Terms and Conditions
Please be advised that the following terms and conditions contain a binding arbitration clause and class action waiver that impact your rights about how to resolve disputes. Please read it carefully.
PAYMENTS: Payment is required in advance of services.
CANCELLATIONS/REFUNDS: If you wish to cancel services, you may do so with a 48-hour notice and receive a full refund. For example, if you have purchased and scheduled a session with your counselor or coach and are unable to keep your appointment, you must notify us at least 48 hours in advance to cancel or reschedule. If you do not cancel or reschedule at least 48 hours prior to your appointment, you may not receive a refund for the unused session. If you have purchased and scheduled an assessment or diagnostic support package and cancel after the services have been partially completed, you may receive a pro-rated refund for any unused portion.
ARBITRATION AGREEMENT: Unless you opt-out of this Arbitration Agreement, any dispute or claim relating in any way to your use of any Well Street service, or to any products or services sold or distributed by Well Street will be resolved by binding arbitration, rather than in court, except that either party may assert claims in small claims court if such claims qualify. We each agree that any dispute resolution proceedings will be conducted only on an individual basis and not in a class, consolidated, or representative action. We also both agree that you or we may bring suit in court to enjoin infringement or other issues of intellectual property rights. The Federal Arbitration Act and federal arbitration law apply to this agreement.
Opt-out of Agreement to Arbitrate: You can decline this Arbitration Agreement. To opt-out, you must notify Well Street in writing, within 30 days of the date you first became subject to this arbitration provision. You must use this address to opt-out: Well Street, 100 S Imperial Hwy, Anaheim, CA 92807. You must include your name and residence address, the email address used to set up your Well Street account, and a clear statement that you want to opt-out of this arbitration agreement.
Arbitration Procedures: The arbitration will be conducted by the American Arbitration Association (AAA) under its rules, including the AAA’s Supplementary Procedures for Consumer-Related Disputes. The AAA’s rules are available at www.adr.org or by calling 1-800-778-7879. Payment of all filing, administration, and arbitrator fees will be governed by the AAA’s rules. We will reimburse those fees for claims totaling less than $5000 unless the arbitrator determines the claims are frivolous. Likewise, Well Street will not seek attorneys’ fees and costs in arbitration unless the arbitrator determines the claims are frivolous. All arbitration shall take place in Anaheim, California.
HIPAA PRIVACY NOTICE: This notice describes how medical information about you may be used and disclosed and how you can get access to this information.
By law, your therapist, coach, or consultant (provider) is required to ensure your Private Health Information (PHI) is kept private. The PHI constitutes information about your past, present, or future health or condition or the payment for such health care. Use of PHI means when your provider shares, applies, utilizes, or analyzes information within the practice; PHI is disclosed when your provider releases, transfers, gives or otherwise reveals it to a third party outside the practice. With some exceptions, your provider may not use or disclose more of your PHI than is necessary to accomplish the purpose for which the use or disclosure is made; however, your provider is always legally required to follow the law described in this Notice. Most disclosures will require your prior written authorization; others will not. Below you will find categories of your provider’s uses and disclosures.
Disclosures Related to Treatment, Payment, or Health Care Operations That Do Not Require Prior Written Consent:
- When disclosure is required by federal, state, or local law; judicial, board, or administrative proceedings; or law enforcement, your provider may make a disclosure to the appropriate officials when the law requires them to report information government or, law enforcement agencies, or if any one places your mental condition as part of any litigation (such as divorce, custody, or personal injury)
- Disclosure is compelled or permitted when you are in such mental or emotional condition as to be dangerous to yourself or when you tell your provider of a serious/imminent threat of physical violence by you against a reasonably identifiable victim or victims. For example, suicidal or serious self-destructive behavior.
- Confidentiality does not apply to disclosure of crimes planned for the future. This applies to interests of national security.
- Disclosure is mandated by the California Child Abuse/Elder/Dependent Adult Abuse and Neglect Reporting law. For example, if your provider has a reasonable suspicion of child/elder abuse or neglect or dependent adult abuse, your provider is legally obligated to report it to the appropriate State Department of Children and Family Services.
- When disclosure is required to obtain payment for treatment. Your provider might send your PHI to your insurance company, health plan, or other third-party payers to receive payment for services.
- Appointment reminders and health-related benefits or services. Your provider may use PHI to provide appointment reminders.
- When disclosure is otherwise specifically required by law.
Other Uses and Disclosures Require Your Prior Written Authorization. For situations not described above, your provider will require written authorization before disclosing any of your PHI. This includes communication with family members or other healthcare providers. Even if you signed an authorization to disclose your PHI, you may later revoke that authorization, in writing, to stop any future disclosures.
The Right to See and Get Copies of Your PHI. In general, you have the right to see or get copies of your PHI from your provider. You must request it in writing, and your provider will respond within 5 days of receiving your written request. Under certain circumstances, your provider may deny your request and will give you, in writing, the reasons for the denial. You have the right to have the denial reviewed. If you ask for copies of your PHI, you will not be charged more than $.25 per page. Your provider may see fit to give you a summary or explanation of the PHI, but only if you agree to it, as well as to the cost, in advance.
The Right to Choose How Your PHI is Sent to You. It is your right to ask that your PHI is sent to you at an alternate address (for example, sending information to your work address rather than your home address) or by an alternate method (for example, via email instead of by regular mail).
The Right to a List of the Disclosures Your Provider Has Made. You are entitled to a list of disclosures of your PHI that your provider has made after April 15, 2003. The list will not include uses or disclosures made before April 15, 2003. After April 15, 2003, disclosure records will be held for six years.
The Right to Amend Your PHI. If you believe that there is some error in your PHI or that important information has been omitted, it is your right to request that your provider correct the existing information or add the missing information. Your request must be made in writing. Your provider may deny your request, in writing, if your provider finds that the PHI is (a) correct and complete, (b) forbidden to be disclosed, (c) not part of their records, or (d) written by someone other than your provider. Your provider’s denial must be in writing and must state the reasons for the denial. You have a right to file a written statement objecting to the denial. You have the right to ask that your request and the denial be attached to any future disclosures of your PHI. When approved, your provider will advise others who need to know about the change to your PHI.
The Right to Get a Copy of This Notice. You have the right to get a copy of this notice by email or paper hard copy.
File a Complaint About Your Provider’s Privacy Practices. If in your opinion, your provider may have violated your privacy rights, or if you object to a decision your provider made about access to your PHI, you are entitled to file a complaint with your provider or if applicable, their clinical supervisor. You may also send a written complaint to the Secretary of the Department of Health and Human Services at 200 Independence Avenue S.W. Washington, D.C. 20201. If you file a complaint about privacy practices, your provider will take no retaliatory action against you.
INFORMED CONSENT: Please read carefully.
I hereby consent to engage in therapy, telehealth, coaching, or consultation services with the providers at Well Street.
- I understand that these services may include clinical consultation, treatment, transfer and communication of medical/psychological data (both orally and visually), emails, telephone conversations, education, and using interactive audio, video, or data communications.
- I understand that I have the right to withhold or withdraw consent at any time without affecting my right to future care or treatment. To withdraw consent to receive services from Well Street, email email@example.com. I understand that withholding or withdrawing my consent to receive services means that my treatment and/or services will be discontinued immediately and until such consent is restored.
- I understand that there are potential risks and benefits associated with any form of therapy, consultation, or coaching and that despite my efforts and the efforts of my provider, my condition may not improve. I understand that results cannot be guaranteed.
- I understand that there are risks involved in telehealth including the following possibilities, despite reasonable efforts on the part of Well Street:
- Video or audio transmission could be disrupted or distorted by technical failures.
- Video or audio transmission could be interrupted by unauthorized persons.
- The electronic storage of my personal health information could be accessed by unauthorized persons.
- I understand that in the case of telehealth appointments, I am responsible for providing:
- the necessary computer, telecommunications equipment, and internet access for my telehealth sessions,
- the level of security on my computer,
- arranging a location with sufficient lighting and privacy that is free from distractions or intrusions for my telehealth session.
Telephone and Emergency Procedures: If you are experiencing an emergency, call 911 or proceed to the nearest hospital emergency room for help. If you are having suicidal thoughts or making plans to harm yourself or others, call the National Suicide Prevention Lifeline at 1-800-273-TALK (8255) for free 24-hour hotline support. If you need to contact your provider between sessions, please leave a message at 855-466-CARE, or with your provider through the portal. Your call will be returned as soon as possible. Please understand that your provider may charge for services rendered over the phone.
Confidentiality of Therapeutic Sessions: All information disclosed within sessions and the written records pertaining to those sessions are confidential and may not be revealed to anyone without your written permission, except where disclosure is required by law. The provisions explaining when the law requires disclosure are described above in the HIPAA PRIVACY NOTICE.
Disclosure Required by Law: Some of the circumstances where disclosure is required by the law are: where there is a reasonable suspicion of child, dependent or elder abuse or neglect and where a Client presents a danger to self, others, or is gravely disabled.
Disclosure May Be Required: Disclosure may be required pursuant to a legal proceeding. If you place your mental status at issue in litigation initiated by you, the defendant may have the right to obtain the psychotherapy records and/or testimony by your provider. In couple and family therapy, or when different family members are seen individually, confidentiality and privilege do not apply between the couple or among family members. Your provider will not release records to any outside party unless they are authorized to do so by all adult family members who were part of the treatment.
Litigation Limitation: Due to the nature of the therapeutic process and the fact that it often involves making a full disclosure with regard to many matters which may be highly sensitive and of a confidential nature, it is agreed that should there be legal proceedings (such as, but not limited to divorce and custody disputes, injuries, lawsuits, etc.), neither you, nor your attorney, nor anyone else acting on your behalf will call your provider to testify at any proceeding, nor will a disclosure of the psychotherapy records be requested.
Consultation: Your provider may consult with other professionals regarding your services; however, your name or other identifying information is never mentioned. Your identity remains completely anonymous, and confidentiality is fully maintained. Consultation with other professionals is done to provide you with the best care possible.
Dual Relationships: A dual relationship exists when you have some type of relationship with your provider outside the clinical setting. This may include civic and philanthropic groups, religious communities, sports leagues, etc. Appropriate dual relationships are not unethical. Therapy never involves sexual or any other dual relationship that can be exploitative in nature, or impairs your provider’s objectivity, clinical judgment and/or therapeutic effectiveness. Appropriate non-sexual dual relationships can be clinically beneficial, and may, in fact, be the reason you chose your provider. Your provider will discuss with you the potential benefits and difficulties that may be involved in dual relationships and will discontinue the dual relationship if it interferes with the effectiveness of the therapeutic process.
Termination of Therapy: You have the right to terminate therapy at any time. Ideally, this happens when the goals of therapy have been met. If at any point during treatment, your provider believes they are not effective in helping you reach the therapeutic goals, they are obliged to discuss it with you and, if appropriate, to terminate treatment.
By purchasing and making use of the services provided, I verify that I am at least 18 years of age, that I am mentally sound, and that I have read, understood, and hereby agreed to the terms and conditions provided above.