Common use of CONTACTING ME Clause in Contracts

CONTACTING ME. I use a telephone voice mail that will confidentially record your messages. If you need to contact me between sessions due to an emergency and would like me to call you back, please request that in your message. I check messages fairly regularly during the weekday and somewhat less often on weekends. Please talk to me if you have questions or concerns about these arrangements. I will make every effort to return your call the same day or early the following business day. If we have difficulty reaching each other, please leave times when I can reach you and alternative phone numbers. Lengthy phone conversations will be prorated (see Billing and Payments above). If you are experiencing a clinical emergency and cannot reach me or wait for me to return your call, you should call your family physician, psychiatrist, Crisis Clinic of the Peninsulas at (000) 000-0000. (a 24- hour crisis hot-line with counselors that can help insure your safety or talk to you about the crisis) or go to the nearest hospital. If I know that I will be out of town for an extended period of time, I will have another counselor designated to be on-call for me in crisis situations. If you feel that you might potentially utilize these crises options, please let me know during our session so that we can develop a comprehensive crisis plan. If you choose to contact me via email, text message or fax, be aware that these modalities are not appropriate in crisis situations, or are they to be used as a substitute for therapy. Also, be aware that although your confidentiality is of prime concern to me, I cannot guarantee confidentiality, when using electronic correspondence due to the nature of those types of communication. Email: Email communication is possible only after discussion with your counselor. Clients are cautioned that e- mail is not a confidential means of communication and is not the appropriate way to communicate confidential, urgent, or emergency information. A signed electronic communication informed consent must be on file. This is to ensure that you are aware of the risks to your confidentiality with the use of email, texting and other forms of electronic communication. Email replies greater than 8 lines will be prorated by the time spent reading and replying to your message. Professional Records Both law and the standards of my profession require that I keep Protected Health Information about you in your Clinical Record. Except in situations where you are a danger to yourself (or others) or where others have supplied information to me confidentially, you may examine and/or receive a summary of your Clinical Record. This request must be made in writing. Because they are professional records, they can be misinterpreted or upsetting to lay readers. If you wish to see your records, I will require that you review them in my presence so that we can discuss the contents. If you would like me to send your information to another medical or mental health professional, I am happy to do so at your request. Patient Rights Please see attached HIPAA Notice Form for a listing of your rights. Minors & Parents In the state of Washington Providers may provide outpatient treatment to a minor 13 to 17 years of age without the consent of a parent. The minor is the client and has the right to confidentiality. The client’s authorization is required to release information to third parties. If the minor has consented to treatment on their own (i.e. without their parent’s involvement) the treatment Provider will disclose information to the parent without the client’s consent, only to the extent that it serves the best interest of the client or is required or permitted by law. If consent to treatment is given by either parent for a minor, then both parents may be allowed access to the minor’s records. Confidentiality I take the matter of confidentiality quite seriously. The confidentiality of all communications between a client and a counselor is protected by law and I can only release information about our work together with others if you sign a written Authorization form that meets certain legal requirements imposed by HIPAA. There are some situations that require only your advance consent. Your signature on this Agreement provides consent for the following activities:  Occasionally, I may consult with other professionals about strategies or resources that may benefit you. I make every effort to avoid revealing the identity of my clients and often change identifying information in my description. The consultant is, of course, also legally bound to keep the information confidential. Unless you object, I will not tell you about these consultations unless I feel it is important to our work together. I will note all consultations in your Clinical Record.  You should be aware that a secretary at my office might have access to your name or phone number if I need to reach you. All mental health professionals are bound by the same rules of confidentiality. All therapists and staff at this location have agreed not to release any client information unless specifically instructed to by the appropriate mental health professional. There are some situations where I am permitted or required to disclose information without either your consent or authorization:  In most legal situations, you have the right to decline permission for me to release any information about your treatment. In some circumstances (like child custody proceedings and situations where your emotional health is relevant), a judge may require my testimony if he/she determines that resolution of the issues demands it. As I am not trained in testifying in legal situations, I may not be the right therapist to help you in a court case. Please notify me if you have reason to believe that our work together might be relevant in current or future legal proceedings.  Legally, I am required to take action to protect others from harm even if it means revealing some information about a client’s treatment. If I believe that a child, elderly person, or disabled person is being abused, I am mandated by law to report this to the appropriate state agency.  If I believe that a client is threatening serious bodily harm to another, I am required to take protective actions that may include: notifying the potential victim, calling the police, or seeking appropriate hospitalization. If a client threatens to harm him/herself, I am required to seek hospitalization for the client or to contact family members or others who can help provide protection.  If a government agency is requesting the information for health oversight activities, I may be required to provide the requested information. Examples include: public health authorities, coroner or medical examiner, military/veteran’s affairs agencies, law enforcement, or for national security purposes.  If a client files a complaint or lawsuit against me, I may disclose relevant information regarding that client to defend myself.  Worker’s compensation cases may require records to be submitted to the Chairman of the Worker’s Compensation Board. These situations are quite rare in my practice. If such a situation should occur, I will make every effort to discuss with you my intended actions prior to making any disclosures. I have read and understand the above information. My signature indicates that I agree to abide by the terms of this Agreement during our professional relationship. Signature Date Print your name here Signature of parent or legal guardian Date

CONTACTING ME. I use a telephone voice mail that Due to the nature of the work, texting is the easiest method to contact. Every effort will confidentially record your messages. If you need to contact me between sessions due to an emergency and would like me to call you back, please request that in your message. I check messages fairly regularly during the weekday and somewhat less often on weekends. Please talk to me if you have questions or concerns about these arrangements. I will make every effort be made to return your call within 12 hours, with the same day or early the following business day. If we have difficulty reaching each other, please leave times when I can reach you exception of weekends and alternative phone numbers. Lengthy phone conversations will be prorated (see Billing and Payments above)holidays. If you are experiencing a clinical emergency unable to reach me and feel that you cannot reach me or wait for me to return your call, you should call contact your family physician, psychiatrist, Crisis Clinic of the Peninsulas at (000) 000-0000. (a 24- hour crisis hot-line with counselors that can help insure your safety physician or talk to you about the crisis) or go to the nearest hospitalemergency room. If I know that I we will be out of town unavailable for an extended period of time, we will let you know 2-12 months in advance unless it is an emergency. PROFESSIONAL FEES Sessions are between $240-$350 per session (and this fee goes up $20 for individual and $50 for couples each January) depending on the type of session. In addition to weekly appointments, I charge the cost of your session fee for other professional services, although I will have another counselor designated to be on-call break down the hourly cost if we worked for me in crisis situationsperiods of less than one hour. Other services include report writing, telephone conversations lasting longer than 5 minutes, consulting with other professionals at your request, preparation of records or treatment summaries, and time spent performing any other service you may request. If you become involved in legal proceedings that require my participation in the form of paperwork my feel is $500 per hour. I do not participate in any court matters. BILLING AND PAYMENTS You will be expected to pay weekly or monthly for sessions depending on what is agreed. Payment schedules for other professional services will be agreed to when requested. If your account has not been paid for more than 60 days and arrangements for payment have not been agreed upon, I maintain the option of using legal means to secure the payment. This may involve hiring a collection agency, which will require the disclosure of otherwise confidential information. In most collection situations, the only information released regarding a patient’s treatment is his/her name, the nature of services provided, and the amount due. If such legal action is necessary, the costs will be included in the claim. INSURANCE REIMBURSEMENT If you have a health insurance policy, it will usually provide some coverage for mental health treatment. I will fill out forms and provide you with whatever assistance I can in helping you receive the benefits to which you are entitled; however, you (not your insurance company) are responsible for full payment of fees. It is important that you might potentially utilize these crises options, please let me know during our session so determine exactly what mental health services your insurance policy covers. You should carefully read the section in your insurance coverage booklet that we can develop a comprehensive crisis plandescribes mental health services. If you choose to contact me via emailhave questions about the coverage, text message or fax, be aware that these modalities are not appropriate in crisis situations, or are they to be used as a substitute for therapy. Also, be aware that although call your confidentiality is of prime concern to me, I cannot guarantee confidentiality, when using electronic correspondence due to the nature of those types of communication. Email: Email communication is possible only after discussion with your counselor. Clients are cautioned that e- mail is not a confidential means of communication and is not the appropriate way to communicate confidential, urgent, or emergency information. A signed electronic communication informed consent must be on file. This is to ensure that you are aware of the risks to your confidentiality with the use of email, texting and other forms of electronic communication. Email replies greater than 8 lines will be prorated by the time spent reading and replying to your message. Professional Records Both law and the standards of my profession require that I keep Protected Health Information about you in your Clinical Record. Except in situations where you are a danger to yourself (or others) or where others have supplied information to me confidentially, you may examine and/or receive a summary of your Clinical Record. This request must be made in writing. Because they are professional records, they can be misinterpreted or upsetting to lay readers. If you wish to see your records, I will require that you review them in my presence so that we can discuss the contents. If you would like me to send your information to another medical or mental health professional, I am happy to do so at your request. Patient Rights Please see attached HIPAA Notice Form for a listing of your rights. Minors & Parents In the state of Washington Providers may provide outpatient treatment to a minor 13 to 17 years of age without the consent of a parent. The minor is the client and has the right to confidentiality. The client’s authorization is required to release information to third parties. If the minor has consented to treatment on their own (i.e. without their parent’s involvement) the treatment Provider will disclose information to the parent without the client’s consent, only to the extent that it serves the best interest of the client or is required or permitted by law. If consent to treatment is given by either parent for a minor, then both parents may be allowed access to the minor’s records. Confidentiality I take the matter of confidentiality quite seriously. The confidentiality of all communications between a client and a counselor is protected by law and I can only release information about our work together with others if you sign a written Authorization form that meets certain legal requirements imposed by HIPAA. There are some situations that require only your advance consent. Your signature on this Agreement provides consent for the following activities:  Occasionally, I may consult with other professionals about strategies or resources that may benefit you. I make every effort to avoid revealing the identity of my clients and often change identifying information in my description. The consultant is, of course, also legally bound to keep the information confidential. Unless you object, I will not tell you about these consultations unless I feel it is important to our work together. I will note all consultations in your Clinical Record.  You should be aware that a secretary at my office might have access to your name or phone number if I need to reach you. All mental health professionals are bound by the same rules of confidentiality. All therapists and staff at this location have agreed not to release any client information unless specifically instructed to by the appropriate mental health professional. There are some situations where I am permitted or required to disclose information without either your consent or authorization:  In most legal situations, you have the right to decline permission for me to release any information about your treatment. In some circumstances (like child custody proceedings and situations where your emotional health is relevant), a judge may require my testimony if he/she determines that resolution of the issues demands it. As I am not trained in testifying in legal situations, I may not be the right therapist to help you in a court case. Please notify me if you have reason to believe that our work together might be relevant in current or future legal proceedings.  Legally, I am required to take action to protect others from harm even if it means revealing some information about a client’s treatment. If I believe that a child, elderly person, or disabled person is being abused, I am mandated by law to report this to the appropriate state agency.  If I believe that a client is threatening serious bodily harm to another, I am required to take protective actions that may include: notifying the potential victim, calling the police, or seeking appropriate hospitalization. If a client threatens to harm him/herself, I am required to seek hospitalization for the client or to contact family members or others who can help provide protection.  If a government agency is requesting the information for health oversight activities, I may be required to provide the requested information. Examples include: public health authorities, coroner or medical examiner, military/veteran’s affairs agencies, law enforcement, or for national security purposes.  If a client files a complaint or lawsuit against me, I may disclose relevant information regarding that client to defend myself.  Worker’s compensation cases may require records to be submitted to the Chairman of the Worker’s Compensation Board. These situations are quite rare in my practice. If such a situation should occur, I will make every effort to discuss with you my intended actions prior to making any disclosures. I have read and understand the above information. My signature indicates that I agree to abide by the terms of this Agreement during our professional relationship. Signature Date Print your name here Signature of parent or legal guardian Dateplan administrator.

CONTACTING ME. I use a telephone voice mail that will confidentially record your messages. If you need would like to contact me between sessions due to an emergency and would like by phone, I can be reached on my cell phone. My patient schedule may preclude me to call from answering my phone immediately, but you back, please request that in your may leave a confidential voicemail message. I check messages fairly regularly during the weekday and somewhat less often on weekends. Please talk to me if you have questions or concerns about these arrangements. I will make every effort to promptly return your call the same day or early the following business daycall. Response times are likely to be longer on weekends and holidays. If we have difficulty reaching each otheryou are difficult to reach, please leave inform me of times when I can reach you and alternative phone numbers. Lengthy phone conversations will be prorated (see Billing and Payments above)available. If I will be unavailable for an extended time, I will provide you with the name of a colleague to contact, should you find it necessary. If you are experiencing a clinical emergency and cannot reach me or wait for me to return your callan emergency, you should call your family physician, psychiatrist, Crisis Clinic of the Peninsulas at (000) 000-0000. (a 24- hour crisis hot-line with counselors that can help insure your safety or talk to you about the crisis) 911 or go directly to the nearest hospitalemergency room. If I know that I will be out of town for an extended period of time, I will have another counselor designated to be on-call for me in crisis situations. If you feel that you might potentially utilize these crises options, please let me know during our session so that we can develop a comprehensive crisis plan. If you choose to You may also contact me via by email. Please be aware, text message or faxhowever, be aware that these modalities are not appropriate in crisis situations, or are they to be used as a substitute for therapy. Also, be aware that although your confidentiality is of prime concern to me, I cannot guarantee confidentiality, when using electronic correspondence due to the nature of those types of communication. Email: Email communication is possible only after discussion with your counselor. Clients are cautioned that e- mail email is not a confidential means secure form of communication and is not the appropriate way to communicate confidential, urgent, or emergency information. A signed electronic communication informed consent must be on file. This is to ensure that you are aware of the risks to your confidentiality with cannot be assured. I recommend limiting email use to scheduling and basic logistics. LIMITS ON CONFIDENTIALITY The law protects the use of email, texting and other forms of electronic communication. Email replies greater than 8 lines will be prorated by the time spent reading and replying to your message. Professional Records Both law and the standards of my profession require that I keep Protected Health Information about you in your Clinical Record. Except in situations where you are a danger to yourself (or others) or where others have supplied information to me confidentially, you may examine and/or receive a summary of your Clinical Record. This request must be made in writing. Because they are professional records, they can be misinterpreted or upsetting to lay readers. If you wish to see your records, I will require that you review them in my presence so that we can discuss the contents. If you would like me to send your information to another medical or mental health professional, I am happy to do so at your request. Patient Rights Please see attached HIPAA Notice Form for a listing of your rights. Minors & Parents In the state of Washington Providers may provide outpatient treatment to a minor 13 to 17 years of age without the consent of a parent. The minor is the client and has the right to confidentiality. The client’s authorization is required to release information to third parties. If the minor has consented to treatment on their own (i.e. without their parent’s involvement) the treatment Provider will disclose information to the parent without the client’s consent, only to the extent that it serves the best interest of the client or is required or permitted by law. If consent to treatment is given by either parent for a minor, then both parents may be allowed access to the minor’s records. Confidentiality I take the matter of confidentiality quite seriously. The confidentiality privacy of all communications between a client patient and a counselor is protected by law and psychologist. In most situations, I can only release information about our work together with your treatment to others if you sign a written Authorization authorization form that meets certain legal requirements imposed by HIPAAHIPAA and/or Maryland law. There are some situations that require only your advance consent. Your signature on this Agreement provides consent for However, in the following activitiessituations, no authorization is required:  Occasionally, - I may occasionally find it helpful to consult with other health and mental health professionals about strategies or resources that may benefit youa case. During a consultation, I make every effort to avoid revealing the identity of my clients and often change identifying information in my descriptionpatient. The consultant is, of course, These other professionals are also legally bound to keep the information confidential. Unless you object, I will not only tell you about these consultations unless if I feel that it is important to our work together. I All consultations will note all consultations be noted in your Clinical RecordRecord (which is called PHI in my Notice of Psychologist’s Privacy Policies and Practices).  You should be aware that a secretary at my office might have access - Disclosures required by health insurers or to your name or phone number if I need to reach youcollect overdue fees, discussed elsewhere in this agreement. All mental health professionals - If you are bound by the same rules of confidentiality. All therapists and staff at this location have agreed not to release any client information unless specifically instructed to by the appropriate mental health professional. There are some situations where I am permitted or required to disclose information without either your consent or authorization:  In most legal situations, you have the right to decline permission for me to release any information about your treatment. In some circumstances (like child custody proceedings and situations where your emotional health is relevant), a judge may require my testimony if he/she determines that resolution of the issues demands it. As I am not trained in testifying in legal situations, I may not be the right therapist to help you involved in a court caseproceeding and a request is made for information concerning your diagnosis and treatment, such information is protected by the psychologist-patient privilege law. Please notify me if you have reason to believe that our work together might be relevant in current I cannot provide any information without your written authorization or future legal proceedings.  Legally, I am required to take action to protect others from harm even if it means revealing some information about a client’s treatmentcourt order. If I believe that you are involved in or contemplating litigation, consult with your attorney to determine whether a child, elderly person, or disabled person is being abused, I am mandated by law court would be likely to report this order me to the appropriate state agencydisclose information.  If I believe that a client is threatening serious bodily harm to another, I am required to take protective actions that may include: notifying the potential victim, calling the police, or seeking appropriate hospitalization. If a client threatens to harm him/herself, I am required to seek hospitalization for the client or to contact family members or others who can help provide protection.  - If a government agency is requesting the information for health oversight activities, I may be required to provide the requested informationit for them. Examples include: public health authorities, coroner or medical examiner, military/veteran’s affairs agencies, law enforcement, or for national security purposes.  - If a client patient files a complaint or lawsuit against me, I may state law permits me to disclose relevant information regarding that client patient in order to defend myself.  WorkerThere are some situations in which I am legally obligated to take actions I believe are necessary to protect others from harm and in which I may have to reveal some information about a patient’s compensation cases may require records to be submitted to the Chairman of the Worker’s Compensation Boardtreatment. These situations are quite rare unusual in my practice, but they include: - If I have reason to suspect that a child or vulnerable adult has been subjected to abuse or neglect, or that vulnerable adult has been subjected to self-neglect or exploitation, the law requires that I file a report with the appropriate government agency, usually the local Department of Social Services. Once such a report is filed, I may be required to provide additional information. - If I know that a patient has a propensity for violence and the patient indicates that he/she has the intention to inflict imminent physical injury upon a specified victim(s), I may be required to take protective actions. These include establishing and undertaking a treatment plan targeted to eliminate the possibility that the patient will carry out the threat, seeking hospitalization of the patient, and/or informing the potential victim or the police about the threat. - If I believe that there is an imminent risk that a patient will engage in potentially life-threatening behaviors or that immediate disclosure is required to provide for the patient’s emergency health care needs, I may be required to take appropriate protective actions, including hospitalization and/or notifying family members or others who can protect the patient. If such a situation should occurarises, I will make every effort to fully discuss it with you before taking any action, and I will limit the disclosure to what is necessary. While this written summary of exceptions to confidentiality aims to inform you about potential problems, it is important that we discuss any questions or concerns you may have now or in the future. The laws governing confidentiality can be quite complex, and in situations where specific guidance is required, formal legal advice may be needed. PROFESSIONAL RECORDS The laws and standards of my profession require that I keep Protected Health Information about you in your Clinical Record. You may examine or receive a copy of your Clinical Record if you request it in writing. In unusual circumstances in which disclosure is reasonably likely to endanger the life or physical safety of you or another person, I may refuse your request. In those situations, you have a right to a summary and to have your record sent to another mental health provider. Because these are professional records, they can be misinterpreted and/or upsetting to untrained readers. For this reason, I recommend you initially review them in my presence, or have them forwarded to another mental health professional so you can discuss the contents. In most circumstances, the State of Maryland permits a copying fee and certain other expenses. If I refuse your request for access to your records, you have a right of review, which I will discuss with you upon your request. PATIENT RIGHTS HIPAA provides you with several new or expanded rights with regard to your clinical Record and disclosures of PHI. These rights include: requesting that I amend your record; requesting restrictions on what information from your Clinical Record is disclosed to others; requesting an accounting of most disclosures of PHI that you have neither consented to nor authorized; determining the location to which PHI disclosures are sent; having any complaints you make about my intended actions prior policies and procedures recorded in my records; and the right to making any disclosuresa paper copy of this agreement, the attached Notice form, and my privacy policies and procedures. I have read am happy to discuss these rights with you. MINORS AND PARENTS It is important for patients under the age of 18 years of age who are not emancipated, and understand their parents, to be aware that the above law may allow parents to examine their child’s treatment records. However, because privacy in psychotherapy is very important, particularly with teenagers, I usually ask parents to respect the child’s privacy and allow for the therapist and minor to keep elements of our interactions in confidence, though not any related to danger to the child (see Limits on Confidentiality). On the other hand, because parental involvement in therapy is essential to successful treatment, I am always willing to share with parents general information about the progress of treatment and their child’s attendance at scheduled sessions. Parents may also request an oral summary of their child’s treatment when it is complete. Before giving parents any information. My signature indicates that , I agree will discuss the matter with the child, if possible, and do my best to abide by the terms of this Agreement during our professional relationship. Signature Date Print your name here Signature of parent or legal guardian Datehandle any objections he/she may have.

CONTACTING ME. I use a telephone voice mail that will confidentially record your messages. If you need would like to contact me between sessions due to an emergency and would like by phone, I can be reached at 000-000-0000. My patient schedule may preclude me to call from answering my phone immediately, but you back, please request that in your may leave a confidential voicemail message. I check messages fairly regularly during the weekday and somewhat less often on weekends. Please talk to me if you have questions or concerns about these arrangements. I will make every effort to promptly return your call the same day or early the following business daycall. Response times are likely to be longer on weekends and holidays. If we have difficulty reaching each otheryou are difficult to reach, please leave inform me of times when I can reach you and alternative phone numbers. Lengthy phone conversations will be prorated (see Billing and Payments above)available. Please note that I do not communicate by text. If I will be unavailable for an extended time, I will provide you with the name of a colleague to contact, should you find it necessary. If you are experiencing a clinical emergency and cannot reach me or wait for me to return your callan emergency, you should call your family physician, psychiatrist, Crisis Clinic of the Peninsulas at (000) 000-0000. (a 24- hour crisis hot-line with counselors that can help insure your safety or talk to you about the crisis) 911 or go directly to the nearest hospitalemergency room. If I know that I will be out of town for an extended period of time, I will have another counselor designated to be on-call for me in crisis situations. If you feel that you might potentially utilize these crises options, please let me know during our session so that we can develop a comprehensive crisis plan. If you choose to You may also contact me via by email. Please be aware, text message or faxhowever, be aware that these modalities are not appropriate in crisis situations, or are they to be used as a substitute for therapy. Also, be aware that although your confidentiality is of prime concern to me, I cannot guarantee confidentiality, when using electronic correspondence due to the nature of those types of communication. Email: Email communication is possible only after discussion with your counselor. Clients are cautioned that e- mail email is not a confidential means secure form of communication and is not the appropriate way to communicate confidential, urgent, or emergency information. A signed electronic communication informed consent must be on file. This is to ensure that you are aware of the risks to your confidentiality with cannot be assured. I recommend limiting email use to scheduling and basic logistics. LIMITS ON CONFIDENTIALITY The law protects the use of email, texting and other forms of electronic communication. Email replies greater than 8 lines will be prorated by the time spent reading and replying to your message. Professional Records Both law and the standards of my profession require that I keep Protected Health Information about you in your Clinical Record. Except in situations where you are a danger to yourself (or others) or where others have supplied information to me confidentially, you may examine and/or receive a summary of your Clinical Record. This request must be made in writing. Because they are professional records, they can be misinterpreted or upsetting to lay readers. If you wish to see your records, I will require that you review them in my presence so that we can discuss the contents. If you would like me to send your information to another medical or mental health professional, I am happy to do so at your request. Patient Rights Please see attached HIPAA Notice Form for a listing of your rights. Minors & Parents In the state of Washington Providers may provide outpatient treatment to a minor 13 to 17 years of age without the consent of a parent. The minor is the client and has the right to confidentiality. The client’s authorization is required to release information to third parties. If the minor has consented to treatment on their own (i.e. without their parent’s involvement) the treatment Provider will disclose information to the parent without the client’s consent, only to the extent that it serves the best interest of the client or is required or permitted by law. If consent to treatment is given by either parent for a minor, then both parents may be allowed access to the minor’s records. Confidentiality I take the matter of confidentiality quite seriously. The confidentiality privacy of all communications between a client patient and a counselor is protected by law and psychologist. In most situations, I can only release information about our work together with your treatment to others if you sign a written Authorization authorization form that meets certain legal requirements imposed by HIPAAHIPAA and/or Maryland law. There are some situations that require only your advance consent. Your signature on this Agreement provides consent for However, in the following activitiessituations, no authorization is required:  Occasionally, - I may occasionally find it helpful to consult with other health and mental health professionals about strategies or resources that may benefit youa case. During a consultation, I make every effort to avoid revealing the identity of my clients and often change identifying information in my descriptionpatient. The consultant is, of course, These other professionals are also legally bound to keep the information confidential. Unless you object, I will not only tell you about these consultations unless if I feel that it is important to our work together. I All consultations will note all consultations be noted in your Clinical RecordRecord (which is called PHI in my Notice of Psychologist’s Privacy Policies and Practices).  You should be aware that a secretary at my office might have access - Disclosures required by health insurers or to your name or phone number if I need to reach youcollect overdue fees, discussed elsewhere in this agreement. All mental health professionals - If you are bound by the same rules of confidentiality. All therapists and staff at this location have agreed not to release any client information unless specifically instructed to by the appropriate mental health professional. There are some situations where I am permitted or required to disclose information without either your consent or authorization:  In most legal situations, you have the right to decline permission for me to release any information about your treatment. In some circumstances (like child custody proceedings and situations where your emotional health is relevant), a judge may require my testimony if he/she determines that resolution of the issues demands it. As I am not trained in testifying in legal situations, I may not be the right therapist to help you involved in a court caseproceeding and a request is made for information concerning your diagnosis and treatment, such information is protected by the psychologist-patient privilege law. Please notify me if you have reason to believe that our work together might be relevant in current I cannot provide any information without your written authorization or future legal proceedings.  Legally, I am required to take action to protect others from harm even if it means revealing some information about a client’s treatmentcourt order. If I believe that you are involved in or contemplating litigation, consult with your attorney to determine whether a child, elderly person, or disabled person is being abused, I am mandated by law court would be likely to report this order me to the appropriate state agencydisclose information.  If I believe that a client is threatening serious bodily harm to another, I am required to take protective actions that may include: notifying the potential victim, calling the police, or seeking appropriate hospitalization. If a client threatens to harm him/herself, I am required to seek hospitalization for the client or to contact family members or others who can help provide protection.  - If a government agency is requesting the information for health oversight activities, I may be required to provide the requested informationit for them. Examples include: public health authorities, coroner or medical examiner, military/veteran’s affairs agencies, law enforcement, or for national security purposes.  - If a client patient files a complaint or lawsuit against me, I may state law permits me to disclose relevant information regarding that client patient in order to defend myself.  WorkerThere are some situations in which I am legally obligated to take actions I believe are necessary to protect others from harm and in which I may have to reveal some information about a patient’s compensation cases may require records to be submitted to the Chairman of the Worker’s Compensation Boardtreatment. These situations are quite rare unusual in my practice, but they include: - If I have reason to suspect that a child or vulnerable adult has been subjected to abuse or neglect, or that vulnerable adult has been subjected to self-neglect or exploitation, the law requires that I file a report with the appropriate government agency, usually the local Department of Social Services. Once such a report is filed, I may be required to provide additional information. - If I know that a patient has a propensity for violence and the patient indicates that he/she has the intention to inflict imminent physical injury upon a specified victim(s), I may be required to take protective actions. These include establishing and undertaking a treatment plan targeted to eliminate the possibility that the patient will carry out the threat, seeking hospitalization of the patient, and/or informing the potential victim or the police about the threat. - If I believe that there is an imminent risk that a patient will engage in potentially life-threatening behaviors or that immediate disclosure is required to provide for the patient’s emergency health care needs, I may be required to take appropriate protective actions, including hospitalization and/or notifying family members or others who can protect the patient. If such a situation should occurarises, I will make every effort to fully discuss it with you before taking any action, and I will limit the disclosure to what is necessary. While this written summary of exceptions to confidentiality aims to inform you about potential problems, it is important that we discuss any questions or concerns you may have now or in the future. The laws governing confidentiality can be quite complex, and in situations where specific guidance is required, formal legal advice may be needed. PROFESSIONAL RECORDS The laws and standards of my profession require that I keep Protected Health Information about you in your Clinical Record. You may examine or receive a copy of your Clinical Record if you request it in writing. In unusual circumstances in which disclosure is reasonably likely to endanger the life or physical safety of you or another person, I may refuse your request. In those situations, you have a right to a summary and to have your record sent to another mental health provider. Because these are professional records, they can be misinterpreted and/or upsetting to untrained readers. For this reason, I recommend you initially review them in my presence, or have them forwarded to another mental health professional so you can discuss the contents. In most circumstances, the State of Maryland permits a copying fee and certain other expenses. If I refuse your request for access to your records, you have a right of review, which I will discuss with you upon your request. PATIENT RIGHTS HIPAA provides you with several new or expanded rights with regard to your clinical Record and disclosures of PHI. These rights include: requesting that I amend your record; requesting restrictions on what information from your Clinical Record is disclosed to others; requesting an accounting of most disclosures of PHI that you have neither consented to nor authorized; determining the location to which PHI disclosures are sent; having any complaints you make about my intended actions prior policies and procedures recorded in my records; and the right to making any disclosuresa paper copy of this agreement, the attached Notice form, and my privacy policies and procedures. I have read am happy to discuss these rights with you. MINORS AND PARENTS It is important for patients under the age of 18 years of age who are not emancipated, and understand their parents, to be aware that the above law may allow parents to examine their child’s treatment records. However, because privacy in psychotherapy is very important, particularly with teenagers, I usually ask parents to respect the child’s privacy and allow for the therapist and minor to keep elements of our interactions in confidence, though not any related to danger to the child (see Limits on Confidentiality). On the other hand, because parental involvement in therapy is essential to successful treatment, I am always willing to share with parents general information about the progress of treatment and their child’s attendance at scheduled sessions. Parents may also request an oral summary of their child’s treatment when it is complete. Before giving parents any information. My signature indicates that , I agree will discuss the matter with the child, if possible, and do my best to abide by the terms of this Agreement during our professional relationship. Signature Date Print your name here Signature of parent or legal guardian Datehandle any objections he/she may have.

CONTACTING ME. If you choose to communicate with me by email, you are advised to limit your messages to logistical matters such as scheduling appointments and I use a telephone will respond to you accordingly. However, communicating with me by email is not recommended because emailing is not secure and confidentiality may be breached. Also, my response time by email is likely to be slower. When I am not immediately available by phone my voice mail that will confidentially record your take messages. If you need to contact me between sessions due to an emergency and would like me to call you back, please request that in your message. I check messages fairly regularly during the weekday and somewhat less often on weekends. Please talk to me if you have questions or concerns about these arrangements. I will make every effort to return your call on the same day or early the following business dayyou make it, except for evenings, weekends, holidays and vacations. If we have difficulty reaching each otherIn case of a clinical emergency, please leave times when I can reach if you do not hear back from me promptly, and alternative phone numbers. Lengthy phone conversations will be prorated (see Billing and Payments above). If you feel you are experiencing facing a clinical emergency and cannot reach me or wait for me to return your calllife-threatening situation, you should always call your family physician, psychiatrist, Crisis Clinic of the Peninsulas at (000) 000-0000. (a 24- hour crisis hot-line with counselors that can help insure your safety or talk to you about the crisis) 911 or go to a nearby hospital emergency department. FEES Therapy sessions generally run about 45 minutes, leaving me the nearest hospital. If I know that I will be out of town for an extended period of time, I will have another counselor designated to be on-call for me in crisis situations. If you feel that you might potentially utilize these crises options, please let me know during our session so that we can develop a comprehensive crisis plan. If you choose to contact me via email, text message or fax, be aware that these modalities are not appropriate in crisis situations, or are they to be used as a substitute for therapy. Also, be aware that although your confidentiality is of prime concern to me, I cannot guarantee confidentiality, when using electronic correspondence due to the nature of those types of communication. Email: Email communication is possible only after discussion with your counselor. Clients are cautioned that e- mail is not a confidential means of communication and is not the appropriate way to communicate confidential, urgent, or emergency information. A signed electronic communication informed consent must be on file. This is to ensure that you are aware remainder of the risks appointment hour to your confidentiality with the use of email, texting complete paperwork and other forms of electronic communication. Email replies greater than 8 lines will be prorated by the time spent reading and replying to your message. Professional Records Both law and the standards of my profession require that I keep Protected Health Information about you in your Clinical Record. Except in situations where you are a danger to yourself (or others) or where others have supplied information to me confidentially, you may examine and/or receive a summary of your Clinical Record. This request must be made in writing. Because they are professional records, they can be misinterpreted or upsetting to lay readers. If you wish to see your records, I will require that you review them in my presence so that we can discuss the contents. If you would like me to send your information to another medical or mental health professional, I am happy to do so at your request. Patient Rights Please see attached HIPAA Notice Form for a listing of your rights. Minors & Parents In the state of Washington Providers may provide outpatient treatment to a minor 13 to 17 years of age without the consent of a parent. The minor is the client and has the right to confidentiality. The client’s authorization is required to release information to third parties. If the minor has consented to treatment on their own (i.e. without their parent’s involvement) the treatment Provider will disclose information to the parent without the client’s consent, only to the extent that it serves the best interest of the client or is required or permitted by law. If consent to treatment is given by either parent for a minor, then both parents may be allowed access to the minor’s records. Confidentiality I take the matter of confidentiality quite seriously. The confidentiality of all communications between a client and a counselor is protected by law and I can only release information about our work together with others if you sign a written Authorization form that meets certain legal requirements imposed by HIPAA. There are some situations that require only your advance consent. Your signature on this Agreement provides consent for the following activities:  Occasionally, I may consult with other professionals about strategies or resources that may benefit you. I make every effort to avoid revealing the identity of my clients and often change identifying information in my description. The consultant is, of course, also legally bound to keep the information confidential. Unless you object, I will not tell you about these consultations unless I feel it is important to any necessary phone calls regarding our work together. My standard hourly fee for psychological services is $140 for each visit, unless you request that your fee be set according to a sliding scale, based on factors such as your family income and the number of people supported by this income. Please note that if you are using insurance your co-payment and the payments I will note all consultations receive from your insurance company are determined by your insurance plan and may be different than the fees set out in your Clinical Recordthis agreement.  You should be aware that a secretary at Besides weekly appointments, I charge my office might have access to your name or phone number standard hourly fee for other professional services you may need, though I break down the hourly cost if I need work for periods of less than one hour. Other services include report writing, phone conversations lasting longer than 5 minutes, consultations with other professionals with your permission, preparation of records or treatment summaries, and the time spent performing any other service you may request of me. If you become involved in legal proceedings that require my participation, you will be expected to reach you. All mental health professionals are bound by the same rules pay for all of confidentiality. All therapists my professional time and staff at this location have agreed not to release any client information unless specifically instructed to by the appropriate mental health professional. There are some situations where transportation costs, even if I am permitted called to testify by another party. Because of the difficulty of legal involvement, I charge $300 an hour for my professional time spent in consultations with attorneys, report writing, preparation and attendance at any legal proceeding and any other duties I perform relating to such legal matters. BILLING AND PAYMENTS You will be expected to pay for each session by cash or required check at the time it is held. Unless we agree otherwise or unless you have insurance coverage that requires another arrangement, fees not paid at the time of the visit will be subject to a late penalty fee of $10. Accounts not paid within 30 days will be subject to additional late penalty fees of $10/month. If your account has not been paid within 60 days and arrangements for payment have not been agreed upon, I have the option of using legal means to secure the payment. This may involve hiring a collection agency or going through small claims court which will require me to disclose information without either your consent or authorization:  otherwise confidential information. In most legal collection situations, you have the right to decline permission for me to only information I release any information about your treatment. In some circumstances (like child custody proceedings and situations where your emotional health is relevant), a judge may require my testimony if he/she determines that resolution of the issues demands it. As I am not trained in testifying in legal situations, I may not be the right therapist to help you in a court case. Please notify me if you have reason to believe that our work together might be relevant in current or future legal proceedings.  Legally, I am required to take action to protect others from harm even if it means revealing some information about regarding a client’s treatment. If I believe that a childtreatment is his or her name, elderly personthe nature of services provided, or disabled person is being abused, I am mandated by law to report this to and the appropriate state agency.  If I believe that a client is threatening serious bodily harm to another, I am required to take protective actions that may include: notifying the potential victim, calling the police, or seeking appropriate hospitalization. If a client threatens to harm him/herself, I am required to seek hospitalization for the client or to contact family members or others who can help provide protection.  If a government agency is requesting the information for health oversight activities, I may be required to provide the requested information. Examples include: public health authorities, coroner or medical examiner, military/veteran’s affairs agencies, law enforcement, or for national security purposes.  If a client files a complaint or lawsuit against me, I may disclose relevant information regarding that client to defend myself.  Worker’s compensation cases may require records to be submitted to the Chairman of the Worker’s Compensation Board. These situations are quite rare in my practiceamount due. If such a situation should occurlegal action is necessary, I its costs will make every effort be included in the claim. CANCELLED/MISSED APPOINTMENTS Once an appointment hour is scheduled, you will be expected to discuss with pay for it unless you my intended actions prior provide at least 24 hours notice of cancellation. Insurance companies do not provide reimbursement for cancelled sessions. Missed appointments are charged at the full session rate. Appointments cancelled or rescheduled within 24 hours are billed at half the hourly fee. HIPAA Notice of Psychologists’ Policies and Practices to making any disclosuresProtect the Privacy of Your Health Information THIS NOTICE DESCRIBES HOW PSYCHOLOGICAL AND MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. I have read and understand the above information. My signature indicates that I agree to abide by the terms of this Agreement during our professional relationship. Signature Date Print your name here Signature of parent or legal guardian DatePLEASE REVIEW IT CAREFULLY.

CONTACTING ME. I use a During workdays, my telephone is answered by my office manager or voice mail that will confidentially record your messages. If you need to contact me between sessions due to an emergency and would like me to call you back, please request that in your message. I check messages fairly regularly during the weekday and somewhat less often on weekends. Please talk to me if you have questions or concerns about these arrangementsmonitor frequently. I will make every effort to return your call within 24 hours, with the same day exception of weekends and holidays. During weekends or early holidays, I will return your call on the following next business day. If we have difficulty reaching each otheryou are difficult to reach, please leave inform me of some times when I can reach you and alternative phone numbers. Lengthy phone conversations will be prorated (see Billing and Payments above)available. If you are experiencing a clinical emergency and cannot unable to reach me or and feel that you can’t wait for me to return your call, you should call contact your family physician, psychiatrist, Crisis Clinic of the Peninsulas at (000) 000-0000. (a 24- hour crisis hot-line with counselors that can help insure your safety or talk to you about the crisis) or go to the nearest hospitalemergency room, or dial 9-1-1. If I know that I will be out of town unavailable for an extended period of time, I will have another counselor designated to be on-call for me in crisis situations. If provide you feel that you might potentially utilize these crises options, please let me know during our session so that we can develop a comprehensive crisis plan. If you choose to contact me via email, text message or fax, be aware that these modalities are not appropriate in crisis situations, or are they to be used as a substitute for therapy. Also, be aware that although your confidentiality is of prime concern to me, I cannot guarantee confidentiality, when using electronic correspondence due to the nature of those types of communication. Email: Email communication is possible only after discussion with your counselor. Clients are cautioned that e- mail is not a confidential means of communication and is not the appropriate way to communicate confidential, urgent, or emergency information. A signed electronic communication informed consent must be on file. This is to ensure that you are aware of the risks to your confidentiality with the use of email, texting and other forms of electronic communication. Email replies greater than 8 lines will be prorated by the time spent reading and replying to your message. Professional Records Both law and the standards of my profession require that I keep Protected Health Information about you in your Clinical Record. Except in situations where you are a danger to yourself (or others) or where others have supplied information to me confidentially, you may examine and/or receive a summary of your Clinical Record. This request must be made in writing. Because they are professional records, they can be misinterpreted or upsetting to lay readers. If you wish to see your records, I will require that you review them in my presence so that we can discuss the contents. If you would like me to send your information to another medical or mental health professional, I am happy to do so at your request. Patient Rights Please see attached HIPAA Notice Form for a listing of your rights. Minors & Parents In the state of Washington Providers may provide outpatient treatment to a minor 13 to 17 years of age without the consent name of a parentcolleague to contact, if necessary. LIMITS ON CONFIDENTIALITY The minor is law protects the client and has the right to confidentiality. The client’s authorization is required to release information to third parties. If the minor has consented to treatment on their own (i.e. without their parent’s involvement) the treatment Provider will disclose information to the parent without the client’s consent, only to the extent that it serves the best interest of the client or is required or permitted by law. If consent to treatment is given by either parent for a minor, then both parents may be allowed access to the minor’s records. Confidentiality I take the matter of confidentiality quite seriously. The confidentiality privacy of all communications between a client patient and a counselor is protected by law and psychologist. In most situations, I can only release information about our work together with your treatment to others if you sign a written Authorization form that meets certain legal requirements imposed by HIPAA. There are some other situations that require only your that you provide written, advance consent. Your signature on this Agreement provides consent for the following those activities, as follows:  Occasionally, I may occasionally find it helpful to consult with other health and mental health professionals about strategies or resources that may benefit youa case. During a consultation, I make every effort to avoid revealing the identity of my clients and often change identifying information in my descriptionpatient. The consultant is, of course, other professionals are also legally bound to keep the information confidential. Unless If you don’t object, I will not tell you about these consultations unless I feel that it is important to our work together. I will note all consultations in your Clinical RecordRecord (which is called “PHI” in my Notice of Psychologist’s Policies and Practices to Protect the Privacy of Your Health Information).  Disclosures required by health insurers or to collect overdue fees are discussed elsewhere in this Agreement. The laws governing confidentiality can be quite complex, and I am not an attorney. In situations where specific advice is required, formal legal advice may be needed. PROFESSIONAL RECORDS You should be aware that, pursuant to HIPAA, I keep Protected Health Information about you in two sets of professional records. One set constitutes your Clinical Record. It includes information about your reasons for seeking therapy, a description of the ways in which your problem impacts on your life, your diagnosis, the goals that we set for treatment, your progress towards those goals, your medical and social history, your treatment history, any past treatment records that I receive from other providers, reports of any professional consultations, your billing records, and any reports that have been sent to anyone, including reports to your insurance carrier. Except in unusual circumstances that involve danger to yourself and others or where information has been supplied to me confidentially by others, you may examine and/or receive a secretary at my office might have copy of your Clinical Record, if you request it in writing. I believe that trust is the cornerstone of a positive therapeutic relationship. Reading the Clinical Record can sometimes lead to unnecessary misunderstandings that can undermine the therapeutic process. Therefore, I strongly discourage the direct releast of notes to an individual in active treatment. I will gladly forward your Clinical Record to another clinician or legal representative. If I refuse your request for access to your name or phone number if I need to reach you. All mental health professionals are bound by the same rules of confidentiality. All therapists and staff at this location have agreed not to release any client information unless specifically instructed to by the appropriate mental health professional. There are some situations where I am permitted or required to disclose information without either your consent or authorization:  In most legal situationsrecords, you have the a right to decline permission for me to release any information about your treatment. In some circumstances (like child custody proceedings and situations where your emotional health is relevant)of review, a judge may require my testimony if he/she determines that resolution of the issues demands it. As I am not trained in testifying in legal situations, I may not be the right therapist to help you in a court case. Please notify me if you have reason to believe that our work together might be relevant in current or future legal proceedings.  Legally, I am required to take action to protect others from harm even if it means revealing some information about a client’s treatment. If I believe that a child, elderly person, or disabled person is being abused, I am mandated by law to report this to the appropriate state agency.  If I believe that a client is threatening serious bodily harm to another, I am required to take protective actions that may include: notifying the potential victim, calling the police, or seeking appropriate hospitalization. If a client threatens to harm him/herself, I am required to seek hospitalization for the client or to contact family members or others who can help provide protection.  If a government agency is requesting the information for health oversight activities, I may be required to provide the requested information. Examples include: public health authorities, coroner or medical examiner, military/veteran’s affairs agencies, law enforcement, or for national security purposes.  If a client files a complaint or lawsuit against me, I may disclose relevant information regarding that client to defend myself.  Worker’s compensation cases may require records to be submitted to the Chairman of the Worker’s Compensation Board. These situations are quite rare in my practice. If such a situation should occur, which I will make every effort to discuss with you upon request. In addition, I also keep a set of Psychotherapy Notes. These Notes are for my intended actions prior own use and are designed to making assist me in providing you with the best treatment. While the contents of Psychotherapy Notes vary from client to client, they can include the contents of our conversations, my analysis of those conversations, and how they impact on your therapy. They also contain particularly sensitive information that you may reveal to me that is not required to be included in your Clinical Record. They can also include information from others provided to me confidentially. These Psychotherapy Notes are kept separate from your Clinical Record. Your Psychotherapy Notes are not available to you and cannot be sent to anyone else, including insurance companies without your written, signed Authorization. Insurance companies cannot require your authorization as a condition of coverage nor penalize you in any disclosures. I have read and understand the above information. My signature indicates that I agree way for your refusal to abide by the terms of this Agreement during our professional relationship. Signature Date Print your name here Signature of parent or legal guardian Dateprovide it.