MMG Counseling, LLC

1416 Monroe Ave Suite 204

Dunmore PA 18509-2477
570-483-8956

1. Notice of Privacy Practices

THIS NOTICE DESCRIBES HOW HEALTH INFORMATION MAY BE USED AND DISCLOSED AND HOW YOU
CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY.

I. MY PLEDGE REGARDING HEALTH INFORMATION:

I understand that health information about you and your health care is personal. I am committed to protecting
health information about you. I create a record of the care and services you receive from me. I need this record to
provide you with quality care and to comply with certain legal requirements. This notice applies to all of the records
of your care generated by this mental health care practice. This notice will tell you about the ways in which I may
use and disclose health information about you. I also describe your rights to the health information I keep about
you, and describe certain obligations I have regarding the use and disclosure of your health information. I am
required by law to:

• Make sure that protected health information (“PHI”) that identifies you is kept private.
• Give you this notice of my legal duties and privacy practices with respect to health information.
• Follow the terms of the notice that is currently in effect.
• I can change the terms of this Notice, and such changes will apply to all information I have about you. The new
Notice will be available upon request, in my office, and on my website.

II. HOW I MAY USE AND DISCLOSE HEALTH INFORMATION ABOUT YOU:

The following categories describe different ways that I use and disclose health information. For each category of
uses or disclosures I will explain what I mean and try to give some examples. Not every use or disclosure in a
category will be listed. However, all of the ways I am permitted to use and disclose information will fall within one of
the categories.

For Treatment Payment, or Health Care Operations: Federal privacy rules and regulations allow health care
providers who have direct treatment relationship with the client to use or disclose the client’s personal health
information without the client’s written authorization, to carry out the health care provider’s own treatment, payment
or health care operations. I may also disclose your protected health information for the treatment activities of any
health care provider. This too can be done without your written authorization. For example, if a clinician were to
consult with another licensed health care provider about your condition, we would be permitted to use and disclose
your person health information, which is otherwise confidential, in order to assist the clinician in diagnosis and
treatment of your mental health condition.

Disclosures for treatment purposes are not limited to the minimum necessary standard. Because therapists and
other health care providers need access to the full record and/or full and complete information in order to provide
quality care. The word “treatment” includes, among other things, the coordination and management of health care
providers with a third party, consultations between health care providers and referrals of a patient for health care
from one health care provider to another.

Lawsuits and Disputes: If you are involved in a lawsuit, I may disclose health information in response to a court or
administrative order. I may also disclose health information about your child in response to a subpoena, discovery
request, or other lawful process by someone else involved in the dispute, but only if efforts have been made to tell
you about the request or to obtain an order protecting the information requested.

III. CERTAIN USES AND DISCLOSURES REQUIRE YOUR AUTHORIZATION:

1. Psychotherapy Notes. I do keep “psychotherapy notes” as that term is defined in 45 CFR § 164.501, and any
use or disclosure of such notes requires your Authorization unless the use or disclosure is:
a. For my use in treating you.
b. For my use in training or supervising mental health practitioners to help them improve their skills in group, joint,
family, or individual counseling or therapy.
c. For my use in defending myself in legal proceedings instituted by you.
d. For use by the Secretary of Health and Human Services to investigate my compliance with HIPAA.
e. Required by law and the use or disclosure is limited to the requirements of such law.
f. Required by law for certain health oversight activities pertaining to the originator of the psychotherapy notes.
g. Required by a coroner who is performing duties authorized by law.
h. Required to help avert a serious threat to the health and safety of others.

2. Marketing Purposes. As a psychotherapist, I will not use or disclose your PHI for marketing purposes.
3. Sale of PHI. As a psychotherapist, I will not sell your PHI in the regular course of my business.

IV. CERTAIN USES AND DISCLOSURES DO NOT REQUIRE YOUR AURTHORIZATION. Subject to certain
limitations in the law, I can use and disclose your PHI without your Authorization for the following reasons:

1. When disclosure is required by state or federal law, and the use or disclosure complies with and is limited to the
relevant requirements of such law.
2. For public health activities, including reporting suspected child, elder, or dependent adult abuse, or preventing or
reducing a serious threat to anyone’s health or safety.
3. For health oversight activities, including audits and investigations.
4. For judicial and administrative proceedings, including responding to a court or administrative order, although my
preference is to obtain an Authorization from you before doing so.
5. For law enforcement purposes, including reporting crimes occurring on my premises.
6. To coroners or medical examiners, when such individuals are performing duties authorized by law.
7. For research purposes, including studying and comparing the mental health of patients who received one form of
therapy versus those who received another form of therapy for the same condition.
8. Specialized government functions, including, ensuring the proper execution of military missions; protecting the
President of the United States; conducting intelligence or counter-intelligence operations; or, helping to ensure the
safety of those working within or housed in correctional institutions.
9. For workers' compensation purposes. Although my preference is to obtain an Authorization from you, I may
provide your PHI in order to comply with workers' compensation laws.
10. Appointment reminders and health related benefits or services. I may use and disclose your PHI to contact you
to remind you that you have an appointment with me. I may also use and disclose your PHI to tell you about
treatment alternatives, or other health care services or benefits that I offer.

V. CERTAIN USES AND DISCLOSURES REQUIRE YOU TO HAVE THE OPPORTUNITY TO OBJECT.

1. Disclosures to family, friends, or others. I may provide your PHI to a family member, friend, or other person that
you indicate is involved in your care or the payment for your health care, unless you object in whole or in part. The
opportunity to consent may be obtained retroactively in emergency situations.
 VI. YOU HAVE THE FOLLOWING RIGHTS WITH RESPECT TO YOUR PHI:

1. The Right to Request Limits on Uses and Disclosures of Your PHI. You have the right to ask me not to use or
disclose certain PHI for treatment, payment, or health care operations purposes. I am not required to agree to your
request, and I may say “no” if I believe it would affect your health care.
2. The Right to Request Restrictions for Out-of-Pocket Expenses Paid for In Full. You have the right to request
restrictions on disclosures of your PHI to health plans for payment or health care operations purposes if the PHI
pertains solely to a health care item or a health care service that you have paid for out-of-pocket in full.
3. The Right to Choose How I Send PHI to You. You have the right to ask me to contact you in a specific way (for
example, home or office phone) or to send mail to a different address, and I will agree to all reasonable requests.
4. The Right to See and Get Copies of Your PHI. Other than “psychotherapy notes,” you have the right to get an
electronic or paper copy of your medical record and other information that I have about you. I will provide you with
a copy of your record, or a summary of it, if you agree to receive a summary, within 30 days of receiving your
written request, and I may charge a reasonable, cost based fee for doing so.
5. The Right to Get a List of the Disclosures I Have Made. You have the right to request a list of instances in which I
have disclosed your PHI for purposes other than treatment, payment, or health care operations, or for which you
provided me with an Authorization. I will respond to your request for an accounting of disclosures within 60 days of
receiving your request. The list I will give you will include disclosures made in the last six years unless you request
a shorter time. I will provide the list to you at no charge, but if you make more than one request in the same year, I
will charge you a reasonable cost based fee for each additional request.
6. The Right to Correct or Update Your PHI. If you believe that there is a mistake in your PHI, or that a piece of
important information is missing from your PHI, you have the right to request that I correct the existing information
or add the missing information. I may say “no” to your request, but I will tell you why in writing within 60 days of
receiving your request.
7. The Right to Get a Paper or Electronic Copy of this Notice. You have the right get a paper copy of this Notice,
and you have the right to get a copy of this notice by e-mail. And, even if you have agreed to receive this Notice via
e-mail, you also have the right to request a paper copy of it.

ACKNOWLEDGEMENT OF RECEIPT OF PRIVACY NOTICE

Under the Health Insurance Portability and Accountability Act of 1996 (HIPAA), you have certain rights regarding
the use and disclosure of your protected health information. By signing this document, you are acknowledging that
you have received a copy of HIPAA Notice of Privacy Practices.

Signature
Jacob Schelinski

Jacob Schlenski: By signing this I acknowledge that I've read, fully understand and agree to all information contained here.
Signed: 10/26/2023 06:34 PM ET
 2. Informed Consent for Psychotherapy

General Information

The therapeutic relationship is unique in that it is a highly personal and at the same time, a contractual agreement.
Given this, it is important for us to reach a clear understanding about how our relationship will work, and what each
of us can expect. This consent will provide a clear framework for our work together. Feel free to discuss any of this
with me. Please read and indicate that you have reviewed this information and agree to it by filling in the checkbox
at the end of this document.

The Therapeutic Process

You have taken a very positive step by deciding to seek therapy. The outcome of your treatment depends largely
on your willingness to engage in this process, which may, at times, result in considerable discomfort. Remembering
unpleasant events and becoming aware of feelings attached to those events can bring on strong feelings of anger,
depression, anxiety, etc. There are no miracle cures. 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.

Confidentiality

The session content and all relevant materials 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 a specifically named person/persons.
Limitations of such client held privilege of confidentiality exist and are itemized below:
1. If a client threatens or attempts to commit suicide or otherwise conducts him/her self in a manner in which there
is a substantial risk of incurring serious bodily harm.
2. If a client threatens grave bodily harm or death to another person.
3. If the therapist has a reasonable suspicion that a client or other named victim is the perpetrator, observer of, or
actual victim of physical, emotional or sexual abuse of children under the age of 18 years.
4. Suspicions as stated above in the case of an elderly person who may be subjected to these abuses.
5. Suspected neglect of the parties named in items #3 and # 4.
6. If a court of law issues a legitimate subpoena for information stated on the subpoena.
7. If a client is in therapy or being treated by order of a court of law, or if information is obtained for the purpose of
rendering an expert’s report to an attorney.

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

If we see each other accidentally outside of the therapy office, I will not acknowledge you first. Your right to privacy
and confidentiality is of the utmost importance to me, and I do not wish to jeopardize your privacy. However, if you
acknowledge me first, I will be more than happy to speak briefly with you, but feel it appropriate not to engage in
any lengthy discussions in public or outside of the therapy office.

Signature
Jacob Schelinski

Jacob Schlenski: By signing this I acknowledge that I've read, fully understand and agree to all information contained here.
Signed: 10/26/2023 06:34 PM ET
 3. Policies and Procedures 1

POLICIES AND PROCEDURES

Welcome! Here is some information you need to know:This guide to office policies and procedures will provide
answers about fees, appointments, insurance, messages, and other issues. Please read this guide carefully and
keep it for your records to refer back to if needed. If you have any questions or concerns, feel free to discuss them
with me.

WILL THERAPY WORK FOR ME?

Research shows that therapy is helpful to most people. Studies have also shown that the people who benefit the
most from therapy participated in weekly counseling sessions for three to six months. Some people also find they
feel better or achieve their therapy goals in a shorter amount of time, but often people quit too soon and don’t get
the full benefit of counseling.

If you find that counseling isn’t helpful for you, that happens sometimes, and the best way to approach it is to
discuss that with your therapist. Most therapists are trained and experienced in a variety of different counseling
approaches and styles, and can make changes to your therapy sessions to help you get the maximum benefit.
Don’t be shy! Speak up about what’s not working, what you’d like more of, etc. Good therapists welcome this type
of feedback. It helps us tailor our services and improve our skills so that we can be more effective.

APPOINTMENTS
Except for rare emergencies, I will see you at the time scheduled. Because this time is set aside for you, it is
important that you keep this appointment. It is understood that circumstances may arise which necessitate the
cancellation of an appointment. In these cases, please provide at least 24 hour's notice of any appointment that
you need to cancel. You will be charged for appointments missed without 24 hours advance notice. **** Fee
$50.00****. Please call or text if you cannot make your appointment.

COST FOR SERVICES

Many factors go into determining what your fee will be (what your insurance company allows, what your therapist
charges, etc.). It is your responsibility to know what your insurance will cover and what your portion is (deductible,
co-pay and co-insurance). A session typically runs about 45-55 minutes. Payment is required at the beginning or
end of each session. If you have difficulty paying your bill, please discuss a payment schedule with me.
There is a $30.00 fee for returned checks.

HEALTH CARE INSURANCE

Many health care insurance policies will cover SOME of the cost of your therapy. The reimbursement varies
considerably from policy to policy. Read your policy carefully and be aware of what is and what is not covered,
whether or not your therapist is a provider with your insurance company, and if you need a referral or
preauthorization. It is your responsibility to obtain authorization and a referral if necessary. You may wish to call
your insurance company and ask about your benefits for outpatient psychotherapy.

I do file insurance forms as a courtesy to you. It is your responsibility to provide me with the proper forms and
information. Ultimate responsibility for payment lies with you.

VACATIONS
If I am away, a back-up therapist can be arranged to be available to you in the event that you need help. If a
therapist is unavailable, CMC has a crisis unit which can be utilized. In a true emergency, dial 911.
 FEEDBACK
The course and success of your therapy is a joint responsibility between the two of us. It is expected that you will
communicate any concerns about what is happening in therapy to me. This is an important part of the therapeutic
relationship.

TERMINATION PROCESS
Termination of therapy should be mutually agreed upon within a scheduled session. The therapeutic relationship is
an important one and therefore usually means a great deal to both therapist and client. In order to maximize the
benefits of therapy, it is in your best interest to terminate therapy in a planned session.

CLOSED FILES
If there is no contact, through scheduled appointments for 3 months, your case would be considered inactive and
will be closed. By signing this agreement, you acknowledge this policy. This means you will not be considered an
active client of this therapist if your case is closed due to no contact. You may reopen your case at any time by
calling and scheduling an appointment, pending availability of this therapist.

I, the undersigned, have read about the policies and procedures of MMG
Counseling, LLC and I agree to their terms.
Signature
Jacob Schelinski

Jacob Schlenski: By signing this I acknowledge that I've read, fully understand and agree to all information contained here.
Signed: 10/26/2023 06:34 PM ET
 4. Standard Intake Questionnaire 1

What brings you to therapy at this time?

What is your major concern?
Major depression, PTSD and ADHD are my main concerns

Have you previously suffered from this concern?

Yes

If Yes, enter previous therapist(s) seen for concern, describe treatment

Margret Soloman - Cognitive behavioral therapy ,

Stressors
**No answer given**

Relieving Factors/Hobbies/Interests
Music , writing

Current Symptoms
(check all that apply)

Anxiety

Appetite Issues

Avoidance

Crying Spells

Depression

Excessive Energy

Fatigue

Guilt

Hallucinations

Impulsivity

Irritability

Libido Changes

Loss of Interest

Panic Attacks

Racing Thoughts

Risky Activity

Sleep Changes
 Suspiciousness

Medical History
Exercise Frequency
none

Exercise Type
**No answer given**

Allergies
none

What medications are you currently using?

lexapro and Strattera daily , vistril as needed

Previous diagnoses/mental health treatment

Depression , ADHD , Anxiety, PTSD

Family doctor:
Dr. Spagnolini

Do you give permission to contact your PCP?

yes

Date of last physical exam

**No answer given**

Previous medical conditions

asthma

Previous surgeries
tonsils removed

Family History
Were you adopted? If yes, at what age?
**No answer given**

How is your relationship with your mother?

overall good

How is your relationship with your father?

overall good

Siblings and their ages

4 sisters and one brother , 32, 34, 34, 39, 41

Are your parents married?

yes

Did your parents divorce? If yes, how old were you?

**No answer given**
Did your parents remarry? If yes, how old were you?
**No answer given**

Who raised you? Where did you grow up?

my parents, Exeter, PA

Family member medical conditions

Dad - Stage 4 Prostate cancer; cardiomyopathy, sleep apnea, high blood pressure. Siblings - unknown.
Mom - hypoactive thyroid, hiatel hernia and reflux.

Family member mental conditions

None/Not aware

Treated with medication?

Dad - Yes

Medications
For Mom and Dad - many and if absolutely needed can provide a list.

Present Situation
Work
Unemployed

Where did you attend high school?

Wyoming area

College, Trade School, or highest level of education? Name, city, degree

**No answer given**

What is your occupation? What is your level of satisfaction with your job and/or what are the stressors?
**No answer given**

Are you married? If yes, specify date of marriage

no

Are you divorced? If yes, specify date of divorce

no

Prior marriages? If yes, how many?

no

What is your sexual orientation?

gay

Are you sexually active?

yes

How is your relationship with your partner? What is their occupation?

na

Do you have child(ren)? If yes, how is your relationship with your child(ren)?
no
Are you a member of a religion/spiritual group?
no

Have you ever been arrested? If yes, when and why?

no

Have you ever tried the following?

(check all that apply)

Alcohol

Tobacco

Marijuanna

Hallucinogens (LSD)

Heroin

Methamphetamines

Cocaine

Stimulants (Pills)

Ecstasy

Methadone

Tranquilizers

Pain Killers

If yes to any, list frequency/dates of use

used medical marijuanna for my mental health for a few years but not anymore, I vape nicotine daily , tried
LSD once and shrooms twice in my life, alcohol socially 2/3 days a week

Have you ever been treated for drug/alcohol abuse? If yes, when?
no

Do you smoke cigarettes? If yes, how many per day?

no

Do you drink caffeinated beverages? If yes, how many per day?

**No answer given**

Have you ever abused prescription drugs? If yes, which ones?

no

Additional
Have you ever experienced any of thefollowing as a child or adult?

Physical Abuse
 Sexual Abuse

Emotional Abuse

Victim of a Crime

Suicidal Thoughts

Suicide Attempt

Other Trauma

Anything else you want the therapist to know?

**No answer given**

How did you find out about us?

friend of a friend

Jacob Schlenski: By signing this I acknowledge that I've read, fully understand and agree to all information contained here.
Signed: 10/26/2023 06:34 PM ET
 7. TELEHEALTH: Informed Consent 1

Informed Consent for TELEHEALTH

Telehealth is a method to deliver health care services using information and communication technologies to
facilitate the diagnosis, consultation, treatment and care management while the patient and provider are at two
different sites. This form of service is usually live videoconferencing through a personal computer with a webcam. I
hereby consent to engaging in distance counseling with MMG Counseling as part of my therapy. I understand that
distance counseling includes the practice of health care delivery, diagnosis, consultation, treatment, transfer of
medical data and education using interactive audio, video or data communications. I attest to being physically
located in the state of Pennsylvania and hereby consent to engaging in telehealth with MMG Counseling for the
purpose of therapy. I understand that telemedicine or telehealth includes the practice of health care delivery,
diagnosis, consultation, treatment, transfer of medical data and education using interactive audio, video or data
communications. I understand that telehealth also involves the communication of my medical/mental information,
both orally and visually, to health care practitoners located in Pennsylvania.

I understand that I have the following rights with respect to distance counseling:I have the right to withhold or
withdraw consent at any time without affecting my right to future care or treatment nor risking the loss or withdrawal
of any program benefits to which I would be otherwise entitled. The laws that protect the confidentiality of my
medical information also apply to distance counseling. As such, I understand that the information disclosed by me
during the course of my therapy is generally confidential. However, there are both mandatory and permissive
exceptions to confidentiality, including, but not limited to, reporting child, elder and dependent adult abuse,
expressed threats of violence towards a victim and suicidal threats and intent. I understand that video conferencing
technology used in this therapy will not be exactly the same as an in-person health care provider-consumer
relationship / visit due to the fact that I ( the consumer) will not be in the same room as my therapist / health care
provider. While I understand that my telemental health session is being conducted over a highly secure technical
system, I accept the potential risks of this technology, including interruptions, unauthorized access, and technical
difficulties. I understand that my therapist / health care provider or I can discontinue the telemedicine sessions if it
is felt that the videoconferencing connections are not adequate for the situation. I agree that if the
videoconferencing connection drops while I am in session, my phone line will be available to contact my therapist /
health care provider or to be contacted by my therapist / health care provider. If an emergency situation occurs
during a telemental health session, then I understand that my therapist will contact emergency services and my
emergency contacts according to and established safety plan we discussed at the onset of treatment. The
responsibility of this therapist will conclude upon the termination of the videoconferencing connection. I understand
that if my therapist believes I would be better served by another form of therapy services such as face to face,
group therapy, inpatient, I will be referred to such services or a provider who can provide such services. This may
mean that tele mental health services will cease. I understand that I have the opportunity to ask further questions or
discuss the process further during my video sessions. Even though I may have a need to discuss this process
further, I agree to continue with this process and understand the risks, benefits and any practical alternatives. I
understand the alternatives to a telemental health consultation and am choosing to particpate in a telemedicine
therapy session or sessions. I understand that I may benefit from distance counseling, but that results cannot be
guaranteed or assured. I have read and understand the information provided. I have discussed it with my therapist
and all of my questions have been answered to my satisfaction.

If you have an emergency, feel suicidal or homicidal please: Call 911, or Go to the nearest hospital emergency
room or crisis center in your county or Call the National Suicide Prevention Lifeline 1-800-273-8255.* Please sign
and date that you have read the form and fully understand and are comfortable with its content including the risks
and benefits.*****Please enter your name in the box below giving your consent.

Electronic Signature
Jacob Schelinski
 Date
10/26/2023

Jacob Schlenski: By signing this I acknowledge that I've read, fully understand and agree to all information contained here.
Signed: 10/26/2023 06:34 PM ET
 9. Credit / Debit Card Payment consent - updated 2/23

Client name
Jacob Schelinski

(Card holder) Name on card if different than client

Michelle M Valenti

Card Type
Visa

Card number
4737028053455161

Expiration Date
07/27

CVV
492

Zip code card is under

18643

I authorize MMG Counseling, LLC to charge my credit/debit/health account card for professional services after
session is rendered. For new client intake sessions, you may not see a charge until the first explanation of benefits
"EOB" has processed from the insurance company. Typically, copays or coinsurance will be charged the day or
week services are rendered. Your invoice will be emailed to you after charges are made to your card, there you will
find details of session dates for corresponding charges.

Please be aware of your insurance plan, as you may have a deductible that needs to be met prior to insurance
paying for sessions. Deductibles will also be charged after EOB's are received by the practice from the insurance.

Please reach out to your therapist with any questions or concerns about payment or if you need to change the card
on file.

I understand and consent there is a charge for late cancel/no show fee of $50 that will be charged to my card on
file.

I understand my card will be charged, if applicable, for my deductible, copays or coinsurance at time of session
OR when EOB has been received by the practice.

I verify that my credit card information, provided above, is accurate to the best of my knowledge. If this information
is incorrect or fraudulent or if my payment is declined, I understand that I am responsible for the entire amount
owed and any interest or additional costs incurred if denied. I also understand by signing and initialing this form that
if no payment has been made by me, my balance will go to collections if another alternative payment is not made
within thirty days.

Client Initials
JS

Card holder Initials (If different than client)

MV
 Date
10/26/2023

Signature
Michelle M Valenti

Jacob Schlenski: By signing this I acknowledge that I've read, fully understand and agree to all information contained here.
Signed: 10/26/2023 06:34 PM ET