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Terms and Policy

Professional Disclosure Statement


As you may already know, therapy can be an intense, informative and life-changing experience. I hope the following information will help prepare you for the journey ahead by clarifying some details about the counseling process, the boundaries of our working relationship and my personal style in therapy.

My Credentials & Approach
I earned a Master of Social Work (MSW) degree from Virginia Commonwealth University in 1995. I am currently licensed in Virginia through the Virginia Board of Health Professions as a Licensed Clinical Social Worker (LCSW). My education in social work helped shape how I view and work with the whole person utilizing a biopsychosocial-spiritual approach.

I believe we are all connected and find meaning and a greater understanding of who we are through one another. Therefore, I feel honored and grateful when someone invites me to join them for a portion of their life journey. I view the therapeutic relationship as an equal partnership with you as the expert on your life and the one who determines where we are going on the journey. I can offer my knowledge and experience to identify the possible paths we might take, the skills or tools that are needed along the way and how to make the trip safely and successfully.

The Therapeutic Relationship
I believe the purpose of therapy is for you to more deeply discover who you are, what you want, and how to get it. During therapy, I will do my best to honor your personal experiences and perspective. I hope to provide you with honest feedback and to offer suggestions based on my clinical training and life experiences. I expect your active participation and collaboration as we develop our therapeutic relationship and work to meet your chosen goals. 

I believe that most people are amazingly resilient and have the capacity to resolve their own problems. Sometimes, though, they need a little assistance or a reminder of their strengths. I believe that we are all doing the best we can in life, yet also have the capacity to learn to be even more effective. If counseling is successful, you should feel that you are able to face life's future challenges without my support or intervention. Some clients need only a few counseling sessions to achieve their goals, while others may require more long-term counseling. 

A diagnosis will likely be developed as we work together. While sometimes helpful, you should also understand that a diagnosis is just a description of behavior and can vary frequently between situations and even among professionals. Diagnoses should not be construed as evidence of some defect, chemical imbalance, or permanent status. 

Some clients develop strong feelings about their therapist. Please do not offer gifts or ask me to relate to you in any other manner than the professional context of our counseling sessions. You will be best served if our relationship remains strictly professional and if our sessions concentrate exclusively on your concerns. 

How to Contact Me
Clients may contact me by phone or email, but I cannot accept texts as these are less reliable and secure. Please understand that I am seldom able to answer my phone as I am in sessions. I will return calls as promptly as I can, usually within 24 hours. If you have an urgent need, please indicate this in your voicemail message and I will do my best to respond. 

I prefer using phone calls or email only to arrange or modify appointments. Please do not email me personal information or content related to your therapy sessions, as email is not completely secure or confidential. You should know that any emails I receive from you and any responses that I send to you become a part of your legal record.

If you wish to send private, therapy-related information by electronic messaging, please access the Secure Client Area via the Client Login on my website. All traffic is secure, the site is HIPAA-compliant, and all sensitive information is encrypted. (HIPAA is an acronym for "Health Insurance Portability and Accountability Act" that was enacted to ensure the privacy and confidential handling of medical and mental health information for all patients in the U.S.)

If you experience a mental health crisis and I am not immediately available, please call 911 or go to the nearest hospital Emergency Department. 

Records & Confidentiality
All of our communication (e.g., progress notes, diagnosis, emails, phone calls) becomes part of your clinical record, which is accessible to you upon written request (unless doing so would be psychologically harmful). Please refer to the Notice of Privacy Practices &Limits of Confidentiality for details on how I protect your privacy and the limits of confidentiality in my practice.

Risks of Therapy
You should know there are potential risks to psychotherapy. The first and most important one is that people sometimes feel worse at the beginning of therapy. Therapy can complicate your life. After all, you may discover that you have feelings about people that you never realized you had. You may want or need things you have overlooked and may not have access to them yet. You may be asked to look at things about yourself that you may not like. You may have had experiences in the past that must be reconciled, which can be difficult and challenging, but ultimately quite rewarding and healing. 

Despite my best attempts, there are no absolute guarantees that you, specifically, will find my services helpful. However, research seems to indicate that those in psychotherapy are better off than 80% of those who do not seek treatment. 

Final Thoughts
If at any time, and for any reason, you feel we may not be a good therapeutic "match," I encourage your feedback and will make every attempt to adjust my approach. If we are not able to come to an agreement about therapy, I will be more than happy to assist you in finding another counselor. 

Acceptance of Terms
By signing, I agree to these terms and will follow these guidelines.

(Revised January 2019)

( Type Full Name )
Scheduling & Payment Agreement
Scheduling Appointments
Appointments may be scheduled, rescheduled or canceled by phone, email or directly through the Client Login on my website. However, appointments cannot be scheduled or canceled online with less than 24 hours' notice. For maximum availability, plan on scheduling your appointment at least one week in advance.  

If you need to reschedule or cancel an appointment, please tell me as soon as possible so that I can adjust my schedule. If you are unable to keep an appointment, please call at least 24 hours in advance.  However, a last-minute phone call is preferable to simply not showing up.

If you are late for your appointment and we are unable to meet for the full 50 minutes, you will still be charged for the full fee. 

Cancellation Policy
I certainly appreciate as much notice as possible if you need to cancel your appointment as this allows me to more likely fill the session time. However, you may cancel your appointment without being charged with 24 hours' notice. 

If you cancel with less than 24 hours' notice, you will be charged full fee for the missed session.

If you do not call to cancel and do not show for your session, you will be charged the full fee.  If I do not call to cancel and fail to show up for your scheduled appointment, your next session will be free. Yes, it works both ways.

I understand that emergencies and last-minute illnesses do occur. If you have a fever or are not feeling well, have active cold/flu symptoms, if you have been in the hospital, have been vomiting or had diarrhea within 24 hours of your scheduled appointment, or if you develop symptoms a few hours before your session, or if your children are ill and you need to be at home, please cancel. Additionally, if there is a snow or ice storm and you do not feel comfortable driving, feel free to call and reschedule your appointment. There will be no charge for these types of cancellations.

Payment is expected at the time of service. I accept cash, checks, credit cards, and payment via PayPal.  Clients receive a receipt of payment via email. Currently, the session cost is $110 for a 50-minute therapy session (office/phone/video).

Acceptance of Terms
By signing, I agree to these terms.

(Revised January 2019)

( Type Full Name )
Appointment Reminders Agreement

Deirdre Staton, LCSW, PLLC sends out automatic appointment reminders 48 hours before scheduled appointments, an email invoice on the day of appointments, and other reminders as a courtesy. I understand the risks involved and that Deirdre Staton has no control over who might see any messages once they are sent, even though they are sent to the phone number or email I have specified.

I understand that I may opt out of some or all reminders by taking the following steps:

1.    Log in to the Secure Client Area at

2.    Go to My Info in the top row of navigational links

3.    Click the Notifications link

4.    Uncheck (or check) desired notification preferences for email, text message and phone calls.

5.    Notify Deirdre Staton in writing with alternate communication option as specified in the Notice of Privacy Practices & Limits of Confidentiality.

Acceptance of Terms
By signing, I agree to these terms.

(Revised January 2019)

( Type Full Name )
Notice of Privacy Practices & Limits of Confidentiality



As a rule, I will not disclose information about you or the fact that you are my patient, without your written consent. My formal Mental Health Record describes the services provided to you and contains the dates of our sessions, your diagnosis, functional status, symptoms, prognosis and progress, and any correspondence or reports. Health care providers are legally allowed to use or disclose records or information for treatment, payment, and health care operations purposes. I choose not to routinely disclose information in such circumstances. Therefore, I will require your permission in advance, either through your consent at the onset of our relationship or through your written authorization at the time the need for disclosure arises. You may revoke your permission, in writing, at any time, by contacting me.

Limits of Confidentiality: Possible Uses and Disclosures of Mental Health Records without Consent or Authorization

There are some important exceptions to this rule of confidentiality-some exceptions are created voluntarily by my own choice and some are required by law. If you wish to receive mental health services from me, you must sign this form indicating that you understand and accept my policies about confidentiality and its limits. You are welcome to ask any questions for clarification and you may revisit and discuss this policy with me at any time during our work together.

I may use or disclose records or other information about you without your consent or authorization in the following circumstances, either by policy or because legally required:

     Emergency: If you are involved in a life-threatening emergency and I cannot ask your permission, I will share information if I believe you would have wanted me to do so, or if I believe it will be helpful to you. Furthermore, in the event of my death, disability or other incapacity, I have contracted with Dana Blauch, LPC to notify my clients, assist with referrals to a new therapist, and serve as custodian of my client records, storing and later disposing of them according to Virginia Law. Dana Blauch, LPC can be reached at 544 South Main Street, Harrisonburg, VA 22801 or (540) 217-2780.  

    Child Abuse Reporting: If I have reason to suspect that a child is abused or neglected, I am required by Virginia law to report the matter immediately to the Virginia Department of Social Services.

     Adult Abuse Reporting: If I have reason to suspect that an elderly or incapacitated adult is abused, neglected or exploited, I am required by Virginia law to immediately make a report and provide relevant information to the Virginia Department of Social Services.

     Health Oversight: Virginia law requires that licensed social workers report misconduct by a health care provider of their own profession. By policy, I also reserve the right to report misconduct by health care providers of other professions. By law, if you describe unprofessional conduct by another mental health provider of any profession, I am required to explain to you how to make such a report. If you are yourself a health care provider, I am required by law to report to your licensing board that you are in treatment with me if I believe your condition places the public at risk. Virginia Licensing Boards have the power, when necessary, to subpoena relevant records in investigating a complaint of provider incompetence or misconduct.

     Court Proceedings: If you are involved in a court proceeding and a request is made for information about your diagnosis and treatment and the records thereof, such information is privileged under state law, and I will not release information unless you provide written authorization or a judge issues a court order. If I receive a subpoena for records or testimony, I will notify you so you can file a motion to quash (block) the subpoena. However, while awaiting the judge's decision, I am required to place said records in a sealed envelope and provide them to the Clerk of Court. In Virginia civil court cases, therapy information is not protected by patient-therapist privilege in child abuse cases, in cases in which your mental health is an issue, or in any case in which the judge deems the information to be "necessary for the proper administration of justice." In criminal cases, Virginia has no statute granting therapist-patient privilege, although records can sometimes be protected on another basis. Protections of privilege may not apply if I do an evaluation for a third party or where the evaluation is court-ordered. You will be informed in advance if this is the case.

     Serious Threat to Health or Safety: Under Virginia law, if I am engaged in my professional duties and you communicate to me a specific and immediate threat to cause serious bodily injury or death, to an identified or to an identifiable person, and I believe you have the intent and ability to carry out that threat immediately or imminently, I am legally required to take steps to protect third parties. These precautions may include: (1) warning the potential victim(s), or the parent or guardian of the potential victim(s), if under 18; (2) notifying a law enforcement officer; or (3) seeking your hospitalization. By my own policy, I may also use and disclose medical information about you when necessary to prevent an immediate, serious threat to your own health and safety. If you become a party in a civil commitment hearing, I can be required to provide your records to the magistrate, your attorney or guardian ad litem, a CSB evaluator, or a law enforcement officer, whether you are a minor or an adult.

     Workers Compensation: If you file a worker's compensation claim, I am required by law, upon request, to submit your relevant mental health information to you, your employer, the insurer, or a certified rehabilitation provider.

Other uses and disclosures of information not covered by this notice or by the laws that apply to me will be made only with your written permission. 

Patient's Rights and Provider's Duties

     Right to Request Restrictions: You have the right to request restrictions on certain uses and disclosures of protected health information about you. You also have the right to request a limit on the mental health or medical information I disclose about you to someone who is involved in your care or the payment for your care. If you ask me to disclose information to another party, you may request that I limit the information I disclose. However, I am not required to agree to a restriction you request. To request restrictions, you must make your request in writing, and tell me: (1) what information you want to limit; (2) whether you want to limit my use, disclosure or both; and (3) to whom you want the limits to apply.

     Right to Receive Confidential Communications by Alternative Means and at Alternative Locations: You have the right to request and receive confidential communications of PHI by alternative means and at alternative locations. (For example, you may not want a family member to know that you are seeing me. Upon your request, I will send any correspondence to another address. You may also request that I contact you only at work, or that I do not leave voice mail messages.) To request alternative communication, you must make your request in writing, specifying how or where you wish to be contacted.

     Right to an Accounting of Disclosures: You generally have the right to receive an accounting of disclosures of PHI for which you have neither provided consent nor authorization (as described under Limits of Confidentiality in this Notice). On your written request, I will discuss with you the details of the disclosure(s) and accounting process.

     Right to Inspect and Copy: In most cases, you have the right to inspect and copy your medical and billing records. To do this, you must submit your request in writing. If you request a copy of the information, I may charge a fee for costs of copying and mailing. I may deny your request to inspect and copy in some circumstances. I may refuse to provide you access to certain psychotherapy notes or to information compiled in reasonable anticipation of, or use in, a civil criminal, or administrative proceeding.

     Right to Amend: If you feel that PHI I have about you is incorrect or incomplete, you may ask me to amend the information. Any request for amendment must be made in writing and submitted to me. In addition, you must provide a reason that supports your request. I may deny your request if you ask me to amend information that: (1) was not created by me, in which case I will add your request to the information record; (2) is not part of the medical information kept by me; (3) is not part of the information which you would be permitted to inspect and copy; (4) is accurate and complete.

     Right to a copy of this notice: You have the right to a paper copy of this notice. You may ask me to give you a copy of this notice at any time. I reserve the right to change my policies and/or to change this notice, and to make the changed notice effective for mental health and medical information I already have about you as well as any information I receive in the future. The notice will contain the effective date. A new copy will be given to you. I will have copies of the current notice available on request.

     Complaints: If you believe your privacy rights have been violated, you may file a complaint. To do this, you must submit your request in writingto my office. You may also send a written complaint to the U.S. Department of Health and Human Services.

Acceptance of Terms

By signing, I state that I understand these policies and that I have the right to ask questions about them at any time in the future.

I consent to accept these policies as a condition of receiving mental health services.

(Revised January 2019)

( Type Full Name )
‌Technology & Social Media Policy

This document is intended to help you understand how I conduct myself on the Internet as a mental health professional and how you can expect me to respond to various interactions that may occur between us on the Internet. If you have any questions about anything within this document, I encourage you to bring them up when we meet. 

I do not accept friend requests from current or former clients on any social networking site (Facebook, Instagram, LinkedIn, 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. 

I keep Facebook, LinkedIn and Instagram pages for my professional practice to allow people to share my posts, practice updates and news about upcoming groups and workshops with other social media users. Information about groups and workshops is also available on my website.

You are welcome to view my Facebook, LinkedIn and Instagram pages and read or share posts, but I do not accept clients as followers of these pages. I believe having clients Like or Follow my pages creates a greater likelihood of compromised client confidentiality and I feel it is best to be explicit to all who may view my list of followers to know that they will not find client names on that list. In addition, the National Association of Social Workers' Code of Ethics prohibits my soliciting testimonials from clients. I feel that the terms such as "Like" and "Following" come too close to an implied request for a public endorsement of my practice. 

Interacting via Technology

     Texting/Messaging: Please do not use SMS (mobile phone text messaging) or messaging on any Social Networking sites to contact me. These sites are not secure and I may not read these messages in a timely fashion. Do not use wall postings, @replies, or other means of engaging with me in public online. Engaging with me this way could compromise your confidentiality. It may also create the possibility that these exchanges become a part of your legal medical record and will need to be documented and archived in your chart.

     Video Conferencing: While I do offer online therapy sessions, I only do so through VSee and will provide a link for you as needed.  To ensure your confidentiality, VSee is a secure audio/video conferencing system used for telemedicine. It is encrypted and HIPAA-compliant. None of your Protected Health Information (PHI) is accessible by VSee.

     Emailing: If you need to contact me between sessions for issues such as scheduling or modifying appointment, the best way to do so is to call (540) 820-4396, (leaving a voice mail message if necessary) or send an email to Please do not email me content related to your therapy sessions as email is not completely secure or confidential. If you choose to communicate with me by email, be aware that all emails are retained in the logs of your and my Internet service providers. While it is unlikely that someone will be looking at these logs, they are, in theory, available to be read by the system administrators of the Internet service provider. If you wish to send a secure email, sign in to the Secure Client Area via my website. You should also know that any emails I receive and any responses I send to you become part of your legal record.

Use of Search Engines
It is NOT a regular part of my practice to search for clients on Facebook, other social media sites, Google, or other search engines. Extremely rare exceptions may be made during times of crisis. If I have a reason to suspect that you are in danger and you have not been in touch with me via our usual means (coming to appointments, phone, or email) there might be an instance in which using a search engine (to find you, find someone close to you, or to check on your recent status updates) becomes necessary as part of ensuring your welfare. These are unusual situations and if I ever resort to such means, I will fully document it and discuss it with you when we next meet.

Business Review Sites
You may find my private practice on sites such as Yelp, Healthgrades, Bing, or other places that list businesses. Some of these sites include forums in which users rate their providers and add reviews. Many of these sites comb search engines for business listings and automatically add listings regardless of whether the business has added itself to the site. If you should find my listing on any of these sites, please know that my listing is NOT a request for a testimonial, rating, or endorsement from you as my client.

"Social workers should not engage in solicitation of testimonial endorsements (including solicitation of consent to use a client's prior statement as a testimonial endorsement) from current clients or from other people who, because of their particular circumstances, are vulnerable to undue influence" (NASW, 2017, Ethical Responsibilities as Professionals section, 4.07(b)). 

Of course, you have a right to express yourself on any site you wish. Due to confidentiality, however, I cannot respond to any review on any of these sites whether it is positive or negative. I urge you to take your own privacy as seriously as I take my commitment of confidentiality to you. You should also be aware that if you are using these sites to communicate indirectly with me about your feelings about our work, it is likely I will never see it.

If we are working together, I hope that you will bring your feelings and reactions to our work directly into the therapy process. This can be an important part of therapy, even if you decide we are not a good fit. None of this is meant to keep you from sharing that you are in therapy with me wherever and with whomever you like. Confidentiality means that I cannot tell people that you are my client and my Code of Ethics prohibits me from requesting testimonials. You are more than welcome to tell anyone you wish that I'm your therapist or how you feel about the treatment I provided to you, in any forum of your choosing.

If you do choose to write something on a business review site, I hope you will keep in mind that you may be sharing personally revealing information in a public forum. I urge you to create a pseudonym that is not linked to your regular email address or social media networks for your own privacy and protection. If you feel I have done something harmful or unethical and you do not feel comfortable discussing it with me, you can always contact the Virginia Board of Social Work, which oversees licensing, and they will review the services I have provided.

Virginia Department of Health Professions
Board of Social Work
Perimeter Center 
9960 Mayland Drive, Suite 300
Henrico, Virginia 23233-1463
Phone: (804) 367-4400

Location-Based Services
If you use location-based services (LBS) on your mobile phone, you may wish to be aware of the privacy issues related to using these services. I do not place my practice as a check-in location on various sites such as Google Maps, Facebook, Foursquare, Yelp, etc. However, if you have GPS tracking enabled on your device, it is possible that others may surmise that you are a therapy client due to regular check-ins at my office. Please be aware of this risk if you are intentionally "checking in" from my office or if you have a passive LBS app enabled on your phone.

Thank you for taking the time to review my Social Media Policy. If you have any questions or concerns about any of these policies and procedures or regarding our potential interactions on the Internet, do bring them to my attention so that we can discuss them.

Acceptance of Terms
By signing, I agree to these terms.

(Revised January 2019)

( Type Full Name )