Privacy Policy

Informed Consent for Psychotherapy 

I am pleased to have this opportunity to work with you. To foster a supportive therapeutic relationship, both therapists and clients hold rights and responsibilities. As a client in psychotherapy, you have certain rights and responsibilities that are important for you to know about. Informed consent refers to the concept that an individual should be well informed of the nature and anticipated course of therapy, fees, involvement of third parties, and limits to confidentiality, so he or she can make an informed decision about whether or not to enter the therapeutic relationship. Participation in psychotherapy is voluntary. By signing this document, you are agreeing to enter treatment; however, you can terminate at any time. Please read the material so your clinician can answer any questions you have during the first session. 

Psychotherapy Services 

Psychotherapy has many benefits, but also has some risks. Therapy is intended to generate change in your life, and this may cause discomfort or strong emotions at times. Discussing painful aspects of your life that caused you to seek treatment may cause you to experience uncomfortable feelings like sadness, guilt, anger, frustration, embarrassment, or helplessness.Therapy can also result in benefits such as greater self-awareness, self-acceptance, and self-esteem, the ability to make more self-affirming choices, better relationships, solutions to specific problems, and reductions in distressful feelings. There are no guarantees of what you will experience, and success can depend on how actively you participate in your own treatment.Therapy can also provoke feelings of affection or anger toward your therapist. It’s helpful and part of your therapy to discuss these feelings with your clinician.Your initial contact with me will involve collecting important information about your health and mental health in order to get a better sense of who you are and what problems you are experiencing. During this time, you and I can both decide if you are a good match. If you feel that I cannot meet your needs, I will provide you with alternative recommendations. If you agree to continue therapy, you and I will collaborate to establish goals. I depend on your feedback to be the most effective therapist for you, and I invite you to raise questions about your progress and therapy termination at any point. I also appreciate it when clients tell us what they find helpful and what is ineffective.You and I will schedule weekly 45-minute sessions. However, based on the nature and severity of the presented problem, you and I may schedule more frequent appointments. 

Cancellation Policy 

I have a 48 hour cancellation policy. If you need to cancel a session less than 48 hours before an appointment, I will make every effort to reschedule with you. If we cannot find a mutual time, you will be charged your regular session fee. 

Contacting Your Clinician 

Unless you and I have made other arrangements, I use phone contact and e-mail only for scheduling, billing, or other logistical concerns. While I have a dedicated email address for my psychotherapy practice, I discourage the use of email to communicate about clinical matters because it is not a completely secure mode of communication, information may not be sent to the intended recipient, it may not always be the most efficient method of communication, and it is dependent on technology, which may not work at all times. I will not discuss clinical matters via email in order to respect your confidentiality. If you need to contact me between sessions, please email me. Please note, however, that phone calls and emails regarding the scheduling of appointments or for general advice will be returned to you during regular office hours of Monday through Friday. 

Emergencies 

While I do my best to respond to any urgent matters outside of your regular appointment time, I may not be available to immediately respond to emergency situations that you experience between sessions. If you are having a mental health crisis or emergency, contact your physician, call 911, a telephone crisis line, or go to the nearest emergency room and ask for the Mental Health Professional on call. I cannot meet with you unless you have scheduled an appointment in advance. 

My Qualifications

I have completed graduate and post-graduate training in clinical social work. I am fully licensed to provide clinical social work services in New York, New Jersey, and Minnesota. 

My Responsibilities to You 

I. Confidentiality 

As therapists, it is my ethical and legal responsibility to preserve confidentiality unless otherwise specified by law. You may provide written consent for me to share your personal health information with whomever you choose, and you can revoke that permission at any time. You are also protected under the provisions of the Federal Health Insurance Portability and Accountability Act (HIPAA). This law ensures the confidentiality of all electronic transmission of information about you. Whenever I transmit information about you electronically (for example, sending bills or faxing information), it will be done with special safeguards to ensure confidentiality. Please see the HIPAA notice for more information. If I consult about cases to improve treatment, I will always act so as to protect your privacy. I do not disclose the identity of my clients. I am legally bound to keep the information confidential. If you don’t object, I won’t tell you about these consultations unless I feel it is important in our work together. 

The following are legal exceptions to your right to confidentiality. I will inform you of any time when I think I will have to put these into effect, and will always disclose the least amount of information possible: 

1. I am legally required to take action to protect others from harm. For example, if a clinician has good reason to believe that a client is abusing or neglecting a child or vulnerable adult, or if the client gives them information about someone else who is doing this, the clinician must inform Child Protective Services within 48 hours and Adult Protective Services immediately. 

2. If I believe that a client is threatening serious bodily harm to another, I am required to take protective actions- including notifying the potential victim, contacting the police, or seeking hospitalization for the client. 

3. If I believe that a client is at high risk of suicide or serious self-harm, I may be obligated to seek hospitalization for them or to contact family members or others who can provide protection, In this situation, I would first explore options to guarantee the client’s safety before calling a crisis team. 

4. In most legal proceedings, you have the right to prevent your clinician from providing any information about your treatment. In some proceedings, however, such as those involving child custody or those in which your emotional condition is an important issue, a judge may order your clinician’s testimony. When the clinician is so ordered by the court, they are obligated to release information, but will make every effort to disclose the least amount of information possible. 

Please be aware that when communicating through phones, faxes, or e-mails, there is no guarantee of confidentiality. All e-mails are retained in the logs of your or our Internet service provider. While under normal circumstances no one looks at these logs, they are, in theory, available to be read by the system administrator(s) of the Internet service provider. 

If you are using insurance to pay for therapy, I will need to disclose information to the insurance company or other third party payer in order to bill and collect payment. Typically, I only disclose session date and length, procedure code, symptoms, diagnoses, and treatment methods. At times, third party payers request more detailed information. In this case, I will make every effort to review with you the information to be disclosed before releasing it. As with the situations above, I will always disclose the least amount of information possible. You must provide signed authorization before I can release this information to your insurance company. 

II. Tests, Reports, and Diagnoses 

Testing instruments are commonly used to gain a better understanding of the nature and severity of problems in order to provide adequate treatment intervention. Before utilizing a test, I will tell you the purpose of the test, how the results will be used, and limitations of the test. You have the right to make an informed decision about whether you want to participate in testing procedures. After taking the test, you have the right to receive an explanation of the results. 

Reports to third parties are either made because they are legally mandated or because your insurance company requires it for service reimbursement. If I make a report, I will inform you about who receives what information. I must get your written consent before releasing this information. 

If you use insurance to help pay for your therapy, I am normally required to give a diagnosis to the insurance company in order for you to be reimbursed. Diagnoses are technical terms that describe the nature and severity of your problems. Once a diagnosis is made, it will become a part of your permanent health record. I will inform you about any diagnoses recorded. 

III. Record-Keeping 

After each session, I will record what interventions happened in session, the topics discussed, and future treatment plans. I will maintain your records in a secure, protected location. You have the right to a copy of your records, or I can prepare a summary for you. Because they are professional records, they contain jargon that is specific to psychotherapy; this can be misinterpreted or upsetting to untrained readers. Thus, if you wish to see your records, I recommend that you review them with me so that I can answer your questions. 

IV. Clinician Absences 

I may need to cancel sessions in advance due to vacation, sick days, or other circumstances. I will tell you in advance of any absence. If you experience an emergency when I am out of town, please call 911. 

V. Insurance Policies 

I do not participate in any managed mental health care plans, nor am I on provider lists for any insurance companies. Therefore, I do not accept co-payments or insurance assignments as session payment for services rendered. Sometimes, I may be covered as “out-of-network” providers. You may request that I fill out the necessary forms for your insurance company and/or speak by phone to an insurance representative to gain authorization for your treatment. For out-of-network coverage, you would pay for sessions out of pocket and then be reimbursed directly by your insurance company. 

Notice of Privacy Practices

THIS NOTICE DESCRIBES HOW HEALTH INFORMATION MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY. 

I. MY PLEDGE REGARDING HEALTH INFORMATION: 

I understand that health information about you and your health care is personal. I am committed to protecting health information about you. I create a record of the care and services you receive from me. I need this record to provide you with quality care and to comply with certain legal requirements. This notice applies to all of the records of your care generated by this mental health care practice. This notice will tell you about the ways in which I may use and disclose health information about you. I also describe your rights to the health information I keep about you, and describe certain obligations I have regarding the use and disclosure of your health information. I am required by law to: 

• Make sure that protected health information (“PHI”) that identifies you is kept private. 

• Give you this notice of my legal duties and privacy practices with respect to health information. 

• Follow the terms of the notice that is currently in effect. 

• I can change the terms of this Notice, and such changes will apply to all information I have about you. The new Notice will be available upon request, in my office, and on my website. 

II. HOW I MAY USE AND DISCLOSE HEALTH INFORMATION ABOUT YOU: 

The following categories describe different ways that I use and disclose health information. For each category of uses or disclosures I will explain what I mean and try to give some examples. Not every use or disclosure in a category will be listed. However, all of the ways I am permitted to use and disclose information will fall within one of the categories. 

For Treatment Payment, or Health Care Operations: Federal privacy rules and regulations allow health care providers who have direct treatment relationship with the client to use or disclose the client’s personal health information without the client’s written authorization, to carry out the health care provider’s own treatment, payment or health care operations. I may also disclose your protected health information for the treatment activities of any health care provider. This too can be done without your written authorization. For example, if a clinician were to consult with another licensed health care provider about your condition, we would be permitted to use and disclose your person health information, which is otherwise confidential, in order to assist the clinician in diagnosis and treatment of your mental health condition. 

Disclosures for treatment purposes are not limited to the minimum necessary standard. Because therapists and other health care providers need access to the full record and/or full and complete information in order to provide quality care. The word “treatment” includes, among other things, the coordination and management of health care providers with a third party, consultations between health care providers and referrals of a patient for health care from one health care provider to another. 

Lawsuits and Disputes: If you are involved in a lawsuit, I may disclose health information in response to a court or administrative order. I may also disclose health information about your child in response to a subpoena, discovery request, or other lawful process by someone else involved in the dispute, but only if efforts have been made to tell you about the 

request or to obtain an order protecting the information requested. 

III. CERTAIN USES AND DISCLOSURES REQUIRE YOUR AUTHORIZATION: 

1. Psychotherapy Notes. I do keep “psychotherapy notes” as that term is defined in 45 CFR § 164.501, and any use or disclosure of such notes requires your Authorization unless the use or disclosure is: a. For my use in treating you. b. For my use in training or supervising mental health practitioners to help them improve their skills in group, joint, family, or individual counseling or therapy. c. For my use in defending myself in legal proceedings instituted by you. d. For use by the Secretary of Health and Human Services to investigate my compliance with HIPAA. e. Required by law and the use or disclosure is limited to the requirements of such law. f. Required by law for certain health oversight activities pertaining to the originator of the psychotherapy notes. g. Required by a coroner who is performing duties authorized by law. h. Required to help avert a serious threat to the health and safety of others. 

2. Marketing Purposes. As a psychotherapist, I will not use or disclose your PHI for marketing purposes. 

3. Sale of PHI. As a psychotherapist, I will not sell your PHI in the regular course of my business. 

IV. CERTAIN USES AND DISCLOSURES DO NOT REQUIRE YOUR AUTHORIZATION. Subject to certain limitations in the law, I can use and disclose your PHI without your Authorization for the following reasons: 

1. When disclosure is required by state or federal law, and the use or disclosure complies with and is limited to the relevant requirements of such law. 2. For public health activities, including reporting suspected child, elder, or dependent adult abuse, or preventing or reducing a serious threat to anyone’s health or safety. 3. For health oversight activities, including audits and investigations. 4. For judicial and administrative proceedings, including responding to a court or administrative order, although my preference is to obtain an Authorization from you before doing so. 5. For law enforcement purposes, including reporting crimes occurring on my premises. 6. To coroners or medical examiners, when such individuals are performing duties authorized by law. 7. For research purposes, including studying and comparing the mental health of patients who received one form of therapy versus those who received another form of therapy for the same condition. 8. Specialized government functions, including, ensuring the proper execution of military missions; protecting the President of the United States; conducting intelligence or counter-intelligence operations; or, helping to ensure the safety of those working within or housed in correctional institutions. 9. For workers' compensation purposes. Although my preference is to obtain an Authorization from you, I may provide your PHI in order to comply with workers' compensation laws. 10. Appointment reminders and health related benefits or services. I may use and disclose your PHI to contact you to remind you that you have an appointment with me. I may also use and disclose your PHI to tell you about treatment alternatives, or other health care services or benefits that I offer. 

V. CERTAIN USES AND DISCLOSURES REQUIRE YOU TO HAVE THE OPPORTUNITY TO OBJECT. 

1. Disclosures to family, friends, or others. I may provide your PHI to a family member, friend, or other person that you indicate is involved in your care or the payment for your health care, unless you object in whole or in part. The opportunity to consent may be obtained retroactively in emergency situations. 

VI. YOU HAVE THE FOLLOWING RIGHTS WITH RESPECT TO YOUR PHI: 

1. The Right to Request Limits on Uses and Disclosures of Your PHI. You have the right to ask me not to use or disclose certain PHI for treatment, payment, or health care operations purposes. I am not required to agree to your request, and I may say “no” if I believe it would affect your health care. 2. The Right to Request Restrictions for Out-of-Pocket Expenses Paid for In Full. You have the right to request restrictions on disclosures of your PHI to health plans for payment or health care operations purposes if the PHI pertains solely to a health care item or a health care service that you have paid for out-of-pocket in full. 3. The Right to Choose How I Send PHI to You. You have the right to ask me to contact you in a specific way (for example, home or office phone) or to send mail to a different address, and I will agree to all reasonable requests. 4. The Right to See and Get Copies of Your PHI. Other than “psychotherapy notes,” you have the right to get an electronic or paper copy of your medical record and other information that I have about you. I will provide you with a copy of your record, or a summary of it, if you agree to receive a summary, within 30 days of receiving your written request, and I may charge a reasonable, cost based fee for doing so. 5. The Right to Get a List of the Disclosures I Have Made. You have the right to request a list of instances in which I have disclosed your PHI for purposes other than treatment, payment, or health care operations, or for which you provided me with an Authorization. I will respond to your request for an accounting of disclosures within 60 days of receiving your request. The list I will give you will include disclosures made in the last six years unless you request a shorter time. I will provide the list to you at no charge, but if you make more than one request in the same year, I will charge you a reasonable cost based fee for each additional request. 6. The Right to Correct or Update Your PHI. If you believe that there is a mistake in your PHI, or that a piece of important information is missing from your PHI, you have the right to request that I correct the existing information or add the missing information. I may say “no” to your request, but I will tell you why in writing within 60 days of receiving your request. 7. The Right to Get a Paper or Electronic Copy of this Notice. You have the right get a paper copy of this Notice, and you have the right to get a copy of this notice by e-mail. And, even if you have agreed to receive this Notice via e-mail, you also have the right to request a paper copy of it. 

ACKNOWLEDGEMENT OF RECEIPT OF PRIVACY NOTICE 

Under the Health Insurance Portability and Accountability Act of 1996 (HIPAA), you have certain rights regarding the use and disclosure of your protected health information. By signing this document, you are acknowledging that you have received a copy of HIPPA Notice of Privacy Practices.