Authorization to Bill Insurance

I authorize Gradients of Need, LLC to submit insurance claims on my behalf. I acknowledge that my personal information will be shared with the insurance company listed above. This information will include, but not be limited to, demographic information, visit dates, length of sessions, diagnoses and treatment plans.

I authorize Gradients of Need, LLC to release information specifically related to insurance claims to the primary insured. By signing this authorization, I acknowledge that my personal information will be shared with the primary insured listed above. This information will be limited to demographic information, visit dates, length of sessions and diagnoses.

BY CLICKING ON THE CHECKBOX BELOW I AM AGREEING THAT I HAVE READ, UNDERSTOOD AND AGREE TO THE ITEMS CONTAINED IN THIS DOCUMENT.

ADDITIONAL INFORMED CONSENT AND CLIENT AGREEMENT

WEB-BASED/TELEHEALTH SERVICES

Telehealth services, otherwise referred to as web-based services, create an opportunity to experience psychotherapy from the comfort of your own home or preferred location in Arizona. However, engaging in web-based services increases some risks related to privacy and safety and it is important that you enter into an agreement regarding these concerns prior to engaging in web-based services.

At this time, Gradients of Need, only offers web-based services.

Services

At Gradients of Need it is our expectation that you will benefit from web-based psychotherapy as part, or all of your service needs. Web- based services are provided through the Simple Practice platform, a secure and HIPPA compliant service delivery program. This service is an interactive audio-visual experience.

Web-based services may not be appropriate for your needs. If it is determined that face-to- face services are more appropriate, we will provide you with local referrals.

The “Client Questionnaire” and the “Needs and Concerns” forms are required to be submitted prior to scheduling your first session. Upon review of these forms, a provider will contact you to schedule for web-based services or to discuss the importance of face-to-face services should that be necessary.

Identification of Supervising Therapist

Amber Abila, DSW, LCSW

PMB 205, 2700 S Woodlands Blvd, Ste 300, Flagstaff, AZ 86001

(928) 228-0942

Specialty: Clinical Social Work, Clinical Supervisor

License: LCSW – 197575

Licensing Board: Arizona Board of Behavioral Health Examiners (http://www.azbbhe.us) 

The Arizona Revised Statues (32-3251) states that the:

“Practice of Social Work” means the professional application of social work theory, principles, methods and techniques to (a) treat mental and emotional disorders, (b) assist individuals, families, groups and communities to enhance or restore the ability to function physically, socially, emotionally, mentally and economically, (c) assess, appraise, diagnose, evaluate and treat individuals, couples, families and groups through the use of psychotherapy.

Therapist Expectations

The National Association of Social Workers (NASW) approved a standardized Code of Ethics in 1960, updated in 2017. This Code of Ethics offers a set of values, principles and standards to guide decision-making and everyday professional conduct of social workers. The providers at Balance – Health and Wellness commit to strictly adhere to the NASW Code of Ethics. As such, we are committing to the most ethical practice with respect to client self- determination, informed consent, competence, cultural awareness and social diversity, conflicts of interest, privacy and confidentiality, access to records, professional boundaries, payment for services, termination or interruption of services, and referral for services. A complete and detailed description of this commitment can be found posted online by NASW at (https://www.socialworkers.org/About/Ethics/Code-of-Ethics.aspx).

With respect to commitment to professional boundaries, the providers will not engage in friendship or activities that could be construed as friendships on social media platforms. A professional page is available on FaceBook to allow clients to follow Gradients of Need. Additionally, resources and tools are available on the Gradients of Need website at www.gradientsofneed.com. Please ask your provider for the client password to gain access to these resources.

Client Expectations

While web-based services make it easier to engage in important psychotherapeutic and case management services without leaving your home, there remain to be some necessary requirements for effective services to be rendered. The client is expected to be focused solely on the therapy session while engaged in services. The client is expected to be dressed appropriately for session, which includes wearing, at minimum, a shirt and pants/shorts/skirt or a dress. Unless bed-bound, the client is expected to be seated on a chair, couch, stool or bench during the duration of the session. Effective therapy includes attention to verbal interactions as well as non-verbal interactions, such as facial expressions and mannerisms. As the therapist is limited by the confines of the camera quality and scope, the client is expected to focus the camera on their face, keeping their face free of obstructive objects, such as masks. The client is expected to end each session in a mutual manner after determining plans for a follow up session or termination. The client will not video or audio record any sessions without prior consent of the provider.

The client is expected to disclose any suicidal thoughts, intent and means to engage in self- harm. As such, the client is also expected to provide a contact person who can be reached should a safety plan need to be invoked. The client is also expected to provide an address and phone number for contact during session to ensure a safety plan can be invoked regardless of possible technical difficulties encountered during the session.

Limitations

Web-based services are intended to provide quality interactions related to current and short-term concerns. Web-based services are not generally intended to provide in-depth long-term psychotherapy as this venue is not entirely suited for such interventions and work. If you have a history of major psychiatric episodes, hospitalizations or drug/alcohol dependence or have been diagnosed with any of the following: Borderline Personality Disorder, Major Depressive Disorder, Bipolar Disorder Type I, and/or Schizophrenia, you must disclose this to your provider prior to being considered for web-based services. Failure to disclose such information or knowingly misleading or withholding the above information excludes Gradients of Need and your provider from any legal obligation or liability related to such diagnoses, prognosis, outcome and actions.

Confidentiality

Please refer to the Privacy Practices information packet that you have received and is available on the Gradients of Need website at (www.gradientsofneed.com). Web-based services pose additional concerns related to privacy and confidentiality. Your provider will make all necessary arrangements to ensure a private environment, free from distractions and interruptions, from where they will log into Simple Practice.

You will be expected to make all necessary arrangements to ensure for a private environment, free from interruptions and distractions, in the location from which you log in to Simple Practice. You will be expected to maintain such an environment throughout the entirety of the session. You will be expected to disclose all persons present during the session and not attempt to hide a third party from your provider.

You should be aware that Simple Practice has taken precautions to secure and encrypt the connection used for transmitting private information; however, web-based services could possibly be disturbed or distorted by technical failures or interrupted or accessed by unauthorized persons.

Technical Difficulties

It is understood that when communicating via the internet or other electronic means, disruptions in service or other technical difficulties will likely occur from time to time. Should a disruption occur at the time of a crisis, you will be responsible for immediately calling the office at (928) 228-0942. You will need to provide a phone number where you can be reached as well. If re-connection is not able to occur with the provider, and you find yourself in crisis, you will be expected to immediately call 9-1-1 or go to your nearest emergency room.

Agreements

BY CLICKING ON THE CHECKBOX BELOW I AGREE TO THE FOLLOWING SERVICE POLICIES AND PROCEDURES:

1. I am at least 18 years of age, or parent is signing on my behalf

2. I reside in the state of Arizona while receiving licensed provider services (not applicable to those receiving mental health consultation services)

3. I will provide a scanned or photographed copy of a legal form of identification prior to the onset of services

4. I am aware that a “Notice of Privacy Practices” is available to me online at www.gradientsofneed.com 

5. I will arrange for, and remain in, a secure location, free from distractions and interruptions, prior to logging in to my appointment through Simple Practice.

6. I will email the address of the secure location from where I will be attending session to my provider prior to session.

7. I will email a phone number where I can be reached during my session. 8. I will dress appropriately for each session.

9. I will include only those persons in the session who have been mutually agree upon with my provider

10. I will mutually end each session.

11. I will refrain from video/audio recording without the consent of my provider.

I agree to participate in online psychotherapy and/or case management services. I have read, understood and comply with the agreed upon policies and procedures. I understand that should it be discovered that, at any time during the course of therapy, I have misrepresented my identity to my provider, services will be terminated immediately. I understand that all above services are voluntary and I retain the right to withdraw from services at any time.

BY CLICKING ON THE CHECKBOX BELOW I AM AGREEING THAT I HAVE READ, UNDERSTOOD AND AGREE TO THE ITEMS CONTAINED IN THIS DOCUMENT.

Consent for Telehealth Consultation

1. I understand that my health care provider wishes me to engage in a telehealth consultation.

2. My health care provider explained to me how the video conferencing technology that will be used to affect such a consultation will not be the same as a direct client/health care provider visit due to the fact that I will not be in the same room as my provider.

3. I understand that a telehealth consultation has potential benefits including easier access to care and the convenience of meeting from a location of my choosing.

4. I understand there are potential risks to this technology, including interruptions, unauthorized access, and technical difficulties. I understand that my health care provider or I can discontinue the telehealth consult/visit if it is felt that the videoconferencing connections are not adequate for the situation.

5. I have had a direct conversation with my provider, during which I had the opportunity to ask questions in regard to this procedure. My questions have been answered and the risks, benefits and any practical alternatives have been discussed with me in a language in which I understand.

CONSENT TO USE THE TELEHEALTH BY SIMPLEPRACTICE SERVICE

Telehealth by SimplePractice is the technology service we will use to conduct telehealth videoconferencing appointments. It is simple to use and there are no passwords required to log in. By signing this document, I acknowledge:

1. Telehealth by SimplePractice is NOT an Emergency Service and in the event of an emergency, I will use a phone to call 911.

2. Though my provider and I may be in direct, virtual contact through the Telehealth Service, neither SimplePractice nor the Telehealth Service provides any medical or healthcare services or advice including, but not limited to, emergency or urgent medical services.

3. The Telehealth by SimplePractice Service facilitates videoconferencing and is not responsible for the delivery of any healthcare, medical advice or care.

4. I do not assume that my provider has access to any or all of the technical information in the Telehealth by SimplePractice Service – or that such information is current, accurate or up-to-date. I will not rely on my health care provider to have any of this information in the Telehealth by SimplePractice Service.

5. To maintain confidentiality, I will not share my telehealth appointment link with anyone unauthorized to attend the appointment.

By signing this form, I certify:

• That I have read or had this form read and/or had this form explained to me.

• That I fully understand its contents including the risks and benefits of the prcedure(s).

• That I have been given ample opportunity to ask questions and that any questions have been answered to my satisfaction.

BY CLICKING ON THE CHECKBOX BELOW I AM AGREEING THAT I HAVE READ, UNDERSTOOD AND AGREE TO THE ITEMS CONTAINED IN THIS DOCUMENT.

OMB Control Number: 1210-0169

Right to Receive a Good Faith Estimate of Expected Charges Under the No Surprises Act

You have the right to receive a “Good Faith Estimate” explaining how much your health care will cost. Under the law, health care providers need to give patients who don’t have certain types of health care coverage or who are not using certain types of health care coverage an estimate of their bill for health care items and services before those items or services are provided.

• You have the right to receive a Good Faith Estimate for the total expected cost of any health care items or services upon request or when scheduling such items or services.

• If you schedule a health care item or service at least 3 business days in advance, you will receive a Good Faith Estimate in writing within 1 business day after scheduling. If you schedule a health care item or service at least 10 business days in advance, you will receive a Good Faith Estimate in writing within 3 business days after scheduling. You can also ask any health care provider or facility for a Good Faith Estimate before you schedule an item or service. If you do, you will receive a Good Faith Estimate in writing within 3 business days after you ask.

• If you receive a bill that is at least $400 more for any provider or facility than your Good Faith Estimate from that provider or facility, you can dispute the bill.

• Make sure to save a copy or picture of your Good Faith Estimate and the bill.

For questions or more information about your right to a Good Faith Estimate, visit www.cms.gov/nosurprises/consumers, email FederalPPDRQuestions@cms.hhs.gov, or call 1- 800-985-3059.

By your electronic signature of this form, you authorize charges to your credit card through Stripe via SimplePractice for services rendered. These charges will appear on your bank/credit card statement as Stripe. You have the right to request a paper copy of this document.

I authorize Gradients of Need, LLC to charge my credit card through Stripe. I understand that this credit card will be automatically billed at the time of the provided service. If Gradients of Need, LLC is unable to process my payment, the card on file will be attempted several more times before I will be requested to provide an alternate method of payment. I will be responsible for providing an alternate method of payment at that time. I understand that I must provide 24 hours advance notice in order to cancel an appointment; otherwise I will automatically be billed a late cancellation/missed appointment fee. Please reference the Fee Arrangement form for specific billing amounts related to various services provided.

Rates are subject to change and notification of any changes will be provided in writing along with the effective date of the rate changes. By signing this form, I acknowledge that I have read and agree to all of the above information and have completed the Fee Arrangement form.

I understand that this authorization will remain in effect until I cancel it in writing, and I agree to notify Gradients of Need, LLC in writing of any changes in my account information or termination of this authorization.

I certify that I am an authorized user of this credit card and will not dispute these scheduled transactions with my bank or credit card company as long as the transactions correspond to the terms indicated in this authorization form. I acknowledge that credit card transactions could be linked to Protected Health Information. 

I acknowledge that if I choose to dispute a scheduled transaction that the process for responding to this dispute will require Gradients of Need, LLC to disclose Protected Health Information.

Gradients of Need, LLC

(928) 228-0942

PMB 205, 2700 S Woodlands Village Blvd, Ste 300 Flagstaff, AZ 86001

This notice went into effect on June 20, 2025.

NOTICE OF PRIVACY PRACTICES

THIS NOTICE PERTAINS TO ALL CLIENTS ENGAGED IN, OR HAVING ENGAGED IN, SERVICES WITH BALANCE - HEALTH AND WELLNESS EMPLOYEES AND CONTRACTORS, INCLUDING THOSE CONTRACTORS UNDER THE COOPERATIVE PRACTICE MODEL.

THIS NOTICE DESCRIBES HOW HEALTH INFORMATION MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY.

I. OUR PLEDGE REGARDING HEALTH INFORMATION:

• Your health record contains personal information about you and your health. This information about you may identify you and relate to your past, present or future physical or mental health and any related health care services is referred to as Protected Health Information (PHI). This Notice of Privacy Practices describes how we may use or disclose your PHI in accordance with applicable law and the NASW Code of Ethics. It also describes your rights regarding how you may gain access to and control your PHI.

• We are required by law to maintain the privacy of your PHI and to provide you with notice of our legal duties and privacy practices with respect to your PHI. We are required to abide by the terms of this Notice of Privacy Practices. We reserve the right to change the terms of our Notice of Privacy Practices at any time. Any new Notice of Privacy Practices will be effective for all PHI that we maintain at that time. We will provide you with a copy of the revised Notice of Privacy Practices by posting a copy on our website, sending a copy to you in the mail upon request or providing one to you at your next appointment.

II. HOW WE MAY USE AND DISCLOSE HEALTH INFORMATION ABOUT YOU:

1. For Treatment: Your PHI may be used or disclosed by those who are involved in your care for the purpose of providing, coordinating, or managing your health care treatment and related services. This includes consultation with clinical supervisors or other treatment team members. We may disclose PHI to any other consultant only with your authorization. We may also contact you to remind you of your appointments or to provide information to you about treatment alternatives or other health-related benefits and services that may be of interest to you.

2. For Payment: We may use or disclose PHI so that we can receive payment for the treatment services provided to you. This will only be done with your authorization. Examples of payment-related activities are: making a determination of eligibility or coverage for insurance benefits, processing claims with your insurance company, reviewing services provided to you to determine medical necessity, or undertaking utilization review activities. If it becomes necessary to use collection processes due to lack of payment for services, we will only disclose the minimum amount of PHI necessary for purposes of collection.

3. For Health Care Business Operations: We may use or disclose, as needed, your PHI in order to support our business activities including, but not limited to, quality assessment activities, employee review activities, licensing, and conducting or arranging for other business activities. For example, we may share your PHI with third parties that perform various business activities (e.g., billing or typing services) provided we have a written contract with the business that requires it to safeguard the privacy of your PHI. For training or teaching purposes, PHI will be disclosed only with your authorization.

4. Required by Law: As required by law, we must disclose your PHI to you upon your request. In addition, we must make disclosures to the Secretary of the Department of Health and Human Services for the purpose of investigating or determining our compliance with the requirements of the Privacy Rule.

5. Without Authorization: The following is a list of categories, uses and disclosures permitted by the Health Insurance Portability and Accountability Act (HIPAA) without patient authorization. Applicable law and ethical standards permit us to disclose information about you without your authorization only in a limited number of situations.

6. Verbal Permission: We may also use or disclose your information to family members that are directly involved in your treatment with your verbal permission.

7. With Authorization: Uses and disclosures not specifically permitted by applicable law will be made only with your written authorization, which may be revoked at any time.

As social workers and counselors licensed in this state, as mental health consultants committed to ethical practice and as members of professional associations, including the National Association of Social Workers, it is our practice to adhere to more stringent privacy requirements for disclosures without an authorization. The following language addresses these categories to the extent consistent with the NASW Code of Ethics and HIPAA.

• Child Abuse or Neglect: We may disclose your PHI to a state or local agency that is authorized by law to receive reports of child abuse or neglect.

• Judicial and Administrative Proceedings: We may disclose your PHI pursuant to a subpoena (with your written consent), court order, administrative order or similar process.

• Deceased Patients: We may disclose PHI regarding deceased patients as mandated by state law. A release of information regarding deceased patients may be limited to an executor or administrator of a deceased person’s estate.

• Medical Emergencies: We may use or disclose your PHI in a medical emergency situation to medical personnel only in order to prevent serious harm. Our staff will try to provide you a copy of this notice as soon as reasonably practicable after the resolution of the emergency.

• Family Involvement in Care: We may disclose PHI to close family members or friends directly involved in your treatment based on your consent or as necessary to prevent serious harm.

• Health Oversight: If required, we may disclose PHI to a health oversight agency for activities authorized by law, such as audits, investigations, and inspections. Oversight agencies seeking this information include government agencies and organizations that provide financial assistance to the program (such as third-party payors based on your prior consent) and peer review organizations performing utilization and quality control.

• Law Enforcement: We may disclose PHI to a law enforcement official as required by law, in compliance with a subpoena (with your written consent), court order, administrative order or similar document, for the purpose of identifying a suspect, material witness or missing person. This includes information in connection with the victim of a crime, a deceased person, the reporting of a crime in an emergency, or a crime on the premises.

• Specialized Government Functions: We may review requests from United States Military Command Authorities if you have served as a member of the U.S. Armed Forces, authorized officials for national security and intelligence reasons, and the Department of State for medical suitability determinations, and disclose your PHI based on your written consent, mandatory disclosure laws, and the need to prevent serious harm.

• Public Health: If required, we may use or disclose your PHI for mandatory public health activities to a public health authority authorized by law to collect or receive such information for the purpose of preventing or controlling disease, injury, or disability, or if directed by a public health authority, to a government agency that is collaborating with that public health authority.

• Public Safety: We may disclose your PHI if necessary to prevent or lessen a serious and imminent threat to the health or safety of a person or the public. If information is disclosed to prevent or lessen a serious threat it will be disclosed to a person or persons reasonably able to prevent or lessen the threat, including the target of the threat.

• Research: PHI may only be disclosed after a special approval process. III. YOUR RIGHTS REGARDING YOUR PHI: You have the following rights regarding the PHI we maintain about you. To exercise any of these rights, please submit your request in writing to: Gradients of Need, C/O Privacy Officer, PMB 205, 2700 S Woodlands Village Blvd, Ste 300, Flagstaff, AZ 86001.

1. Right of Access to Inspect and Copy: You have the right, which may be restricted only in exceptional circumstances, to inspect and copy PHI that is maintained in a “designated record set.” A designated record set contains medical/mental health and billing records and any other records that are used to make decisions about your care. Your right to inspect and copy PHI will be restricted only in those situations where there is compelling evidence that access would cause serious harm to you. We may charge a reasonable, cost-based fee for copies. If your records are maintained electronically, you may also request an electronic copy of your PHI.

2. Right to Amend: If you feel that the PHI we have about you is incorrect or incomplete, you may ask us to amend the information although we are not required to agree to the amendment. If we deny your request for amendment, you have the right to file a statement of disagreement with us. We may prepare a rebuttal to your statement and will provide you with a copy. Please contact the Privacy Officer if you have any questions regarding this.

3. Right to an Accounting of Disclosures: You have the right to request an account of the disclosures that we make of your PHI. We may charge you a reasonable fee if you request more than one account in any 12-month period.

4. Right to Request Restrictions: You have the right to request a restriction or limitation on the use or disclosure of your PHI for treatment, payment, or health care operations. We are not required to agree to your request unless the request is to restrict disclosure of PHI to a health plan for purposes of carrying out payment or health care operations, and the PHI pertains to a health care item or service that you paid for out of pocket. In that case, we are required to honor your request for a restriction.

5. Right to Request Confidential Communication: You have the right to request that we communicate with you about medical matters in a certain way or at a certain location.

6. Breach Notification: If there is a breach of secured PHI concerning you, we may be required to notify you of this breach, including what happened and what you can do to protect yourself.

7. Right to a Copy of this Notice: You have the right to a copy of this notice. IV. 

COMPLAINTS:

If you believe we have violated your privacy rights, you have the right to file a complaint in writing or with the Secretary of Health and Human Services at 200 Independence Avenue SW, Washington, D.C. 20201, or by calling (202) 619-0257. We will not retaliate against you for filing a complaint.

ACKNOWLEDGEMENT AND RECEIPT OF PRIVACY PRACTICES

Acknowledgement of Receipt of Privacy Notice

I hereby acknowledge that I have received and have been given an opportunity to read a copy of Notice of Privacy Practices for Gradients of Need. I also acknowledge that I have received the Welcome Letter for Gradients of Need, outlining policies, procedures and client rights related to obtaining services at Gradients of Need. I consent to treatment and services provided by Gradients of Need employees and those under contract in the cooperative practice of Gradients of Need. I understand that the Notice of Privacy Practices and the Welcome Letter are available on the website for my review at any time (www.gradientsofneed.com) and I can request an additional copy of these documents via email or paper. I understand that if I have any questions regarding this notice, my privacy rights, client rights, or policies and procedures for accessing services at Gradients of Need, I can contact the Clinical Director, Amber L Abila, DSW, LCSW at (928) 228-0942 or amber.abila@gradientsofneed.com. 

BY CLICKING ON THE CHECKBOX BELOW I AM AGREEING THAT I HAVE READ, UNDERSTOOD

AND AGREE TO THE ITEMS CONTAINED IN THIS DOCUMENT.