Now taking private insurance for short-term evaluation and consultation for children, adults, and families

I am now taking most Massachusetts private insurance in order to provide more people with affordable access to care. I am unfortunately having a difficult time taking MassHealth as a solo clinician, but I will keep trying. 

More about types of services I provide and my general philosophies can be found here.

I am particularly prioritizing brief short-term work with individuals and families who are finding themselves on someone's radar and needing to connect with services quickly in order to receive an initial evaluation and recommendations for pursuing further services (or assurance that nothing formal is needed at this time). I can provide brief developmental and psychological assessment of infants and children of all ages with and without disabilities, brief diagnostic and clinical assessment for adults with and without disabilities, and other related types of brief assessment and recommendations. I also specialize in working with adults, particularly parents, who may have undiagnosed neurodivergence and may be facing misdiagnosis or misconceptions as to the reasons they present as "a bit different" and are in need of an affirming evaluation. My evaluations are disability-positive, neurodiversity-affirming, and respectful of family culture including subcultural affinities. 

I also offer flexible consultation models for children and adults with disabilities who have no pressing clinical concerns, but find themselves needing an established connection with a clinician for verification of disability status or other systems-related reasons. I believe that most people who have had psychiatric or neurodevelopmental disabilities all of their lives do not need treatment, but I also understand that the medical model believes that disabled folks "are followed by someone for that" and I am happy to be that someone. 

Similarly, I offer flexible consultation/training models for children for whom frequent talk therapy is not the best model due to trauma, neurodivergence, culture, or some combination, and who may do better with a model in which the clinician teaches the family and familiar providers to support the youth more indirectly. 

I understand that when working with systems, time is often of the essence in terms of establishing an initial connection with a provider and having someone on record. I make it a point to see folks for an initial appointment usually within the week, though subsequent meetings, collateral contacts if appropriate, and written evaluations unfortunately always take some time. My main goal is to prevent families from being referred to crisis services in the absence of an actual emergency and/or reported to DCF "to make sure services are in place" absent concerns of actual abuse or neglect, as these types of contacts are traumatic and an unnecessary use of services that should be reserved for emergencies. 

photo I took of a red maple leaf on rocky pavement

Accepting most Massachusetts private insurance for gender-affirming care letters

More info here.

I am currently accepting Aetna, Cigna, Carelon, and soon will be accepting most of the other private insurance plans, except for BCBS unfortunately.

I will typically write a gender-affirming care letter in 1-2 sessions. I believe in personal autonomy and client-directed care. I may require documentation or collateral consults in a few instances, but there is very little about someone's presentation or history that I would consider a barrier to a grown adult pursuing care that has been shown to improve quality of life and stability in almost all instances. I am very familiar with the diverse presentation of autistic and other neurodivergent adults and make it a point to be sensitive and educate myself about clients' ethnicities, religions, and other cultural aspects when performing assessments. 

Naming and shaming: Mental health companies using obnoxious spammy recruiters

Like an increasing number of us, I have added to my LinkedIn profile that I do not wish to hear from recruiters. For years, I have had in my "about" section that I do not provide ongoing therapy and do not wish to hear from recruiters regarding therapy jobs. I do also of course explain what types of services I do provide, and that I am happy to discuss sliding scales and creative solutions for those who, you know, actually have some idea what I do and are looking for something in that ballpark.

The recruiters don't actually read the profiles though, despite sending messages stating they are extremely impressed with my profile and thought I would be a good fit. 

Since the "about" section text wasn't working to get them to stop, I moved my message to recruiters to the headline: 

Image: My LinkedIn profile, showing a white middle-aged person with pink hair. Text reads Erika Shira (Ask me my pronouns) LMHC, MT-BC. Not interested in hearing from recruiters about services I do not provide. Messages from individuals or businesses who ignore boundaries will be reposted publicly.

They kept messaging, so I added "messages from individuals or businesses who ignore boundaries will be reposted publicly" and now will be doing so. I certainly would not want to seek mental health care nor employment with a company that doesn't know how to treat humans like humans, so I will be calling them out when I see them. Honestly, doesn't it seem like basic human decency to browse someone's social media or public online presence a little bit before contacting them? I make it a habit to always do this when messaging people with whom I do not have regular contact; more than once, I have seen that someone I was considering messaging has posted about a loss in the family or something similar that is occupying their mind. I've been grateful to see this so I knew not to message them some annoying question, but rather to send them a message of support if we have that sort of relationship and to leave them in peace if we do not. Some of these recruiters apparently don't even read people's headlines before spamming them, and may be using bots.

Here's one I got recently:

LinkedIn message from Ali Turin, asking me to apply for a job at Charlie Health

Ali Turin, a Senior Clinical Talent Acquisition Specialist at Charlie Health, messaged me with a job listing. The message reads, in part, "Our Creative Arts Programming Leadership flagged your profile as a great fit for Charlie Health..." 

How? They saw the headline that says I don't provide therapy and don't wish to hear from recruiters, yet thought they'd try anyway? Interesting. 

LinkedIn message with my response, which is in the text below

I replied, stating "Is there a reason you are ignoring where my profile clearly states I do not provide therapy and not to contact me with such offers?" I did not receive any reply.

I did, however, receive not one but two e-mails from Ali Turin of Charlie Health, apparently just wanting to make sure I was not interested in working for such a ridiculous organization:

E-mail from Ali Turin, which I detail below

The e-mail reads, "Hey Erika, I hope you're well! I just shot you a note on LinkedIn but also wanted to follow up via email in case you don't check your LinkedIn often," then proceeds to discuss the job listing and has a Calendly link to schedule a 30-minute chat in case I just hadn't gotten enough of Ali Turin.

Another e-mail from Ali Turin and my response, which I detail below

This e-mail reads "Hey Erika, Wanted to quickly double down on my last note, in case it slipped through the cracks. I'm excited to share more about how we have built a world-class clinical team and model. It would also be great to learn more about you (your online profile can only tell me so much!). Are you up for a call?"

My response reads, "Hi, I responded to you on LinkedIn. I don't appreciate the spamming and ignoring of boundaries, though it does let me know something about your company's values in case anyone asks."

So yeah, if anyone is interested in knowing more about Charlie Health, there you go. 

If you are administering screening tools to everyone, this is poor clinical practice

When using screening tools, make sure you are actually at the point where this is necessary/appropriate.

What is a screening tool? It's exactly that. It's something that's meant to be administered to broad populations in order to flag undetected conditions that might otherwise go unnoticed, so these can be addressed. The tool is administered, and if it is positive for certain things, it then creates a record that the person has a previously undetected/currently unmet need.

If you are in a setting that uses these, make sure you understand this, and only administer screening tools to people who need to be screened, i.e., people who don't know if they have any conditions for which the tool screens. 

If you are doing hearing screenings, don't administer these to people with known hearing loss. Ask everyone if they've been previously identified, because medical/school records are often inaccurate (no need to ask someone who you do know is Deaf/hard of hearing). Just document that it was deferred due to already being identified. If you administer a screener, this create a records at the individual and population level showing they have a previously undetected/currently unmet need, which they don't. It skews data on how many people are going around with undetected conditions, and it enters into the person's individual medical or school record that they are experiencing medical neglect that they are actually not.

If you are doing screenings to detect emotional/behavioral concerns in children, don't administer these to youth/families who report their child has a diagnosed psychiatric disability for which they are receiving treatment. It still may be appropriate to administer other brief tools that look at social functioning, mood, etc. over time, but not the tools that are intended to flag undetected concerns.

Also, with the tools that are based on self-report, most are unclear whether the person is to answer them based on how they function with their accommodations (medication, learned strategies, loved ones who are aware and support appropriately, accommodations in place at work or school) or how they would function without these. If we fill them out based on current functioning, we create a medical record showing that a person with an ongoing disability has no functional impairment. This creates problems. If we fill them out based on how the person would function with no intervention, we create a medical record that someone is functioning poorly and has unmet needs. This also creates problems.

If you work somewhere that has no way to indicate that you deferred a screening for a valid clinical reason, or which returns metrics that the provider or facility are out of compliance for not administering a tool, this is not patient-centered and is poor practice. Aside from the clinical reasons I discussed, any person should be able to decline any procedure without any context of pressure or resentment around this. Aside from rare true imminent risk situations, health care and social services participation should be no different from going to the hairdresser or auto mechanic in terms of how the professional explains the pros and cons of something, the customer decides what they would like, and that's the end of it. Insurance sometimes complicates this, but dealing with the insurance companies is something we as providers have chosen to take on, and should not be passing on to the patient. 

Massachusetts has a sudden secret policy for rejecting sex marker changes for trans minors

UPDATE December 24: Victory! 

Several of the senators and representatives I contacted who cosponsored the initial bill met with DPH regarding their "policy" of not following the law as passed. DPH has now amended their website and affidavit to make it clear that only one parent signature is required. Families who previously received rejections are now receiving e-mails that their amendments will be processed promptly. 

Original post:

As anyone who is paying attention should know, trans folks are being urged to get all of their paperwork correct and matching before the incoming administration. However, families I work with are having one hell of a time getting amended birth certificates for trans minors in Massachusetts. 

Here is the information on how to request an amendment to a birth certificate, from the Registry of Vital Records and Statistics. The website states "A parent or guardian must complete this form if the record change is for a minor."

The affidavit itself is here.

Screenshot of part of the affidavit, showing one line for signature of parent/guardian

Note that it has one line for the signature of one parent/guardian, and it requests the name and signature of parent/guardian in the singular.

The relevant Massachusetts General Law is here, and states:

(1) A person who is 18 years of age or older, an emancipated minor or the parent or guardian of a person who is a minor may request a change in the sex designation on the person’s birth record to a sex designation including, but not limited to, “female”, “male” or “X”. An “X” designation may indicate that the person is another gender or an undesignated gender. A request for a change in the sex designation on a birth record shall be accompanied by an affidavit executed under the penalty of perjury by the person to whom the record relates or by the parent or guardian of the person if the person is a minor attesting that the request is to conform the person’s birth record to the person’s gender identity and is not made for any fraudulent purpose. No medical or healthcare related documentation, court order or proof of change of name shall be required by a town clerk or other official in connection with a request under this paragraph.

Nowhere, anywhere, does any of this state that both parents must sign the affidavit if the minor has two legal parents. For the record, I don't care if they did require that if it were how the law were passed; it actually makes sense. However, they don't state anywhere that it is required, or even suggested, and it appears to have been done suddenly, and secretly, and really appears to coincide with the recent passage of the law that allows amendment without requiring any medical documentation.

So what is happening in practice is that the Registry of Vital Records and Statistics is rejecting these affidavits and sending a letter stating the form must be signed by both parents. When the law is cited to the amendments supervisor, the supervisor states that yes, the law only requires one signature, but the Registry of Vital Records and Statistics legal department has decided to have a policy that requires both signatures. Also, they don't post their policies on their website, and instead just reject amendments from parents of trans kids.

Oh, and the Registry of Vital Records and Statistics will not allow the form to be resubmitted by e-mail, and will not pay for printing or postage for the resubmission. They are in the process of redoing their form, but for now, they expect families to be psychic and know that they need to provide something that is listed nowhere on their documents. I attempted to correspond with a supervisor there, who wouldn't acknowledge that this is a sudden secret policy that is not stated anywhere whatsoever:

Screenshot of e-mail from Christina Bocolos, Amendments Supervisor, stating, "I do recognize in the law it says one parent but policy request both parents. Is there a reason why the other parent cannot sign?"

Screenshot of e-mail from Christina Bocolos, Amendments Supervisor, stating, "With any amendment for children, we ask for both parents to sign off on an amendment. Our policies are not always posted on our website. The form was designed to go with the law but after further discussions with legal on the need for the second signature, we are getting the form changed to ask for both parents to sign. I understand the inconvenience, but this is what is required for the amendment."

I cannot post the other e-mails as they contain private information about people, but the supervisor states they do not pay for printing or postage and states that many forms are filled out "incorrectly" and have to be redone. 

I have had a lot of jobs in public health and state-contracted agencies, though none employed directly by the state. At all of these, if I failed to get something signed or filled out correctly because I did not adequately explain the policy to a family, I would be required to travel to the family immediately and get the form correctly filled out and signed. I would absolutely not be required to make a family pay for printing and postage due to my own error. What is with these state agencies just being allowed to do whatever they want? It's already ridiculous that it costs $82 for a correct birth certificate for a trans child to be safe, with no provision for a reduced fee for families receiving public assistance. The supervisor with whom I corresponded did not address any of this, just repeatedly stating that this was their policy, and also repeatedly referring to forms "that were not filled out correctly."

I cannot find anything addressing this in the guidance about changing documents from Massachusetts Transgender Political Coalition, Fenway Health, GLAD, or any other sources. I would urge all of these folks to publicize this widely so that no one else receives rejections and is unable to get their birth certificate before the inauguration. 

UPDATE 

December 17 11:39am: After posting this on social media, I have been contacted by a few attorneys with organizations specializing in public policy and discrimination issues. They have verified that they also believe I am interpreting the law correctly, and that they believe it is illegal for a state agency to have a policy that goes beyond the law. Advocacy is underway, though anyone who has additional expertise or suggestions is very much welcome to contact me as well and I can get you connected with the group of us working on this. 

December 19 2:27pm: We have some legislators meeting with DPH. Fenway and MTPC are updating their information to let people know this is happening so they can make an informed decision whether to comply with being asked for information beyond what the law requires in order to not risk having their amendment rejected. 

NCTSN has a number of free NBCC/LMHC CEUs

It requires creation of an account to see very much, but there are dozens of self-study free CEUs at their website here. Reminder that for Massachusetts LMHCs, we can obtain up to half (15) of our CEUs via asynchronous methods; at least 15 are required to be live online or live in-person trainings.

EDIT 11/01/24: I did one on working with young children in the foster care system. It was pretty awful -- completely lacking in any competence regarding the biases of the system, provided a case example with absolutely no mention of culture, referred to parents of a reunifying child as "birth parents," and was clearly not remotely informed by formerly adopted or fostered adults. It was also based on a model in which a local CPS agency had contracted with an agency to provide highly qualified clinicians for all of a family's visitation and extensive therapeutic work with child/family and foster providers. Which, great, but not applicable to nearly all families involved in the system who don't have such a thing available. I'm going to try one of the trainings that isn't CPS-specific and see if it is any better. 

Disclaimer: My only affiliation with this organization is having served on a regional advisory board of theirs in the past that had nothing to do with CEUs. I post free/low-cost LMHC CEUs when I come across them, as one of many efforts to decolonize mental health practice.

Free and low-cost online subclinical services for minors

I have begun creating this directory. Please feel free to add more resources, and please share in relevant spaces. 

From the intro: This is intended to be a listing of affordable online subclinical services serving those under 18. The intention here is to provide resources for families whose child's needs are not currently at the level of requiring medical therapies (or who have financial difficulty in accessing these), but are higher than requiring no formal support. 

Resources should focus on those provided by folks with professional degrees or connection to a mainstream clinical or social services organization, as the intention here is that families are able to assure schools and pediatricians that their child is receiving appropriate services. 

While the owner of this resource places high value on lived experience and community-based healing over "evidence-based practices,"* resources here should be free of blatant pseudoscientific approaches and must be trauma-informed, antiracist, queer/transgender-inclusive, neurodiversity-affirming, disability-positive, fat-positive, and so forth. Religious resources may be included, provided they are truly inclusive, including of those who express skepticism toward their faith background or may be looking to leave it. No ABA providers may be included, unless they publicly and consistently identify as someone who has left the field due to its problematic nature. 

*Research is important, and I constantly seek it out and cite it – or cite that no research has been done that adequately takes into account the intersections at play in the situation at hand. The majority of research, particularly that which is used in recommending and funding treatment approaches, reflects ableism and cultural bias. We absolutely should be looking at well-designed studies that are done or advised by people of the same demographics as those being studied. "Evidence-based practice" literature usually isn't this. 

Financial disclosure: One of my own LGBTQ+/neurodivergent youth spaces is included. I do make money off of this, though you can see based on the prices that this was not my primary goal in creating the space.