NOTICE OF PRIVACY PRACTICES
THIS NOTICE DESCRIBES HOW MEDICAL AND MENTAL HEALTH INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY.
Personalized Solutions (the "Practice") is committed to protecting the privacy and security of your Protected Health Information ("PHI"). This Notice explains how the Practice may use and disclose PHI, your rights regarding PHI, and the Practice's legal duties under federal law. Where applicable, more stringent state or federal law will control.
Practice Contact Information
Practice Name
Personalized Solutions LLC
Address
3502 Westridge Dr, Lawrence, KS 66046
Privacy Officer / Contact
Jesse J. Rowley
Phone
seveneightfivesevensixzerofourtwothreethree
info at personalizedsolutionsllc dot com
1. Our Legal Duties and Privacy Commitment
The Practice is required by law to maintain the privacy of PHI, provide you with this Notice, and follow the terms of the Notice currently in effect. The Practice creates and maintains records of the care and services you receive in order to provide quality care and comply with legal requirements.
· Maintain the privacy and security of PHI that identifies you.
· Provide you with this Notice of the Practice's legal duties and privacy practices.
· Notify you following a breach of unsecured PHI as required by law.
· Abide by the terms of this Notice while it is in effect.
· Reserve the right to revise this Notice. Any revision will apply to PHI the Practice already maintains, and the revised Notice will be available upon request, in the office, and on the Practice website: https://www.personalizedsolutionsllc.com/
2. Your Rights Regarding PHI
You have the following rights regarding your PHI. To exercise any of these rights, please submit a written request to the Practice using the contact information above.
A. Right to Inspect and Copy PHI
· You may request an electronic or paper copy of your medical record and other PHI maintained by the Practice (excluding psychotherapy notes, as defined by law, unless otherwise permitted).
· The Practice will generally respond within 30 days of receiving your written request.
· The Practice may charge a reasonable, cost-based fee for copies or summaries.
· In limited circumstances, the Practice may deny your request and will provide a written explanation. You may have the right to a review of certain denials.
B. Right to Request an Amendment
· You may request a correction or amendment if you believe PHI is incorrect or incomplete.
· The Practice may require your request to be in writing and may request a reason supporting the amendment.
· If the Practice denies your request, the Practice will provide a written explanation and allow you to submit a written statement of disagreement.
C. Right to Request Confidential Communications
· You may request that the Practice contact you in a specific way (for example, at a certain phone number or mailing address).
· The Practice will accommodate all reasonable requests.
D. Right to Request Restrictions
· You may request limits on how the Practice uses or discloses PHI for treatment, payment, or health care operations. The Practice is not required to agree if the restriction would affect your care or legal obligations.
· If you pay for a health care item or service out-of-pocket in full, you may request that the Practice not disclose related PHI to your health plan for payment or health care operations. The Practice will honor this request unless disclosure is otherwise required by law.
· You may request that the Practice not share PHI with family members, friends, or others involved in your care by identifying the specific restriction and person(s) involved.
E. Right to an Accounting of Disclosures
· You may request a list of certain disclosures of your PHI made by the Practice, excluding disclosures for treatment, payment, health care operations, and certain other disclosures permitted by law.
· The Practice will generally respond within 60 days.
· You are entitled to one accounting in any 12-month period at no charge. The Practice may charge a reasonable, cost-based fee for additional accountings within the same 12-month period.
F. Right to Receive a Copy of This Notice
· You may request a paper copy of this Notice at any time, even if you agreed to receive it electronically.
G. Right to Choose a Personal Representative
· If you have given someone medical power of attorney, or if someone is your legal guardian, that person may exercise your rights and make choices about your PHI to the extent permitted by law.
H. Right to File a Complaint
· You may file a complaint with the Practice if you believe your privacy rights have been violated. The Practice will not retaliate against you for filing a complaint.
· You may also file a complaint with the U.S. Department of Health and Human Services, Office for Civil Rights, by mail at 200 Independence Avenue, S.W., Washington, DC 20201, by phone at 1-877-696-6775, or through the OCR complaint process online.
I. Right to Opt Out of Fundraising Communications
· If the Practice engages in fundraising communications, you may opt out of receiving those communications at any time.
3. How the Practice May Use and Disclose PHI
Federal privacy rules permit the Practice to use and disclose PHI without your written authorization for treatment, payment, and health care operations. The Practice may also disclose PHI to another health care provider for that provider's treatment activities and, as permitted by law, for certain payment and health care operations activities.
A. Treatment
· The Practice may use and disclose PHI to provide, coordinate, or manage your care, including consultations and referrals with other health care providers.
· Example: A clinician consults with another licensed provider regarding diagnosis or treatment planning.
· Disclosures for treatment are not limited to the minimum necessary standard when full information is needed to provide quality care.
B. Payment
· The Practice may use and disclose PHI to bill and collect payment from you, your health plan, or another responsible party.
· Example: The Practice submits necessary information to your health insurer for reimbursement.
C. Health Care Operations
· The Practice may use and disclose PHI to operate the Practice, improve care, perform quality assessment, conduct training, and manage administrative functions.
· Example: The Practice reviews records for quality improvement or compliance activities.
D. Appointment Reminders and Health-Related Communications
· The Practice may contact you with appointment reminders and information about treatment alternatives or other health-related benefits or services offered by the Practice.
4. Uses and Disclosures That May Be Made Without Your Authorization
Subject to applicable legal requirements and limitations, the Practice may use or disclose PHI without your authorization for the following purposes:
· As required by federal, state, or local law.
· Public health activities, including reporting abuse, neglect, domestic violence, or other matters required by law, and to prevent or reduce a serious threat to health or safety.
· Health oversight activities, such as audits, investigations, inspections, and licensure or regulatory actions.
· Judicial and administrative proceedings, including in response to court orders, subpoenas, or lawful process (subject to legal requirements).
· Law enforcement purposes, including reporting crimes on the premises or assisting law enforcement as permitted by law.
· Coroners, medical examiners, and funeral directors performing duties authorized by law.
· Organ donation and transplantation, if applicable.
· Research, when approved and conducted in compliance with applicable law and privacy protections.
· Specialized government functions, including military, national security, intelligence, protective services, and correctional institution or law enforcement custody situations, as permitted by law.
· Workers' compensation or similar programs, as required or authorized by law.
· Business associates and service providers performing functions on behalf of the Practice under appropriate confidentiality protections.
· The Secretary of Health and Human Services for compliance and enforcement of HIPAA.
5. Uses and Disclosures for Which You May Be Given an Opportunity to Agree or Object
Unless you object, the Practice may share PHI with a family member, friend, or other person identified by you if the PHI is directly relevant to that person's involvement in your care or payment for your care. If you are not able to state your preference, the Practice may disclose PHI if, in professional judgment, it is in your best interest. In emergency situations, your opportunity to agree or object may be obtained retroactively when feasible.
6. Uses and Disclosures Requiring Your Written Authorization
Except as otherwise described in this Notice or permitted by law, the Practice will obtain your written authorization before using or disclosing your PHI. You may revoke an authorization at any time in writing, except to the extent the Practice has already relied on it.
A. Psychotherapy Notes
The Practice maintains psychotherapy notes as defined in 45 CFR 164.501. Any use or disclosure of psychotherapy notes requires your written authorization unless the use or disclosure is:
· For the Practice's use in treating you.
· For the Practice's use in training or supervising mental health practitioners to improve their skills in group, joint, family, or individual counseling or therapy.
· For the Practice's use in defending itself in legal proceedings brought by you.
· For use by the Secretary of Health and Human Services to investigate or determine the Practice's compliance with HIPAA.
· Required by law, if the use or disclosure is limited to the legal requirement.
· Required for certain health oversight activities related to the originator of the psychotherapy notes.
· For a coroner or medical examiner performing duties authorized by law.
· Necessary to avert a serious threat to health or safety.
B. Marketing and Sale of PHI
· The Practice will not use or disclose your PHI for marketing purposes without your written authorization, except as permitted by law.
· The Practice will not sell your PHI without your written authorization.
C. Other Uses and Disclosures
· Any other use or disclosure not described in this Notice will be made only with your written authorization.
7. Additional Confidentiality Protections for Substance Use Disorder Records (42 CFR Part 2)
If applicable, records relating to substance use disorder ("SUD") diagnosis, treatment, or referral may be protected by federal law under 42 CFR Part 2, which provides additional confidentiality protections beyond HIPAA.
A. Consent Requirements and Limited Exceptions
· A separate patient consent may be required for the use and disclosure of SUD counseling notes and certain other Part 2 records.
· Disclosures made with patient consent must include a copy of the consent or a clear explanation of the scope of the consent and must include the written notice required by 42 CFR Part 2.32(a).
· Part 2 records generally require your explicit written consent, except in limited circumstances such as medical emergencies, reporting crimes on program premises, child abuse reporting, and certain other disclosures permitted by law.
· If the Practice conducts fundraising, you will be given an opportunity to decline fundraising communications before such communications are sent, as required by law.
· You may revoke Part 2 consent in writing at any time, except to the extent action has already been taken in reliance on the consent.B. Prohibitions on Use and Disclosure in ProceedingsPart 2 records received from a Part 2 program, or testimony relaying the content of such records, may not be used or disclosed in civil, criminal, administrative, or legislative proceedings against you unless based on your written consent or a court order issued in compliance with Part 2 (including notice and an opportunity to be heard, when required).A court order authorizing use or disclosure of Part 2 records must be accompanied by a subpoena or other legal requirement compelling disclosure before the requested record is used or disclosed. If Part 2 records are disclosed to the Practice or its business associates pursuant to your written consent for treatment, payment, or health care operations, the Practice and its business associates may further use and disclose that information only as permitted by HIPAA and consistent with applicable Part 2 requirements.
8. Complaints and Questions
If you have questions about this Notice, want to exercise your rights, or wish to file a complaint with the Practice, please contact the Practice using the contact information listed at the beginning of this Notice.
9. Effective Date and Changes to This Notice
Effective Date: 01-01-2026
The Practice may change the terms of this Notice at any time. Any revised Notice will apply to all PHI maintained by the Practice and will be made available upon request and on the Practice website, if applicable.
Optional Acknowledgment of Receipt of Notice of Privacy Practices
By signing below, you acknowledge that you received a copy of this Notice of Privacy Practices. This acknowledgment documents receipt only and does not limit your rights or the Practice's obligations under HIPAA or other applicable law.
Patient Name (Print)
________________________________________
Patient Signature
________________________________________
Date
________________________________________
Personal Representative (if applicable)
________________________________________
Informed Consent for Psychotherapy
Understanding Psychotherapy and Other Services Provided by Personalized Solutions LLC
Psychotherapy and other services offered by Personalized Solutions LLC are designed to help individuals make meaningful changes.
At times, this process can be difficult because it may involve thoughts, emotions, and concerns that have been avoided or kept
private.
Potential benefits of therapy may include:
• Improved mood
• Healthier behaviors
• Better relationships
• Stronger communication skills
• Increased self-awareness
Psychotherapy is not an exact science, and outcomes vary from person to person. While we often see positive results, Personalized
Solutions LLC cannot guarantee the success of any treatment.
The Therapeutic Process
Seeking therapy is an important and positive step. The outcome of treatment depends largely on your willingness to participate
actively in the therapeutic process.
Therapy may involve discussing difficult or painful experiences. This can lead to strong emotional responses, including sadness,
anxiety, anger, or frustration. There are no “quick fixes” or guaranteed outcomes. Your provider cannot promise that your
circumstances or behaviors will change in a specific way.
However, your provider will make every effort to support you, understand your patterns, and help you clarify your goals.
Grievance Procedure
At times, clients may experience conflict or disagreement with their therapist regarding some aspect of treatment. This may result
from a misunderstanding or a difference of opinion about how treatment should proceed.
When concerns arise, we encourage clients to first discuss the issue directly with their therapist so that an effort can be made to
resolve the matter in a way that supports treatment while maintaining professional standards.
If the issue cannot be resolved, Personalized Solutions LLC may recommend referral to another provider or practice. You may also
contact your insurance provider for a list of in-network mental health providers.
Second Opinions and Referral for Services
Clients have the right to seek a second opinion. A second opinion may be helpful if you do not agree with a diagnosis, treatment
recommendation, or clinical finding made by Personalized Solutions LLC.Personalized Solutions LLC does not routinely recommend a specific provider for second opinions. However, if we determine that we
do not have the training, experience, or services necessary to meet your needs, we may recommend other providers or resources
that are more appropriate.
This may occur more often in adult cases when specialized services are needed that we do not provide.
Confidentiality
All services provided by Personalized Solutions LLC are confidential. We will not release information about your case to anyone
outside of Personalized Solutions LLC without your written consent, except as permitted or required by law. Please also refer to the
Notice of Privacy Practices for additional information regarding Protected Health Information (PHI).
At times, your provider may consult with other professionals to support quality care. In those situations, information may be shared
without identifying you by name.
If we see each other outside the office, your provider will not acknowledge you first in order to protect your privacy. If you choose to
acknowledge your provider first, they may respond briefly, but it is generally not appropriate to engage in detailed discussions
outside the therapy setting.
Limits of Confidentiality (Exceptions)
Confidentiality is important, but there are exceptions in which disclosure may be required or permitted by law. These include, but
are not limited to, the following:
1. Duty to Warn and Protect
If a client expresses a serious intent or plan to harm another person, the mental health professional may be required to warn the
intended victim and notify appropriate legal authorities.
If a client expresses or implies a serious risk of self-harm or suicide, the mental health professional may be required to notify
emergency responders and/or make reasonable efforts to notify family members or other appropriate persons.
2. Abuse or Neglect of Children or Vulnerable Adults
If a client reports or suggests abuse or neglect of a child or vulnerable adult, or if there is reason to believe a child or vulnerable
adult is at risk of abuse or neglect, the mental health professional is required to report this information to the appropriate social
service agency and/or legal authorities.
3. Prenatal Exposure to Controlled Substances
Mental health professionals may be required to report prenatal exposure to controlled substances when disclosure is required by
law.
4. Minors and Guardianship
Parents or legal guardians of a non-emancipated minor generally have the right to access the minor client’s treatment records,
unless otherwise limited by law or court order.
5. Insurance and Third-Party BillingIf insurance or another third-party payer is used, Personalized Solutions LLC may provide information necessary for billing and
payment. This may include, but is not limited to:
• Type of service
• Dates and times of service
• Diagnosis
• Treatment plans
• Clinical summaries
• Progress information
• Other information required for claims review or payment
6. Court Orders and Subpoenas
If records are requested through a subpoena or court order, we may attempt to assert privileged communication if you or your
attorney requests that we do so. However, in some circumstances, the court may order disclosure despite privilege protections.
Personalized Solutions LLC also reserves the right to contact law enforcement or emergency services at any time if there is concern
about danger to self or others.
Crisis Intervention
Personalized Solutions LLC provides therapy services for children, teens, families, adults, and couples. However, we are not a crisis
response agency and may not be able to meet all crisis intervention needs.
If you believe you may require ongoing psychiatric crisis support, or if you have used crisis services in prior treatment, please discuss
this with your therapist so we can review available resources and community alternatives.
For after-hours emergencies, contact:
• Your local Mental Health Center
• The nearest hospital emergency department
• 911 (or emergency services)
Coordination of Care With Your Physician
In many cases, it is in your best clinical interest for Personalized Solutions LLC to coordinate care with your physician, especially if
you are receiving medication management.
By signing this document, you authorize Personalized Solutions LLC to contact your physician as needed for treatment coordination.
Financial Responsibility (Obligation)
By signing this document, you agree to pay for services provided by Personalized Solutions LLC. Please review the following billing
policies carefully and ask your therapist if you have any questions.
Payment Method (Required)Please select the applicable payment method:
Self-Pay:
I am responsible for payment of all fees in full (cash or credit card).
OR
Insurance:
I have provided my insurance information to Personalized Solutions LLC and intend to use insurance for payment of services.
Please note: Insurance coverage must be reviewed and verified before services are provided. Personalized Solutions LLC may not
accept all insurance plans.
Attendance, Missed Appointments, and Late Cancellations
I understand that missed appointments and late cancellations are charged at 100% of the agreed session/program amount.
• A missed appointment (no-show) is an appointment not canceled at least 24 hours in advance.
• A late cancellation is an appointment canceled with less than 24 hours’ notice.
Fees for missed or late-canceled appointments due to legitimate emergencies may be waived at the discretion of Personalized
Solutions LLC.
Personalized Solutions LLC may provide appointment reminders as a courtesy; however, failure to receive a reminder does not waive
the no-show or late cancellation fee.
Additional attendance policies:
• Two missed or late-canceled appointments may result in loss of your regular therapy appointment time and/or placement
on a call list.
• Services may be terminated if three (3) or more missed appointments occur.
Responsibility for Payment and Late Fees
I understand that I am responsible for all charges related to my care.
If I am age 18 or older and another person (such as a parent or guarantor) agrees to pay my bill, I understand that I remain primarily
responsible for all outstanding balances if that person does not pay.
Additional billing terms:
• Returned checks may incur fees of up to 30% of the check amount
• Any unpaid balance not paid within 7 days may incur a 15% late fee
• An additional 15% late fee may be added every 30 days from the date of the original appointment until the balance is paid
in full (where permitted by law)Acknowledgment and Consent
By signing electronically, I acknowledge that I have read the statements above (or had them explained to me), that my questions
have been answered, and that I understand the terms of this informed consent.
I consent to receive services from Personalized Solutions LLC, if services are offered, under the terms outlined in this document.
I understand that this form addresses the core elements of informed consent and that additional issues may arise during therapy. If
that occurs, I understand that I may discuss those issues with my therapist at any time.
_________________________________________________________ / ______________________________
Signature of Client or (parent or guardian to child under 18) Date
____________________
Practice Policies
Recording of Sessions
No party may audio record or video record any session under any circumstances. No exceptions will be made to this policy unless the
provider gives prior express written consent.
Any recording made without the provider’s express written consent is unauthorized, and the Practice does not consent to its use for any
litigation or other legal proceeding.
Appointments, Cancellations, and No-Shows
A cancellation, late cancellation, or no-call/no-show fee applies to any missed appointment or any appointment canceled with less than
24 hours’ notice.
Please cancel or reschedule at least 24 hours in advance. If less than 24 hours’ notice is provided, you will be responsible for the full
session fee. This is considered a same-day cancellation.
Appointment times are reserved exclusively for you. If you arrive late, your session may be shortened, and the full session fee may still
apply.
Payment Policy
Payment is due at the time of service for all services provided.
If a court order, parenting plan, visitation agreement, or other arrangement assigns financial responsibility to one party (or splits
payment between parties), it is the responsibility of the parties involved to resolve payment arrangements before the scheduled
service. The full fee remains due at the time of service regardless of which party is ultimately responsible.
All clients are required to keep a valid payment card on file, which will be collected during the intake process.
If the card on file is declined for any reason, the Practice may send an invoice by email. Payment must be made before the next
scheduled session unless otherwise approved.
Late Fees
Any unpaid balance not paid within 7 days may incur a 15% late fee. An additional 15% late fee may be added every 30 days from the
original date of service until the balance is paid in full (where permitted by law).
Insurance and Client Financial Responsibility
If you plan to use insurance benefits, you must review this with your therapist before your first session.
I understand that I remain responsible for all amounts owed by me, including but not limited to:• Copays
• Coinsurance
• Deductibles
• Services not covered by my insurance plan
• Services denied due to lack of prior authorization
• Mutually agreed-upon services or fees deemed not medically necessary
The Practice will submit claims to your insurance carrier on your behalf. Any amount assigned to client responsibility by the insurance
plan may be charged to the payment method on file.
Accepted Payment Methods
• Cash
• Credit card / debit card
Checks are not accepted (unless specifically approved by the Practice). If a check is accepted by exception and returned for any reason,
a service charge of up to 30% of the check amount may apply.
Out-of-Session Contact and Case-Related Services
Any contact or work performed outside of your scheduled session(s) may be billed in 15-minute increments, with a minimum charge of
$35.00.
Billable out-of-session services may include, but are not limited to:
• Reviewing messages in OurFamilyWizard or similar platforms
• Emails and text messages requiring clinical or case-related response
• Phone calls
• Communication with attorneys, case managers, Guardians ad Litem (GALs), or other professionals involved in your case
• Case review, documentation, or other case-related work
To reduce out-of-session charges, please address non-urgent issues during scheduled sessions whenever possible. If other professionals
involved in your case need to communicate with the Practice, please ask them to coordinate in advance so you are aware of potential
charges.
The Practice will make reasonable efforts to respond promptly, but response times may vary.
Telephone Accessibility
If you need to contact your provider between sessions, please leave a voicemail message. Providers are often not immediately available,
but we will make reasonable efforts to return your call within 24 hours (excluding weekends, holidays, or provider unavailability).
Face-to-face sessions are generally preferred over phone contact. However, phone sessions may be available in certain situations (for
example, if you are traveling, ill, or need additional support).
If you are experiencing a true emergency, call 911 or go to the nearest emergency room.
Social Media and Online ContactTo protect confidentiality and maintain appropriate therapeutic boundaries, the Practice generally does not accept friend requests,
follow requests, or contact requests from current or former clients on social media platforms (including, but not limited to, Facebook,
LinkedIn, Instagram, etc.).
Connecting on social media may compromise confidentiality and blur the boundaries of the therapeutic relationship. If you have
questions about this policy, please discuss them with your therapist during a session.
Electronic Communication Policy
The Practice cannot guarantee the confidentiality or security of electronic communications, including text messages and email.
If you choose to communicate by email or text for scheduling or administrative matters, the Practice may respond through those
methods. However:
• Response times are not guaranteed
• Electronic communication should not be used for emergencies
• Electronic communication should not be used to discuss detailed therapeutic content unless specifically approved by your
provider
If you need immediate help or are in crisis, call 911 or seek emergency services.
Clinical Limitations of Technology-Based Communication
Effective therapy often depends on direct observation in addition to verbal communication. When services are provided through phone,
electronic messaging, or other technology, the provider may not be able to observe important clinical information such as appearance,
behavior, nonverbal communication, hygiene, or other physical indicators that may be relevant to treatment.
As a result, important clinical information may be missed if it is not shared directly by the client.
Email and Text Communication
Email Contact
At your discretion, you may contact your therapist by email for the same general purpose you might initiate phone contact (for
example, scheduling or brief administrative matters).
Please note:
• The Practice considers all contact to be part of the therapeutic process and may bill for contact as appropriate.
• Administrative/supportive communication may still be billable if it requires provider time beyond routine scheduling.
• Email is protected to some extent by law but should not be considered fully secure.
• Email should not be used for urgent or emergency matters.
By initiating email communication, you acknowledge and accept these risks and limitations. If you prefer no response by email, please
state that clearly in your message (for example: “Please do not reply by email.”).
Text Messaging
Text messaging may be used for limited communication, including scheduling or appointment reminders, if you choose to allow it.Please provide your preferred number for text communication, or notify your therapist if you do not want to be contacted by text
message.
Minors
If you are a minor, your parent(s) or legal guardian(s) may have legal rights to certain information about your treatment, unless
otherwise restricted by law or court order.
Your therapist will discuss with you and your parent(s)/guardian(s) what information is appropriate to share and what issues may
remain confidential within the treatment relationship.
Parenting Program (If Applicable)
The Parenting Program offered by Personalized Solutions LLC is an evidence-informed program tailored to the needs of each case.
By participating in the Personalized Solutions LLC Parenting Program, you understand and agree that the program includes an
evaluation and educational process. The Practice cannot complete its final evaluation until the treatment plan developed with you and
your therapist has been completed.
Your full participation and consistency with appointments are necessary for the therapist to make an appropriate evaluation and final
recommendations regarding program completion.
Important Terms
• Program outcomes are not guaranteed.
• Payment for the Parenting Program is due in full at the beginning of the program.
• No refund will be issued if you fail to participate, discontinue, or are dissatisfied with final recommendations.
You are encouraged to discuss any questions or concerns about your treatment plan or progress with your therapist at any time during
the program.
Acknowledgment Regarding Recommendations
By signing this document, you acknowledge that you have read this section and understand that recommendations made by
Personalized Solutions LLC as part of the Parenting Program are based on your participation and clinical judgment.
(If you want, I can also help revise the “no legal recourse” sentence into stronger but more enforceable language for a formal legal
review.)
Termination of Services
Ending treatment can be difficult, and a thoughtful termination process is often important for closure and continuity of care. The length
and structure of termination will depend on the nature and duration of treatment.
The Practice may terminate services after appropriate discussion with you if:
• Treatment is not being effectively used,
• You are in default on payment, or• Other clinical or administrative reasons require transition of care
The Practice will make reasonable efforts to discuss and process termination before ending the therapeutic relationship, when
appropriate.
If treatment is terminated for any reason, or if you request a different provider, the Practice can provide referral options for other
qualified providers. You may also choose another provider independently.
Inactive Cases
If you do not schedule an appointment for three consecutive weeks, and no other arrangements have been made in advance, the
Practice may consider the professional relationship discontinued for legal and ethical reasons.
Acknowledgment of Receipt and Agreement to Practice Policies
By signing electronically, I acknowledge that I have read, understood, and agree to the policies and terms contained in this document.
Signature: _______________________________________________________ Date: ________________
POLICY FOR PARENTS WHO ARE SEPARATED, PENDING SEPARATION, DIVORCED, OR IN LITIGATION
AND COURT FEE SCHEDULE
1. Divorce, Separation, and Custody-Related Matters
Personalized Solutions is a counseling practice and does not provide custody evaluations. We do not make custody
recommendations. If a custody evaluation is needed, please consult your attorney for a referral to a qualified custody evaluator.
Because divorce, separation, custody disputes, and related litigation can involve sensitive and complex issues, the following
policies apply before and during treatment.
2. Required Court Documents and Parenting Orders
Before the intake session, Personalized Solutions requires a copy of the most current court orders that identify the custodial
rights of each parent and/or the current parenting agreement signed by both parents and the judge.
If any motions are filed to modify an existing order, you must provide those documents as soon as possible so we can maintain
both the original order and any pending modifications in the client file.
Personalized Solutions is not responsible for interpreting, enforcing, or modifying court orders, and we do not provide legal
advice. If there is disagreement or confusion regarding the meaning of a court order, you must address that issue through the
appropriate legal or court-appointed professionals, including your attorney, Guardian ad Litem (GAL), case manager, judge, or
another authorized professional overseeing the case.
Court documents may be submitted by:
• Secure Fax: 785-371-0037
• Email (document submission only): info@personalizedsolutionsllc.com
Please note: the email address above is for document submission only and is not intended for clinical correspondence.
3. Consent to Treat Minor Children
In most cases, Personalized Solutions must have contact with, and written/signed consent from, one or both legal guardians
before providing counseling services to a minor child involved in divorce, custody, or litigation proceedings.
If one parent has final decision-making authority regarding healthcare and requests counseling services for the child, even if the
other parent does not agree, Personalized Solutions will determine, in its sole discretion, whether services will be provided.
4. Communication With Court-Ordered Professionals
Personalized Solutions will cooperate with court-ordered professionals (such as a GAL, case manager, custody evaluator, or other
professionals authorized by court order) who are permitted access to the child’s treatment information.Any time spent on interviews, consultations, case coordination, or other professional contact related to these individuals is
billable to the client at the current Out-of-Session / Professional Contact rate listed in this policy.
5. Parent Participation and Counseling Process
When parents share legal custody, Personalized Solutions will make reasonable efforts to work equitably with both parents,
provided both are willing participants.
We encourage both parents to participate in parent consultations when appropriate and clinically indicated. Family sessions may
also be recommended. Depending on the circumstances of the case, we may request to meet with:
• Both parents and the child(ren) together
• Each parent separately
• Siblings and/or other significant family members living in the child’s home(s)
All treatment decisions will be based on clinical judgment and the best interests of the client.
6. Court Involvement, Subpoenas, and Testimony
Personalized Solutions does not require clients to waive their right to subpoena a therapist.
However, by signing this policy, you acknowledge that Personalized Solutions reserves the right to decline requests for
recommendations, opinions, or testimony to attorneys, GALs, case managers, the court, or other parties if, in our professional
judgment, doing so would compromise the therapeutic relationship or the integrity of treatment.
Each legal case is unique. Special circumstances must be reviewed on a case-by-case basis.
If Personalized Solutions is subpoenaed or requested to appear in court, we require at least two (2) weeks’ advance notice,
whenever possible, due to the need to adjust existing appointments and professional obligations.
All time related to court involvement is billable, including but not limited to:
• Court testimony
• Court preparation and case review
• Communication with attorneys, GALs, case managers, and other professionals
• Phone calls, emails, and other out-of-session case-related communications
7. Financial Responsibility for Services
The parent/guardian who initially sets up the child’s services is financially responsible for all fees, copays, and balances associated
with treatment unless otherwise arranged in writing with Personalized Solutions.
If your divorce decree or custody order requires a split of medical expenses, it remains the responsibility of the parents and/or
their attorneys to coordinate payment and reimbursement between themselves. Personalized Solutions is not responsible for
enforcing cost-sharing provisions in court orders.A valid card must be kept on file. Payment is due at the time of service.
If a card charge is declined:
1. 2. 3. 4. An invoice will be sent to the email address on file.
A 7-day grace period will be provided.
If payment is not received within 7 days, a 15% late fee will be added.
An additional 15% late fee will be added every 30 days thereafter until the balance is paid (where permitted by law).
FEE SCHEDULE FOR COURT PROCEEDINGS
1. Court Testimony Retainer
If court testimony or court appearance is requested based on our work with you or your child, a $550.00 non-refundable retainer
is required no later than two (2) weeks before the requested court date.
This retainer applies whether:
• An attorney issues a subpoena, or
• A parent/client requests our presence for support or to make a statement on the client’s behalf
The retainer is non-refundable because we must reserve time and reschedule other standing appointments.
2. Communication Before Court Appearance
Please communicate clearly regarding what is being requested of Personalized Solutions. If legal counsel is involved, the attorney
must schedule time directly with us to discuss the purpose and scope of our participation.
Our role is to provide professional opinions and testimony based on our treatment relationship and clinical work with the client.
Our work is guided by the best interests of the client.
3. Responsibility for Court-Related Fees
Court-related fees are charged to:
• The parent requesting our appearance, or
• The parent whose attorney has subpoenaed our appearance
If another party is ultimately responsible for all or part of the fees under a court order, it is the responsibility of the parents
and/or attorneys to seek reimbursement through the appropriate legal process.
4. How Court Time Is Calculated
Billable court time begins when the clinician leaves the office and ends when the clinician is released by the court.The $550 retainer may or may not cover the full cost of services depending on the circumstances of the case.
After the court proceeding, an itemized bill will be provided. If a remaining balance is due, the card on file will be charged and a
receipt will be sent after final billing is completed.
5. Court-Related Rates and Billable Services
The following services may be billed against the court retainer and/or billed additionally if the retainer is exceeded:
• Case file review / records review / preparation time: $140.00/hour
• Attorney trial preparation or consultation time: $140.00/hour
• Out-of-session professional contact (phone, email, GAL, case manager, attorneys, etc.): $140.00/hour
• In-office attorney meetings/interviews with clinician (must be scheduled directly with us): $140.00/hour
• Court appearance / testimony time (beyond retainer coverage): $275.00/hour
6. Example of Court Billing
Example:
• 2 hours in court: $275 x 2 = $550
• 1 hour with GAL/attorney before hearing: $140
• 1 hour reviewing case file: $140
Total: $830
Less $550 non-refundable retainer
Balance due: $280
7. Questions About Court Fees
If you have questions about the court retainer or what it covers, please ask before the court date. We strive to be transparent
about all fees; however, we cannot predict every circumstance, including how long a hearing may last.
If the total charges exceed the retainer, the remaining balance will be charged to the card on file after the court proceeding.
Acknowledgment and Agreement
By signing electronically, I acknowledge that I have read, understand, and agree to the policies and fee schedule set forth in this
document.
Signature: _______________________________________________________ Date: ________________
Printed Name: ____________________________________________________