DECLARATION OF PRACTICES AND PROCEDURES
Mallory Garza, Ph.D., LP KS #03223
Garza Psychological Services
Qualifications: I earned doctoral degree in Counseling Psychology from Louisiana Tech University in 2019. I am a Licensed Psychologist in the state of Kansas (LP #03223) and hold a license with the Kansas Behavioral Sciences Regulatory Board located at 700 SW Harrison St #420, Topeka, KS 66603; (785) 296-3240.
Services Offered and Clients Served: I provide individual psychotherapy services via telehealth to individuals aged 18 and older. I strive to provide a therapeutic relationship that is based on collaboration, trust, and authenticity. I believe that all people have the capacity for self-awareness and that each person has a unique identity that can be known only through genuine relationships with others. I believe that the role of therapist is to help individuals focus on personal responsibility for making decisions in their lives, and I often use cognitive-behavioral therapies as a means of helping individuals exert personal control over their own behaviors. Areas of clinical interest include working with young adults who present with concerns related to anxiety, depression, identity exploration, existential concerns, and general adjustment concerns.
Areas of Focus: I primarily work with young adults between the ages of 18 and 40. I have
experience working with young adults who present with a wide range of concerns, including but not limited to: anxiety disorders, depression, adjustment concerns, bipolar disorder, personality disorders, and trauma. I do not offer group psychotherapy, couple’s therapy, therapy to minors, medication management, court-ordered evaluations, or letters for emotional support animals.
Evaluation: The first session will involve my evaluation of your needs. This evaluation typically lasts 60- 90 minutes. By the end of the first appointment, we will discuss if I am the right therapist for you and I will offer a tentative treatment plan. I will refer you to another therapist if I believe someone else is better suited.
Psychotherapy: Psychotherapy is a collaborative effort that requires active participation from you. The approach used may vary depending on your needs and it may involve discussing uncomfortable topics. There are no guarantees about the outcome of therapy, but studies have shown psychotherapy to be helpful to those who undergo it.
Benefits and Risks of Therapy: Therapy requires a significant investment of time, money, and energy. Therapy can be a helpful and effective way to address emotional and behavioral difficulties. Potential benefits of therapy include improved mood, reduced stress, better coping skills, and enhanced relationships. However, therapy can also involve some emotional discomfort as you explore challenging issues. Throughout any therapy sessions, I encourage you to ask questions. Also, feel free to seek a second opinion at any time.
Code of Conduct: As a Licensed Psychologist, I observe the American Psychological Association Ethics Code and am required by law to adhere to the laws and statutes set forth by the Kansas Behavioral Sciences Regulatory. A copy of the Code of Conduct is available to you upon request. Should you wish to file a disciplinary complaint regarding my practice as a Licensed Psychologist, you may contact the Kansas Behavioral Sciences Regulatory Board.
Confidentiality: All information discussed in therapy sessions will be kept confidential, unless you give me written permission to share such information, with some exceptions as outlined below.
I may be required by law to report suspected abuse or neglect, for example regarding children, elders, or disabled adults.
I may also be required to disclose information if compelled by a court order.
If I believe you may harm yourself or others, I may need to take steps to ensure your safety or the
safety of others.
I may consult with other professionals about your case to help provide you with appropriate care.
If I do such consultations, I will make every effort to avoid revealing information that could
identify you to maintain your privacy.
If you use your insurance benefits, I must share clinical information about you.
If you are concerned about confidentiality in any situation, please bring it to my attention.
Privileged Communication: It is my policy to assert privileged communication on behalf of the client and the right to consult with the client, if possible, except during an emergency, before mandated disclosure. I will endeavor to apprise clients of all mandated disclosures as conceivable.
Your Right to Access Records: Your protected health information is confidential. As your therapist, I am obligated by federal law (HIPAA) and state law to protect your privacy. You have the right to access and obtain a copy of most of the health information in your record. What your record includes:
Clinical/Progress Notes: This is the official and most comprehensive part of your record. It includes your assessments, diagnoses, treatment plans, a summary of your symptoms and progress, and any communication with third parties. You have a legal right to access these notes.
Psychotherapy Notes: These are my private notes, recorded for my own use, to analyze and document the content of our conversations. Under HIPAA, psychotherapy notes are given extra protection and are kept separate from the rest of your record. You do not have a legal right to access these notes, and I am not obligated to share them with you or anyone else unless required by a court order or other specific legal mandate.
How to Request Your Records:
Please submit a formal request in writing.
Your request will be processed within the legally mandated timeframe, typically 30 days.
I may charge a reasonable, cost-based fee for the copies.
Limitations on Your Access: In rare circumstances, access to your clinical record may be denied. These circumstances include instances where a licensed professional has determined that providing access is reasonably likely to endanger the life or physical safety of you or another person. You have the right to have this denial reviewed by an independent practitioner.
Releasing Your Records to a Third Party: If you want your records sent to another healthcare provider, attorney, or any other party, you must first sign a specific written Authorization to Release Information. This authorization will specify exactly what information can be released and to whom.
Emergency Situations: GPS does not provide walk-in or emergency services. GPS also does not provide after-hours on-call services. When the psychologist is unavailable to answer calls during or after normal office hours and you are in an emergency where an immediate response is necessary, you may seek help through hospital emergency facilities local to you. You may also call 911 in the event of an emergency.
Fees and Payment: Clients are seen by appointment only. Clients can find more information about individual psychotherapy services through provider’s website, by emailing provider at drmallorygarza@gmail.com, or by visiting provider’s website. I require that a method of payment (debit or credit card) be kept on file for the purpose of payment. Payment is due at the time of service unless otherwise agreed upon. I do not currently accept insurance; however, I can provide you with a detailed receipt that you may submit to your insurance company to seek reimbursement. There is a $75 fee for cancellations with less than 24 hours’ notice. There is a $75 fee for no-show appointments. If your account is unpaid after 90 days, I may use legal means, such as the help of a collection agency, to collect payment. Fees for services are provided below:
30-min $ 75
45-min $100
60-min $150
90-min $200
Additional services, including the list below, will be billed at a rate of $150 per hour.
Report writing
Telephone conversations at your request
Attendance at meetings with other professionals per your request
Preparation of records or treatment summaries
Time spent performing any other service you may request of me and to which I agree
Tasks under one hour will be pro-rated (meaning the cost will be calculated proportionally to the time spent on the task and not the full hourly rate).
Legal Matters: You are responsible for my professional time if legal matters require my participation, even if I am subpoenaed. My fee for legal preparation and attendance at proceedings is $200 per hour.
Contacting Me: When you contact me via email or phone, you are welcome to leave me a message. I will make every effort to return your call within 48-hours excluding weekends/holidays. If you cannot reach me and require immediate help, call 911 or call 988. In case of an extended absence on my part, I will provide you with contact information of a colleague who may be able to provide you with services. *Please keep in mind that communication via phone and email is not secure nor HIPAA compliant. I discourage clients from contacting me via these methods. Instead, you can contact me via secure message in your TherapyNotes patient portal (which is HIPAA compliant and secure).
Social Media Policy: I do not accept friend or contact requests from current 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 and we can discuss them.
Your Rights:
You have the right to participate actively in your treatment and make informed decisions about
your care.
You have the right to ask questions and request clarification at any time.
You have the right to terminate therapy at any time.
You have the right to seek a second opinion.
You have the right to access your treatment records, with some exceptions. Please let me know if
you would like to discuss.
Psychologist Responsibilities: I am committed to providing you with competent and ethical psychological care. I will respect your privacy and confidentiality. I will discuss the limitations of my expertise and refer you to another provider if necessary.
Client Responsibilities: The client is expected to participate fully in each session alongside the therapist. We are equal partners in the therapy room, and we work together to set goals and work together to solve your presenting concerns. For the therapy relationship to work, I ask that you be honest with me. Any suggestions or concerns you might have can be discussed in therapy. We will work to make any changes to make you feel like the therapeutic relationship is working. If at any point I feel that you would be better served by another mental health professional, I will help make the referral.
Telehealth: To participate in online or distance counseling, you will be required to have access to a computer or smart device with internet access. A high-speed internet connection will be necessary for video calls. Video sessions will take place through a HIPPA compliant website (your TherapyNotes Patient Portal). 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 during a session, you agree to immediately call me via phone. It is acknowledged that online or distance counseling is not a substitute for medication given under the care of a psychiatrist or doctor. It is further understood that online distance counseling is not appropriate if you are experiencing a crisis or having suicidal or homicidal thoughts. Online communications (e.g., email, chats, or video sessions) via the chosen website (e.g., TherapyNotes) are encrypted, but emails sent from or to personal accounts are not secure. Although I have taken substantial steps to ensure the confidentiality and privacy of therapy provided online, I cannot guarantee the security of any internet or all phone transmissions or communications. You agree to take full responsibility for the security of any communications or treatment documents on your own computer and in your physical location. If I believe you are a danger to or may become a danger to yourself or anyone else, I am mandated by law to inform others or insist that you be evaluated in person by another health care professional. I will contact local authorities if a crisis arises during a telehealth session. As a rule, personal and clinical communications (i.e. communication for purposes other than scheduling) should be reserved for session times (in-person sessions, video sessions, or phone sessions) except in the cases of emergency you further acknowledge that if either you or your LPC use a cell phone, the conversation may not be secured therefor not confidential. I am only able to conduct teletherapy sessions to residents in Kansas at this time. You must be present in the state of Kansas at the time of your therapy appointment in order to receive services (i.e., we cannot meet for a therapy appointment if you are out of the state at the time of the appointment). All teletherapy sessions will be scheduled by phone with me. I will send a link to the teletherapy session prior to the scheduled session. In emergency situations call the National Suicide Prevention Lifeline at 1-800-273-TALK (8255), dial 911, or go to your nearest emergency room. If teletherapy is no longer a viable means of conducting mental health services, I will personally seek a referral source for you to continue your access to quality mental health care.
Agreement: By signing below, you acknowledge that you have read and understand this Informed Consent document, that you have had all your questions answered to your satisfaction, and you consent to the releases of information described above. You agree to participate in therapy voluntarily.
Client Signature: __________________________________________Date: _______________
Psychologist Signature: __________________________________ Date: _______________