Please read the following forms:

  • Signature page


When you arrive for your appointment, you will be asked to sign the “signature from” which states that you have read and understand this information.


Health Insurance Portability and Accountability Act (HIPPA)

This notice describes how psychotherapy information about you may be used and disclosed and how you can get access to this information.

This notice explains how your protected health information may be used and disclosed to carry out payment and health care operations and for other purposes that are permitted or required by law.  “Protected health information” (PHI) in this notice means any personally identifiable information, including demographic information, that may be gathered in evaluating your current condition, making a diagnosis, deciding a course of treatment, assessing your progress, coordinating care with other health service providers, and documenting and obtaining payment for services provided.  I reserve the right to change the terms of the Notice of Privacy Practices.  Any new Notice of Privacy Practice will be effective for all PHI that I maintain at that time.  You will be provided with a copy of the revised Notice of Privacy practice.

How I may use or disclose your health information.
  1. Assessment and treatment.  I may use your health information to evaluate your current condition, to make a diagnosis, to determine course of treatment, and to monitor and assess the progress of your treatment, as well as to coordinate care with other health service providers as may be appropriate.

  2. Obtaining Payment.  I may use and disclose your health information to obtain payment for services provided.  This may entail communication with an insurance company or managed care organization, and/or working with a billing agency.  All these entities and business associated are obligated to protect the privacy of your health information.

  3. Health care operations:  I may use or disclose your health information for health care operations that are necessary to assess quality of care and effectiveness of treatment services.  I may send you a reminder that you have an appointment.  I may tell you about alternative treatments and programs or about services that may be of interest to you.

  4. Disclosure with authorization:  uses and disclosures not specifically permitted by law will be made only with your written authorization, which you may revoke.

  5. Disclosure required by law without authorization.  Applicable law and ethical standards permit disclosure of information about you without your authorization only in a limited number of situations.  The types of uses and disclosures that may be made without your authorization are those that are:

  • Required by law; such as the mandatory reporting of child abuse and neglect or mandatory government agency audits or investigations (such as the state social work licensing board)

  • Required by court order

  • Necessary to prevent or lessen a serious and imminent threat to the health or safety of a person or the public. If the information is disclosed to prevent or lessen a serious threat, it well be disclosed to a person or persons reasonably able to prevent or lessen the threat, including the target of the threat.

Your rights regarding your health information
  • Right to request restriction:  You have the right to request in writing additional restrictions or limitations on the use or disclosure of your health information.  I am not legally required to agree with your request.

  • Right to an accounting disclosure:  You have the right to request that I communicate with you about your health information in a certain way or at a certain location.

  • Right of access to inspect and copy:  You have the right to inspect and obtain a copy of certain health information that I maintain to make decisions about your care.  In limited circumstances, I may deny your request to inspect or copy your health information.  If I deny your request, I will notify you in writing of the reason for the denial.

  • Right to amend:  If you feel that the health information I maintain about you in incomplete or inaccurate, you may request in writing that I amend the information.  I am not required to agree to the amendment.

  • Right to a copy upon this notice:  Upon request.


If you have any questions about this privacy practices, please speak with or write to me.  If you should believe that your privacy rights have been violated, you may file a complaint with me in writing.  You may also notify the Secretary of the U.S. Department of Health and Human Services of your complaint.  You will not be penalized for filing a complaint.




Laws and Rules Relating to Licensed Clinical Social Workers- Vermont




(a) Unprofessional conduct shall include:

  1. Fraudulent or deceptive procuring of a license

  2. Willfully making or filing false reports or records in the practice of clinical social work, willfully impeding or obstructing the proper making or filing of reports or records, or willful failing to file the proper report or record;

  3. advertising which is intended to deceive the public;

  4. Exercising undue influence on or taking improper advantage of a person using clinical social work service, or promoting the sale of services or goods in a manner which exploits a person for the financial gain of the practitioner or of a third party;

  5. Failure to comply with statutes governing the practice of clinical social work;

  6. Conviction of a crime that evidences an unfitness to practice clinical social work;

  7. Failing to make available to succeeding health care professionals or institutions, upon written request of a person using clinical social work services, copies of that person’s records in the  possession or under the control of the clinical social worker;

  8. Practicing clinical social work when medically or psychologically unfit to do so;

  9. Failing to use a correct title in professional activity;

  10. Conduct which evidences unfitness to practice clinical social work;

  11. Gross or repeated malpractice;

  12. Engaging in any sexual conduct with a client, or with the immediate family member of a client, with whom the licensee has had a professional relationship within the previous two years;

  13. Harassing, intimidating, or abusing a client or patient;

  14. Entering into an additional relationship with a client, supervisee, research participant or student that might impair the clinical social worker’s objectivity or otherwise interfere with the clinical social worker’s professional obligations;

  15. Practicing outside or beyond a clinical social worker’s area of training, experience or competence without appropriate supervision;

(b). After hearing, and upon a finding of unprofessional conduct, the  special panel may take disciplinary action against a licensed clinical social worker of applicant.


To make a consumer inquiry or file a complaint, contact the Vermont Secretary of State, Office of Professional Regulations, 109 State Street, Montpelier, Vermont 05609 or call 802-828-2367.


Policy & Fees

APPOINTMENTS: appointments are 50 minutes long and scheduled on a once a week or every other week basis. 

Please give me as much notice as possible if you need to cancel your appointment. I do have a cancellation policy as follows:   24 hours notice  in advance if you are unable to keep your scheduled appointment.  Notification of less than 24 hours in advance of your appointment will result in a charge of the full session fee.

FEES AND PAYMENTS:  My fee is $150 per psychotherapy session.

Payment is due at the time of session.

I offer a sliding fee scale if you are unable to pay the full fee.

I am available for phone and SKYPE sessions.

INSURANCE: I am considered an “out of network provider”.  I do no direct billing to insurance. I will give you a receipt with all the required information for you to submit for reimbursement. Reimbursement from your insurance depends on your policy and what kind of benefits you have. 

CONFIDENTIALITY: I will make every attempt to safeguard the information you share with me and to keep it in strict confidence.  However, there are legal exceptions to this policy as follows:

  1. Vermont state and local law mandate that a mental health professional who has reasonable cause to believe that any child or elder has been physically, emotionally, ,or sexually abused or neglected must report such abuse or neglect to The Department of Children and Family for possible investigation.

  2. If a therapist has reasonable cause to believe that a client may inflict harm upon him or herself or another or another’s property, the therapist is bound ethically and legally to do whatever is necessary to protect human life and/or property.

  3. If a therapist is involved in a court case, clinical records and/or therapist testimony may be subpoenaed.

  4. I participate in regular supervision and consultation with other skilled mental health professionals about my work.  Rules of confidentiality apply to these sessions.  Any use of personal names or identifying information is avoided.


EMERGENCIES: During the time we are working together, if an emergency should arise and you need to speak to me, you may call my voice mail number, 651-7676 and press “0”.  The service will contact me, and I will call you back, usually within 24 hours.  For a life threatening mental health emergency that requires immediate assistance, you may call the crisis clinic at 488-6400, call 911 or go directly to your closest emergency room.

PROFESSIONAL DISCLOSURE: I received a Master’s Degree in Social Work from New York University in 1991.  In 1996, I received a certificate from Metropolitan Institute in Training for Psychoanalytic Psychotherapy.  Additionally, I completed level I (2009) and level II (2013) in trauma and attachment through the Sensorimotor Psychotherapy Institute.  I am licensed in the state of Vermont as a Clinical Social Worker.  I am a general practitioner with specific interest in mindfulness, life transitions and adjustments, anxiety and relationship issues.


Signature Page

My signature acknowledges that I have read the HIPPA- notice of privacy act, professional qualifications of Tasha C. Lansbury, LICSW and a list of actions that constitutes unprofessional conduct, and the method for filing a complaint.

My signature acknowledges that I will not request Determination of Disability information from Tasha C. Lansbury, LICSW. 

Furthermore, I understand that Tasha C. Lansbury, LICSW  and/or her records/files will not be available for any court proceedings or hearings and I agree not to subpoena Tasha C. Lansbury, LICSW for her records/files.


My signature Acknowledges that I am giving consent for Tasha C. Lansbury, LICSW to treat me (us) and/or my minor child (children) listed below.


         Client/Guardian Signature ______________________________________________



        Name of child _______________________________________________________


        Relationship to child___________________________________________________


444 South Union Street, Suite 220    |     Burlington, VT 05401     |     (802) 734-6981

© 2019 by Tasha Lansbury, LICSW