BE WHERE YOUR FEET ARE.

Recovery Inside Out, LLC
800 Old Roswell Lakes Parkway, STE 220, Roswell, GA 30076
404-509-25014
allison@recoveryinsideout.com

INFORMATION, AUTHORIZATION, &
CONSENT TO TREATMENT

Welcome to Recovery Inside Out, LLC (RIO, LLC). We are very pleased that you selected our facility for your therapy, and we are sincerely looking forward to assisting you. This document is designed to inform you about what you can expect from your therapist, Allison Basham, LPC, MAC, Certified ARISE® Interventionist (CAI), Intensively Trained DBT Therapist (DBT), Certified Professional Counselor Supervisor (CPCS) and a Somatic Experiencing Student in Training Level II, policies regarding confidentiality and emergencies, and several other details regarding your treatment here at RIO, LLC. Although providing this document is part of an ethical obligation to our profession, more importantly, it is part of our commitment to you to keep you fully informed of every part of your therapeutic experience. Please know that your relationship with your therapist or group leader is a collaborative one, and we welcome any questions, comments, or suggestions regarding your course of therapy at any time.

Background Information, Theoretical Views, & Client Participation

“A journey of a thousand miles begins with a single step”- LAO TZU

Beginning the counseling process can be filled with mixed emotions. We are honored you have chosen us to assist you during this process. The counseling process involves an initial intake, in which we will be collecting information to best understand how we can meet your needs. We will also identify specific goals you would like to get out of the therapy process.

We believe it is our job to help you figure out what skills you need to create a life worth living and therefore, reduce the amount of suffering you experience in your life. As therapists, we have observed as people become more aware and accepting of themselves, they are more capable of finding a sense of peace and contentment in their lives. However, self-awareness and self-acceptance are goals that may take a long time to achieve. Some clients need only a few sessions to achieve these goals, whereas others may require months or even years of therapy. As a client, you are in complete control of your session in the sense that you may end your relationship with your therapist at any point. Our goal as your therapist is to meet you where you are and utilize the most effective mode of therapy to facilitate change.

Allison is a Licensed Professional Counselor, Certified Psychodrama Facilitator, Master Addiction Counselor, an Intensively Trained DBT therapist, Certified ARISE Interventionist, Certified Professional Counselor Supervisor, and a Somatic Experiencing Student in Training Level II. Allison has been in the counseling field for over 20 years, working with adolescents, young adults, adults and families. Allison has worked in a variety of settings including residential, intensive outpatient, and private practice.

Allison draws from years of professional experience and a variety of theoretical approaches, including, Motivational Interviewing, Stages of Change, 12-step Model, Family Systems, Dialectical Behavioral Therapy (DBT), Cognitive Behavioral Therapy (CBT), Experiential/Psychodrama, and Somatic Experiencing.

Allison holds an Undergraduate Degree in Psychology with a Minor in Criminology from
Kennesaw State University and a Masters in Professional Counseling with a Concentration in Marriage and Family Therapy from Argosy University. Allison received extensive training from Behavioral Tech, LLC in DBT. Allison actively participates in DBT Consultation Team to adhere to DBT protocol. In 2016, Allison received a Master Addiction Counselor certification. In 2017, Allison completed training through the ARISE® Network and am a Certified ARISE® Interventionist. In 2019, I begin training in Somatic Experiencing and she is currently a student in Level II training.

Allison specializes in treating adolescent and young adults with substance use, mis-use, abuse, and addiction, assessment and treatment placement for substance use and mental health concerns, recovery management, mood disorders, anxiety disorders, suicidal ideation, self-harming behaviors, trauma, relationship issues, parenting skills (with particular expertise around adolescent and young adult concerns), DBT skills training and Somatic Experiencing techniques.

There are three areas Allison is most passionate about: 1- helping young people and families who have been impacted by substance use; 2- helping young people and families reduce the amount of suffering they experience and create a life worth living and 3- helping people move out of shame and/or negative emotions to a place of peace and joy.

For therapy to be most effective, it is important for you to take an active role. This means working on the things you and Allison talk about both during and between sessions. This also means avoiding any mind-altering substances like alcohol or non-prescription drugs for at least eight hours prior to your therapy sessions. Generally, the more of yourself you are willing to invest, the greater the return.

Furthermore, it is Allison’s policy to work with clients who have the capacity and willingness to resolve their own problems with the assistance of individual and/or family therapy. It is Allison’s intention to empower her clients in his/her growth process to the degree that he/she is capable of facing life’s challenges in the future without therapy. As a therapist, Allison does not believe in creating dependency or prolonging therapy if the therapeutic intervention does not seem to be helping. If this is the case, Allison will direct you to other resources that will be of assistance to you.

Your personal development is the number one priority in therapeutic process. Allison encourages her clients to let her know if he/she feels that transferring to another facility or another therapist is necessary at any time. Allison’s goal is to facilitate healing and growth and she is very committed to helping her client in whatever way seems to produce maximum benefit.

If at any point the client is unable to keep his/her appointments or we don't hear from the client for three weeks, we will need to close the client’s chart. Please note, reopening the client’s chart and resuming treatment is always an option.

Confidentiality, Records, Simple Practice & Patient Portal

The client’s communications with Allison Basham, LPC, MAC, CAI, DBT, CPCS, or with any of our professional therapists on staff at Recovery Inside Out, LLC, will become a part of a clinical record of treatment and it is referred to as Protected Health Information (PHI). At Recovery Inside Out, LLC, we store your PHI in two places: Simple Practice (a HIPPA compliant electronical medical record program) and in a file stored in a locked cabinet in our locked business office. It is our duty and responsibility to protect your confidentiality to the fullest extent. Additionally, Allison Basham, LPC, MAC, CAI, DBT, CPCS, and our professional therapists on staff at Recovery Inside Out, LLC, will always keep everything you say completely confidential, with the following exceptions: (1) You direct her to tell someone else and you sign a “Release of Information” form; (2) She determines that you are a danger to yourself or to others; (3) You report information about the abuse of a child, an elderly person, or a disabled individual who may require protection; or (4) She is ordered by a judge to disclose information. In the latter case, her license does provide her with the ability to uphold what is legally termed “privileged communication.” Privileged communication is your right as a client to have a confidential relationship with a counselor. The state of Georgia has a very good track record in respecting this legal right. If for some unusual reason a judge were to order the disclosure of your private information, this order can be appealed. Allison, including our professional therapists on staff at Recovery Inside Out, LLC, cannot guarantee that the appeal will be sustained, but we will do everything in our power to keep what you say confidential.

Upon entering into the counseling relationship with Allison Basham, LPC, MAC, CAI, DBT, CPCS, she asks all clients to provide updated contact information (address, phone number, and emails) and an Emergency Contact number. The emergency contact number will be used in instances including, but not limited to: missed appointments, if the client is perceived to be in danger to themselves or to others (i.e., intoxicated, reports suicidal thoughts, actively participating in self-harming behavior, etc.), and if we are unable to reach the client for any reason. Please be sure to provide a contact you are comfortable with having any of this information listed above communicated too in case of an emergency.

Please note that in couples and family counseling, Allison Basham, LPC, MAC, CAI, DBT, CPCS, does not agree to keep secrets. Information revealed in any context may be discussed with either partner or family member. Each family member who participates in the counseling process will be required to sign a Collateral Informed Consent.

Recovery Inside Out, LLC and Allison Basham, LPC, MAC, CAI, DBT, CPCS, utilize a HIPPA Compliant electronical medical record program specifically designed for therapists, Simple Practice. Simple Practice ensures this portal is encrypted to the federal standard, HIPAA compatible, and has agreed to sign a HIPAA Business Associate Agreement (BAA). The BAA means that Simple Practice is willing to attest to HIPAA compliance and assumes responsibility for keeping our interactions secure and your PHI confidential. Simple Practice allows our practice to do a variety of things including: store clients protected health information, online scheduling, online billing, submitting insurance claims, and therapist documentation storage.

More importantly, Simple Practice provides a secure patient portal for every client that is a part of the practice. On this portal, clients will be able to schedule/cancel appointments, sign paperwork, access superbills, store credit card information and more. If you are 18 years old or older and you want someone else to have access to your patient portal you will need to sign a release of information. We will send you an email with detailed directions regarding how to log-in securely. We also strongly suggest that you only communicate through a device that you know is safe (e.g., has a firewall, anti-virus software installed, is password protected, not accessing the internet through a public wireless network, etc.).

Additionally, through the client portal, you have the option of receiving text and/or email reminders of your appointments with us and/or billing information. If you would like this service, please indicate on the client information page or let Allison Basham, LPC, MAC, CAI, DBT, CPCS, know that you would like this service. It is also important to note, it is the responsibility of the client to keep track of scheduled appointments. If for any reason Simple Practice does not send a notification about your scheduled appointment you are still responsible for payment of the appointment.

Structure and Cost of Sessions

Allison Basham, LPC, MAC, CAI, DBT, CPCS, agrees to provide psychotherapy for the following fees:

School evaluations (1.5 hrs)- $350 ($100per 30 mins if over 1.5 hrs)

Assessment (2-2.5hrs)- $300 per hour

Intake (1-1.5hrs)- $195

Individual session (50 min)- $170
Family session (60min)- $250
Letters/Documentation/Coordination of care- $200 (per hour)/$50 minimum

Consultation (1-1.5 hrs)- $350

All appointments require a non-refundable $150 deposit to schedule the appointment. The deposit will be put toward the final amount. TeleMental Health services follow the same procedures and fees outlined in this form and section.

Doing psychotherapy by telephone is not ideal, and needing to talk to your therapist between sessions may indicate that you need extra support. If this is the case, we will need to explore adding sessions or developing other resources you have available to help you. Telephone calls that exceed 10 minutes in duration will be billed at $50.00 per minute. Texting and emails are billed at your therapist's hourly rate for the time he or she spends reading and responding.

Currently, RIO, LLC requires all patients to keep a credit card/ debit card on file. We require a credit card ahead of time for all therapy sessions for ease of billing. Please sign the Credit Card Payment Form, which was sent to you separately and indicates that we may charge your card without you being physically present. The credit card will be charged at the end of each session through Simple Practice. Visa, MasterCard, Discover, or American Express are acceptable for payment. Please note that there is a $35 fee for any returned checks. You WILL NOT be allowed to schedule another appointment until this fee is paid.

Insurance companies have many rules and requirements specific to certain plans. It is your responsibility to find out your insurance company’s policies and to file for insurance reimbursement. Currently, Allison Basham, LPC, MAC, CAI, DBT, CPCS, does not accept any insurance plans; therefore, it is your responsibility to pay for the session. Once we have received payment for services, you can obtain a superbill online through your patient portal. The superbill may also be used for insurance, if applicable to you.

Allison Basham, LPC, MAC, CAI, DBT, CPCS, changes her rates once a year to reflect increases in standard of living, experience, and/or additional training. Therefore, if there is a gap in treatment for more than 2 months for non-therapeutic reasons, current rates for counseling will apply.

Assessment/School Evaluation

When participating in the assessment and/or school evaluation process Allison Basham, LPC, MAC, CAI, DBT, CPCS, will provide you with recommendations in regards to next steps at the end of the appointment. If you are attempting to utilize insurance to cover any of the recommendations given you will need to notify Allison Basham, LPC, MAC, CAI, DBT, CPCS, at the time of the appointment or within 7-10 days of the evaluation. Often times your insurance provider will require you to provide clinical information in order to access benefits. In general, the longer the time between meeting with Allison Basham, LPC, MAC, CAI, DBT, CPCS, and providing the clinical information to your insurance company the more it interferes with their likely hood of covering what is being recommended. It is also important to note, if you need Allison Basham, LPC, MAC, CAI, DBT, CPCS, to speak with your insurance company to provide any clinical information there will be an additional fee. There is a $50 minimum charge and a $200 charge per hour. If you have any questions in regards to this service please speak to Allison Basham, LPC, MAC, CAI, DBT, CPCS, directly.

Letters/Documentation/Coordination of Care

If during the counseling process you need Allison Basham, LPC, MAC, CAI, DBT, CPCS, to write a letter, send any documentation, and/or coordinate care with another provider (i.e., talking with a psychiatrist, another therapist, treatment center, probation officer, etc.) the following fees will apply for the services rendered. There is a $50 minimum charge and a $200 charge per hour per service rendered. If you have any specific questions concerning this service please speak to Allison Basham, LPC, MAC, CAI, DBT, CPCS, directly.

Cancellation Policy/ Hours of Operations

Allison, including the professional therapists on staff at Recovery Inside Out, LLC, are required to make sure that the client is aware that Recovery Inside Out, LLC, is located in the Southeast and we abide by Eastern Standard Time.

Currently Allison Basham, LPC, MAC, CAI, DBT, CPCS, is in the office Mon, Tues, Thurs 10am-5pm and Wed by appointment only. It is important to note, If you need to reach Allison Basham, LPC, MAC, CAI, DBT when she is not in the office you can email her directly at azitobasham@gmail.com and she will get back to you during her normal business hours. However, if you are in need of more immediate assistance please contact the resources in the next section “In Case of Emergency”.

In the event that you are unable to keep an appointment, you must notify RIO, LLC at least 24 hours in advance. Acceptable forms of cancellation include: accessing the patient portal, calling our office, leaving a message on the office voicemail, or email. Please do not text message the office or your therapist. If such advance notice is not received, or if you do not show, you will be financially responsible for the session you missed. Please note that insurance companies do not reimburse for missed sessions. You will also be required to pay for the missed appointment before you can schedule another appointment.

In Case of an Emergency

Recovery Inside Out, LLC is considered to be an outpatient facility and we are set up to accommodate individuals who are reasonably safe and resourceful. We do not carry beepers nor are we available at all times. If at any time this does not feel like sufficient support, please inform Allison Basham, LPC, MAC, CAI, DBT, CPCS, and she can discuss additional resources or transfer your case to a therapist or clinic with 24-hour availability. Generally, she will return phone calls within 24– 48 hours during hours of business noted above. If you have a mental health emergency, she encourages you not to wait for a call back, but to do one or more of the following:

• Call Behavioral Health Link/GCAL: 800-715-4225
• Call Ridgeview Institute at 770.434.4567
• Call Peachford Hospital at 770.454.5589
• Call 911.
• Go to your nearest emergency room.

Professional Relationship

Psychotherapy is a professional service Allison Basham, LPC, MAC, CAI, DBT, CPCS, will provide to you. Because of the nature of therapy, your relationship with her has to be different from most relationships. It may differ in how long it lasts, the objectives, or the topics discussed. It must also be limited to only the relationship of therapist and client. If you were to interact with her in any other ways, you would then have a "dual relationship," which could prove to be harmful to you in the long run and is, therefore, unethical in the mental health profession. Dual relationships can set up conflicts between the therapist's interests and the client’s interests, and then the client’s (your) interests might not be put first. In order to offer all of her clients the best care, her judgment needs to be unselfish and purely focused on your needs. This is why your relationship with her must remain professional in nature.

Additionally, there are important differences between therapy and friendship. Friends may see your position only from their personal viewpoints and experiences. Friends may want to find quick and easy solutions to your problems so that they can feel helpful. These short-term solutions may not be in your long-term best interest. Friends do not usually follow up on their advice to see whether it was useful. They may need to have you do what they advise. A therapist offers you choices and helps you choose what is best for you. A therapist helps you learn how to solve problems better and make better decisions. A therapist's responses to your situation are based on tested theories and methods of change.

You should also know that therapists are required to keep the identity of their clients confidential. As much as Allison Basham, LPC, MAC, CAI, DBT, CPCS, would like to, for your confidentiality she will not address you in public unless you speak to her first. She also must decline any invitation to attend gatherings with your family or friends. Lastly, when your therapy is completed, she will not be able to be a friend to you like your other friends. In sum, it is the duty of Allison Basham, LPC, MAC, CAI, DBT, CPCS, to always maintain a professional role. Please note that these guidelines are not meant to be discourteous in any way, they are strictly for your long-term protection.

Statement Regarding Ethics, Client Welfare & Safety

Recovery Inside Out, LLC and Allison Basham, LPC, MAC, CAI, DBT, CPCS, assures you that our services will be rendered in a professional manner consistent with the ethical standards of the American Counseling Association. If at any time you feel that we are not performing in an ethical or professional manner, we ask that you please let Allison Basham, LPC, MAC, CAI, DBT, CPCS, know immediately.

Due to the very nature of psychotherapy, as much as Allison Basham, LPC, MAC, CAI, DBT, CPCS, would like to guarantee specific results regarding your therapeutic goals, she is unable to do so. However, with your participation, she will work to achieve the best possible results for you. Please also be aware that changes made in therapy may affect other people in your life. For example, an increase in your assertiveness may not always be welcomed by others. It is her intention to help you manage changes in your interpersonal relationships as they arise, but it is important for you to be aware of this possibility nonetheless.

Additionally, at times people find that they feel somewhat worse when they first start therapy before they begin to feel better. This may occur as you begin discussing certain sensitive areas of your life. However, a topic usually isn’t sensitive unless it needs attention. Therefore, discovering the discomfort is actually a success. Once you and Allison Basham, LPC, MAC, CAI, DBT, CPCS, are able to target your specific treatment needs and the particular modalities that work the best for you, help is generally on the way.
It is also important to note, when you receive any recommendations from Allison Basham, LPC, MAC, CAI, DBT, CPCS, in regards for further treatment (which may include, and are not limited to: Intensive Outpatient Treatment, Inpatient Treatment, Detox, Residential Treatment, Sober living, other therapist referrals, etc) she is not responsible for the care you may receive once you engage in the treatment process. Any client who follows the recommendations given by Allison Basham, LPC, MAC, CAI, DBT, CPCS, assumes all risks associated with participating in the recommendations and releases Allison Basham, LPC, MAC, CAI, DBT, CPCS, and Recovery Inside Out, LLC from any harm that may be acquired.

Technology Statement
In our ever-changing technological society, there are several ways RIO, LLC and Allison Basham, LPC, MAC, CAI, DBT, CPCS, could potentially communicate and/or follow each other electronically. It is of utmost importance to us that we maintain your confidentiality, respect your boundaries, and ascertain that your relationship with us remains therapeutic and professional.

Therefore, we’ve developed the following policies:
Cell phones: It is important for you to know that cell phones may not be completely secure and confidential. However, we realize that most people have and utilize a cell phone. We may also use a cell phone to contact you. If this is a problem, please feel free to discuss this with Allison Basham, LPC, MAC, CAI, DBT, CPCS.

Text Messaging and Email:
Both text messaging and emailing are not secure means of communication and may compromise your confidentiality. However, we realize that many people prefer to text and/or email because it is a quick way to convey information. If you choose to utilize texting or email, please discuss this with Allison Basham, LPC, MAC, CAI, DBT, CPCS. However, please know that it is our policy to utilize these means of communication strictly for brief topics such as appointment confirmations. Please do not bring up any therapeutic content via text or email to prevent compromising your confidentiality. You also need to know that we are required to keep a copy of all emails and texts as part of your clinical record.

Even though we will only utilize texting for appointments, Allison Basham, LPC, MAC, CAI, DBT, CPCS utilizes a special text messaging software called HIPPA Bridge for your added protection. She has chosen this technology because it is encrypted to the federal standard, HIPAA compatible, and the company has signed a HIPAA Business Associate Agreement (BAA). The BAA means that the company is willing to attest to HIPAA compliance and assume responsibility for keeping your PHI secure. We encourage you to also utilize this software if you do not wish for others to have access to your communications. We also strongly suggest that you only communicate through a device that you know is safe and technologically secure (e.g., password protected). If you choose to utilize this software, Allison Basham, LPC, MAC, CAI, DBT, CPCS will store your information by your first name and last initial. We encourage you to also utilize this software if you do not wish for others to have access to your communications and we will provide you with directions as to how to access this software.

Facebook, LinkedIn, Instagram, Pinterest Etc:
It is Allison Basham, LPC, MAC, CAI, DBT, CPCS’s policy not to accept requests from any current or former client on her personal social networking sites such as Facebook, LinkedIn, Instagram, Pinterest, etc. because it may compromise your confidentiality. RIO, LLC is on Facebook. You are welcome to follow us on this page. However, please do so only if you are comfortable with the general public being aware of the fact that your name is attached to RIO, LLC and/or our employees. If you would like to follow us on any media, you might want to consider using an alias to keep your connection with us confidential, but that is entirely your decision.

Google, etc.:
It is our policy not to search for our clients on Google or any other search engine. We respect your privacy and make it a policy to allow you to share information about yourself to your therapist as you feel appropriate. If there is content on the Internet that you would like to share with Allison Basham, LPC, MAC, CAI, DBT, CPCS for therapeutic reasons, please print this material out and bring it to your session.

Twitter & Blogs:
We may post psychology news on Twitter or write an entry on a blog. If you have an interest in following either of these, please let Allison Basham, LPC, MAC, CAI, DBT, CPCS know. She will discuss any potential implications to your therapeutic relationship. Once again, maintaining your confidentiality is a priority. We would recommend using an RSS feed or locked Twitter list, which would eliminate you having a public link to our content.

Recording Sessions:
Upon entering into the counseling relationship, you agree to not utilize any type of recording device (including, but not limited to voice recording on cell phone, voice recording on texting, digital recorder, etc.) during our sessions without informing Allison Basham, LPC, MAC, CAI, DBT, CPCS first. This is to ensure your confidentiality and protect the relationship between the two of you. Allison Basham, LPC, MAC, CAI, DBT agrees to not use any recording devices without your permission first.

In summary, technology is constantly changing, and there are implications to all of the above that we may not realize at this time. Please feel free to ask questions, and know that we are open to any feelings or thoughts you have about these and other modalities of communication.

Consultation
At Recovery Inside Out, LLC we believe therapists need to continually monitor their effectiveness as professionals and take steps to improve when necessary. We believe this occurs through consultation, continuing education, professional trainings, and supervision with other professionals in the counseling field. Therefore, we support therapists in our practice, to seek peer supervision and/or consultation to evaluate their efficacy as therapists. When consultation occurs we will be sure to use information that is germane in nature as to not break your confidentiality. If we feel it is necessary to consult with another professional and there is a potential to threaten your confidentiality we will discuss this with you first and have you sign a release form. If you have any concerns or questions in regard to consultation please feel free to speak with your therapist.

Dialectical Behavioral Therapy (DBT) Terms
Allison Basham, LPC, MAC, CAI, DBT, CPCS is an adherent Intensively Trained DBT therapist and provides DBT individual sessions. Once it is determined DBT counseling will be an effective mode of treatment, Allison Basham, LPC, MAC, CAI, DBT, CPCS will review specific DBT Terms of Therapy before you begin. If you have any questions about these terms before you begin please speak with her directly.

Somatic Experiencing
Somatic Experiencing® (SE™) is a naturalistic form of healing that will help you learn how to settle and release physiological activation from your body. Very often this process helps people to reduce stress and return to a sense of regulation and mastery in their lives. SE™ will support you in learning how to attend to uncomfortable sensations in your body and gently unwind them through your conscious attention. SE™ is particularly useful in managing stress because so many of the symptoms are physiological. If you would like to read more about SE™, visit our website at www.traumahealing.org or read In an Unspoken Voice by Dr. Peter Levine.

• SE™ employs awareness of body sensation to help people "renegotiate" and heal rather than re-live or re-enact trauma.
• SE™ 's guidance of the bodily "felt sense," allows the highly aroused survival energies to be safely experienced and gradually discharged.
• SE™ may employ touch in support of the renegotiation process.
• SE™ “titrates” experience (breaks down into small, incremental steps), rather than evoking catharsis - which can overwhelm the regulatory mechanisms of the organism.

Once it is determined Somatic Experiencing® will be the mode of treatment utilized, Allison Basham, LPC, MAC, CAI, DBT, CPCS will review with you a SE informed consent and terms of therapy before beginning.

Interventions
Allison Basham, LPC, MAC, CAI, DBT, CPCS is a Certified ARISE® Interventionist and provides intervention services by professional referral only. If you are interested in finding out more about these services, you can speak to her directly.

Our Agreement to Enter into a Therapeutic Relationship

We are sincerely looking forward to facilitating you on your journey toward healing and growth. If you have any questions about any part of this document, please ask Allison Basham, LPC, MAC, CAI, CPCS, Intensively Trained DBT Therapist.

LISTEN TO YOUR BODY.

EXPLORE YOUR WORLD!

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