevant records should I be the focus of an inquiry.

• Judicial or Administrative Proceedings: If you are involved in a court proceeding and a request is made for information about your diagnosis and treatment and the records thereof, such information is privileged under state law, and I will not release information without the written authorization of you or your legal representative, or a subpoena (of which you have been served, along with the proper notice required by state law). However, if you move to quash (block) the subpoena, I am required to place said records in a sealed envelope and provide them to the clerk of court of the appropriate jurisdiction so that the court can determine whether the records should be released. The privilege does not apply when you are being evaluated for a third party or where the evaluation is court ordered. You will be informed in advance if this is the case.

• Serious Threat to Health or Safety: If I am engaged in my professional duties and you communicate to me a specific and immediate threat to cause serious bodily injury or death, to an identified or to an identifiable person, and I believe you have the intent and ability to carry out that threat immediately or imminently, I must take steps to protect third parties. These precautions may include (1) warning the potential victim(s), or the parent or guardian of the potential victim(s), if under 18; or (2) notifying a law enforcement officer.

• Worker's Compensation: If you file a worker's compensation claim, I am required by law, upon request, to submit your relevant mental health information to you, your employer, the insurer, or a certified rehabilitation provider.

IV. Patient's Rights and Psychologist's Duties

Patient's Rights:

• Right to Request Restrictions You have the right to request restrictions on certain uses and disclosures of protected health information about you. However, I am not required to agree to a restriction you request.

• Right to Receive Confidential Communications by Alternative Means and at Alternative Locations You have the right to request and receive confidential communications of PHI by alternative means and at alternative locations. (For example, you may not want a family member to know that you are seeing me. Upon your request, I will send your bills to another address.)

• Right to Inspect and Copy You have the right to inspect or obtain a copy (or both) of PHI and psychotherapy notes in my mental health and billing records used to make decisions about you for as long as the PHI is maintained in the record. I may deny your access to PHI under certain circumstances, but in some cases you may have this decision reviewed. On your request, I will discuss with you the details of the request and denial process.

• Right to Amend You have the right to request an amendment of PHI for as long as the PHI is maintained in the record. I may deny your request. On your request, I will discuss with you the details of the amendment process.

• Right to an Accounting You generally have the right to receive an accounting of disclosures of PHI for which you have neither provided consent nor authorization (as described in Section III of this Notice). On your request, I will discuss with you the details of the accounting process.

• Right to a Paper Copy You have the right to obtain a paper copy of the notice from me upon request, even if you have agreed to receive the notice electronically.

Counselor 's Duties

• I am required by law to maintain the privacy of PHI and to provide you with a notice of my legal and privacy practices with respect to PHI

• I reserve the right to change the privacy policies and practices described in this notice. Unless I notify you of such changes, however, I am required to abide by the terms currently in effect.

• If I revise my policies and procedures, I will inform you by mail.

V. Complaints

If you are concerned that I have violated your privacy rights or you disagree with a
decision I made about access to your records you may contact the Board of Professional Counselors in Richmond Virginia.

You may also send a written complaint to the Secretary of the US Department Of Health and Human Services. The person listed above can provide you with the appropriate address upon request.

Effective Date, Restrictions and Changes to Privacy Policy

This notice will go into effect on April 14, 2003.
( Type Full Name )