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Notice of Privacy Practices and Client Rights, January 2021 And Informed Consent 

THIS NOTICE DESCRIBES HOW MEDICAL/MENTAL HEALTH INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU MAY ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY. Only information in accordance with state and federal laws and the ethics of the counseling profession will be released upon request. “Use and disclosure of protected health information for the purposes of providing services. Providing treatment services, collecting payment and conducting healthcare operations are necessary activities for quality care. State and federal laws allow us to use and disclose your health information for these purposes.”
TREATMENT Use and disclose health information to:
▪ Provide, manage or coordinate care
▪ Consultants
▪ Referral sources
PAYMENT Use and disclose health information to:
▪ Process claims and collect fees
HEALTHCARE OPERATIONS Use and disclose health information for:
▪ Review of treatment procedures
▪ Review of business activities
▪ Certification
▪ Staff training
▪ Compliance and licensing activities
▪ Mandated reporting
▪ Emergencies
▪ Criminal damage
▪ Appointment scheduling
▪ Treatment alternatives
▪ As required by law
▪ Written authorization to release records to others
▪ Right to revoke release in writing
▪ Revocation is not valid to the extent that you have acted in reliance on such previous authorization 


Psychotherapy is not easily described in general statements. It varies depending on the personalities of the therapist and client, and the particular problems you bring forward. There are many different methods I may use to deal with the problems that you hope to address. Psychotherapy is not like a medical doctor visit. Instead, it calls for a very active effort on your part. In order for the therapy to be most successful, you will have to work on things we talk about both during our sessions and at home.


My religious orientation is Christian and I use biblical principles outlined in the Bible as a foundation for teaching life principles. However, we may or may not discuss God, scripture or spirituality in our sessions.


Psychotherapy can have benefits and risks. Since therapy often involves discussing unpleasant aspects of your life, you may experience uncomfortable feelings like sadness, guilt, anger, frustration, loneliness, and helplessness. On the other hand, psychotherapy has also been shown to have benefits for people who go through it. Therapy often leads to better relationships, solutions to specific problems, and significant reductions in feelings of distress. But there are no guarantees of what you will experience.


Our first sessions will involve an evaluation of your needs. By the end of the evaluation, I will be able to offer you some first impressions of what our work will include and a treatment plan to follow, if you decide to continue with therapy. You should evaluate this information along with your own opinions of whether you feel comfortable working with me. Therapy involves a large commitment of time, money, and energy, so you should be very careful about the therapist you select. If you have questions about my procedures, we should discuss them whenever they arise. 


I usually schedule one 50-minute session (one appointment hour of 50 minutes duration) per week. Once an appointment hour is scheduled, you will be expected to pay for it unless you provide 48 hours [days] advance notice of cancellation [unless we both agree that you were unable to attend due to circumstances beyond your control]. [If it is possible, I will try to find another time to reschedule the appointment.] 



My hourly rate is $150. I offer several pricing options for counseling packages and for group counseling, which is contingent upon the size and longevity of the group. 



The laws and standards of my profession require that I keep treatment records. You are entitled to receive a copy of your records, or I can prepare a summary for you instead. Because these are professional records, they can be misinterpreted and/or upsetting to untrained readers. If you wish to see your records, I recommend that you review them in my presence so that we can discuss the contents. [I am sometimes willing to conduct a review meeting without charge.] 



If you are under eighteen years of age, please be aware that the law provides your parents the right to examine your treatment records. I discourage parents from using this privilege unless there is a high risk that you will seriously harm yourself or someone else. Before giving them any information, I will discuss the matter with you, if possible, and do my best to handle any objections you may have with what I am prepared to discuss.


In general, law protects the privacy of all communications between a client and therapist, and I can only release information about our work to others with your written permission. But there are a few exceptions.


There are some situations in which I am legally obligated to take action to protect others from harm, even if I have to reveal some information about a client’s treatment. For example, if I believe that a child [elderly person, or disabled person] is being abused, I must [may be required to] file a report with the appropriate state agency.


If I believe that a client is threatening serious bodily harm to another, I am [may be] required to take protective actions. These actions may include notifying the potential victim, contacting the police, or seeking hospitalization for the client. If the client threatens to harm himself/herself, I may be obligated to seek hospitalization for him/her or to contact family members or others who can help provide protection. 

These situations have rarely occurred in my practice. If a similar situation occurs, I will make every effort to fully discuss it with you before taking any action.


I may occasionally find it helpful to consult other professionals about a case. During a consultation, I make every effort to avoid revealing the identity of my client. The consultant is also legally bound to keep the information confidential. If you don’t object, I will not tell you about these consultations unless I feel that it is important to our work together.


While this written summary of exceptions to confidentiality should prove helpful in informing you about potential problems, it is important that we discuss any questions or concerns that you may have at our next meeting. I will be happy to discuss these issues with you if you need specific advice, but formal legal advice may be needed because the laws governing confidentiality are quite complex, and I am not an attorney. [If you request, I will provide you with relevant portions or summaries of the state laws regarding these issues.]


Your signature below indicates that you have read the information in this document and agree to abide by its terms during our professional relationship. 

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