By typing my full legal name in the following fields below and submitting this form electronically, I acknowledge that I have read and understand the information contained in this document. I understand that my typed name serves as my electronic signature and has the same legal effect as a handwritten signature. I affirm that I am the person signing this document and that I am signing voluntarily.

Your privacy is important. This Notice of Privacy Practices explains how Hope and Healing with Cara and Affiliates may use and disclose your protected health information, your rights regarding that information, and the steps taken to protect your privacy. Please review this document carefully and keep it for your records. If you have any questions about how your information is used or shared, please ask.

Notice of Privacy Practices 

Your privacy is important. This Notice of Privacy Practices explains how Hope and Healing with Cara and Affiliates may use and disclose your protected health information, your rights regarding that information, and the steps taken to protect your privacy. Please review this document carefully and keep it for your records. If you have any questions about how your information is used or shared, please ask.

Notice of Privacy Practices 

This form explains the fees associated with services provided by Hope & Healing with Cara and outlines your financial responsibilities as a client. It includes information about payment expectations, outstanding balances, and fees for missed or late-cancelled appointments. Please review this policy carefully to ensure a clear understanding of the financial aspects of your care.

Financial Responsibility Policy

This form outlines the practice's expectations regarding appointment attendance, cancellations, rescheduling, and missed sessions. Consistent attendance is important for maintaining progress in therapy and ensuring appointment availability. Please review this policy to understand the notice required for cancellations, applicable late cancellation or no-show fees, and how missed appointments may impact ongoing treatment.

Attendance and Cancellation Policy

This form provides important information about psychotherapy services offered through Hope & Healing with Cara. It explains the nature and purpose of therapy, your rights as a client, the potential benefits and risks of treatment, confidentiality and its legal limitations, and your right to participate voluntarily in services. Please review this document carefully and keep it for your records.

Consent for Telehealth

At Hope & Healing with Cara, I use Commure Scribe, a secure HIPAA-compliant AI documentation tool, to help create accurate and thorough therapy notes. As a therapist, I believe my role is to be fully present with you during our sessions. As a person, my most important role is being a mom. By reducing the time spent on administrative documentation outside of sessions, AI-assisted note-taking allows me to devote more time to my family while continuing to provide high-quality care to my clients.

Using AI-assisted documentation also helps ensure that important details, themes, goals, and interventions discussed during our sessions are captured accurately. This allows me to better track your progress, prepare thoughtfully for future sessions, and provide more consistent, effective care over time.

Because AI-assisted documentation is an integral part of how I operate my practice and maintain both quality of care and work-life balance, consent to the use of this technology is required in order to receive services at Hope & Healing with Cara. If you are not comfortable consenting to AI-assisted documentation, I will not be able to provide therapy services. Please review the consent form carefully and save a copy for your records.

Consent for AI-Assisted Documentation

A Good Faith Estimate is a document that provides an estimate of the expected costs of your therapy services. Federal law requires health care providers to give uninsured clients and clients who choose not to use their insurance an estimate of anticipated charges before services are provided. The estimate is intended to help you understand the potential cost of treatment and make informed decisions about your care. Please note that the estimate is not a contract and actual costs may vary based on the frequency, duration, and type of services you receive. Under the No Surprises Act, you have the right to dispute a bill if you are charged substantially more than the amount listed in your Good Faith Estimate.

Good Faith Estimate (No Surprises Act)

I acknowledge that I have received, reviewed, or been provided access to the following documents and policies from Hope & Healing with Cara. I understand that these documents contain important information regarding my rights, responsibilities, privacy protections, financial obligations, and treatment services.

• Notice of Privacy Practices

• Consent to Treat

• Financial Responsibility Policy

• Attendance and Cancellation Policy

• Consent to Telehealth

• Consent to Electronic Communications

• Consent to AI Documentation

• Good Faith Estimate

I understand that:

• My therapist has provided me with the opportunity to ask questions regarding these documents.

• I may request additional copies of these documents at any time.

• I am responsible for reviewing and understanding the information contained within these documents.

• My signature below acknowledges receipt of these documents and does not necessarily indicate agreement with every provision contained within them.

• I understand that policies and procedures may be updated periodically and that I will be notified of significant changes when required by law or professional standards.