General Information
Shannon Bowden, LCSW, a Utah licensed clinical social worker (the “Clinician”), provides clinical behavioral health services (the “Services”) via the Fort technology platform (“Practice”, “we”, “our” or “us”) for patients with support from administrative and technology partner, Fort Health, Inc. (“Fort”). This Agreement describes Practice’s services and clinical offerings. It is important for you to read this document and discuss any questions you might have with us.
When you or your minor child (either individually or on behalf of your child, or collectively, as applicable, “you”) become a patient of Practice (a “Member”), you will be given access to Fort’s website platform (the “Fort Platform”) and the Clinician. The Fort Platform provides simple tools for scheduling appointments and billing, serves as your hub of information, and connects you to the Clinician.
You will have access to 1:1 behavioral therapy in real-time audio-visual and audio-only consultations with the Clinician through the Fort Platform.
You are entitled to receive information from the Clinician about the methods of therapy, the credentials of the Clinician, the techniques used, the duration of your therapy (if known), and the fee structure. You can seek a second opinion from another therapist or terminate therapy at any time.
The Services are available for use by children (under 18 years of age) but children are not authorized to consent to treatment on their own behalf, may not create an account on the Fort Platform, and may not use the Services without the supervision and verifiable consent of a parent or legal guardian. If you register as the parent or legal guardian on behalf of a minor, you will be fully responsible for complying with the terms of this agreement.
By signing below, if you are signing as a guardian or personal representative of any children registered under your account on the Platform, you affirmatively attest and certify that you have legal authority to act as guardian or personal representative and you consent to the treatment of all minors registered under your account.
We do not bill insurance and the services provided by Practice are not covered by insurance. We will inform you of any amounts owed and charge your credit card before you schedule a visit with Clinician. By providing us with your credit card information, you are authorizing Clinician to charge your credit card for agreed upon purchases and save your credit card information for future transactions on your account. You understand you are paying Clinician and not Fort for these services. If you fail to pay for appointments with us, you understand that you may be terminated from the Practice and no longer have access to the Clinician.
You agree that all people or companies (third parties) who pay any part of your Practice bill shall pay these amounts directly to Practice. You understand that you must pay Practice any costs not paid by your insurance or other third parties, unless state or federal regulations do not allow this.
We understand you may have to reschedule or cancel an appointment from time to time. We ask that you notify us at least 24 hours in advance of your scheduled appointment. If you fail to notify us within this 24-hour window, we reserve the right to charge you for any missed appointments. If you repeatedly miss scheduled appointments or if Clinician is unable to contact you for a significant period of time, you understand that you may be terminated from the Practice and no longer have access to the Clinician.
The Clinician will provide medical care via telehealth using voice calls, video calls and messaging services. You understand that you will be asked to confirm your identity and your location to the Clinician. The Clinician may recommend other treatments, as needed. Telehealth care is a flexible and convenient way to get healthcare, but it may not be right for treating certain symptoms or illnesses that need in-person clinical care. If you are having a medical emergency, call 9-1-1 or go to the nearest emergency room. Clinician does not handle emergencies. You should seek emergency help or follow-up care when recommended by any healthcare provider or when otherwise needed.
You will have an opportunity to develop ongoing care relationships with the Clinician, however, your initial encounter may begin as a consultation (e.g. to determine the most appropriate treatment setting for you to receive care) and will not necessarily give rise to an ongoing treatment relationship.
All laws and protections for in-person medical visits also apply to telehealth visits. This includes confidentiality of information, access to medical records, and sharing of information that could identify you personally.
You have a right to know who is attending each telehealth visit. You may decide that you do not want to use these telehealth services at any time. This will not make you lose your health program benefits or your rights to future health care.
Telehealth services are convenient and offer better access to health care. However, as with any health service, there are potential risks associated with using technology. These risks include service problems due to technology or internet failures, not having enough information to make health care decisions, rare security errors, and other risks. You agree to take on the risk for information lost due to technical problems.
If you need to receive follow-up care, assistance in the event of an adverse reaction to treatment, or in the event of an inability to communicate as a result of a technological equipment failure, please contact us at care@FortHealth.com
We follow federal healthcare privacy and security laws to protect your health information and use standard physical, electronic, and business security methods (such as encryption) to help prevent access to your health information by people who should not see it. But we cannot promise that data sent over the Internet or through a data storage facility will be perfectly secure. So, although we try to protect your personal information, we cannot guarantee the security of any information you send to us. [You can read more information about our use of health information and other personal information in our Privacy Policy
As part of providing services, we may share your health records with the following individuals under the following circumstances:
By signing below, you agree to let us share your records as described above and acknowledge receipt of the Notice of Privacy Practices.
As part of providing services, we may communicate with you, including for purposes such as appointment reminders and announcements. If you have provided us with a cell phone number and email address, we may send you SMS text messages and emails. Text messages and emails are not always secure because they travel over networks that we do not control.
By signing below and providing us your cell phone number and email address, you permit us to contact you by SMS text message and email. You may also ask us to stop by contacting us at incidents@forthealth.com. You understand that you may have to pay data costs to receive SMS text messages that we send to your mobile phone.
All Members have the right to communicate grievances regarding their care. Should you wish to make a formal complaint you may do so in writing and submit the concern to Practice at incidents@forthealth.com.
You can report a complaint relating to the care provided by Clinician by contacting the professional licensing board in the state where the care was received. In a professional relationship, sexual intimacy is never appropriate and should be reported to the board or agency that licenses, registers, or certifies the licensee. You can find the contact information for each of the state professional licensing boards governing social workers.
If you and Clinician decide to engage in group or couples therapy (collectively “Group Therapy”), you understand that information discussed in Group Therapy is for therapeutic purposes and is not intended for use in any legal proceedings involving Group Therapy participants. You agree not to subpoena the Clinician to testify for or against other Group Therapy participants or provide records in court actions against other Group Therapy participants. You understand that anything any Group Therapy participant tells the Clinician individually, whether on the phone or otherwise, may at the therapist’s discretion be shared with the other Group Therapy participants. You agree to share responsibility with the Clinician for the therapy process, including goal setting and termination. You understand that we cannot prevent a Group Therapy participant from sharing information discussed in Group Therapy sessions with others outside of Group Therapy. You acknowledge that we cannot guarantee other Group Therapy participants are participating in sessions in a private and secure environment.]
If you have questions about any of the contents of this clinical services agreement, our procedures, or your role in this process, please discuss them with the Clinician. Remember that the best way to assure quality treatment is to keep communication open and direct with the Clinician.
You understand that your use of the Fort Platform used by Practice is subject to the Fort Health Terms of Service.
By signing below you indicate that you have read and understood this document, and that you agree to abide by its terms. Further, you certify that if you are signing as a personal representative of the Member, you have legal authority to provide consent for the treatment of the Member.
You certify that you have legal authority to act as guardian or personal representative of all children registered under your account on the Platform and you consent to the treatment of all minors registered under your account.
