“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 & Privacy Policy
Return to Baseline, LLC
Effective Date: October 1, 2025This notice describes how your medical and mental health information may be used and disclosed, how your personal information is protected, and how you can access your information. Please review it carefully.
Return to Baseline, LLC (“we,” “our,” or “us”) is committed to protecting your privacy and maintaining the confidentiality of your Protected Health Information (PHI) in accordance with the Health Insurance Portability and Accountability Act (HIPAA).
1. Our Commitment to Your Privacy
We are a HIPAA-compliant provider and safeguard all Protected Health Information (PHI), which includes any information that identifies you and relates to your past, present, or future mental health care or payment for services.
We protect your information through:
Secure, encrypted electronic health record (EHR) systems
HIPAA-compliant telehealth, billing, and communication platforms
Limited access to records on a need-to-know basis
Ongoing staff training in privacy and security practices
2. Your Rights Under HIPAA
You have the right to:
Access and obtain a copy of your health and billing records
Request corrections to inaccurate or incomplete records
Request confidential communication (e.g., alternate phone, email, or address)
Request restrictions on how we use or share your information
Receive an accounting of disclosures of your information
Receive a copy of this notice
Designate someone to act on your behalf
File a complaint without fear of retaliation
3. How We Use and Disclose Your Information
We may use and share your information for the following purposes:
Treatment
To provide, coordinate, or manage your care. We may share information with other providers involved in your treatment, with your consent except in emergencies.
Healthcare Operations
To operate our practice, improve quality of care, conduct training, and perform administrative functions.
Payment
To bill and receive payment for services, including submitting information to insurance providers or billing platforms.
4. Other Uses and Disclosures
We may also disclose your information:
As required by law, court order, or legal process
To report suspected abuse, neglect, or exploitation
To prevent or reduce a serious and imminent threat to health or safety
For health oversight activities (e.g., licensing boards, audits)
With your written authorization for uses not otherwise permitted
5. Special Protections for Psychotherapy Notes
Psychotherapy notes are maintained separately from your clinical record and receive additional protections under HIPAA.
We will not disclose psychotherapy notes without your written authorization, except in limited circumstances, including:
When required by law
To prevent a serious and imminent threat
For internal use related to treatment, training, or quality improvement
For oversight activities such as audits or investigations
Psychotherapy notes are never used for marketing or non-healthcare purposes.
6. Personally Identifiable Information (PII)
We may collect personal information through forms, scheduling systems, or communication tools, including:
Name, phone number, email, and address
Insurance and payment information
This information is used only for care delivery, communication, and administrative purposes. We do not sell or share your information for advertising.
7. Website Use, Cookies, and Analytics
Our website may use cookies or analytics tools to understand user activity (e.g., pages visited, device type).
These tools:
Do not collect Protected Health Information
Are used only to improve website functionality
You may disable cookies through your browser settings.
8. Third-Party Services
We use HIPAA-compliant third-party platforms for scheduling, telehealth, billing, and documentation.
Our website may include links to external sites (e.g., directories or social media). We are not responsible for:
The privacy practices of those sites
Their content or security
9. Email and Communication
Standard email and website contact forms are not considered secure under HIPAA.
Please use our secure client portal or approved communication platforms for sensitive or clinical information.
10. Data Security
We take reasonable and appropriate measures to protect your information, including:
Encryption and secure storage
Password-protected systems
Limited access controls
Ongoing monitoring and staff confidentiality agreements
While no system is completely risk-free, we follow industry standards to minimize risk.
11. Our Responsibilities
We are required by law to:
Maintain the privacy and security of your information
Provide you with this notice
Follow the terms of this notice
We will notify you if a breach occurs that may have compromised your information.
We may update this notice at any time. The updated version will be available upon request and on our website.
12. Your Consent
By engaging in services or using our website, you acknowledge and accept the practices described in this notice.
You may withdraw consent for optional communications at any time.
13. Contact Information
Return to Baseline, LLC
10437 W Innovation Dr, Suite 416
Wauwatosa, WI 53226
📞 414-279-0002
📧 nikki@returntobaselinellc.com
🌐 www.returntobaselinellc.com14. Filing a Complaint
If you believe your privacy rights have been violated, you may file a complaint with us or with the U.S. Department of Health and Human Services. You will not be penalized for filing a complaint.
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Informed Consent and Service Agreement
Return to Baseline, LLC
Before we begin, this document explains how services work here, your rights as a client, and the practical policies that support care, confidentiality, and professionalism.
Effective as of the date of client signature.
Consent for Services
By engaging in services with Return to Baseline, LLC, you acknowledge that you understand the nature and goals of counseling (therapy) and/or professional consultation, consent to participate in services including telehealth when appropriate, understand the limits of confidentiality, agree not to record sessions, and acknowledge that services provided are not crisis or emergency services.
Distinction Between Counseling and Consultation Counseling (Therapy):
Counseling involves assessment and treatment of mental and behavioral health concerns and may include diagnosis when clinically indicated. Consultation: Consultation is non-clinical, goal-directed, and focused on clarity, leadership support, burnout prevention, stress management, and intentional living.
No Guarantees; Risks and Potential Benefits
Counseling and consultation involve active participation. While many clients experience meaningful benefits, specific outcomes cannot be guaranteed. Potential benefits include insight, coping skills, clarity, and growth. Potential risks include temporary emotional discomfort or changes in perspective. Outcomes vary by individual.
Confidentiality and Its Limits
Information shared during services is confidential except when disclosure is legally or ethically required, including risk of serious harm, suspected abuse or neglect, lawful court orders, reporting of professional misconduct, or Texas law requirements related to human trafficking.
Telehealth Services
Telehealth services are provided using secure, HIPAA-compliant technology. Misuse may result in suspension or termination of telehealth services.
Insurance, Billing, and Financial Responsibility
If Return to Baseline, LLC accepts your insurance, we will bill your insurance carrier directly as a courtesy. Clients are solely responsible for verifying that Return to Baseline, LLC and their provider are in-network with their specific insurance plan.
Clients are fully responsible for all co-payments, co-insurance, deductibles, and any other charges determined by their insurance carrier, including charges resulting from out-of-network services, denied claims, or benefit limitations.
Insurance coverage is a contract between the client and their insurer. Return to Baseline, LLC is not responsible for coverage determinations.
Credit Card on File Policy
A valid credit card is required to be kept on file for all clients of Return to Baseline, LLC, regardless of service type or payment method. The card on file may be charged for co-payments, deductibles, late cancellations, no-shows, administrative services, session fees, and any services not covered by insurance or third-party payers.
No-Show and Late Cancellation Policy
Appointments are reserved specifically for you. 48 hours’ notice is required to cancel or reschedule without charge. Late cancellations and no-shows incur a $125 fee.
Additional Consents
Certain services, including Walk & Talk Therapy, require a separate informed consent form. Clients must review and sign the applicable additional consent prior to participation.
Arbitration and Dispute Resolution
Disputes shall be resolved through binding arbitration except where prohibited by law.
Limitation of Liability
Return to Baseline, LLC is not liable for indirect or consequential damages. Clients remain responsible for decisions made outside of sessions.
Client Rights, Respect, and Professional Conduct
Clients will be treated with dignity and respect in accordance with professional ethical standards, regardless of race, color, national origin, sex, gender identity or expression, sexual orientation, age, religion, disability, marital status, military or veteran status, or any other protected category under applicable law.
Return to Baseline, LLC is committed to providing professional services that are respectful, ethical, and aligned with client needs. If a client has concerns regarding the conduct of a provider, those concerns are encouraged to be raised directly when possible. Information regarding the appropriate state licensing board for the provider will be made available upon request.
If a client determines that services are not a good fit, Return to Baseline, LLC will make reasonable efforts to assist with referral to another provider or resource when appropriate.
Texas Residents
Nicole Espil, LCSW — Texas License #116692. Texas residents may request records or file complaints with the Texas Behavioral Health Executive Council (BHEC).
Emergencies
Return to Baseline, LLC is not a crisis service. In emergencies, call 911 or 988.
Acknowledgment and Signature
By signing below, I acknowledge that I have read and understood this Informed Consent and Service Agreement, had the opportunity to ask questions, and voluntarily agree to the terms described above.
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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 Therapy Consent Form
Return to Baseline, LLC
Effective Date: October 1, 2025Introduction
Walk and Talk Therapy is a form of clinical counseling (psychotherapy) provided by Return to Baseline, LLC in an outdoor setting. Sessions take place while walking together in a public or semi-public environment, such as a park or walking path.
This consent form explains the nature of Walk and Talk Therapy, including its benefits, limitations, and specific considerations related to privacy, safety, and confidentiality.
Nature of Walk and Talk Therapy
Walk and Talk Therapy integrates traditional evidence-based psychotherapy with gentle physical movement in an outdoor setting.
Sessions are conducted by a licensed clinical social worker and follow the same professional, ethical, and clinical standards as office-based therapy.
Sessions are typically the same length as standard counseling appointments.
This format may be beneficial for clients who find movement or outdoor environments supportive of reflection, emotional regulation, or engagement in therapy.
Participation in Walk and Talk Therapy is voluntary, and clients may request to transition to in-office or telehealth sessions at any time.
Potential Benefits
Increased comfort or ease of conversation for some clients
Support for emotional regulation through movement
A less formal setting that may reduce barriers to engagement
Opportunity to integrate mind-body awareness into therapy
Benefits may vary, and Walk and Talk Therapy may not be appropriate for all clinical concerns.
Risks and Limitations
Environmental Factors
Sessions take place outdoors and may involve weather conditions, uneven terrain, noise, or other environmental distractions.Privacy and Confidentiality
Because sessions occur in public or semi-public spaces, complete privacy cannot be guaranteed. While confidentiality standards remain the same, there is a possibility of being seen or overheard by others.Safety Considerations
Clients are responsible for notifying the therapist of any medical conditions, mobility concerns, or physical limitations that could affect safety during walking sessions.Recording
Audio or video recording of Walk and Talk Therapy sessions is not permitted by either the client or the therapist.Emergencies
In the event of a medical or mental health emergency during a Walk and Talk session, the therapist may need to seek immediate assistance or contact emergency services to ensure safety.Confidentiality
All standard confidentiality protections that apply to counseling services remain in effect during Walk and Talk Therapy. Reasonable precautions will be taken to minimize the risk of disclosure, including adjusting conversation topics, lowering voices, or changing direction when others are nearby.
Clients acknowledge and accept the inherent privacy limitations associated with outdoor therapy settings.
Client Responsibilities
By choosing Walk and Talk Therapy, clients agree to:
Wear appropriate clothing and footwear suitable for walking outdoors
Ensure they are physically able to participate safely in walking sessions
Consult with a medical provider if they have health conditions that may affect participation
Inform the therapist of any discomfort, pain, dizziness, or safety concerns immediately
Remain aware of surroundings and communicate any concerns during the session
Arrive on time and follow standard scheduling, cancellation, and attendance policies
Clinician Safety Protocols
For Walk and Talk Therapy sessions, Return to Baseline, LLC maintains clinician safety protocols. As part of these protocols, a designated administrative contact may have access to the clinician’s general location for safety and emergency purposes only.
This measure is intended solely to support clinician safety and continuity of care and does not involve monitoring of clients or session content.
Consent and Acknowledgement
By signing below, I acknowledge that:
I understand the nature, benefits, and limitations of Walk and Talk Therapy
I understand that Walk and Talk Therapy is a form of clinical counseling (psychotherapy)
I understand the privacy and safety considerations associated with outdoor sessions
I have had the opportunity to ask questions and receive clarification
My participation is voluntary, and I may discontinue or request an alternative format at any time
I consent to participate in Walk and Talk Therapy under the conditions 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