Notice of Practice Policies

---

Exclusively Inclusive LLC dba

Center of Intrinsic Alignment

910 Old Steese Hwy Suite B

Fairbanks, AK 99701

907.328.5965

PRACTICE POLICIES

APPOINTMENTS AND APPLICABLE FEES The minimum meeting time for an appointment is 30 minutes with the average appointment time being 45-60 mins. It is up to youth communicate with your practitioner to determine the most appropriate length of time for your sessions. Requests to change the minimum session needs to be discussed with the health care provider in order for time to be scheduled in advance.

A $50.00 service charge will be charged for any checks returned for any reason for special handling.

A 4% convenience fee will apply to any electronic and/or credit card payments.

A current and valid credit/debit card is required to reserve an appointment. You authorize the card on file for agreed upon reservations, whether solitary or recurring, in accordance with the consented to policies.  You understand that your information will be saved and encrypted securely in your client file for future transactions on your account and will only be executed upon with your prior knowledge and/or consent.

CANCELLATION & RESCHEDULING Cancellations and rescheduling will be subject to a $100.00 charge if NOT RECEIVED AT LEAST 24 HOURS IN ADVANCE, and/or $200.00 charge if there is a failure to attend your scheduled appointment without prior notification. This necessary fee will be charged within 24 hours of said infraction because a valued time commitment is made to you and is held exclusively for youth professional considerations. If you are late for a session, you may lose some of that session time, however the applicable fees will not be prorated.

You give consent to Exclusively Inclusive LLC dba The Center of Intrinsic Alignment to charge your credit/debit card on file for agreed upon purchases whether solitary or recurring and in accordance with the consented to policies.

TELEPHONE ACCESSIBILITY If you need to contact me between treatment sessions, please leave a message on the clinic voicemail at 907.328.5965. I am often not immediately available; however, I will attempt to return your call within 24-48 hours. If a true emergency situation arises, please call 911 or any local emergency room.

SOCIAL MEDIA AND TELECOMMUNICATION Due to the importance of your confidentiality and the importance of minimizing dual relationships, I do not accept friend or contact requests to my personal page(s) from current or former clients on any social networking site (Facebook, LinkedIn, etc). I believe that adding clients as friends or contacts on these sites can compromise your confidentiality and our respective privacy. It may also blur the boundaries of our therapeutic relationship. If you have questions about this, please bring them up when we meet and we can talk more about it.

ELECTRONIC COMMUNICATION I cannot ensure the confidentiality of any form of communication through electronic media, including text messages. If you prefer to communicate via email or text messaging for issues regarding scheduling or cancellations, I will do so. While I may try to return messages in a timely manner, I cannot guarantee immediate response and request that you do not use these methods of communication to discuss therapeutic content and/or request assistance for emergencies. All therapeutic content should be directed to your unique client portal, and all true emergencies should be directed to 9-1-1. Services by electronic means, including but not limited to telephone communication, the Internet, facsimile machines, and e-mail is considered telemedicine by the State of California. Under the California Telemedicine Act of 1996, telemedicine is broadly defined as the use of information technology to deliver medical services and information from one location to another. If you and your therapist chose to use information technology for some or all of your treatment, you need to understand that:

1. You retain the option to withhold or withdraw consent at any time without affecting the right to future care or treatment or risking the loss or withdrawal of any program benefits to which you would otherwise be entitled.
2. All existing confidentiality protections are equally applicable.
3. Your access to all medical information transmitted during a telemedicine consultation is guaranteed, and copies of this information are available for a reasonable fee.
4. Dissemination of any of your identifiable images or information from the telemedicine interaction to researchers or other entities shall not occur without your consent.
5. There are potential risks, consequences, and benefits of telemedicine. Potential benefits include, but are not limited to improved communication capabilities, providing convenient access to up-to-date information, consultations, support, reduced costs, improved quality, change in the conditions of practice, improved access to treatment, better continuity of care, and reduction of lost work time and travel costs. Effective treatment is often facilitated when the healthcare provider gathers within a session or a series of sessions, a multitude of observations, information, and experiences about the client. The provider may make assessments, diagnosis, and interventions based not only on direct verbal or auditory communications, written reports, and third person consultations, but also from direct visual and olfactory observations, information, and experiences. When using information technology in services, potential risks include, but are not limited to the provider’s inability to make visual and olfactory observations of clinically or therapeutically potentially relevant issues such as: your physical condition including deformities, apparent height and weight, body type, attractiveness relative to social and cultural norms or standards, gait and motor coordination, posture, work speed, any noteworthy mannerism or gestures, physical or medical conditions including bruises or injuries, basic grooming and hygiene including appropriateness of dress, eye contact (including any changes in the previously listed issues), sex, chronological and apparent age, ethnicity, facial and body language, and congruence of language and facial or bodily expression. Potential consequences thus include the provider not being aware of what he or she would consider important information, that you may not recognize as significant to present verbally to the provider.

MINORS If you are a minor, your parents may be legally entitled to some information about your treatment. I will discuss with you and your parents what information is appropriate for them to receive and which issues are more appropriately kept confidential.

TERMINATION Ending relationships can be difficult. Therefore, it is important to have a termination process in order to achieve some closure. The appropriate length of the termination depends on the length and intensity of the treatment. I may terminate treatment after appropriate discussion with you and a termination process if I determine that the treatment is not being effectively used or if you are in default on payment. I will not terminate the therapeutic relationship without first discussing and exploring the reasons and purpose of terminating. Should you fail to schedule an appointment for three consecutive weeks, unless other arrangements have been made in advance, for legal and ethical reasons, I must consider the professional relationship discontinued.