aligned.
Healing and Wellness Therapy
Disclosures
In the interest of full transparency, you will find disclosures and privacy practices here.
Practice Disclosure
Welcome to my practice.
I am honored to have you as a client. This document will inform you about me, my professional services and my business policies. Please pay careful attention and jot down any questions you might have so that we can discuss them during our first session.
Education and Licensure
I have a Masters in Social Work from St. Ambrose University. This program is accredited, well-rounded, integrated, and experiential, and I have an excellent foundation to have a productive and successful career as a psychotherapist. I am licensed in the State of Iowa as a Licensed Independent Social Worker (080441). I am fully licensed and have been approved as a Clinical Supervisor. I adhere to the Ethics of Social Work (https://www.socialworkers.org/About/Ethics/Code-of-Ethics/Code-of-Ethics-English).
I am an integrative and humanistic therapist with training in EMDR, CBT, DBT, IFS and Integrative Health. I am certified from Postpartum International Support as a perinatal mental health clinician. I take a neuro and polyvagal informed approach to connect your brain and body together. I also use a person in environment approach to understanding your unique adaptive and maladaptive, conscious and unconscious strategies in order to connect a heightened awareness for healing. It is my belief that our experiences, cognitions, behaviors, thoughts and feelings all work together in our life and balance my approach based on your needs.
The Therapy Process
Psychotherapy is a process of examining feelings, thoughts, behaviors, and relationships that cause distress. The goal of psychotherapy is to help an individual, couple, or family, examine and change distressing areas in life, and to reduce suffering. Your active participation is a necessary part of this process. By signing this contract, you are committing to prioritize your appointments with me. To maximize the benefit of therapy in your quest to heal and change, you must commit and be consistent. While I cannot guarantee that any specific goal will be achieved, your ability to be open and honest with me will greatly enhance the effectiveness of your therapy.
I am dedicated to working through the entire therapeutic process with you. I have a general practice, which means that I work with a variety of problems facing adults and families while also specializing in Maternal Mental Health, Neurodivergence and Women’s Issues as a whole. The process of psychotherapy varies depending on the personalities of the therapist and the client, and the particular problems you bring forward. Since I have an eclectic and integrated education, there are many different methods I may use to address the problems you bring to therapy, ranging from the pragmatic to the more symbolic and expressive. Some problems result in physical conditions and medical consultation may be advised. I believe body, mind and soul are connected, and when one part of you suffers, all areas in your life are affected. Your health and happiness are important to me.
Getting Started
It is imperative I have all forms for intake completed within 48 hours of our first appointment. This allows me time to verify insurance and explore your answers with intentionality.
What to Expect
I normally conduct an intake that will last from 2 to 4 sessions. During this time, we can both decide if I am the best person to provide the services you need. If I determine that your problems are not within the scope of my expertise, I will provide you with a referral to a more appropriately specialized therapist. If you decide I am not the best clinician then I will assist you in identifying other options. If we work together, we will try to determine a regular meeting time for your sessions. I usually schedule a 45-55 minute session every week, although some sessions may be longer or more or less frequent depending on your situation. You can expect therapy to last anywhere from a few weeks to a few years depending on the nature of your concerns and the amount of change you want to make in your life. Typically, the end of therapy occurs when the problems for which you sought help have been alleviated.
I take a collaborative approach to your care and therefore welcome you to share feedback, at any time, about your care, treatment plan goals and how you feel about sessions.
Rights, Responsibilities, and Records
I use an Electronic Health Record, Simple Practice, for storage of progress notes, treatment plans and your consents, authorizations and other documentation. Simple Practice is required to maintain confidentiality. If, at any time, I question the integrity of their platform I will immediately end my contract with them and notify you of where your files will be stored until an EHR has been secured.
Therapy is a relationship that works in part because of clearly defined rights and responsibilities held by each person. This frame helps to create the safety to take risks and the support to become empowered to change. As a client in psychotherapy, you have certain rights that are important for you to know about because this is your therapy, and my goal is your well-being. There are also certain limitations to those rights that you should be aware of. As your therapist, I have corresponding responsibilities to you.
If at any point you have questions or concerns about our relationship or the direction of our work together, please feel free to address these with me. You also have the right to a second opinion, a different approach, or a different therapist.
I keep a record of the services I provide you. You may ask to see and copy that record. You may also ask me to correct that record. I will not disclose your record to others unless you direct me to do so or unless the law authorizes or compels me to do so. You may see your record or get more information about it by asking me.
You are free to leave therapy at any time. You have the right to refuse anything that I suggest. You are also free to discuss your treatment with anyone you wish, and you do not have any responsibility to maintain confidentiality about your therapeutic experience since you are the person who has the right to decide what you want kept confidential.
Therapists do not have social or sexual relationships with clients or former clients because that would not only be unethical and illegal, it would be an abuse of the therapist’s power.
Therapy has potential emotional risks. Approaching feelings or thoughts that you have tried not to think about for a long time may be painful. You may feel worse before you feel better. Making changes in your beliefs or behaviors can be scary and sometimes disruptive to the relationships you already have. You may find your relationship with your therapist to be a source of strong feelings. It is important that you consider carefully whether these risks are worth the benefits to you of changing. Most people who take these risks find that therapy is helpful.
Therapy may also be ended under the following conditions: If I determine that I am not able to help you because of the kind of challenges you are facing or my training and skills are not appropriate, you will be informed of this fact and referred to another therapist who may better meet your needs. In addition, if you cancel three appointments in a row, or frequently cancel appointments, we will evaluate whether we are a good fit, and I reserve the right to end therapy and refer you to another therapist.
If you wish to attend therapy “as needed”; I do require quarterly appointments to monitor symptoms as your practicing psychotherapist. If this is not possible then you have the right to discharge therapy and can return at any time.
Please refer to privacy practices for comprehensive rights regarding confidentiality.
Telehealth Services
To use telehealth, you need an internet connection and a device with a camera for video. I can explain how to log in and use any features on the telehealth platform. It is important you are in a safe and secure location. I may need to conclude the session early if your privacy can not be maintained and/or there are too many distractions for an effective session. I may impose a late cancellation fee if this occurs.
To use telehealth, I am licensed in the State of Iowa with rare exceptions. If you are traveling out of state please let me know 24-48 hours in advance to ensure that I can proceed with the session. I may impose a late cancellation if it is determined that I cannot meet with you due to your location if I am not notified in advance of your travel.
Complaints / Unprofessional Conduct
If you wish to file a complaint about me or the services provided; this can be done by visiting:
https://hhs.iowa.gov/Licensure/complaints#:\~:text=You can file a complaint,0254 during regular business hours
or writing a letter to the following address:
Bureau of Professional Licensure
321 E 12th St.
Des Moines, IA 50319-0075
Or email: Plpublic@idph.iowa.gov
Professional Supervision and Consultation
I participate in ongoing consultation with other mental health professionals, and in ongoing continuing education and supervision. Such activities allow me to stay current with professional standards and new developments in the field. It also allows me to receive valuable input on my work. When discussing cases, I will not disclose any identifying information about you.
Messages and Emergencies
Phone Calls, Texts, Messages: You may leave a confidential message on my voicemail at any time. I regularly check for messages. Unless I am on vacation, I will make every effort to respond within 24 business hours of the time you try to reach me. I may respond with a text or brief message if we have a pending appointment, and prefer to discuss matters in person if possible. I keep my work phone password protected at all times but there are limitations to your privacy and you should consider whether or not you are comfortable with texting anything outside of scheduling changes.
Emergencies: As an individual therapist in private practice, I am unable to respond immediately to your calls or texts in an emergency. Therefore, if you believe that you cannot keep yourself safe, please call 911, or go to the nearest hospital emergency room for assistance. Please call me after you have taken care of getting immediate help in a crisis.
No Surprises
Fees and Payments for Services
Under the law, health care providers need to give patients who don’t have insurance or who are not using insurance, a Good Faith Estimate; an estimate of the bill for medical items and services.
You have the right to receive a Good Faith Estimate for the total expected cost of any non-emergency items or services.
Five Magnolias will make sure that we give you a Good Faith Estimate in writing at least 1 business day before your first appointment.
You can also ask your healthcare provider, and any other provider you choose, for a Good Faith Estimate before you schedule a service.
If you receive a bill that is at least $400 more than your Good Faith Estimate, you can dispute the bill.
Make sure to save a copy or picture of your Good Faith Estimate.
For questions or more information about your right to a Good Faith Estimate, visit www.cms.gov/nosurprises.
For a full list of Five Magnolias Therapy Fees please email me at sarahgallagher@fivemagnolias.org
Cancellations and Missed Appointments
If you are unable to keep an appointment for any reason, please text, email or send message on the portal with 24 hours notice of your appointment. A fee of $125 is collected for missed or canceled appointments with less than 24 hours notice. If you are a no-show and do not contact me, you automatically forfeit future appointment times. If you miss or cancel three sessions in a row, or frequently cancel appointments, we will discuss whether we are a good fit, and I reserve the right to end therapy and refer you to another therapist. If you are more than 15 minutes late this may be considered a late cancellation and the fee will be assessed.
Please note: insurance companies do not reimburse for canceled or missed sessions.
Outcome Measures
I will be using outcome measures on a regular basis to assess symptoms as well as monitor progress. I want to specifically mention two outcome measures. The Working Alliance Inventory and Therapy Session Evaluation are two that may be challenging to complete. I want to assure you that all answers are valuable and helpful to our process. You are never required to complete any outcome measure you are not comfortable with. Furthermore, no question is required and can be skipped if you choose. These outcome measures are for our use in the therapy practice and are not considered testimonials or business reviews.
I will send the Working Alliance Inventory on a monthly basis and the Therapy Session Evaluation will be sent randomly. Because of the way Simple Practice is set up; if you do not complete the assessment then within one week I will have to remove it from your documents to fill out, otherwise it does not allow me to send the outcome measure in the future.
Informed Consent
INFORMED CONSENT FOR PSYCHOTHERAPY
This form is called a Consent for Services (the "Consent"). Sarah Gallagher, LISW (“Provider”) has asked you to read and sign this Consent before you start therapy. Please review the information. If you have any questions, contact your Provider.
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Informed Consent for Psychotherapy
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The therapeutic relationship is unique in that it is a highly personal and at the same time, a contractual agreement. Given this, it is important for us to reach a clear understanding about how our relationship will work, and what each of us can expect. Feel free to discuss any of this with me. Please read and indicate that you have reviewed this information and agree to it by filling in the checkbox at the end of this document.
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The Therapeutic Process
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Participation in therapy can result in a number of benefits to you, including improving relationships and resolution of the specific concerns and/or symptoms that led you to seek therapy. I will ask for your feedback and views on your therapy, its progress, and other aspects of the therapy. Sometimes more than one approach can be helpful in dealing with a certain situation. During therapy, remembering or talking about unpleasant events, feelings, or thoughts can result in you experiencing considerable discomfort or strong feelings of anger, sadness, worry, fear, etc., or experiencing anxiety, depression, insomnia, etc. I cannot guarantee a specific outcome. During the course of therapy, I am likely to draw on various therapeutic approaches according, in part, to the issue that is being treated and my assessment of what will best benefit you. Please feel free to discuss any of these matters with me in more detail.
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Confidentiality
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The session content and all relevant materials to the client’s treatment will be held confidential unless the client requests in writing to have all or portions of such content released to a specifically named person/persons. Limitations of such client held privilege of confidentiality exist and are itemized below:
If a client threatens or attempts suicide or otherwise conducts themselves self in a manner in which there is a substantial risk of incurring serious bodily harm.
If a client threatens grave bodily harm or death to another person.
If the therapist has a reasonable suspicion that a client or other named victim is the perpetrator, observer of, or actual victim of physical, emotional or sexual abuse of children under the age of 18 years.
If a court of law issues a legitimate subpoena for information stated on the subpoena.
Occasionally I may need to consult with other professionals in their areas of expertise in order to provide the best treatment for you. Information about you may be shared in this context without using your name.
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With respect to telemedicine/telemental health:
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You have the right to withdraw consent at any time without affecting my right to future care, services or program benefits to which you would otherwise be entitled.
There are risks, benefits and consequences associated with telemental health, including but not limited to, disrupted transmission by technology failures, interruption and/or breaches of confidentiality by unauthorized persons, and/or limited ability to respond to emergencies.
There will be no recording of any online session by either party. All information disclosed within sessions and written records pertaining to those sessions are confidential and may not be disclosed to anyone without written authorization, except where disclosure is permitted and/or required by law.
There is a risk of being overheard by persons near you and you are responsible for using a location that is private and free from distractions or intrusions.
The privacy laws that protect confidentiality of your protected health information (PHI) also apply to telemental health unless an exception to confidentiality applies (ie. mandatory reporting, danger to self or others).
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If you are having suicidal or homicidal thoughts, actively experiencing psychotic symptoms or experiencing a mental health crisis that cannot be resolved remotely, it may be determined that a referral for in person services is required.
During a telemedicine appointment, we could encounter technical difficulties resulting in service interruptions. If this occurs, end and restart the session. If we are unable to reconnect within ten minutes, please call me at 319-988-2243. I will also attempt to call you.
Your location is needed for each session in case of an emergency.
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No Surprises
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Under the law, health care providers need to give patients who don’t have insurance or who are not using insurance, a Good Faith Estimate; an estimate of the bill for medical items and services.
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You have the right to receive a Good Faith Estimate for the total expected cost of any non-emergency items or services.
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Aligned will make sure that we give you a Good Faith Estimate in writing at least 1 business day before your first appointment.
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You can also ask your health care provider, and any other provider you choose, for a Good Faith Estimate before your schedule an item or service.
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If you receive a bill that is at least $400 more than your Good Faith Estimate, you can dispute the bill.
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Make sure to save a copy or picture of your Good Faith Estimate.
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For questions or more information about your right to a Good Faith Estimate, visit
Privacy Practices
Privacy Practice
EFFECTIVE DATE OF THIS NOTICE This notice went into effect on 7/10/23. This notice has been updated as of 12/5/24.
NOTICE OF PRIVACY PRACTICES
The Privacy Practices of Sarah Gallagher/dba aligned are in full compliance with Iowa Code 228, 42 CFR Part 2, Health Insurance Portability and Accountability Act of 1996 (HIPAA) and HITECH Act.
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. MY PLEDGE REGARDING HEALTH INFORMATION: I understand that health information about you and your health care is personal. I am committed to protecting health information about you. I create a record of the care and services you receive from me. I need this record to provide you with quality care and to comply with certain legal requirements. This notice applies to all of the records of your care generated by this mental health care practice. This notice will tell you about the ways in which I may use and disclose health information about you. I also describe your rights to the health information I keep about you, and describe certain obligations I have regarding the use and disclosure of your health information. I am required by law to:
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Make sure that protected health information (“PHI”) that identifies you is kept private.
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Give you this notice of my legal duties and privacy practices with respect to health information.
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Follow the terms of the notice that is currently in effect.
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I can change the terms of this Notice, and such changes will apply to all information I have about you. The new Notice will be available upon request, in my office, and on my website.
II. HOW I MAY USE AND DISCLOSE HEALTH INFORMATION ABOUT YOU:
The following categories describe different ways that I use and disclose health information. For each category of uses or disclosures I will explain what I mean and try to give some examples. Not every use or disclosure in a category will be listed. However, all of the ways I am permitted to use and disclose information will fall within one of the categories.
For Treatment Payment, or Health Care Operations: Federal privacy rules (regulations) allow health care providers who have direct treatment relationship with the patient/client to use or disclose the patient/client’s personal health information without the patient’s written authorization, to carry out the health care provider’s own treatment, payment or health care operations. I may also disclose your protected health information for the treatment activities of any health care provider. This too can be done without your written authorization. For example, if a clinician were to consult with another licensed health care provider about your condition, we would be permitted to use and disclose your personal health information, which is otherwise confidential, in order to assist the clinician in diagnosis and treatment of your mental health condition.
Disclosures for treatment purposes are not limited to the minimum necessary standard. Because therapists and other health care providers need access to the full record and/or full and complete information in order to provide quality care. The word “treatment” includes, among other things, the coordination and management of health care providers with a third party, consultations between health care providers and referrals of a patient for health care from one health care provider to another.
III. CERTAIN USES AND DISCLOSURES REQUIRE YOUR AUTHORIZATION:
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Psychotherapy Notes. I do keep “psychotherapy progress notes” as that term is defined in 45 CFR § 164.501, and any use or disclosure of such notes requires your Authorization unless the use or disclosure is: a. For my use in treating you. b. For my use in training or supervising mental health practitioners to help them improve their skills in group, joint, family, or individual counseling or therapy. c. For my use in defending myself in legal proceedings instituted by you. d. For use by the Secretary of Health and Human Services to investigate my compliance with HIPAA. e. Required by law and the use or disclosure is limited to the requirements of such law. f. Required by law for certain health oversight activities pertaining to the originator of the psychotherapy notes. g. Required by a coroner who is performing duties authorized by law. h. Required to help avert a serious threat to the health and safety of others.
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Marketing Purposes. As a psychotherapist, I will not use or disclose your PHI for marketing purposes.
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Sale of PHI. As a psychotherapist, I will not sell your PHI in the regular course of my business.
IV. CERTAIN USES AND DISCLOSURES DO NOT REQUIRE YOUR AUTHORIZATION. Subject to certain limitations in the law, I can use and disclose your PHI without your Authorization for the following reasons:
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When disclosure is required by state or federal law, and the use or disclosure complies with and is limited to the relevant requirements of such law.
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For public health activities, including reporting suspected child, elder, or dependent adult abuse, or preventing or reducing a serious threat to anyone’s health or safety.
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For health oversight activities, including audits and investigations.
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For judicial and administrative proceedings, including responding to a court or administrative order, although my preference is to obtain an Authorization from you before doing so.
V. YOU HAVE THE FOLLOWING RIGHTS WITH RESPECT TO YOUR PHI:
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The Right to Request Limits on Uses and Disclosures of Your PHI. You have the right to ask me not to use or disclose certain PHI for treatment, payment, or health care operations purposes. I am not required to agree to your request, and I may say “no” if I believe it would affect your health care.
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The Right to Request Restrictions for Out-of-Pocket Expenses Paid for In Full. You have the right to request restrictions on disclosures of your PHI to health plans for payment or health care operations purposes if the PHI pertains solely to a health care item or a health care service that you have paid for out-of-pocket in full.
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The Right to Choose How I Send PHI to You. You have the right to ask me to contact you in a specific way (for example, home or office phone) or to send mail to a different address, and I will agree to all reasonable requests.
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The Right to See and Get Copies of Your PHI. Other than “psychotherapy progress notes,” you have the right to get an electronic or paper copy of your medical record and other information that I have about you. I will provide you with a copy of your record, or a summary of it, if you agree to receive a summary, within 30 days of receiving your written request, and I may charge a reasonable, cost based fee for doing so.
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The Right to Get a List of the Disclosures I Have Made.You have the right to request a list of instances in which I have disclosed your PHI for purposes other than treatment, payment, or health care operations, or for which you provided me with an Authorization. I will respond to your request for an accounting of disclosures within 60 days of receiving your request. The list I will give you will include disclosures made in the last six years unless you request a shorter time. I will provide the list to you at no charge, but if you make more than one request in the same year, I will charge you a reasonable cost based fee for each additional request.
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The Right to Correct or Update Your PHI. If you believe that there is a mistake in your PHI, or that a piece of important information is missing from your PHI, you have the right to request that I correct the existing information or add the missing information.
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The Right to Get a Paper or Electronic Copy of this Notice. You have the right to get a paper copy of this Notice, and you have the right to get a copy of this notice by email. And, even if you have agreed to receive this Notice via email, you also have the right to request a paper copy of it.
I, Sarah Gallagher, regularly review my practices and processes to identify areas for improvement to protect health information and maintain up to date information about my electronic health record platform, Simple Practice, to monitor any concerns related to technology breaches.
If you ever have questions or concerns about your protected health information please email me at sarah@grow-aligned.com or bring it up during any session.
In summary, it is my goal to protect your health information and provide only what is necessary for your care and wellness. If you have any questions or concerns about this notice; please let me know.
No Show/Late Cancellations
Life happens! I do my best to accommodate the various things that come up but do have the right to impose the following policy regarding not showing up or cancelling appointments without proper notice.
If you are unable to keep an appointment for any reason, please text, email or send message on the portal within 24-48 hours in advance of your appointment. A fee of $125 is assessed for missed or canceled appointments with less than 24 hours notice. If you are a no-show and do not contact me, you automatically forfeit future appointment times. If you miss or cancel three sessions in a row, or frequently cancel appointments, we will discuss whether we are a good fit, and I reserve the right to end therapy and refer you to another therapist.
Please note: insurance companies do not reimburse for canceled or missed sessions.
Feeling better is possible.
FOR A FULL SCHEDULE OF FEES ASSOCIATED WITH THERAPY OR CONSULTING PLEASE EMAIL SARAH@GROW-ALIGNED.COM
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