Professional Disclosure Statement
Professional Disclosure Statement
Maggie Malone, LCSW
Rosebud Psychotherapy, LLC
Practice Mailing Address: 316 Alexander St SE, Marietta, GA
404-919-9723
mmalone@rosebudpsychotherapy.com
rosebudpsychotherapy.com
I only provide telehealth mental health therapy services to residents of Georgia. You must be physically located in the state where I am licensed.
General Information: The therapeutic relationship is unique in that it is highly personal and at the same time, a contractual agreement. Given this, it is important for us to reach a clear understanding of how our relationship will work, and what each of us can expect. This consent will provide a clear framework for our work together. Feel free to discuss any of this with me.
About the therapist: I am a licensed clinical social worker (CSW007586) in Georgia. I provide individual therapy, premarital couples counseling and group therapy online via secure telehealth platforms and in-person at my office. I own and operate Rosebud Psychotherapy, a mental health practice.
Philosophy and Approach: I believe counseling is an important part of self-development. I work from a person-centered, strengths-based, and trauma-informed lens utilizing cognitive-behavioral and psychodynamic strategies to help facilitate growth. I also work from an anti-oppressive, feminist lens.
Education: I have a B.S. Psychology from University of Georgia in Athens, GA, and a M.S.W. from Smith College School for Clinical Social Work in Northampton, MA. I also regularly engage in continuing education, largely focused on trauma education, group psychotherapy, acceptance and commitment therapy, dialectical behavior therapy, women’s mental and physical health, addiction, somatic modalities, anti-oppression and anti-racism work, and more.
I am licensed/registered to practice by the state of Georgia. I abide by the Code of Ethics in this state. To maintain my license I am required to participate in continuing education, taking classes dealing with subjects relevant to this profession.
Good Faith Estimate: As of January 1, 2022, state-licensed or certified health care providers need to give a Good Faith Estimate of healthcare charges to every new and continuing client who is either uninsured or is not planning to submit a claim to their insurance for the healthcare services they seek.
You have the right to receive a “Good Faith Estimate” explaining how much your medical and mental health care will cost. Under the law, health care providers need to give patients who don’t have insurance or who are not using insurance an estimate of the expected charges for medical services, including psychotherapy services. You have the right to receive a Good Faith Estimate for the total expected cost of any non-emergency healthcare services, including psychotherapy services. You can ask your health care provider, and any other provider you choose, for a Good Faith Estimate before you schedule a service. If you receive a bill that is at least $400 more than your Good Faith Estimate, you can dispute the bill. Make sure to save a copy or picture of your Good Faith Estimate.
This Good Faith Estimate doesn’t account for late cancellations, no-show fees, crisis sessions, non-therapeutic charges, case management fees, court litigation fees, or other financial arrangements determined on a case by case form. See practice policies disclosure form.
For questions or more information about your right to a Good Faith Estimate, visit www.cms.gov/nosurprises. The below information will help you estimate your treatment costs.
Appointments and cancellations: A credit/debit card is required to reserve appointments. It is your responsibility to make sure your card is up-to-date, and funds are available.
Please remember to cancel or reschedule 48 hours in advance. You will be responsible for the entire fee if cancellation is less than 48 hours.
The standard meeting time for individual psychotherapy is 50 minutes. It is up to you, however, to determine the length of time of your sessions. Requests to change the 50-minute session needs to be discussed with the therapist in order for time to be scheduled in advance. For group psychotherapy, the meeting time is typically between 1 - 3 hours, depending on the format and intent of the group. Premarital or Precommitment couples counseling is usually between 60-90 minutes for standard sessions.
Cancellations and re-scheduled sessions will be subject to a full charge if NOT RECEIVED AT LEAST 48 HOURS IN ADVANCE. This is necessary because a time commitment is made to you and is held exclusively for you. If you are running late for a session, please notify me immediately through the patient portal. I will only hold your appointment for 15 minutes. After 15 minutes, you will be required to reschedule, and you will be charged the full fee for late cancellation/no-show. All cancellations must be done through Simple Practice. I am not guaranteed to receive emails or voice messages in time.
At the time of your initial appointment, a recurring spot may be reserved for you. Should you decline the recurring appointment, you will be responsible for scheduling as needed. If you do not schedule within a two-month period, your chart will be moved to inactive, and you will be notified that you will need to complete a new intake process to reestablish care.
If you cancel multiple recurring appointments, your reserved spot will be removed until we speak further about your scheduling needs.
Billing: Your card on file will be charged within 24 hours of your appointment. Please ensure you have sufficient funds to cover your session. If the session is not paid by the time of your appointment, you will be expected to come to the session with full payment before treatment begins.
Fees: The standard 50 min session fee is $190, and group therapy is between $52-80 per group, depending on group. If you are engaging in premarital or precommitment work with a partner, the rate ranges from $215-250 for sessions between 50-90 minutes. I do offer a small number of reduced-fee appointments on a first-come, first-serve basis. If you are in need of a reduced fee application, please notify me during our intake appointment or when the need arises. Initial sessions are charged at $190, and all clients must pay this fee prior to negotiating a reduced fee. Reduced rates are available for up to 60 days. You may only apply once per calendar year, so I may continue to offer support to others in need.
Fees are subject to increase periodically, generally once a year. I will provide you with a 30 to 90 day notice of any such increase. A projection for monthly costs at one 50-min session per week would be $760. A course of therapy depends on the level of acuity and stated client goals.
I do not engage with insurance for any reason. I will not speak with, email, or fax anything to your insurance carrier. You will be provided a superbill or itemized statement at the end of each month. You may be able to submit this to your insurance for reimbursement, which is at the discretion of your carrier.
I do not work with or accept medicare or medicaid.
Court/Legal Fees: Clients are discouraged from having their therapist subpoenaed. Even though you are responsible for the testimony fee, it does not mean that my testimony will be solely in your favor. I can only testify to the facts. If you want to move forward and need legal assistance, my fees are below:
Preparation time (including submission of records): $400/hr
Phone calls: $300/hr
Depositions: $500/hour
Time required in giving testimony: $500/hour
Mileage: $.655/mile
Time away from the office due to depositions or testimony: $500/hour
All attorney fees and costs incurred by the therapist as a result of the legal action, are the responsibility of the client.
Filing a document with the court: $300
The minimum charge for a court appearance: $2000
A retainer of $3000 is due in advance. If a subpoena or notice to meet attorney(s) is received without a minimum of 48-hour notice there will be an additional $250 “express” charge. Also, if the case is reset with less than 72 business hours notice, then the client will be charged $500 (in addition to the retainer of $1500). All fees are double if the therapist is scheduled to be out of town.
The Therapeutic Process: You have taken a very positive step by deciding to seek therapy. The outcome of your treatment depends largely on your willingness to engage in this process, which may, at times, result in considerable discomfort. Remembering unpleasant events and becoming aware of feelings attached to those events can bring on strong feelings of anger, depression, anxiety, etc. There are no miracle cures. I cannot promise that your behavior or circumstance will change. I can promise to support you and do my very best to understand you and your repeating patterns, as well as to help you clarify what it is that you want for yourself.
Confidentiality: The session content and all relevant materials to the client’s treatment will be held confidential unless the client requests in writing to have all or portions of such content released to a specifically named person/persons. Limitations of such client held privilege of confidentiality exist and are itemized below:
If a client threatens or attempts to commit suicide or otherwise conducts him/herself in a manner in which there is a substantial risk of incurring serious bodily harm.
If a client threatens grave bodily harm or death to another person.
If the therapist has a reasonable suspicion that a client or other named victim is the perpetrator, observer of, or actual victim of physical, emotional, or sexual abuse of children under the age of 18 years.
Suspicions as stated above in the case of an elderly person who may be subjected to these abuses.
Suspected neglect of the parties named in items #3 and # 4.
If a court of law issues a legitimate subpoena for information stated on the subpoena.
If a client is in therapy or being treated by order of a court of law, or if the information is obtained for the purpose of rendering an expert’s report to an attorney.
Consultation: Occasionally I may need to consult with other professionals in their areas of expertise in order to provide the best treatment for you. Information about you may be shared in this context without using your name.
Communication in public: If we see each other accidentally outside of the therapy office, I will not acknowledge you first. Your right to privacy and confidentiality is of the utmost importance to me, and I do not wish to jeopardize your privacy. However, if you acknowledge me first, I will be more than happy to speak briefly with you, but feel it appropriate not to engage in any lengthy discussions in public or outside of the therapy office.
Benefits and risks of telehealth: Telehealth refers to providing psychotherapy services remotely using telecommunications technologies, such as video conferencing or telephone. One of the benefits of telehealth is that the client and clinician can engage in services without being in the same physical location. This can be helpful in ensuring continuity of care if the client or clinician moves to a different location, takes an extended vacation, or is otherwise unable to continue to meet in person. It is also more convenient, can promote public health, and takes less time. Telehealth, however, requires technical competence on both our parts to be helpful. Although there are benefits of telehealth, there are some differences between in-person psychotherapy and telehealth, as well as some risks. For example:
Risks to confidentiality. Because telehealth sessions take place outside of the therapist’s private office, there is potential for other people to overhear sessions if you are not in a private place during the session. On my end I will take reasonable steps to ensure your privacy. But it is important for you to make sure you find a private place for our session where you will not be interrupted. It is also important for you to protect the privacy of our session on your cell phone or other device. You should participate in therapy only while in a room or area where other people are not present and cannot overhear the conversation.
Issues related to technology. There are many ways that technology issues might impact telehealth. For example, technology may stop working during a session, other people might be able to get access to our private conversation, or stored data could be accessed by unauthorized people or companies.
Crisis management and intervention. Usually, I will not engage in telehealth with clients who are currently in a crisis situation requiring high levels of support and intervention. Before engaging in telehealth, we will develop an emergency response plan to address potential crisis situations that may arise during the course of our telehealth work.
Efficacy. Most research shows that telehealth is about as effective as in-person psychotherapy. However, some therapists believe that something is lost by not being in the same room. For example, there is debate about a therapist’s ability to fully understand non-verbal information when working remotely.
Electronic Communications: I have decided to use Telehealth services via Simple Practice and Zoom. You may have to have certain computer or cell phone systems to use telehealth services. You are solely responsible for any cost to you to obtain any necessary equipment, accessories, or software to take part in telehealth.
For communication between sessions, I only use phone calls, email communication, and secure chat via Simple Practice. This means that email exchanges and text messages with my office should be limited to administrative matters. This includes things like setting and changing appointments, billing matters, and other related issues. You should be aware that I cannot guarantee the confidentiality of any information communicated by email. Therefore, I will almost never discuss any clinical information by email or text and prefer that you do not either. Also, though I regularly check my email and messages, I may not respond immediately, so these methods should not be used if there is an emergency.
Treatment is most effective when clinical discussions occur at your regularly scheduled sessions. But if an urgent issue arises, you should feel free to attempt to reach me by phone. I will try to return your call as soon as I can. If you cannot get me and feel that you cannot wait for me to return your call, contact your family physician or the nearest emergency room and ask for the psychologist or psychiatrist on call. If I am unavailable for an extended time, I will provide you with the name of a colleague to contact in my absence if necessary.
Appropriateness of telehealth: I will let you know if telehealth is not the right fit for your mental healthcare or if I decide that telehealth is no longer the most appropriate form of treatment for you. We will discuss referrals to another professional in your location who can provide relevant services.
Emergencies and technology: Assessing and evaluating threats and other emergencies can be more difficult when conducting telehealth than traditional in-person therapy. We will create an emergency plan outside of engaging in telhealth services to address some of these difficulties. I will ask you to identify an emergency contact person who is near your location and who I will contact in the event of a crisis or emergency to assist in addressing the situation. I will ask that you complete a separate authorization form allowing me to contact your emergency contact person as needed during such a crisis or emergency.
If the session is interrupted for any reason, such as the technological connection fails, and you are having an emergency, do not call me back; instead, call 911, call 988 Lifeline, or go to your nearest emergency room. Call me back after you have called or obtained emergency services.
If the session is interrupted and you are not having an emergency, disconnect from the session. I will wait two (2) minutes and then re-contact you via the telehealth platform we agreed to conduct therapy. If you do not receive a call back within two (2) minutes, call me on the phone number I provided you (404-919-9723).
Records: The telehealth sessions shall not be recorded in any way unless agreed to in writing by mutual consent. I will maintain a record of our sessions in the same way, I keep records of therapy sessions in accordance with my policies.