Client Services Agreement
Ours Wellness, Inc. (“Ours Wellness”) is a virtual couples therapy platform that matches you and your partner with an experienced provider (“Provider”), such as a therapist or coach, who fits your needs. Ours Wellness and your Provider may be referred to herein as “us”, “we” or “our.” We are honored to help provide you with personalized support and care.
Although this document is long, it is very important that you read and understand it, as it is important that we are clear about how our relationship will work and what you can expect from us. When you sign this document, it will represent an agreement between you and us. Federal and state law require that we provide to you certain information set forth in this document. A full copy of this Client Services Agreement will be furnished for your records upon request. If you have any questions, please ask your provider or our office.
- Information About Your Provider. Upon being matched, your mental health provider’s name, license(s) and/or registration(s), education, theoretical approach and contact information is available by clicking on the clinician’s profile at https://secure.withours.com/account/therapist.
- Your Rights as a Client. As a client, you have the right to
- Receive information about the methods of therapy, the techniques used, the duration of therapy, if known, and the fee structure;
- Seek a second opinion;
- Terminate therapy at any time.
In a professional relationship, sexual intimacy is never appropriate and should be reported to the board that licenses, registers, or certifies the licensee, registrant, or certificate holder. Reports may be made to the appropriate governing boards as listed here: https://help.withours.com/article/17-mental-health-governing-boards.
Your records will be maintained in accordance with federal and state law. You can access your treatment notes by submitting a written request to email@example.com. If you wish your Ours provider to collaborate with an individual therapist or doctor as part of your care, you can contact us about a release of information.
- Subscription Agreement and Individual Session Charges. You can receive services from your matched Provider either through a subscription model, or by purchasing individual sessions. If you have a subscription model, you can also purchase additional individual sessions. In the case of monthly or annual subscriptions, on behalf of the Provider, we charge a subscription fee (the “Subscription Fee”). Our Subscription Fee may be modified and our current Subscription Fee options are available through our web-based application (the “App”). You agreed to pay the Subscription Fee at the intervals indicated when you signed up for your subscription with us. You also authorized Ours Wellness or our third-party payment processor to charge the credit card you provided to Ours Wellness at the intervals you agreed to when you signed up for the subscription, unless you terminate this Agreement prior to the date on which Ours Wellness would charge your card for the Subscription Fee. You understand that Ours Wellness will automatically charge your credit card at such intervals and as you agreed to when booking your individual session. The Subscription Fee covers costs associated with the services that enhance your experience, such as matching you with the right Provider, and providing scheduling support.
Ours Wellness will also automatically charge the credit card you provided us for individual sessions or additional sessions outside of the scope of your subscription.
None of the Providers on our platform are in-network providers with, or otherwise accept payment for our services from, any health or other insurance plans. As a result, you acknowledge that you may not be able to submit and obtain payment for the Subscription Fee or your individual sessions from your insurance or other benefit plan.
- Telehealth. You agree to receive telehealth services from your Provider (the “Telehealth Services”). Telehealth involves the use of audio, video, or other electronic communications to interact with you, consult with your Provider, and/or review your information for the purpose of counseling, follow-up, and/or education. Telehealth may be provided as synchronous (in real time) or asynchronous (not in real time, such as by sending a chat or a photo and later receiving a response). During your telehealth consultation with your Provider, details of your medical history and personal health information may be disclosed through the use of interactive video, audio, and telecommunications technology. The benefits of telehealth include having access to Providers and education without having to travel outside of your home or local health care community. The risks are that you can experience interruptions or technical difficulties, or, in rare circumstances, security protocols could fail, causing a breach of client privacy. You understand the risks and benefits of receiving Telehealth Services. You may ask your Provider any questions you may have regarding Telehealth Services, and you agree not to share your appointment link with anyone unauthorized to attend your appointment. All electronic communications are stored securely via Ours, a HIPAA-compliant EHR. Your provider will respond to communication within a reasonable time frame. In the case you are having trouble connecting with your provider, you may reach out to firstname.lastname@example.org for assistance.
The Ours Engineering team, including external Business Associate (BA) partners, collectively have the ability to access internal application data, including electronic communication, with appropriate safeguards and privilege access controls in place.
- Counseling Services Risks and Benefits. If you agree to receive counseling services through Ours Wellness, you acknowledge that there is a potential risk that you may experience uncomfortable feelings such as sadness, guilt, anxiety, anger, frustration, loneliness, and helplessness because the process of receiving counseling services often requires discussing the unpleasant aspects of your life, and approaching feelings or thoughts you have tried not to think about for a long time that may be painful. Making changes in your beliefs or behaviors can be scary and sometimes disruptive to your established relationships. The benefits of counseling services may include 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. However, there are no guaranteed results from counseling services.
- Emergencies. Telehealth Services should not be used for a medical or mental health emergency. In a medical or mental health emergency, or if you are feeling suicidal or that you cannot keep yourself or others safe, you should dial 911, call or chat with the 988 Suicide & Crisis Lifeline, and/or or go to your local hospital’s Emergency Room.
- Scheduling Services. All services can be scheduled by using the Ours Wellness website or App.
- Payment Methods. You understand that services that you book through Ours Wellness will be charged to your credit card, and you agree that the Subscription Fee shall be due at the intervals or dates you elected to make payment when you signed up for our services. Your payment for services you receive through Ours Wellness shall be made prior to or at the time of service. We are not an in-network provider with, and do not otherwise accept payment for our Services from, any health or other insurance plans.
We accept payment in the form of a credit card, which you expressly authorize us to charge for the services you receive from us.
- Cancellation Policy. You will be charged the full session price for any session that is not cancelled or rescheduled at least 24 business hours in advance of the scheduled session start time. If you cancel a subscription, you will not be charged for the next billing cycle, whether monthly or annual.
- Confidentiality and Compliance. We will take appropriate precautions to keep your health information confidential. We may collect or receive certain personal information and other data about you that is governed by federal law, such as HIPAA, on behalf of the Providers who use our platform. Our collection and use of that personal information is subject to the business associate agreement between us and the Providers, if applicable. Your Providers will keep the content of your sessions confidential and in accordance with the Provider’s Notice of Privacy Practices, if applicable, available here, which governs their use of, disclosure of, and access to information protected by HIPAA. There may be limitations on your privilege of confidentiality, such as if you threaten or attempt to commit grave bodily harm or death upon yourself or another person.
- Consent to Call, Email, and Text; and App Messaging. You expressly consent to allow us to communicate with you by telephone call, email, text message, messaging via our App, and/or other forms of unencrypted electronic messaging (“Electronic Messages”) using any telephone numbers or email addresses that you provide us or that we obtain lawfully, such as through caller ID. You expressly agree to receive prerecorded or automated Electronic Messages from us. You agree to receive these Electronic Messages from us even if your phone number is listed on the National Do Not Call Registry. You agree that you are the current owner of any telephone number you provide us. Wireless or data charges from your carrier may apply, and we are not responsible for these charges.
You understand that we do not require that you give your consent to receive automated Electronic Messages in order to receive services from us.
You understand that Electronic Messages sent by us may include, without limitation, appointment reminders, changes in previously scheduled appointments, actions to take in advance of appointments, follow-ups from appointments, information regarding billing, marketing material, or advice or education.
You understand the risks associated with communicating through Electronic Messages, including, without limitation, that Electronic Messages can easily be mis-addressed to or forwarded to unintended recipients, that Electronic Messages can be stored, that backup copies of Electronic Messages may exist even after the Electronic Messages are deleted, that Electronic Messages may not be secure and thus may be used or forwarded without your permission or knowledge, that Electronic Messages may be inspected by your telephone carrier, and that Electronic Messages may be used as evidence in court. You understand that we are not liable for any breaches of confidentiality caused by you or a third party.
You agree that in a medical emergency, you should not use Electronic Messages. Instead, you should call 911.
You understand that Electronic Messages may be filed in your medical record.
You may opt out of automated Electronic Messages, including in-App messages or notifications, SMS, and/or email, at any time. Your notification options and preferences are available on the Ours Wellness website and App. You may also send your request via in-App message to the Ours Wellness team or via email to email@example.com. You acknowledge and agree to receive a final message confirming your choice to opt out. Unless you revoke your consent to communicate with us via Electronic Messages, your consent will last through the end of your relationship with us.
You acknowledge that telephone calls to or from us may be monitored and recorded. You agree to this monitoring and recording.
In exchange for the services provided by us, you release Ours Wellness from all claims, causes of action, lawsuits, damages, losses, liabilities, or other harms relating to any Electronic Messages you exchange with us. You release Ours Wellness from all claims, causes of action, or lawsuits based on any alleged violations of any laws, including the Telephone Consumer Protection Act, the Truth in Caller ID Act, the CAN-SPAM Act, the Fair Debt Collection Practices Act, the Fair Credit Reporting Act, HIPAA, any similar state and local acts or statutes, and any federal or state tort or consumer protection laws.
- You have read and understand the information provided above and understand and agree to the terms in this agreement, including the services, payment methods, and cancellation policy. Any questions you had have been answered.
- You also understand that, under HIPAA, you have certain rights to privacy regarding your health information. You have received, read, and understand your Provider’s NPP containing a complete description of the uses and disclosures of your health information and understand that your Provider has the right to change its NPP from time to time and that you may contact your Provider at any time to obtain a current copy of the NPP.
- State-Specific Notices to Clients.
Mandatory Disclosure Required by Colo. Rev. Stat. Ann. § 12-245-216:
As stated in this Client Services Agreement, any information you provide during counseling sessions is legally confidential in the case of licensed marriage and family therapists, social workers, professional counselors, and psychologists; licensed or certified addiction counselors; and registered psychotherapists, except as provided in C.R.S.A. § 12-245-220 and except as otherwise provided in the Client Services Agreement.
The New Hampshire Mental Health Bill of Rights provides patients with certain rights. A copy of the Mental Health Bill of Rights is available here.
In addition to the confidentiality information above the following applies to patients in the state of Washington. The content of all sessions will be treated as confidential with the following exceptions:
1) If the therapist becomes aware that a child under 18 is or has been abused or has witnessed domestic violence, or a developmentally disabled person or an elderly person is or has been abused, a report must be made to the appropriate authorities (RCW 26.44.030).
2) If a client poses a threat to another person, the therapist must take steps to protect the potential victim(s), which might include but is not limited to warning the person(s) at risk and reporting the danger to the appropriate authorities (RCW 71.05.120).
3) If a client poses a danger to self or is unable to take care of basic needs, the therapist may take appropriate action to protect the client’s safety (RCW 71.05).
4) If a client discloses an HIV-infection, does not have a physician monitoring the condition and has unsuspecting IV drug-using or sexual partner(s) we may consult with a public health official.
5) If a client is involved in a legal battle, a judge may determine that the records must be turned over to the Court.
6) The Uniform Health Act of WA allows some communication among health care providers and between your health care providers and your family members. In most cases, your therapist will not communicate with any of the above without your consent but you should know that it is allowable.
7) If a client is a health provider licensed by the Washington State Department of Health we are required to report final determinations of unprofessional conduct, actual knowledge of unprofessional conduct and clear and present danger to patient safety due to a mental or physical condition.
- Updates/Revisions. We may update this Client Services Agreement upon thirty (30) days’ notice to you. Notice and updates will be provided via our App and will be available on our website at https://www.withours.com/client-services-agreement.
- Contact Information. You can contact us by email at firstname.lastname@example.org and by mail at 1220 Blalock Rd., Ste. 300, Houston, TX 77055.