Doug DiBrielle, LMHC - Thrive Catalyst, LLC

Online therapy in Massachusetts

Mailing: 185 Devonshire St. STE 500, Boston, MA 02110

p. 617-429-6838 f. 855-532-9720

Doug@ThriveCatalyst.com

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Informed Consent for Treatment

Introduction

Welcome! This document outlines what to expect from the counseling process and clarifies the terms of the therapeutic relationship between counselor (me) and client (you). Legally, this is called “Informed Consent.”  When you sign this document, it represents an agreement between us.  We can discuss any questions or concerns you may have before you sign this document, or at any time in the future once counseling has begun. Please read this in its entirety and indicate that you have reviewed this information and agree to it by filling in the checkbox at the end of this document.

Practice Information

I, Doug DiBrielle, LMHC, own and operate an individual private practice incorporated in the State of Massachusetts under the name “Thrive Catalyst, LLC.” While my physical mailing address is: 185 Devonshire Street, STE 500, Boston, MA 02110, I currently reside in California. I maintain licensure in Massachusetts as a Licensed Mental Health Counselor: MA LMHC License #8027.

Rights, Responsibilities and Limitations

The therapeutic relationship has clearly defined rights, responsibilities, and some legal limitations for both you and me as outlined below:

Counseling Process:

You have taken a very positive step by deciding to seek mental health counseling; a psycho-therapeutic process by which you and I, and sometimes other related individuals, explore your life experiences, challenges, events, feelings, and memories to create lasting positive change.  The intended outcome is for you to experience a more balanced and satisfying life, while providing the opportunity to deeply understand and connect with aspects of your core “Self”. Psychotherapy is a collaborative process between us that requires each of our active participation.

Benefits and Risks of Counseling:

Therapy often leads to feeling worse before feeling better.  Risks may include experiencing uncomfortable feelings, such as sadness, guilt, anxiety, anger, frustration, loneliness, and helplessness, as you remember unpleasant aspects of your life and become aware of the feelings associated with them. However, counseling has also been shown to have great benefits.  Treatment often leads to a significant reduction in feelings of distress, increased satisfaction in interpersonal relationships, greater personal awareness and insight, increased skills for managing stress and resolutions to specific problems.  While there are no miracle cures and I cannot promise that your behavior or circumstance will change, I can promise to support you and do my very best to understand you and repeating patterns, as well as to help you clarify what it is that you want for yourself.  I’ll need your full participation during and outside of our meetings for you to gain maximum benefit.

During the therapeutic process, many clients find that they feel worse before they feel better.  This is generally a normal course of events.  Personal growth and change may at times be easy and swift but may also be slow and frustrating.  I ask you to trust the process, and more importantly please inform me of any concerns you have regarding your progress in therapy.

Overview of Counseling Process

The first 4-6 sessions will involve a comprehensive evaluation of your needs and current situation. By the end of the evaluation, I will be able to offer you some initial impressions of what our work might include, including a clinical diagnosis of the problem(s) that you are electing to work on. At that point, we will discuss your treatment goals and create an initial treatment plan. You should evaluate this information and make your own assessment about whether you feel comfortable working with me. If you have questions about my procedures or this process, I invite you to discuss them whenever they arise.  If your doubts persist, or I am not able to help you reach your goals, I will be happy to offer referrals to other providers.  Keep in mind that you have freedom of choice when it comes to choosing a therapist.

Ending of Therapy and “Termination of Treatment”

Ending relationships can be difficult. Therefore, I have an intentionally thoughtful process in place to offer reflection and closure as treatment concludes. Appropriate length of the closure process depends on the length and intensity of treatment, and is determined collaboratively.

Termination of treatment happens for various reasons:

1. The work is complete:

You have reached your goals, feel satisfied with your ability to manage life, and there are not additional goals you wish to work on.

2. Misalignment between you and I:

There may be another provider who has skills better aligned to meet your needs.  Please speak up if you want something different, or are not satisfied with the services I offer, and I will help you with a referral.

I will let you know if I have any concerns about my ability to meet your stated goals / needs.  If necessary I reserve the right to terminate services in order to refer you to another provider as appropriate.

3. Therapy services underutilized or proving ineffective:

Your healing and growth requires each of our full engagement and participation.  I will let you know if I have concerns about your readiness / ability at this moment to do the work, or if I believe the services I have to offer are ineffective, and will end therapy if necessary.

4. Default in payment:

Payment is due when services are provided.  Therapy will pause if an outstanding balance passes 30 days.  Economic hardship is real and we will work to create a payment plan.  If you default on the payment plan, services will be terminated until balance is paid in full.

5. > 3 week unplanned gap in scheduling:

If you do not reschedule a canceled or missed appointment for more than three weeks and we have not made prior arrangements, for legal and ethical reasons I must consider the relationship discontinued and will no longer consider you a client under my care.  You may contact me at any time to re-engage in service.

The decision to end treatment is not to be taken lightly, and it is a conversation I typically start in our initial interactions. We will periodically dialogue on this topic throughout the work, as I hope for you to one day find yourself feeling confident and comfortable navigating life without my services.

Confidentiality

The session content and all materials relevant 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 self or a specifically named person/persons. Limitations of such client held privilege of confidentiality exist and are outlined in the Notice of Privacy Practices document included in your intake packet.  I make every effort to inform a client when I must break your confidentiality, but certain circumstances necessitate that I prioritize safety.

Electronic Practice Management System

I utilize Simple Practice - a web-based, encrypted, and HIPAA compliant electronic practice management system that integrates client records, online scheduling, online payment, billing, secure messaging, and secure document sharing.

Records and Record Keeping - “What happens to your story?”

I take notes during our sessions and securely maintain them in Simple Practice. Following each session I write a summary of topics explored along with therapeutic interventions employed.  These notes, along with intake paperwork, emails, text communications, secure messages, and billing related business records become part of your medical record and I am required by law to maintain it for seven years following our last contact. (Please see “Notice of Privacy Practices” for further details on your rights regarding how your private information is managed.)

Use of Artificial Intelligence (AI)

I use an AI-assisted tool to help with drafting therapy notes. This tool supports me behind the scenes by helping organize and summarize the key themes and progress points we discuss in session.

I want to be clear: AI is never used to interpret your emotions, analyze your responses, or guide clinical decisions. All notes are reviewed, edited, and finalized by me. Your privacy and confidentiality remain protected, and the AI tool I use is HIPAA-compliant.

Using this kind of support allows me to spend less time behind a screen and more time present with you during our work together. If you have questions or concerns about how this works, I welcome the conversation.

Professional Consultation

Occasionally I may need to consult with other professionals in their areas of expertise to provide the best treatment for you. Information about you may be shared in this context without using your name or other identifying information.

Contact in Public

If we see each other outside of the therapy office, I will not acknowledge you first.  Your right to privacy and confidentiality is of the utmost importance to me.  However, if you choose to acknowledge me first, I will be more than happy to say hello and chat briefly about non-personal related subjects.   We will not engage in a therapeutic discussion and I will limit public conversations outside of the therapy office to be respectful of your confidentiality and maintain my professional boundaries.

PRACTICE POLICIES & PROCEDURES:

Appointments & Scheduling:

• Typical Session Length - 60 minutes

• Typical Frequency - Weekly, same day / time each week

If you are interested in a shorter/longer session or increased/decreased frequency, please let me know and we can discuss options.  Please arrive on time to ensure that you receive your full session, and plan to end our session on time to accommodate other clients who have appointments after you.

Client Portal Scheduling:

You have access to online scheduling where you can view / schedule / change appointments.  Making changes to our regular meeting schedule is your responsibility and is available online up to  48 hours prior to each appointment.

You may also contact me directly by email / phone / text if you need to reschedule.

Cancellation Policy:

Consistency is an essential part of the counseling process.  When you make an appointment, this time is reserved specifically for you and is not available to other clients.

• 48 hours notice

• Late Cancellation / No-Show Fee: $100

• No charge if session is rescheduled same week

If you are unable to keep or reschedule an appointment, you must notify me at least 48 hours in advance of the scheduled appointment to avoid being charged for the session.

If you don’t hear back from me, please call.  Absence of a reply from me means that I did not receive your initial communications.  Please note that appointments may also be canceled / rescheduled through the Client Portal up to 48 hours in advance.

When applicable, late cancellation / no show fees will be automatically charged to the credit card on file at the end of the business day, unless we have communicated otherwise. Insurance companies do not provide reimbursement for canceled sessions / no-shows and the associated fees.

A time commitment is made to you and is held exclusively for you.  If you are late for a session, you may lose some of that session time as well.  Please communicate a cancellation as soon as you know you are unable to attend.  There are some extenuating circumstances where I choose to waive the cancellation fee and I encourage you to communicate concerns.

FEES AND INSURANCE

Fee Schedule:

• 15-20 Minute Initial Phone Consultation – No Charge

• 15 Minute Check-In or extension of session - $65

• 30 Minute Session - $125

• 45 Minute Session - $190

• 60 Minute Session - $250

• 75 Minute Session - $310

• 90 Minute Session - $375

• Cancellation < 48 hour notice / no-show - $100

I reevaluate my fees once per year to consider changes in the cost of running business. You will be notified at least one month in advance of any changes that will impact you directly.

Terms:

Payment is due in full at the beginning of each session. I accept payment by cash, check, credit card, healthcare spending account card, and flexible spending account card.

Billing Procedures

**Following each session, you will be electronically invoiced and the credit/debit card on file will be charged for the appropriate amount.  For your convenience, you may access invoices via your *Client Portal.  ***

Credit Card Authorization:

Each client is required to maintain an active credit card on file, stored securely in the electronic practice management system.  The credit card on file will be charged by midnight on the day services are rendered, for late cancellations (less than 48 hours notice), or no-show for a scheduled session.

By providing a credit card on file as required for payment, and by signing this “Informed Consent for Treatment” you are authorizing the credit card on file to be used for services rendered.

You will be notified if your credit card on file is expired or declined, and will be asked to provide an updated credit card as soon as possible.

Health Insurance:

Insurance companies require diagnosis and treatment planning which can dictate treatment.  As such, I do not participate as an in-network provider with any insurance plans.  I provide services on a private-pay basis, which can offer clients increased privacy by limiting release of sensitive information to insurance companies when choosing not to use insurance benefits.

Out-of-Network Reimbursement:

You may be able to access and utilize your “out-of-network” benefits to defray the cost of services.  Please contact your insurance company directly to discuss the unique benefits of your particular plan.  I provide the necessary documentation (known as a “Super Bill”) required to submit for reimbursement, and provide access to it via the Client Portal.

Reimbursify - I provide each client with free access to an app based service, “Reimbursify”, that serves to help clients submit and manage out-of-network insurance claim reimbursement requests.

COUNSELOR AVAILABILITY OUTSIDE OF SESSIONS

Office Hours:

I am available via email, phone, and telehealth services.

My general “office hours” are as follows:

• Monday: 11:00am-5:30pm ET

• Tuesday: 11:00am-5:30pm ET

• Wednesday: 11:00am-5:30pm ET

• Thursday: 11:00am-5:30pm ET

• Friday: 11:00am-5:30pm ET

I am periodically available at alternative times when extenuating circumstances necessitate flexibility. Please contact me should you need a meeting outside of these hours.

In the event of an emergency, please call your local emergency services department, or go to your nearest Hospital’s Emergency Department.

Virtual / Telehealth:

I conduct all sessions via the secure and HIPAA compliant telehealth platform provided by Simple Practice.  All appointments can be accessed via your Client Portal, or via the mobile based “Telehealth by Simple Practice” app.

Phone:

If you need to contact me between sessions, please leave a voicemail, or send me a secure message through the Client Portal. I am often not immediately available due to the nature of counseling work.  I will attempt to return your call or message within 24 hours on weekdays, and by the following business day during weekends and holidays.

Vacations:

During the calendar year (January – December) I take up to 6 weeks away from the office for seminars, training, and personal vacations.  I try my best to provide at least 2 weeks of advance notice.

Illness:

If I become sick, or have a family event that requires my attention, I will call you to cancel our appointment as soon as I am able.  If I do not speak to you directly, I will leave a voice message and attempt to notify you of the cancellation via both the Secure Portal and Text Message.

Electronic Communication

Text Messaging:

Text messaging should only be used to notify me that you are running late or need to reschedule a session.  Texting personal information is strongly discouraged.  Please be advised that text messaging is not a secure form of communication and if you choose to send a text message you do so at your own risk.  Text messages are considered part of your treatment record and are stored securely in your electronic medical record.

Secure Messaging via Client Portal:

If you wish to share personal information with me or ask a specific question related to your treatment, I encourage you to send me a private and secure message using your Client Portal. You may also securely upload documents to your portal, rather than sending them via email (unsecure).

I receive Client Portal messages during my normal business hours and do my best to respond the same day.

Social Media Policy

Due to the importance of your confidentiality and the importance of minimizing dual relationships, I do not accept friend or contact requests from current or former clients on any social networking site (Facebook, LinkedIn, Twitter, Instagram, etc.). I believe that adding clients as friends or contacts on these sites can compromise your confidentiality and our respective privacy. It may also blur the boundaries of our therapeutic relationship. If you have questions about this, please bring them up when we meet, and we can talk more about it.

About Doug:

I strongly believe that you should feel comfortable with the therapist you choose and hopeful about the therapy. When you feel this way, therapy is more likely to be most helpful to you. I consider myself fortunate and privileged to join with individuals on their journey to find healing, happiness, success, order, peace and understanding. With a passion for working with individuals, I offer support through a trained holistic lens, where we collaboratively examine life through the biological, social, psychological and spiritual lens'. The methods and techniques I use most are pulled from Cognitive Behavioral, Person-Centered, Psychodynamic, Gestalt, Internal Family Systems, Body-Oriented, Interpersonal, and Mindfulness-Based Therapies. I aim to be fully present with you in your self-exploration, while helping to guide your process. I look forward to our work together.

This notice updated and effective August 1, 2025.