Any text-based communication may become part of your record.
I may not be able to respond to your messages and calls immediately. For voicemails and other messages, you can expect a response within 24 hours on weekdays, and 72 hours on weekends. Be aware that there may be times when I am unable to receive or respond to messages, such as when out of cellular range or out of town.
If you are ever experiencing an emergency, including a mental health crisis, please call 911, Lifeline 1-800-273-8255, or go to your nearest emergency room.
If you need to contact me about an emergency, the best method is
- By phone 918-978-0176
- If you cannot reach me by phone, please leave a voicemail and call 911 or go to an emergency room.
In the process of couples counseling, I, your therapist, do not keep secrets for any party.
Cost of Sessions
The cost of your session will be agreed upon between you and me over the phone. It will also be stated on your scheduled appointment on your client portal. The cost of the session depends on the counseling medium used, the date, the time, and any financial hardship that you may have. (During this time of the COVID-19) I will be billing your insurance where applicable.
You, the client, are responsible for the cost of any technology at your location, such as a computer, device, phone, phone call charges, software, and headset. If you are in need of additional support between sessions and choose to use telephone calls, email or chat, you will be billed $1 per minute for every minute that exceeds 10 in duration. However; I will not provide counseling via these methods, only via the Zoom.us.
Email counseling is billed at $40 per email that you send with a maximum of 300 words per email. You will get one email response per email that you send.
There is no Counseling via Texting.
Many insurance providers will not cover distance counseling. Some insurance carriers will cover distance counseling via video conferencing, within their given parameters. I have chosen to provide distance counseling/coaching on a Private Pay/cash basis. Insurance billing will be not be provided typically for this service; however, during the COVID-19 period, we are making an exception. During this time, we will do all sessions online and bill insurance companies for sessions. Once the COVID-19 period is lifted, we will determine future direction regarding billing insurance companies.
You are responsible to pay any fees incurred at the time of your counseling session.
I have a Business Associate Agreement, meaning they agree to adhere to HIPAA law and have measures in place to keep your PHI secure and confidential. If your insurance provider is billed you will likely get statements via mail by Accurate Medical Billing. Cash, personal checks, and all major credit cards are accepted for payment.
There is a $25 fee for any returned checks. If you pay by credit card you might receive a receipt via email, and it will likely show up on your billing statement.
By not canceling your appointment as stated in the cancellation policy, you are agreeing to the price of your session as stated on this counseling form.
The cost for documentation requested, and appearing in court depends on the specific request.
I requite a 24-hour cancellation notice. If the client fails to cancel 24 hours in advance and/or cancels within that window of time. They will be billed $95.00 for that missed time.
Structure of Sessions
I, Jackie Cleary, offer counseling via face-to-face, video conferencing, and email. Distance counseling is considered any of those methods other than face-to-face. If your counseling need is appropriate for distance counseling, you can either solely receive counseling via one medium, or any combination of them.
Face-to-face sessions are held at the following location:
1811 S. Baltimore Ste. 200
Tulsa, Oklahoma 74119
Video conferencing counseling sessions
are held via zoom.us. It is recommended that you sign on to your account at least 5 minutes prior to your session start time. You are responsible for initiating the connection with me at the time of your session.
If at any time you do not have internet access at your home, or private location you can contact me via phone to help you locate internet service (if available) that will be appropriate for distance counseling.
Limitation of Distance Counseling
Distance counseling should not be viewed as a substitute for face-to-face counseling or medication by a physician. It is an alternative form of counseling with certain limitations. By signing this document you agree that you understand that distance counseling:
- May lack visual and/or audio cues, which may cause misunderstanding.
- May have disruptions in the service and quality of the technology used.
- May not be appropriate if you are having a crisis, acute psychosis, or suicidal or homicidal thoughts.
- When using email, chat, or texting, there might be a delay in your counselor receiving your message or they might not ever receive it.
Emergency Management for Distance Counseling
So that I am able to get you help in the case of an emergency and for your safety, the following are important and necessary. In addition, by signing this agreement form you are acknowledging that you understand and agree to the following:
- You, the client, will inform me, your therapist, of the location in which you will consistently be during our sessions, and will inform me if this location changes.
- You, the client, will identify, on your client information form, a person, whom I, your therapist, am allowed to contact in the case that I believe you are at risk.
- Depending on my assessment of risk, you, the client, or your therapist, may be required to verify that your emergency contact person is able and willing to go to your location in the event of an emergency, and if I deem necessary, call 911 and/or transport you to a hospital. In addition, I may assess, and therefore require, that you create a safe environment at your location during the entire time that you are in treatment with me. This may mean disposing of all firearms and excess medication from your location.
Backup Plan in Case of Technology Failure
The most reliable backup is a phone. Therefore, it is recommended that you always have a phone available and that I, your therapist, know your phone number.
If you get disconnected from a video conferencing, end and restart the session. If you are unable to reconnect within five minutes call me. If I do not hear from you within ten minutes you agree (unless you request otherwise) that I can call you on the phone number you provide on the client information form.
If this happens as a result of an issue with technology on my side or yours, and we are not able to reconnect, you will not be charged for the session.
The Counseling relationship is considered a Professional relationship. It is therefore, not therapeutic that the client request to be on the therapist’s personal Facebook.
Should the counseling relationship come to an end, You will be called two times and the third time, a letter will be sent to you with 3 names for a possible referral.
Statement Regarding Ethics, Client Welfare & Safety
All client/patient relationships will be treated with the most respect regarding boundaries, ethics, and safety. The client’s health, life satisfaction and safety will have top priority.