One Affinity, LLC Client Service Agreement & Informed Consent for Treatment

Effective Date: June 1, 2025

This document outlines the terms and conditions for receiving professional counseling services from One Affinity, LLC ("the Practice," "we," "us," or "our"). Please read it carefully. By engaging in counseling services with us, you ("the Client," "you," or "your") agree to these terms.

I. Counselor-Client Relationship and Scope of Practice

  1. Nature of Counseling: Counseling is a professional relationship designed to help individuals, couples, or families address mental and emotional health concerns, improve relationships, and achieve personal growth. It is a collaborative process that requires your active participation, honesty, and commitment. Counseling is not advice-giving but rather a supportive process to facilitate your own insights and solutions.
  2. Voluntary Participation: Your decision to participate in counseling is entirely voluntary. You have the right to terminate counseling at any time, though we encourage a discussion with your counselor about your decision to ensure a proper closure or referral.
  3. Counselor's Role and Credentials: Your counselor will provide professional counseling services within their scope of practice and competence, adhering to the ethical guidelines and regulations set forth by the Georgia Composite Board of Professional Counselors, Social Workers, and Marriage and Family Therapists, and their respective professional associations (e.g., American Counseling Association, Licensed Professional Counselors Association of Georgia). Our counselors are Michal Collier, member of LPCA of GA (Licensed Professional Counselor Association of Georgia) and CCALP (Clinical Certification Association of Licensed Professionals) and Kimberly Goston, member of APC (Licensed Associate Professional Counselor of Georgia).
  4. Limits of Practice: We provide mental health counseling services. We do not provide medical diagnosis, prescription services, legal advice, or forensic evaluations. If your needs fall outside our scope of practice, we will discuss this with you and provide appropriate referrals.

II. Confidentiality

  1. Confidentiality: All information shared during counseling sessions is considered confidential and is protected by federal law (HIPAA) and Georgia state law, as well as the ethical guidelines governing our profession.
  2. Limits of Confidentiality (Mandated Exceptions): While confidentiality is paramount, there are specific, legally and ethically mandated situations where we are required or permitted to break confidentiality without your authorization:
    • Imminent Danger to Self or Others: If your counselor believes there is a reasonable suspicion of imminent and serious danger to yourself or to an identifiable third party, we are legally and ethically obligated to take protective action. This may include notifying emergency services, law enforcement, or the identified victim.
    • Suspected Child Abuse, Dependent Adult Abuse, or Elder Abuse: As mandated reporters under Georgia law, if we have reasonable cause to suspect that a child, dependent adult, or elder is being abused, neglected, or exploited, we are required to report this to the appropriate protective services agencies.
    • Court Order or Subpoena: If we receive a valid court order or legally enforceable subpoena requiring the disclosure of your records or testimony, we are legally obligated to comply. We will make every effort to notify you of such requests unless legally prohibited from doing so.
    • Professional Consultation/Supervision: We may consult with other qualified mental health professionals for purposes of improving the quality of your care. In such consultations, your identifying information will be kept confidential, and only relevant information necessary for consultation will be shared. For counselors-in-training or associates, clinical supervision by a qualified supervisor is a requirement, and your case may be discussed with your supervisor, maintaining your confidentiality.
    • Payment & Healthcare Operations: As described in our Notice of Privacy Practices, limited information may be shared for billing purposes (e.g., with your insurance company) or to manage our practice (e.g., quality assurance, audits, licensing).
    • Workers' Compensation: We may disclose PHI to the extent authorized by and to the extent necessary to comply with laws relating to workers' compensation or other similar programs.
  3. With Your Written Authorization: Any other uses or disclosures of your confidential information not described above will only be made with your specific written authorization. You have the right to revoke any authorization you provide at any time, in writing, but this revocation will not apply to uses or disclosures already made in reliance on your authorization.
  4. Privacy Policy: Our detailed Notice of Privacy Practices, which further outlines your rights regarding your Protected Health Information (PHI) and how it may be used and disclosed, is available upon request and is posted on our website at www.oneaffinity.org/privacy-policy.

III. Minor Consent for Treatment (Georgia Specific)

  1. General Rule: In Georgia, generally, a parent or legal guardian must provide consent for the mental health treatment of a minor (under 18 years of age).
  2. Exceptions to Parental Consent (Minor's Right to Consent in Georgia): There are specific circumstances under Georgia law (O.C.G.A. § 31-9-2 and related statutes) where a minor may consent to their own mental health treatment without parental consent. These include:
    • Minors who are 12 years of age or older may consent to mental health services for substance abuse treatment.
    • Minors who are 14 years of age or older and who are emancipated (e.g., married, on active duty in the U.S. armed forces, or emancipated by court order). An emancipated minor has the right to authorize their own mental health care.
    • Minors who are 14 years of age or older, living separately from their parents/guardians, and managing their own financial affairs.
    • Minors seeking treatment for sexually transmitted infections (STIs) or pregnancy-related services (including contraception and abortion, with specific parental notification requirements for abortion unless judicially bypassed).
    • In situations of emergency medical care where the parent/legal guardian cannot be reached.
  3. Parental Rights and Confidentiality for Minors:
    • For minors whose treatment is consented to by a parent/guardian, parents generally have the right to access their child's records. However, we will work to balance parental rights with the minor's need for privacy and a trusting therapeutic relationship.
    • We will discuss our approach to confidentiality with both the minor and the parents at the outset of treatment. We will strive to create a safe space for the minor to share freely, while informing parents about significant safety concerns or treatment progress as deemed therapeutically appropriate and legally permissible.
    • We encourage open communication between minors and their parents and will assist in facilitating such discussions when beneficial for the client.

IV. Appointments and Fees

  1. Session Length and Frequency: Counseling sessions vary in length. The frequency of sessions will be determined collaboratively between you and your counselor based on your therapeutic needs and goals.
  2. Fees: Our standard fees for counseling session are available at www.oneaffinity.org/session-pricing. Fees for other services (e.g., couples counseling, group therapy, crisis intervention, report writing, court appearances) are also available.
  3. Payment: Payment for services is due at the time of each session. We accept major credit cards, CashApp, checks, and Afterpay.
  4. Insurance: It is your responsibility to verify your insurance benefits and understand your coverage for mental health services.
  5. Cancellation Policy: We require at least 24 hours' notice for cancellation or rescheduling of an appointment. Appointments canceled with less than 24 hours' notice or missed appointments will be charged the full session fee. Exceptions may be made for verifiable emergencies on a case-by-case basis.
  6. Late Arrivals: If you arrive late for a session, the session will still end at the scheduled time, and you will be responsible for the full session fee.
  7. Outstanding Balances: Accounts with outstanding balances may result in a temporary suspension of services until the balance is paid. We reserve the right to pursue collection of unpaid balances in accordance with legal and ethical guidelines.

V. Emergency and Crisis Services

  1. Emergency Contact: In the event of a life-threatening emergency, please call 911 or go to the nearest emergency room.
  2. Crisis During Business Hours: If you experience a crisis during our business hours, please call 404-620-1805 and leave a message. We will return your call as soon as possible.
  3. After-Hours Crisis: For after-hours crises that are not life-threatening, you may call 404-620-1805 and follow the instructions for urgent matters, or contact the National Crisis and Suicide Lifeline by calling or texting 988. Other local Atlanta/Georgia resources include Fulton County Crisis Line, Grady Crisis Center, or specific local hospital emergency psychiatric services.
  4. Non-Emergency Communication: For non-emergency matters (e.g., scheduling changes), please call 404-620-1805. Email is generally not a secure method for transmitting confidential clinical information and should be used sparingly for administrative purposes only.

VI. Social Media and Electronic Communication Policy

  1. Confidentiality Online: To protect your confidentiality and the integrity of the therapeutic relationship, we do not engage with current or former clients on social networking sites (e.g., Facebook, Instagram, LinkedIn, X/Twitter). Please do not send "friend" or "connection" requests.
  2. Online Reviews: We kindly request that clients do not post reviews of our services on public online platforms (e.g., Google Reviews, Yelp). While we appreciate positive feedback, maintaining your confidentiality and privacy is paramount. Responding to online reviews, even positive ones, would inadvertently reveal that you are a client and violate your confidentiality. We encourage you to share any feedback directly with your counselor or the practice owner.
  3. Text Messages/Email: Text messaging and email are generally not secure forms of communication and should only be used for administrative purposes (e.g., appointment reminders, scheduling). Please refrain from discussing clinical or personal information via text or unencrypted email.

VII. Professional Boundaries

  1. Dual Relationships: To maintain professional boundaries and avoid conflicts of interest, we do not engage in dual relationships with clients (e.g., business relationships, social relationships, friendships). Our relationship with you is solely professional and therapeutic.
  2. Gifts: While a thoughtful gesture, accepting gifts can complicate the therapeutic relationship. We maintain a policy of not accepting gifts from clients.
  3. Physical Contact: Physical contact will be limited to professional greetings (e.g., a handshake) and will always be within ethical and professional boundaries.
  4. Sexual Intimacy: Sexual intimacy with current or former clients is strictly prohibited by ethical codes of conduct and Georgia law.

VIII. Termination of Counseling

  1. Client-Initiated Termination: You have the right to terminate counseling at any time. We encourage a final session to process the termination, review progress, and discuss any ongoing needs or referrals.
  2. Counselor-Initiated Termination: Your counselor may initiate termination of services if:
    • It is determined that counseling is no longer beneficial to you.
    • Your needs fall outside the counselor's scope of practice or expertise.
    • There is a consistent failure to pay fees or adhere to scheduled appointments.
    • The counselor determines that the therapeutic relationship is compromised or that continuing would be unethical.
    • There are safety concerns for the counselor or the practice.
  3. Referrals: If termination is initiated by the counselor, we will provide appropriate referrals to other mental health professionals or resources.

IX. Governing Law and Dispute Resolution

This agreement is governed by the laws of the State of Georgia. Any disputes arising from this agreement or the counseling relationship will be resolved through informal discussion, mediation, or as otherwise outlined by the Georgia Composite Board of Professional Counselors, Social Workers, and Marriage and Family Therapists regulations.

X. Acknowledgment and Consent

By continuing to use this website, you acknowledge that you have read, understood, and agree to the terms and conditions outlined in this Client Service Agreement & Informed Consent for Treatment. You have had the opportunity to ask questions and have received satisfactory answers.