Intake Questionnaire

Welcome to LGBTQ Therapy Space! We are an online platform (the “Platform”) that matches members of the LGBTQ+ Queer community (“Clients”) with licensed mental health professionals (“Providers”) using secure, HIPAA-compliant telehealth technology (the “Professional Services”). These Terms and Conditions (this “Agreement”) describes the services we provide (“Services”), the Professional Services that will be provided by our affiliated Providers, our commitment to your privacy and the ways we protect your privacy.

To match you with a Provider that can best meet your needs, we ask that you provide us with basic intake information, including your name, age, gender identity, location, description of your support system and whether you are requesting any particular Providers or specializations. Please review this Agreement and the Authorization and Intake Questionnaire attached as Exhibit A carefully before you start using the Platform. By accessing or using the Platform, you agree to be bound by this Agreement. If you do not agree to be bound to any term of this Agreement, you must not access the Platform.

Risks and Benefits of Telehealth

The Professional Services will be provided via telehealth, which refers to the use of secure, interactive, audio, video, and electronic data communication. Telehealth may be beneficial to some Clients because it makes psychotherapy services more accessible by allowing Clients to participate from their home or location of their choice, thus increasing flexibility and decreasing travel time. However, there are risks with Telehealth. For example, despite reasonable efforts and safeguards on the part of both LGBTQ Therapy Space and your Provider, the transmission of personal information can potentially be disrupted or distorted by technical failures or intercepted by unauthorized persons. Moreover, the Provider cannot control the confidentiality of the Client’s remote location which puts a greater burden on the Client to assess and protect the privacy and security of their own computer or other devices and surrounding environment. Interruptions from others, background noise from radios and TVs, and pets should be considered. In addition, Telehealth may not be the appropriate solution for everyone’s needs, it may not be appropriate for every particular situation, and it may not be a complete substitute for a face-to-face interaction.

IF YOU ARE THINKING ABOUT SUICIDE OR IF YOU ARE CONSIDERING HARMING YOURSELF OR OTHERS OR IF YOU FEEL THAT ANY OTHER PERSON MAY BE IN ANY DANGER OR IF YOU HAVE ANY MEDICAL EMERGENCY, YOU MUST IMMEDIATELY CALL YOUR LOCAL CRISIS HOTLINE OR 911. THE PLATFORM IS NOT DESIGNED FOR USE IN ANY OF THESE CIRCUMSTANCES; LGBTQ THERAPY SPACE AFFILIATED PROVIDERS DO NOT PROVIDE EMERGENCY SERVICES AND CANNOT PROVIDE THE ASSISTANCE REQUIRED IN ANY OF THESE SITUATIONS.

Services provided by LGBTQ Therapy Space.

LGBTQ Therapy Space will host and maintain the Platform, recruit Providers and confirm their credentials, review the information provided in your Intake Questionnaire for the purpose of matching you with a Provider licensed to practice in your State, and provide administrative services including scheduling, billing and payment processing. LGBTQ Therapy Space’s role is expressly limited to the Services described herein.


Services provided by the Providers.

Every Provider that contracts with LGBTQ Therapy Space must be a fully licensed, trained and experienced licensed psychologist (PhD / PsyD), licensed marriage and family therapist (LMFT), licensed clinical social worker (LCSW), licensed professional counselor (LPC), or similar licensed professional in his or her state. All Providers are required to have an academic degree in their field, at least 3 years of experience, and must be qualified and certified by their state’s professional licensing board after successfully completing the required education, supervised professional experience, exams, training and practice requirements. All Providers must provide LGBTQ Therapy Space with a copy of their current license and proof of malpractice insurance showing the dates and amounts of coverage annually.

Your treatment relationship will be strictly with the Provider. LGBTQ Therapy Space is not involved in the relationship between the Provider and the Client, and does not interfere, validate or control the Provider’s treatment. Providers are independent contractors and not employees, representatives or agents of LGBTQ Therapy Space. All Professional Services will be provided by the Provider in their sole professional discretion in compliance with the laws of their state without interference, direction or control from LGBTQ Therapy Space. If you feel the Professional Services do not fit your needs or expectations, we will match you with a different Provider who provides Professional Services through the Platform.

Questions, Concerns and Complaints.

LGBTQ Therapy Space strives to provide the best possible experience for our Clients. We are committed to quality and are always looking for ways to better meet your needs. If you have any questions, concerns or complaints regarding the Services provided by LGBTQ Therapy Space or the Professional Services provided by the affiliated Providers, or if you have any feedback which you believe will assist us to serve you better, please contact us at info@gaytherapyspace.com. We will make every effort to return your email within 24 hours and respond to your concern or complaint in a timely manner.

Limitation of Services

LGBTQ Therapy Space specializes in matching members of the LBGT + Queer community with Providers that have expertise in meeting the needs of our Clients. Problems helped by Providers contracted with LGBTQ Therapy Space include issues related to gender identity and sexual orientation, difficulties in coping with daily life, the impact of trauma, medical illness or loss, like the death of a loved one, marriage and family issues, and specific mental disorders, like depression and anxiety.

Providers affiliated with LGBTQ Therapy Space may not provide certain services requiring that the Client be seen in person such as court-ordered counseling, neuropsychological evaluations, and certification of necessity for emotional support animals.

LGBTQ Therapy Space does not contract with psychiatrists, and most states prohibit the prescribing of medication by psychologists. If your Provider determines in their professional judgment that a referral to a higher level of care, including referral to a psychiatrist, is in your best interest, the Provider will assist in referring you to the appropriate professional.

Billing and Payment.

All individual therapy sessions cost $155 for 50 minutes. All couples therapy sessions cost $185 for 50 minutes. You agree to pay for each therapy session in advance through the Platform via Stripe, an online payment processing company that utilizes state of the art encryption and other security tools to ensure the security of your financial information. You will not be invited to join the session until the fee is paid in full. Please note that all payments will be processed through Stripe’s encrypted online portal. Your credit card information will not be stored on the Platform and will not be accessible to LGBTQ Therapy Space.
Our therapists are not in-network with any insurance companies or health plans including Medi-Cal and Medicare. However, LGBTQ Therapy Space will provide you with a statement/superbill at the end of each month at your request. You may submit the superbill to your insurance company or health plan if they provide you with “out-of-network” psychotherapy benefits. LGBTQ Therapy Space has no control over coverage decisions and does not guarantee reimbursement. It is your responsibility to contact your insurance or health plan and understand what if any coverage they provide.

If you have any concerns about a bill or a payment, please contact us immediately by sending an email to info@gaytherapyspace.com. We will evaluate your issue on a case-by-case basis and, at our discretion, take steps to resolve any issue, including but not limited to helping you find a new Provider, and issuing partial or full refunds when applicable.

Cancellation Policy.

When you schedule an appointment through LGBTQ Therapy Space with one of our Providers, the time is held exclusively for you. This means that if you fail to show without providing enough time for us to reschedule your appointment, not only is it a missed opportunity for you, but it means that another patient who may have needed that appointment time also misses out. It is also a loss to your Provider who has set aside space in their schedule to meet with you. While we understand that emergencies and unanticipated events occur from time to time, LGBTQ Therapy Space requires that you provide notice of at least twenty-four (24) hours to reschedule or cancel your appointment by emailing LGBTQ Therapy Space through the Platform. If you cancel without notice, or with notice of less than 24 hours, you will be charged the full rate of $155 for the missed session. By executing this Agreement and the Acknowledgment of Cancellation Policy and Authorization attached as Exhibit C, you authorize LGBTQ Therapy Space to charge the payment card you used to schedule the appointment (through Stripe) $155 for each no show or cancellation less than 24 hours before the scheduled appointment time. You will not be permitted to schedule another appointment until the cancellation fees have been paid in full unless other arrangements are made. In addition, if you fail to show up for your appointment within 15 minutes of your scheduled start time, we will consider this to be a no-show and charge you the full $155 session fee. The Provider may log out of the session if you are more than 15 minutes late. Please note that if you are late for your session, the Provider will still need to end at the regular time to meet the appointment times of other patients LGBTQ Therapy Space has the right to waive or modify this Cancellation Policy in its discretion depending on your specific circumstances.

Exclusive Use of Platform.

You agree that you will only receive Professional Services from the Provider assigned to you through the Platform and that you will not receive Professional Services from that Provider through any other video conferencing platform, or by telephone, email, text message, or in person, without written consent from LGBTQ Therapy Space.

Privacy and Security

Protecting and safeguarding your confidential information provided through the Platform is extremely important to us. Information about our security and privacy practices can be found on our Notice of Privacy Practices. A copy of the Notice of Privacy Practices is attached as Exhibit B and is also located on our website at www.gaytherapyspace.com.
LGBTQ Therapy Space will collect basic intake information from you to match you with a Provider. This includes your name, age, gender identity, location, a description of support system and whether you are requesting any particular Providers or specializations. LGBTQ Therapy Space will safeguard this information in accordance with its Notice of Privacy Practices. LGBTQ Therapy Space will not have access to your treatment records or any other confidential information related to the Professional Services. These records belong solely to the Provider. You may request copies of your records from your Provider in accordance with the laws and regulations of the state where the Professional Services are provided. Please contact your Provider directly to obtain access to your treatment records.

Please note that the Platform is secure and HIPAA compliant. In addition, LGBTQ Therapy Space executes HIPAA-compliant Business Associate Agreements (“BAA”) with all of our Providers and vendors.

BY AGREEING TO THESE TERMS AND CONDITIONS AND/OR BY USING THE PLATFORM, YOU ARE ALSO AGREEING TO THE TERMS OF THE NOTICE OF PRIVACY PRACTICES. THE SAME RULES THAT APPLY REGARDING CHANGES AND REVISIONS OF THIS AGREEMENT ALSO APPLY TO CHANGES AND REVISIONS OF THE PRIVACY POLICY.

Site Content

Other than the guidance and advice you receive directly from your Provider, the other educational materials, graphics, research and referral sources and other incidental information on the Platform (“Site Content”) is not intended or implied to be a substitute for professional advice, diagnosis, treatment, psychotherapy, counseling, or mental health services. All Site Content, including text, graphics, images and information, contained on or available through this Platform is for general information purposes only. You should always seek the advice of a physician, licensed mental health provider, or other qualified health provider with any questions regarding any mental health or medical symptoms or conditions. NEVER DISREGARD PROFESSIONAL PSYCHOLOGICAL OR MEDICAL ADVICE OR DELAY IN SEEKING EVALUATION OR MEDICAL TREATMENT BECAUSE OF SOMETHING YOU HAVE READ ON OR ACCESSED THROUGH THE PLATFORM.

Modifications, Termination, Interruption and Disruptions to the Platform.

Access to the Services and the information contained in the Platform is provided “as is” and “as available” without any warranty of any kind, express or implied. To the fullest extent permissible pursuant to applicable law, LGBTQ Therapy Space disclaims all warranties of any kind, either express or implied, including but not limited to any implied warranties of title, merchantability, fitness for a particular purpose or non-infringement of copyright.

LGBTQ Therapy Space may modify, suspend, disrupt or discontinue the Platform, any part of the Platform or the use of the Platform, whether to all Clients or to you specifically, at any time with or without notice to you. You agree and acknowledge that we will not be liable for any of these actions or for any losses or damages that are caused by any of these actions.

The Platform depends on various factors such as software, hardware and tools, either our own or those owned and/or operated by our contractors and suppliers. While we make commercially reasonable efforts to ensure the Platform’s reliability and accessibility, you understand and agree that no platform can be 100% reliable and accessible and so we cannot guarantee that access to the Platform will be uninterrupted or that it will be accessible, consistent, timely or error-free at all times.

Please note that in the event the Platform is interrupted, inaccessible or if LGBTQ Therapy Space ceases operation of the Platform, LGBTQ Therapy Space will make reasonable efforts to notify the Clients and the Providers at the email address and/or telephone number provided so that the appropriate arrangements can be made to assure continuity of care.

Notices.

We may provide notices or other communications to you regarding this Agreement or any aspect of the Platform, by email to the email address that we have on record, by regular mail or by posting it online. The date of receipt shall be deemed the date on which such notice is given. Notices sent to us must be delivered by email to info@gaytherapyspace.com

Notice to California Residents:

The Board of Behavioral Sciences receives and responds to complaints regarding services provided within the scope of practice of (marriage and family therapists, clinical social workers, or professional clinical counselors). You may contact the board online at www.bbs.ca.gov, or by calling (916) 574-7830. The Board of Psychology receives and responds to complaints regarding services by licensed psychologists. You may contact the board online at www.psychology.ca.gov. or by calling (866) 503-3221.

CLIENT REPRESENTATIONS:

You confirm and agree that you are legally able to consent to receive the Professional Services or have the consent of a personal representative who is legally able to enter into a contract on your behalf.

You confirm and agree that you have sufficient computer equipment (laptop, desktop computer) and internet connectivity to engage in Telehealth.

You confirm and agree that all the information that you provided in or through the Platform, and the information that you will provide in or through the Platform in the future, is accurate, true, current and complete. You further agree to maintain and update this information so it will continue to be accurate, current and complete.

You confirm and acknowledge that you are responsible for maintaining the confidentiality of your password and any other security information related to your account. We advise you to change your password frequently and to take extra care in safeguarding your password.

You confirm and agree to notify us immediately of any unauthorized use of your account or any other concern for breach of your account security.

You confirm and agree that LGBTQ Therapy Space will not be liable for any loss or damage incurred as a result of someone else using your account, either with or without your consent and/or knowledge.

You confirm and agree that you are solely and fully liable and responsible for all activities performed using your account. You further acknowledge and agree that LGBTQ Therapy Space will hold you liable and responsible for any damage or loss incurred as a result of the use of your account by any person whether authorized by you or not, and you agree to indemnify us for any such damage or loss.

You confirm and agree not to use the account of any other person for any reason.

You confirm and agree that your use of the Platform, including the Professional Services, are for your own personal use only and that you are not using the Platform or the Professional Services for or on behalf of any other person or organization.

You confirm and agree not to interfere with or disrupt, or attempt to interfere with or disrupt, any of our systems, services, servers, networks or infrastructure, or any of the Platform's systems, services, servers, networks or infrastructure, including without limitation obtaining unauthorized access to the aforementioned.

You confirm and agree not to make any use of the Platform for the posting, sending or delivering of any of the following: (a) unsolicited email and/or advertisement or promotion of goods and services; (b) malicious software or code; (c) unlawful, harassing, privacy invading, abusive, threatening, vulgar, obscene, racist or potentially harmful content; (d) any content that infringes a third party right including intellectual property rights; (e) any content that may cause damage to a third party; (f) any content which may constitute, cause or encourage a criminal action or violate any applicable law.

You confirm and agree not to violate any applicable local, state, national or international law, statute, ordinance, rule, regulation or ethical code in relation to your use of the Platform and your relationship with the Providers and LGBTQ Therapy Space.
You confirm and agree that you will indemnify, defend and hold LGBTQ Therapy Space from and against any and all claims, losses, causes of action, demands, liabilities, costs or expenses (including, but not limited to, litigation and reasonable attorneys' fees and expenses) arising out of or relating to any of the following: (a) your access to or use of the Platform; (b) any actions made with your account whether by you or by someone else; (c) your violation of any of the provisions of this Agreement; (d) non-payment for any of the services which were provided through the Platform; (e) your violation of any third party right, including, without limitation, any intellectual property right, publicity, confidentiality, property or privacy right. This clause shall survive expiration or termination of this Agreement.
You confirm and agree to release and hold LGBTQ Therapy Space harmless from any and all causes of action and claims of any nature resulting from the Professional Services, including (without limitation) any act, omission, opinion, response, advice, suggestion, information and/or service of any Provider.

General Provisions

This Agreement and our relationship with you shall both be interpreted solely in accordance with the laws of the state where the Client resides, excluding any rules governing choice of laws. You also agree that the exclusive venue for any action or proceeding arising out of relating to this Agreement or our relationship with you, regardless of theory, shall be the state courts located in the state and county where the Client resides. You consent to the personal jurisdiction of the aforementioned courts and hereby waive any objection to the exercise of jurisdiction by the aforementioned courts.

This agreement constitutes the entire agreement between you and LGBTQ Therapy Space. You confirm that you have not relied upon any promises or representations by LGBTQ Therapy Space except as set forth in this agreement.

We may change this Agreement by posting modifications on the Platform. Unless otherwise specified by us, all modifications shall be effective upon posting. Therefore, you are encouraged to check the terms of these Terms and Conditions frequently. The last update date of these Terms and Conditions is posted at the bottom. By using the Platform after the changes become effective, you agree to be bound by such changes to the Terms and Conditions. If you do not agree to the changes, you must terminate access to the Platform and participation in its services.

The paragraph headings in this Agreement are solely for the sake of convenience and will not be applied in the interpretation of this Agreement.

If any provision of this Agreement is held by a court of competent jurisdiction to be illegal, invalid, unenforceable, or otherwise contrary to law, the remaining provisions of this Agreement will remain in full force and effect. Wherever possible, each provision of this Agreement will be interpreted so that it is valid under applicable law. If any provision of this Agreement is held to be unlawful or unenforceable, that provision may be severed from the Agreement, and the other provision remain in effect on the condition that the essential business and legal provisions of the Agreement are legal and enforceable.



I certify as follows:

• I am over the age of eighteen (18) or I have the legal ability to consent to therapy;
• I am physically located in or are a resident of the State designated above;
• I agree to provide the information on the Initial Intake Questionnaire to LGBTQ Therapy Space for the purpose of matching me with a Provider and for billing purposes;
• I agree to provide contact information for myself and a close family member/friend to act as an information source to my Provider to be used in case of a mental health crises or other emergency where knowledge of my location is crucial;
• I acknowledge that my ability to access and use the LGBTQ Therapy Space Platform is conditioned upon the truthfulness of the information I provide regarding my age, residence and contact information and that Providers are relying on this certification in order to interact with me and provide Professional Services to me;
• I acknowledge that LGBTQ Therapy Space will not sell or otherwise use my personal information provided herein for any purpose other than the purposes stated herein;
• I acknowledge that I can withdraw this Authorization for Release of Information at any time upon written notice to LGBTQ Therapy Space.