Informed Consent, Terms of Use, and Disclaimer of Liability 

Welcome to the ICBT Online Group Program, a group therapy program for people seeking support with OCD symptom management through Inference-Based CBT (ICBT). By participating in this program, you acknowledge and agree to the following Terms of Use, informed consent, and disclaimer of liability. If you do not agree with these terms, please refrain from participating.

This group program includes weekly live meetings as well as ongoing support from a group community.

1. Purpose and Goals of the Program

The  ICBT Online Group Program is designed to help participants manage symptoms of OCD by teaching ICBT techniques. This program emphasizes building skills in recognizing and addressing faulty inferences, reducing distressing thoughts, and developing coping strategies.Therapeutic Objectives: Through weekly group sessions, online learning, and guided exercises, participants will work toward greater emotional resilience and symptom reduction.Role of the Facilitator: The program is facilitated by a licensed mental health professional who will guide the sessions, provide support, and offer feedback to promote therapeutic progress within a group format.Comprehensive Program: Enrollment  includes full access to all aspects of the ICBT Online Group Therapy Program. These benefits are designed to provide continuous support, skills practice, and resources throughout the 12-week program to foster meaningful progress. This encompasses:Weekly Live Group Sessions : Facilitated by a licensed therapist and focused on teaching and practicing ICBT techniques for managing OCD, anxiety, and related challenges.Email Access : Dr. Kertz will answer emails to facilitate personalized use of the strategies taught in the program..Individual Meetings: You will have two, 30 minute 1:1 meetings to schedule with Dr. Kertz during the 12 weeks of the program.Educational Resources : Access to presentations, exercises, and tools designed to reinforce learning and support skill development outside of session time.

2. Nature of Group Therapy and Expectations

To foster a supportive, safe therapeutic environment, members are expected to adhere to the following guidelines.

Attendance: Groups work best when all members make a commitment to the process, each other, and themselves. Regular attendance is encouraged and members are asked to notify the facilitator if they will miss a meeting.Active Participation: Group therapy relies on the active participation of all members. Participants are expected to attend sessions regularly, contribute respectfully to discussions, and engage in activities and exercises designed to support their therapeutic goals.Respect: Interaction with each other should demonstrate respect and empathy.Abusive Behavior: Members will refrain from discriminatory, harmful, or abusive behavior. Anyone who violates this policy will be removed from the group.Solicitation: Not use the program for solicitation or promoting personal business.Failure to adhere to these guidelines may result in removal from the program.

 3. Confidentiality and Privacy 

Confidentiality is essential in creating a safe, supportive environment for all participants in the ICBT Online Group Program group therapy program. By participating, you agree to uphold the confidentiality of the group, including during live telehealth sessions. 

Confidentiality in Groups: While the facilitator upholds confidentiality within legal and ethical limits, please note that absolute confidentiality among group members cannot be guaranteed.Limits of Confidentiality: There are legal exceptions where confidentiality may be broken, such as instances of potential harm to yourself or others or if subpoenaed or required by court order. The facilitator will discuss these exceptions at the beginning of the program.

Confidentiality During Live Telehealth Meetings

Private, Secure Location: You are encouraged to participate in sessions from a private, quiet space where others cannot overhear your conversations. Avoid public spaces or shared areas, such as coffee shops or common rooms, where privacy cannot be assured. This helps ensure that everything shared within the session remains confidential. 

Responding to Interruptions: If someone unexpectedly enters your room or you realize that others may overhear, please turn off your audio and video immediately. This helps protect the confidentiality of the group while you address the situation. Do not resume audio or video until you have re-established a private environment. This ensures that sensitive conversations remain within the group.

Use of Secure Devices: Make sure you are using a secure, password-protected device to prevent unauthorized access. Log out of the telehealth platform after each session, especially if using a shared device, and avoid using devices that others may access.

4. Risks and Benefits of Group Therapy

Potential Benefits 

Symptom Management: Participants may experience reduced symptoms related to OCD, anxiety, and phobias as they learn and apply ICBT techniques.Supportive Community: Group therapy offers the benefit of shared experiences, peer support, and a sense of community with others facing similar challenges.Skill-Building: Participants will learn specific strategies to manage intrusive thoughts and distressing emotions, which may improve their ability to handle anxiety and related symptoms.

Potential Risks

Emotional Discomfort: Discussing personal experiences and engaging in therapeutic exercises can lead to temporary emotional discomfort, anxiety, or distress. This is a normal part of the therapeutic process, but participants should be aware that such feelings may arise.Confidentiality Limits: While every effort is made to ensure confidentiality within the group, it cannot be guaranteed. Participants are responsible for maintaining the privacy of other group members, but the facilitator cannot control all potential breaches of confidentiality.Group Dynamics: In a group setting, interpersonal conflicts or discomfort may occur. The facilitator will work to address and manage these dynamics, but participants may experience varying comfort levels in group interactions.

 5. User Content and Intellectual Property Rights 

Ownership and Licensing: You retain ownership of any content you submit, such as feedback or discussion contributions. Removal of Content: The facilitator reserves the right to remove any content that violates the terms of this agreement or is deemed inappropriate.

6. Payment Terms 

Program Fee : $65 per week for a 12-week program, totaling $780 for the full duration of the program. The weekly fee of $65 is charged each week, regardless of session attendance, for the entire 12-week duration of the program, or unless the participant submits a formal notice of withdrawal from the program via email to the facilitator within the first two weeks of the program. 

Non-Refundable Payments : The weekly fee is non-refundable and will be charged even if a participant is unable to attend a live session. This policy helps to maintain the continuity of the group and supports the accessibility of program benefits for all members, whether or not they attend each session.

Commitment to Full Program : This 12-week program is structured to provide cumulative benefits over the full duration. By enrolling, participants commit to the full program experience, including the understanding that fees are collected for the complete program benefits and not solely for individual sessions.

Termination and Withdrawal Policy : If a participant chooses to withdraw from the program in the first two weeks, they are still financially responsible for the weekly fee up until the date of formal withdrawal notice which must be submitted to the facilitator via email. Participants withdrawing from the program before completion will forfeit access to program resources as of their withdrawal date.

7. Limitation of Liability 

To the fullest extent permitted by law:

Therapeutic Content:  ICBT Group Therapy Program does not endorse or verify the accuracy of individual contributions within the group and is not responsible for the reliability, usefulness, or appropriateness of content shared by participants.Personal Responsibility : By participating, you agree to be responsible for your mental health decisions and actions based on the program content and discussions.No Guarantees : The program is provided “as is,” without guarantees of any kind regarding outcomes, completeness, or accuracy.Harm: By enrolling in the program and creating an account on the membership platform, you acknowledge and agree to hold harmless Anxiety Specialists of St. Louis and your group facilitator from any claims, liabilities, damages, losses, or expenses arising out of or related to your use of the platform or any content, services, or information provided by the program.Responsibility: Engagement in the program is not a substitute for individual professional medical advice or treatment. You are solely responsible for your mental health decisions and understand that any reliance on the information provided in the community is at your own risk.Claims, Demands, or Causes of Action: You agree to release, discharge, and indemnify Anxiety Specialists of St. Louis from any and all claims, demands, or causes of action that may arise from or are in any way connected with your involvement in the ICBT Online Group Program, including but not limited to those arising from the use of information, services, or advice provided.

8. Termination and Changes 

Termination of Access : We reserve the right to terminate or suspend your access to the group at any time if you violate these Terms or for any reason deemed necessary.

Modification of Terms : These Terms may be updated periodically. It is your responsibility to review any changes, and continued participation signifies acceptance.

9. Dispute Resolution 

Governing Law and Arbitration : These Terms are governed by the laws of the state of Missouri. Any disputes arising from these terms will be resolved through binding arbitration, with both parties waiving the right to a class action lawsuit.

11. Agreement to Use the Community 

Personal Use: The ICBT Online Group Program is for personal, non-commercial, lawful purposes related to your therapeutic goals. You must comply with all applicable laws and regulations and respect the rights and confidentiality of other members. 

Registration and Valid Information : To participate in the community, you will be required to register an account. By doing so, you agree to provide relevant information and are responsible for maintaining the confidentiality of your account and all activities conducted under it.

Intellectual Property : All content within this program—text, graphics, videos, and other materials—is owned by Anxiety Specialists of St. Louis and protected by intellectual property laws. You may not reproduce, distribute, or modify content from the Community without prior written consent.

12. Acknowledgment and Consent 

By participating in the ICBT Online Group Program, you acknowledge that:

You have read, understood, and agree to these Terms of Use and informed consent guidelines.You understand the importance of confidentiality and agree to uphold it.You understand that this group does not provide emergency support.You voluntarily assume responsibility for any emotional responses that arise during participation.You agree to the payment terms, including the non-refundable weekly fee and the comprehensive program benefits.

For questions or clarifications, please contact [email protected] or call 314-462-2965.

CREDIT CARD AGREEMENT

By your electronic signature of this form, you authorize charges to your credit card through Stripe for services rendered to you or a third party for whom you are financially responsible. These charges will appear on your bank/credit card statement as “Anxiety Specialists of St. Louis”. You have the right to request a paper copy of this document.

By electronically signing this form, I authorize Anxiety Specialists of St. Louis to charge my credit card through Stripe for the full session fee.

I understand that this authorization will remain in effect until I cancel it in writing, and I agree to notify Anxiety Specialists of St. Louis in writing of any changes in my account information or termination of this authorization.

I certify that I am an authorized user of this credit card and will not dispute these scheduled transactions with my bank or credit card company as long as the transactions correspond to the terms indicated in this authorization form. I acknowledge that credit card transactions could be linked to Protected Health Information.

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. OUR PLEDGE REGARDING HEALTH INFORMATION: We understand that health information about you/your child or other third party and your health care is personal. We are committed to protecting health information. We create a record of the care and services received from us. We need this record to provide quality care and to comply with certain legal requirements. This notice applies to all of the records of care generated by this mental health care practice. This notice will tell you about the ways we may use and disclose health information. We also describe the rights to the health information we keep and describe certain obligations we have regarding the use and disclosure of health information. We are required by law to:

Make sure that protected health information (“PHI”) that identifies you/your child 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.We can change the terms of this Notice, and such changes will apply to all information we have about you. The new Notice will be available upon request, in our office, and on our website.

II. HOW WE MAY USE AND DISCLOSE HEALTH INFORMATION :

The following categories describe different ways that we use and disclose health information. For each category of uses or disclosures we will explain what we mean and try to give some examples. Not every use or disclosure in a category will be listed. However, all of the ways we are permitted to use and disclose information will fall within one of the categories.For Treatment Payment, or Health Care Operations: Federal privacy rules (regulations) allow health care providers who have direct treatment relationship with the patient/client to use or disclose the patient/client’s personal health information without the patient’s written authorization, to carry out the health care provider’s own treatment, payment or health care operations. We may also disclose 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 personal 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, we may disclose health information in response to a court or administrative order. We 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:

Psychotherapy Notes. We 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:For our use in treating you.For our use in training or supervising mental health practitioners to help them improve their skills in group, joint, family, or individual counseling or therapy.For our use in defending ourselves in legal proceedings instituted by you.For use by the Secretary of Health and Human Services to investigate our compliance with HIPAA.Required by law and the use or disclosure is limited to the requirements of such law.Required by law for certain health oversight activities pertaining to the originator of the psychotherapy notes.Required by a coroner who is performing duties authorized by law.Required to help avert a serious threat to the health and safety of others.Marketing Purposes. As psychotherapists, we will not use or disclose your/your child’s PHI for marketing purposes.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 AUTHORIZATION:

Subject to certain limitations in the law, we can use and disclose PHI without your Authorization for the following reasons:

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.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.For health oversight activities, including audits and investigations.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.For law enforcement purposes, including reporting crimes occurring on my premises.To coroners or medical examiners, when such individuals are performing duties authorized by law.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. No personal identifiers (for example your name, date of birth, etc.) will ever be included in research.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.For workers’ compensation purposes. Although our preference is to obtain an Authorization from you, we may provide your PHI in order to comply with workers’ compensation laws.Appointment reminders and health related benefits or services. We may use and disclose your PHI to contact you to remind you that you or your child have/has an appointment with us. We may also use and disclose your/your child’s PHI to tell you about treatment alternatives, or other health care services or benefits that we offer.

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

Disclosures to family, friends, or others. We 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:

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. We are not required to agree to your request, and we may say “no” if we believe it would affect health care.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.The Right to Choose How We Send PHI to You. You have the right to ask us to contact you in a specific way (for example, home or office phone) or to send mail to a different address, and we will agree to all reasonable requests.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 we have about you. We 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 we may charge a reasonable, cost based fee for doing so.The Right to Get a List of the Disclosures We Have Made. You have the right to request a list of instances in which we have disclosed your/your child’s PHI for purposes other than treatment, payment, or health care operations, or for which you provided me with an Authorization. We will respond to your request for an accounting of disclosures within 60 days of receiving your request. The list we will give you will include disclosures made in the last six years unless you request a shorter time. We will provide the list to you at no charge, but if you make more than one request in the same year, we will charge you a reasonable cost based fee for each additional request.The Right to Correct or Update Your PHI. If you believe that there is a mistake in your/your child’s PHI, or that a piece of important information is missing from your PHI, you have the right to request that we correct the existing information or add the missing information. We may say “no” to your request, but we will tell you why in writing within 60 days of receiving your request.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 NoticeUnder 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 checking the box below, you are acknowledging that you have received a copy of HIPAA Notice of Privacy Practices.

BY CLICKING ON THE CHECKBOX I AM AGREEING THAT I HAVE READ, UNDERSTOOD AND AGREE TO THE ITEMS CONTAINED IN THIS DOCUMENT OR IF SIGNING ON BEHALF OF ANOTHER, I AFFIRM I AM AUTHORIZED TO AGREE ON THEIR BEHALF.