Welcome to Dua Health. This document contains important information about our policies and professional services. Please read it carefully and discuss any questions you have with your provider.

Our providers are affiliated with the following professional entity: Dua Health Group PLLC, a Texas professional limited liability company. In this document, the terms “we,” “us,” or “our” refer to Dua Health Group PLLC and any providers practicing through it. The terms “you” and “yours” refer to the individual(s) receiving services from our providers.

Our Notice of Privacy Practices, the policies outlined in this document, as well as applicable federal and state laws, apply to both in-office and teletherapy services, regardless of modality.

By signing this document, you, or the person authorized to act on your behalf, affirm your agreement to the policies contained herein and your consent to receive professional services. Your consent to treatment remains valid until your patient relationship with Dua Health is formally terminated.

Psychotherapy Services

Psychotherapy, often called talk therapy, is a form of treatment that can be helpful to individuals. There are many different definitions and philosophies of psychotherapy, and each of our providers will offer their own unique approach to treatment in alignment with your goals, desires, and preferences. Therapy may be provided as individual therapy or relationship therapy for couples or adult family members.

Therapy has both benefits and risks. Benefits can include improved mood, better relationships, and resolution of specific issues. However, therapy is not guaranteed to work for everyone. It may involve exploring difficult or painful aspects of your life and, at times, may lead to feelings of discomfort (e.g., guilt, anxiety, frustration, etc.) or a temporary increase in symptoms. These effects are usually temporary but should be openly discussed with your provider.

Your course of treatment will be tailored to your individual needs based on the intensity and duration of your concerns, your level of engagement and participation, and the specific nature of the issues being addressed. If you have any questions about the approaches used during your therapy, including possible risks, alternatives, your provider’s qualifications, or the treatment plan in general, please speak with your provider at any time.

You have the right to withdraw from treatment at any time. However, it is strongly encouraged that you discuss your desire to end treatment with your provider before doing so. This allows them to offer final recommendations or appropriate referral options. If at any point your provider determines that sessions are no longer effective in helping you meet your goals, they will discuss this with you and may recommend ending treatment and suggest other services or providers.

If you commit an act of violence or verbally or physically threaten or harass your provider, their colleagues, family members, or anyone affiliated with Dua Health, your provider reserves the right to immediately and unilaterally terminate treatment. Persistent failure or refusal to pay for services after a reasonable period is another valid reason for termination of services.

Confidentiality

Your privacy is important. In general, the privacy of all communications between a patient and a provider is protected by law, and providers can only release information about their work with a patient with the patient’s written permission. However, there are a few important exceptions.

In certain circumstances, your provider is required by law to notify legal authorities or potentially affected individuals in the following situations:

• If there is suspected abuse or neglect of an elder, incapacitated, or dependent adult, or child.
  
  

• If, in your provider’s judgment, you are in danger of harming yourself or another person, or are unable to care for yourself.
  
  

• If you communicate to your provider a serious threat of physical violence against another person.
  
  

Additional limits to confidentiality include:

• If your provider is ordered by a court to release information as part of a legal proceeding, they may be required to share details of your care.
  
  

• Your provider may, on occasion, consult with other professionals in their areas of expertise to provide the best treatment for you. In such cases, information may be shared without identifying you by name.
  
  

• If your provider reasonably believes you are experiencing a psychiatric emergency, they may initiate a welfare check or contact your designated emergency contact.
  
  

• As otherwise required by law and/or outlined in our Notice of Privacy Practices.
  
  

It is also important to note that your provider adheres to a “no-secrets” policy for relationship therapy. This policy will be reviewed with you during your initial session. If you have questions about the “no-secrets” policy, please ask your provider at any time.

No one is permitted to record a session.

While this written summary of exceptions to confidentiality should be helpful in informing you about potential limitations, it is important that you bring up any questions or concerns with your provider directly.

Attendance and Cancellation

Consistency is essential for the overall progress and effectiveness of therapy. Please be on time for your scheduled appointment. Appointments must be canceled or rescheduled at least 24 hours in advance to avoid any charges. You will be considered a no-show if you are more than 15 minutes late to your scheduled appointment. To reschedule or cancel an appointment, please contact hello@duahealth.co.

If you cancel with less than 24 hours’ notice or miss your scheduled appointment, you will be charged a cancellation fee. This cancellation fee is not eligible for insurance reimbursement.

Your provider is often not immediately available by telephone. If you need to contact your provider between sessions for non-urgent issues, please contact hello@duahealth.co.

Billing and Payments

We require payment at the time of service. This includes any applicable copay, coinsurance, or deductible. This consent authorizes us to charge your credit card on file for services rendered and to submit billing claims to your insurance company, health plan, or third-party administrator for reimbursement.

We may update our fees as needed, including at the beginning of each calendar year. All fees are subject to change with 30 days’ written notice.

If you have any questions, please contact us at hello@duahealth.co.

Teletherapy

Services may be provided to you in-person or through teletherapy technologies, as deemed clinically appropriate. This consent provides you with important information about teletherapy. By signing this consent, you agree to participate in teletherapy and receive services from your provider via synchronous and/or asynchronous technologies, as appropriate.

Teletherapy refers to psychotherapy services provided digitally—typically via secure video conference, but in some circumstances via telephone. Teletherapy offers an effective option for continuity of care when in-person sessions are not possible or not preferred. You are not required to receive services via teletherapy and may withdraw your consent at any time.

Your provider will be licensed in the state where you are located when services are rendered, or will otherwise meet a licensure exception permitted by applicable state law. The provider will establish a provider-patient relationship in accordance with relevant state laws and regulations. Please inform your provider if you will be traveling to, or moving to, another state. In some cases, providers may not be able to continue services while you are in another state, even temporarily.

The benefits of teletherapy include:

• Easier access to care and continuity of care
  
  

• Convenience of meeting from your preferred location (subject to applicable laws)
  
  

The potential risks of teletherapy include:

• Interruptions, background noise, or technical difficulties
  
  

• Unauthorized access to your health information if you are not in a private location
  
  

• Inability of your provider to provide immediate in-person support in the event of a crisis
  
  

If you are unable to communicate with your provider due to technological issues, please contact support@duahealth.co.

During the course of treatment, it may be helpful to communicate with you via email, text message, or other electronic means. By signing this consent, you agree to receive periodic electronic communications (e.g., emails, calls, or texts) from us about the services you have received or will receive. You may opt out at any time. While your provider will make reasonable efforts to protect the privacy and security of all electronic communications—including those conducted through teletherapy—we cannot guarantee complete confidentiality through these channels.

Death or Incapacity of Provider

In the event that your provider becomes incapacitated or dies, it may be necessary for another provider to take possession of your file and records. By signing this form, you consent to allow another licensed professional designated by your provider or Dua Health to take possession of your file and records. Upon request, your records may be provided to you or transferred to a provider of your choice.

Research, Writing, Teaching

Your provider and other team members at Dua Health may engage in internal research and training, or publish information for professional or public audiences. De-identified or anonymized information about you and your treatment may be used to support these efforts. No identifying information will be disclosed. Any such use will strictly adhere to standards of privacy and confidentiality.

Emergencies

IF YOU ARE IN A STATE OF CRISIS OR EMERGENCY, PLEASE DIAL 911 OR GO TO THE LOCAL EMERGENCY ROOM. IN THE EVENT YOU ARE EXPERIENCING EMOTIONAL DISTRESS, PLEASE CALL OR TEXT 988, THE SUICIDE AND CRISIS LIFELINE.

If you have any questions or concerns regarding this document, please speak to your provider or contact support@duahealth.co.