“When you pay attention to detail, the big picture will take care of itself.”
~Georges St-Pierre
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No Surprise Act & Good Faith Estimate – Client Summary
Return to Baseline, LLC wants to make sure you understand your rights, specifically that you are informed about recent healthcare protections under federal law.
What is the No Surprises Act?
The No Surprises Act, effective January 1, 2022, is a federal law designed to protect patients from unexpected medical bills. It ensures you are not surprised by high costs for services you didn’t know were out-of-network or not covered.
At Return to Baseline, LLC this applies to clients who:
Do not have insurance
Choose not to use their insurance (self-pay clients)
What is a Good Faith Estimate (GFE)?
If you are uninsured or not using insurance, you have the right to receive a GFE of expected charges before you begin services.
This estimate includes:
The expected cost of your counseling sessions
Any additional fees (if applicable)
A breakdown of services you may receive
Note: the GFE is not a bill – it’s an estimate based on the information available at the time.
Your Rights:
You have the right to receive a written Good Faith Estimate at least one (1) business day before your first session.
You can ask for a GFE at any time during your care.
If your actual charges are $400 or more above the estimate, you can dispute the bill through the Patient-Provider Dispute Resolution Process.
How Return to Baseline, LLC Supports This:
We will provide a clear Good Faith Estimate before services begin.
We’re happy to answer any questions you may have about fees, billing, or your rights under this law.
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Notice of Privacy Practices (NPP)
(required under HIPAA to be given to clients)
Notice of Privacy Practices
Return to Baseline, LLC
Effective Date: 01 October 2025This notice describes how medical and mental health information about you may be used and disclosed, and how you can get access to this information. Please review it carefully.
Your Rights Under HIPAA:
You have the right to:
Get a copy of your health and billing records
Request corrections to your records
Request confidential communication
Ask us to limit what we use or share
Get a list of disclosures we've made of your information
Get a copy of this privacy notice
Choose someone to act for you
File a complaint without fear of retaliation
Our Uses and Disclosures of Your Information:
We may use and share your information to:
Treat you – Share information with other professionals who are treating you (with your consent, except in emergencies).
Run our operations – Improve quality of care, train staff, manage records, and perform audits.
Bill for services – Submit information to insurance companies or billing platforms.
We may also share information:
As required by law or court order
To report suspected abuse or neglect
To prevent or lessen a serious threat to health or safety
For health oversight (licensing boards, audits)
With your authorization, in cases not required or allowed by law
Special Protections for Psychotherapy Notes:
Psychotherapy notes receive additional protection under HIPAA.
We will not share psychotherapy notes without your written authorization, except in rare legal or safety situations.
Psychotherapy notes are separate from your general medical record.
Our Responsibilities:
We are required by law to protect your information and follow the terms of this notice.
We will let you know if a breach occurs that may have compromised your information.
We may change this notice and will provide the new version upon request or on our website.
Contact Information:
Return to Baseline, LLC
Milwaukee, WI 53220
414-279-0002You may also file a complaint with the U.S. Department of Health and Human Services if you believe your rights have been violated:
https://www.hhs.gov/ocr/privacy/hipaa/complaints/ -
Privacy Policy
Return to Baseline, LLC
Effective Date: 01 October 2025Return to Baseline, LLC (“we,” “our,” or “us”) is committed to safeguarding your personal and health information. This Privacy Policy explains how we collect, use, and protect your information when you visit our website or engage in clinical services.
By using our website or services, you consent to the terms of this policy.
1. HIPAA Compliance and PHI Protections
We are a HIPAA-compliant provider, and we treat all Protected Health Information (PHI) with strict confidentiality. PHI includes any information that can identify you and relates to your past, present, or future mental health treatment or payment for services.
How We Protect PHI:
Use of secure, encrypted electronic health record systems (EHR)
HIPAA-compliant platforms for telehealth, billing, and messaging
Limited access to clinical records on a need-to-know basis
Regular staff training in privacy and security practices
2. Your Rights Regarding PHI
You have the right to:
Access your health records and treatment history
Request corrections to inaccurate or incomplete information
Receive confidential communications in the format or location of your choosing
Request restrictions on how we use or share your information
Receive an accounting of disclosures we’ve made of your PHI
Receive a copy of this privacy policy and our full Notice of Privacy Practices (NPP)
File a complaint without retaliation if you believe your rights were violated
3. Psychotherapy Notes and Disclosures
Psychotherapy notes are defined under HIPAA as notes recorded by a mental health professional documenting or analyzing the contents of conversations during a private counseling session, separate from medical records. These are given special protections.
We Will Not Disclose Psychotherapy Notes Without Your Written Authorization
We require your explicit, written authorization to release psychotherapy notes to anyone, including other healthcare providers, unless a legal exception applies.
Disclosure of Psychotherapy Notes Does Not Require Consent in the Following Situations:
If required by law (e.g., court order or legal investigation)
To prevent or lessen a serious and imminent threat to your health or safety or that of another person
If there is suspicion of child, elder, or vulnerable adult abuse or neglect
For internal use by Return to Baseline, LLC for treatment, training, or quality improvement
When required by oversight agencies for audits, investigations, or licensure reviews
We will not use psychotherapy notes for marketing, sales, or non-healthcare purposes under any circumstance.
4. Personally Identifiable Information (PII)
We may collect personal information through forms or online scheduling tools, such as:
Full name
Phone number
Email address
Mailing address
Insurance and payment details
This information is used only for communication, service delivery, or administrative purposes. It is not sold, rented, or shared with advertisers.
5. Cookies and Website Tracking
Our website may use cookies and analytics tools to understand how visitors interact with the site. These may collect data such as:
Device type and browser
Pages visited and time spent on each page
These tools do not collect PHI or psychotherapy notes. You may disable cookies in your browser settings or opt out of analytics tracking.
6. Third-Party Platforms and Links
Return to Baseline, LLC uses HIPAA-compliant third-party services to manage appointments, telehealth, billing, and clinical documentation.
Our website may contain links to third-party websites (e.g., social media or directories like Psychology Today). We are not responsible for:
The content or security of external sites
How those sites collect or use your information
Ads or recommendations shown on those platforms
Once you leave our site, the privacy practices of the third-party site apply.
7. Email Communication
Please avoid sending sensitive information by email or contact form. These are not considered secure methods of communication under HIPAA. Use our secure client portal or encrypted messaging system for clinical matters.
8. Data Security
We take extensive precautions to protect your data:
Encrypted file storage
Password-protected platforms
Limited access permissions
Ongoing security monitoring
Staff bound by confidentiality agreements
No system is 100% risk-free, but we follow industry standards to minimize exposure.
9. Consent and Use of Information
By using our website or receiving services, you consent to our use of your information as outlined. You may withdraw consent for optional communications at any time.
10. Policy Changes
We may update this policy periodically. Changes will be reflected by a new effective date. We recommend checking back periodically to stay informed.
11. Contact Information
If you have questions or wish to exercise your rights under this policy, please contact:
Return to Baseline, LLC
Milwaukee, WI 53220
414-279-0002 -
Informed Consent and Service Agreement
Welcome to Return to Baseline, LLC
This document outlines important information about your rights, confidentiality, and what to expect from services. Please read carefully and ask questions if anything is unclear. Effective date: 01 October 2025
CONSENT FOR TREATMENT
By engaging in services, you acknowledge:
Understanding the nature and goals of counseling or consultation
Acceptance of confidentiality limits (including duty to warn)
Consent to participate in services, including telehealth as needed
Agreement not to record sessions
Billing and records are managed via a HIPAA-compliant third-party platform
Acknowledgement that we do not provide crisis or emergency services
Understanding that therapy may involve temporary emotional stress, but coping information will be provided
You may need to sign additional consent forms for treatment
Your provider will provide their license number and contact information for the state licensing board upon request
CONFIDENTIALITY AND LIMITS
Your privacy is important to us. Information shared in counseling, consultation, and supervision sessions is confidential and protected by law. We will not disclose your information without your written permission unless required by law or in certain circumstances where safety is at risk, such as:
Risk of harm: If you express intent to seriously harm yourself or others
Abuse or neglect: If we suspect abuse or neglect of a child, elderly person, or vulnerable adult
Court orders: If a court requires us to release information
Provider misconduct: If we become aware of misconduct by another licensed provider
Texas law: If we learn of adults involved as victims of human trafficking
We will make every effort to discuss these situations with you when it is safe and appropriate. Confidentiality during supervision or consultation with other providers is also protected by ethical guidelines.
TELEHEALTH SERVICES
Telehealth offers convenience but requires a secure internet connection and private location on your end. It may not be suitable for all issues, and your provider will determine if it’s appropriate. Misuse of telehealth (e.g., recording sessions, driving during a session, or dishonesty about location) may result in suspension of this service.
BILLING AND RECORD KEEPING
We use a HIPAA-compliant platform (Sessions Health) to manage billing, scheduling, and records. You must keep a valid credit card on file, and payments are processed after each session based on the actual time spent.
All services are billed at the original scheduled time, even if the session is canceled or rescheduled.
Appointments must be canceled at least 48 hours in advance to avoid a $125 fee. Three no-shows or late cancellations within 90 days may result in discharge. This applies to both in-person and telehealth sessions.
NO-SHOW AND LATE CANCELLATION POLICY
48 hours’ notice: Required for cancellation to avoid a $125 fee.
No-show: $125 fee. This fee helps compensate for the reserved time that could not be offered to another client.
Emergencies: One-time excusal may apply at the provider’s discretion.
Multiple missed appointments: May lead to discharge from services.
PAYMENT AND CHARGEBACK POLICY
Payment for services is due at the time of the session and is non-refundable. By signing this agreement, you acknowledge and agree that:
Non-refundable payments: Fees for services rendered or scheduled are non-refundable.
Chargebacks: If you dispute, reverse, or initiate a credit card chargeback based on dissatisfaction with the content, clinical approach, or perceived outcomes of a session, we reserve the right to take appropriate action to recover the payment, including collection or legal proceedings.
Therapy outcomes: Therapy does not guarantee specific outcomes, symptom relief, or agreement with all content discussed. Discomfort or differing perspectives may occur and are part of the therapeutic process.
If concerns arise about your experience or the services provided, please address them directly with your provider.
ARBITRATION AGREEMENT
Any disputes arising from your use of our services will be resolved through binding arbitration, not in court, except for certain claims. Arbitration will be conducted by a neutral arbitrator in accordance with the American Arbitration Association (AAA) rules and will take place in the state where Return to Baseline, LLC is registered.
LIMITATION OF LIABILITY
Return to Baseline, LLC and its employees, affiliates, or contractors are not liable for any indirect, incidental, consequential, or punitive damages arising out of your use of our services. This includes, but is not limited to, any financial losses, emotional distress, or other damages resulting from decisions made based on the counseling, consultation, or therapy provided.
Your sole and exclusive remedy for dissatisfaction with services is to discontinue using our services. In the event that any issues arise from your experience, you agree to work directly with your provider to resolve concerns, and we will assist in finding solutions where appropriate.
To the fullest extent permitted by law, Return to Baseline, LLC disclaims all liability for any actions taken or not taken based on the information provided through our services. You acknowledge that therapeutic or consultative services do not guarantee specific outcomes, symptom relief, or agreement with all content discussed.
In the unlikely event of a dispute that cannot be resolved informally, any claims related to services provided will be handled as specified under the Arbitration Agreement section above.
RECORDING POLICY
Recording of sessions is not permitted to protect your privacy and the integrity of the counseling process. You are welcome to take personal notes or request a summary of session content from your counselor.
ADDITIONAL CONSENT FORMS
Separate consent forms may be required for specific services (e.g., Walk and Talk Therapy) and will be explained as needed.
CLIENT RIGHTS
You have the right to:
Be treated with dignity and respect
Ask questions and understand your counselor’s approach
Request a different counselor or stop services at any time
Receive a Good Faith Estimate if not using insurance
TEXAS RESIDENTS
My (Nicole Espil) TX LCSW (Licensed Clinical Social Worker) license number is 116692. As per House Bill 4224 (89th Regular Session, effective Sept. 1, 2025), Texas law requires that you have the right to:
Request a copy of your health care records from the licensee
Contact the Texas Behavioral Health Executive Council (BHEC) for complaints: Contact Us page
File a consumer complaint with the Texas Office of the Attorney General: Consumer Protection webpage
POTENTIAL RISKS AND BENEFITS
Counseling or consultation can provide emotional support, personal growth, and improved coping skills but may also involve emotional discomfort or challenges. Telehealth can improve access to therapy but may limit the ability to observe physical or behavioral cues, which could affect the therapist’s ability to make a full assessment.
OUR SCOPE OF SERVICES
Return to Baseline, LLC is not a crisis service. If you experience an emergency, please call 911 or the 988 Suicide and Crisis Lifeline. We are available to support your ongoing care, but we do not provide emergency or on-call services. If your needs exceed our scope of services, we reserve the right to terminate treatment.
By signing below, you acknowledge:
Understanding of the counseling process, risks, and benefits
Acceptance of policies outlined above
Voluntary participation in services
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DISCLAIMER – WISCONSIN ARMY NATIONAL GUARD MEMBERS
Return to Baseline, LLC is a private counseling practice and does not provide clinical services to current members of the Wisconsin Army National Guard or their spouses.
The provider concurrently serves in an official capacity as a Behavioral Health Officer within the Wisconsin Army National Guard. Providing counseling services to individuals within this population would constitute a dual relationship and present a conflict of interest, raising ethical concerns and potential violations of military regulations and federal compliance standards.
This policy is implemented to uphold professional ethical obligations, protect client confidentiality, maintain appropriate professional boundaries, and ensure compliance with applicable military and federal ethics requirements. Referrals and external resources are available to assist affected individuals in obtaining appropriate care
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Hello to my Texas folks! Your state has additional requirements and rights to you as a consumer of my services. Please see below for more information and please talk with me if you have any questions or concerns related to this information.
My TX LCSW (Licensed Clinical Social Worker) license number is 116692.
House Bill 4224 (89th Regular Session), which went into effect on Sept. 1, 2025, requires licensees to, per Section 181.105 of the Health and Safety Code, prominently post on their website and at any facility detailed instructions for a consumer to:
Request the consumer’s health care records from the licensee;
Contact the Council, as found on the Council's Contact Us webpage; and
File a consumer complaint with the Office of Attorney General’s Consumer Protection webpage.
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Walk and Talk Psychotherapy Consent Form
Return to Baseline, LLC
Effective Date: 01 October 2025Introduction
Walk and Talk Psychotherapy is an outdoor counseling session where therapy takes place while walking, usually in a public park or natural setting. This form explains the benefits, risks, and policies related to this therapy format.
Nature of Walk and Talk Therapy
Sessions combine traditional talk therapy techniques with physical movement in an outdoor setting.
The therapist and client will walk together during the session; sessions typically last the same amount of time as office-based sessions.
This format may be helpful for clients who find outdoor settings relaxing or who prefer not to sit in an office.
Risks and Limitations
Environmental factors: Weather, uneven terrain, noise, and public distractions may occur.
Privacy: Sessions occur in public or semi-public spaces. Complete confidentiality cannot be guaranteed due to the environment.
Safety: The client agrees to inform the therapist of any mobility issues or health concerns that could affect walking safely.
Recording: No audio or video recording is allowed by either party during Walk and Talk sessions.
Emergencies: In case of a medical or mental health emergency during a Walk and Talk session, the therapist may need to seek assistance immediately or call emergency services.
Confidentiality
All standard confidentiality protections apply; however, because of the outdoor and public setting, complete privacy cannot be guaranteed.
If other individuals are nearby during the session, the therapist will take reasonable precautions to minimize disclosure of confidential information.
Client Responsibilities
Wear appropriate clothing and footwear suitable for walking outdoors.
Clients should always obtain guidance from their primary care medical provider to ensure they are physically fit to engage in this activity; for client’s with known medical conditions or mobility limitations, please seek medical advice prior to the first session.
Notify the therapist if you have any medical or physical conditions that may impact walking or your safety.
Be aware of your surroundings and inform the therapist immediately if you feel unsafe or uncomfortable during a session.
Notify the therapist immediately with concerns of pain or other discomfort.
Attend scheduled sessions on time and notify the therapist in advance if you need to cancel or reschedule.
Consent
By signing below (copy will be given for actual signature at first visit) I acknowledge they understand the nature, risks, and benefits of Walk and Talk psychotherapy. I agree to participate voluntarily and accept the limitations and responsibilities described above.
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OUR SCOPE OF SERVICES
Please note RETURN TO BASELINE, LLC IS NOT A CRISIS SERVICE. If you are in immediate danger, are having a medical or mental health emergency, or need urgent support outside of session hours, please:
Call 911 or go to the nearest emergency room
Contact 24/7 crisis lines such as
988 Suicide and Crisis Lifeline (call or text 988)
Crisis Text Line: Text HOME to 741741
We are available to support your ongoing care, but we do not provide emergency response or on-call services.
Should we at Return to Baseline, LLC find we are not a good fit for your needs or that you are not a compatible fit with the services available from us, we will work diligently and with respect to find you a provider(s) that better meets your needs. We reserve the right to end services should the needs go beyond their scope, clinical knowledge, ethical limits, or general comfort/safety.
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RECORDING POLICY
Effective date: 01 October 2025
To protect your privacy and the integrity of the counseling process, recording of sessions by any means (audio, video, or otherwise) is not allowed. This can result in immediate termination of services.
If you would like to remember or reflect on session content, you are welcome to:
Take personal notes during or after sessions
Request access to your clinical notes
Ask your counselor to provide a written summary of key points
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Terms and Conditions
By accessing and using the website of Return to Baseline, LLC ("Company", "we", "us", or "our"), you agree to comply with and be bound by the following Terms and Conditions. If you do not agree with these terms, please do not use this website.
1. Use of Website
This website is intended for users who are 18 years or older. By using this site, you confirm that you meet this age requirement and are accessing it from a location where we are authorized to provide services.
2. Intellectual Property
All content on this website, including but not limited to text, graphics, logos, images, audio, video, and software, is the property of Return to Baseline, LLC and is protected under copyright and intellectual property laws. You may not use, reproduce, or distribute any content without prior written permission.
3. Privacy
We value your privacy. Please refer to our [Privacy Policy] for information on how we collect, use, and protect your personal data.
4. No Guarantees or Warranties
Mental health treatment is a collaborative process and results may vary. We do not guarantee specific outcomes from therapy or coaching services. All services are provided "as is" without warranties of any kind, either express or implied.
5. Errors and Omissions
While we strive to ensure that all information on our website and in our communications is accurate and up to date, occasional errors or omissions may occur. We reserve the right to correct any errors and to update information at any time without prior notice. We are not liable for any such inaccuracies.
6. No Refunds Policy
We understand that investing in your mental health is a significant commitment. Due to the time and preparation involved in delivering therapeutic services, all payments for services rendered or scheduled are non-refundable. If you are unable to attend a session, please refer to our cancellation policy or contact us directly to discuss rescheduling options.
7. Arbitration Agreement
By using our services, you agree that any dispute, claim, or controversy arising out of or relating to your use of the website or our services shall be resolved through binding arbitration rather than in court, except for certain claims such as small claims or equitable relief. Arbitration will be conducted by a single, neutral arbitrator in accordance with the rules of the American Arbitration Association (AAA), and will take place in the state where Return to Baseline, LLC is registered. Each party shall bear its own costs unless the arbitrator determines otherwise.
8. Limitation of Liability
In no event shall Return to Baseline, LLC or its employees, affiliates, or contractors be liable for any indirect, incidental, consequential, or punitive damages arising out of your use of our website or services. Your sole and exclusive remedy is to discontinue using the website or services.
9. Third-Party Links
This website may contain links to third-party websites or services. These are provided as a convenience only. We do not endorse, and are not responsible for, the content or practices of any third-party sites.
10. Modifications
We reserve the right to update or change these Terms and Conditions at any time. Continued use of the site or our services following any changes constitutes your acceptance of the revised terms.
11. Governing Law
These Terms and Conditions are governed by the laws of the state in which Return to Baseline, LLC is registered, without regard to its conflict of law provisions.Item description