Common use of Limits of Confidentiality Clause in Contracts

Limits of Confidentiality. The law protects the privacy of all communications between a patient and a psychologist. In most situations, I can only release information about your treatment to others if you sign a written Authorization form that meets specific legal requirements imposed by state law and HIPAA. But there are some situations where I am permitted or required to disclose information without either your consent or authorization: • If a patient threatens to harm themself, I may be obligated to seek hospitalization for them or contact family members or others who can help provide protection. ▪ If a patient communicates a serious threat of physical violence against an identifiable victim, I must take protective actions, including notifying the potential victim and contacting the police. I may also seek hospitalization of the patient or contact others who can assist in protecting the victim. ▪ Disclosures may be required to health insurers or to collect overdue fees. • I occasionally find it helpful to consult other health and mental health professionals about a case. During a consultation, I make every effort to avoid revealing the identity of my patient. The other professionals are also legally bound to keep the information confidential. If you don’t object, I will not tell you about these consultations unless I feel it is essential to our work together. I will note all consultations in your Clinical Record. • I may be court-ordered to release treatment information and records in alleged criminal or civil liability cases. In addition, if a client files a complaint or lawsuit against me, I may disclose relevant information regarding that client to defend myself. • If a government agency requests the information for health oversight activities under their legal authority, I may be required to provide it. • If a patient files a worker’s compensation claim, I must, upon appropriate request, disclose information relevant to the claimant's condition to the worker’s compensation insurer. ▪ I am required by law to report any suspected child abuse, neglect, or sexual abuse to protect the child/children involved. ▪ I am obligated by law to report any suspected abuse, neglect, or sexual abuse of an older adult or dependent adult to protect the older adult or dependent adult involved. ▪ Please be aware that information shared with me will be disclosed to your partner or family if they participate in couples or family treatment. I will not agree to hold secrets on any one partner’s behalf. If you feel something should not be shared with your partner, please do not tell me your secret(s). At such times, it may be most appropriate for you to seek the support of an individual therapist who is independent of your couple’s treatment and who will consult with me regarding the broad issues and not the specifics of your secret(s). While this written summary of exceptions to confidentiality should prove helpful in informing you about potential problems, it is essential that we discuss any questions or concerns that you may have now or in the future. 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.

Limits of Confidentiality. The law protects the privacy of all communications between a patient and a psychologist. In most situations, I can only release information about your treatment to others if you sign a written Authorization consent form that meets specific certain legal requirements imposed by state law and HIPAAHIPAA and/or Maryland law. But there are some situations where I am permitted or required to disclose information without either your consent or authorizationHowever, in the following situations, no authorization is required: • If a patient threatens to harm themself, I may be obligated to seek hospitalization for them or contact family members or others who can help provide protection. ▪ If a patient communicates a serious threat of physical violence against an identifiable victim, I must take protective actions, including notifying the potential victim and contacting the police. I may also seek hospitalization of the patient or contact others who can assist in protecting the victim. ▪ Disclosures may be required to health insurers or to collect overdue fees. • I occasionally find it helpful to consult other health and mental health professionals about a case. During a consultation, I make every effort to avoid revealing the identity of my patient. The other professionals are 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 essential 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. If you are involved in a court proceeding and a request is made for information concerning your diagnosis and treatment, such information is protected by the psychologist-patient privilege law. I cannot provide any information without your written authorization, or a court order. If you are involved in or contemplating litigation, you should consult with your attorney to determine whether a court would be likely to order me to disclose information. If a government agency is requesting the information for health oversight activities, I may be court-ordered required to release treatment information and records in alleged criminal or civil liability casesprovide it for them. In addition, if If a client patient files a complaint or lawsuit against me, I may disclose relevant information regarding that client patient in order to defend myself. • There are some situations in which I am legally obligated to take actions, which I believe are necessary to attempt to protect others from harm and I may have to reveal some information about a patient’s treatment. These situations are unusual in my practice: If I have reason to believe that a child, adolescent, or vulnerable adult has been subjected to abuse or neglect, or that a vulnerable adult has been subjected to self-neglect, or exploitation, the law requires that I file a report with the appropriate government agency requests agency, usually the information for health oversight activities under their legal authoritylocal office of the Department of Social Services. Once such a report is filed, I may be required to provide itadditional information. • If I know that a patient files has a worker’s compensation claimpropensity for violence and the patient indicates that he/she has the intention to inflict imminent physical injury upon a specified victim(s), I mustmay be required to take protective actions. These actions may include establishing and undertaking a treatment plan that is calculated to eliminate the possibility that the patient will carry out the threat, upon appropriate request, disclose information relevant to seeking hospitalization of the claimant's condition to patient and/or informing the worker’s compensation insurerpotential victim or the police about the threat. ▪ If I am required by law to report any suspected child abuse, neglectbelieve that there is an imminent risk that a patient will inflict serious physical harm or death on him/herself, or sexual abuse 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 initiating hospitalizations and/or notifying family members or others who can protect the child/children involvedpatient. ▪ I am obligated by law to report any suspected abuseIf such a situation arises, neglect, or sexual abuse of an older adult or dependent adult to protect the older adult or dependent adult involved. ▪ Please be aware that information shared with me will be disclosed to your partner or family if they participate in couples or family treatment. I will not agree make every effort to hold secrets on fully discuss it with you before taking any one partner’s behalf. If you feel something should not be shared with your partner, please do not tell me your secret(s). At such times, it may be most appropriate for you action and I will limit my disclosure to seek the support of an individual therapist who what is independent of your couple’s treatment and who will consult with me regarding the broad issues and not the specifics of your secret(s)necessary. While this written summary of exceptions to confidentiality should prove helpful in informing you about potential problems, it is essential important that we discuss any questions or concerns that you may have have, now or in the future. 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 The laws and standards of the profession require that I keep Protected Health Information (PHI) about each client in their clinical record. In some circumstances, I may keep some information in two sets of professional records. One set is your clinical record. It includes information about your reasons for seeking therapy and how these and related issues impact on your life, your diagnosis, goals for treatment, progress towards the goals, your medical treatment and social history, past treatment records I receive from other providers, reports of professional consultations, billing records, and any reports to insurance carriers or others. You may choose, in writing, to examine and/or receive a copy of your clinical record. Because professional records can be misinterpreted it would be important to first review them together or with another mental health professional. In very unusual circumstances, such as a situation in which in my professional judgment disclosing information would endanger someone’s life, then clinical records would not be released. In those situations, the person would have a right to a summary and to have their record sent to another mental health provider. A copying fee of $.60 per page will be charged. There may be other associated costs for review of records. The other set I keep in some instances is a set of psychotherapy notes. These notes are for my own use and are designed to 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 conservations, 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. These psychotherapy notes are kept separate from your clinical record. While insurance companies can request and receive a copy of your clinical record, they cannot receive a copy of your psychotherapy notes without your signed, written authorization. Insurance companies cannot require your authorization as a condition of coverage nor penalize you in any way for your refusal. You may examine and/or receive a copy of your psychotherapy notes unless I determine that knowledge of the health care information would be injurious to your health. Patient Rights HIPAA provides you with expanded rights with regard to clinical records and disclosures of protected health information. These include requesting that I amend your record; requesting restrictions on what information from your clinical record is disclosed; requesting an accounting of disclosures; determining where protected information disclosures are sent; having any complaints you make about my policies recorded in your records; and the right to a paper copy of this agreement, my policies and procedures, and the attached HIPAA notice form. Minors & Parents Parents of clients 16 years of age who are not emancipated may be allowed by law to examine their child’s records. While privacy in psychotherapy is very important, particularly with teenager, parental involvement is also essential to successful treatment. Therefore, it is my policy when treating 16- to 18-year-olds to request that they agree to my sharing occasional general information about the progress of treatment with his/her parents. Unless I feel discussing disclosure prior to parental notification is not realistic, such as when the child is in danger or is a danger to someone else, I will discuss with the child, what I think is in their best interest to discuss with the parents and preferably both the child and I will talk with the parents together.

Limits of Confidentiality. The law protects the privacy of all communications between a patient and a psychologist. In most situations, I can only release information about your treatment to others if you sign a written Authorization consent form that meets specific certain legal requirements imposed by state law and HIPAAHIPAA and/or Maryland law. But there are some situations where I am permitted or required to disclose information without either your consent or authorizationHowever, in the following situations, no authorization is required: • If a patient threatens to harm themself, I may be obligated to seek hospitalization for them or contact family members or others who can help provide protection. ▪ If a patient communicates a serious threat of physical violence against an identifiable victim, I must take protective actions, including notifying the potential victim and contacting the police. I may also seek hospitalization of the patient or contact others who can assist in protecting the victim. ▪ Disclosures may be required to health insurers or to collect overdue fees. • I occasionally find it helpful to consult other health and mental health professionals about a case. During a consultation, I make every effort to avoid revealing the identity of my patient. The other professionals are 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 essential 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. If you are involved in a court proceeding and a request is made for information concerning your diagnosis and treatment, such information is protected by the psychologist-patient privilege law. I cannot provide any information without your written authorization, or a court order. If you are involved in or contemplating litigation, you should consult with your attorney to determine whether a court would be likely to order me to disclose information. If a government agency is requesting the information for health oversight activities, I may be court-ordered required to release treatment information and records in alleged criminal or civil liability casesprovide it for them. In addition, if If a client patient files a complaint or lawsuit against me, I may disclose relevant information regarding that client patient to defend myself. • There are some situations in which I am legally obligated to take actions, which I believe are necessary to attempt to protect others from harm and I may have to reveal some information about a patient’s treatment. These situations are unusual in my practice: If I have reason to believe that a child, adolescent, or vulnerable adult has been subjected to abuse or neglect, or that a vulnerable adult has been subjected to self-neglect, or exploitation, the law requires that I file a report with the appropriate government agency requests agency, usually the information for health oversight activities under their legal authoritylocal office of the Department of Social Services. Once such a report is filed, I may be required to provide itadditional information. • If I know that a patient files has a worker’s compensation claimpropensity for violence and the patient indicates that he/she has the intention to inflict imminent physical injury upon a specified victim(s), I mustmay be required to take protective actions. These actions may include establishing and undertaking a treatment plan that is calculated to eliminate the possibility that the patient will carry out the threat, upon appropriate request, disclose information relevant to seeking hospitalization of the claimant's condition to patient and/or informing the worker’s compensation insurerpotential victim or the police about the threat. ▪ If I am required by law to report any suspected child abuse, neglectbelieve that there is an imminent risk that a patient will inflict serious physical harm or death on him/herself, or sexual abuse 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 initiating hospitalizations and/or notifying family members or others who can protect the child/children involvedpatient. ▪ I am obligated by law to report any suspected abuseIf such a situation arises, neglect, or sexual abuse of an older adult or dependent adult to protect the older adult or dependent adult involved. ▪ Please be aware that information shared with me will be disclosed to your partner or family if they participate in couples or family treatment. I will not agree make every effort to hold secrets on fully discuss it with you before taking any one partner’s behalf. If you feel something should not be shared with your partner, please do not tell me your secret(s). At such times, it may be most appropriate for you action and I will limit my disclosure to seek the support of an individual therapist who what is independent of your couple’s treatment and who will consult with me regarding the broad issues and not the specifics of your secret(s)necessary. While this written summary of exceptions to confidentiality should prove helpful in informing you about potential problems, it is essential important that we discuss any questions or concerns that you may have have, now or in the future. 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 The laws and standards of the profession require that I keep Protected Health Information (PHI) about each client in their clinical record. In some circumstances, I may keep some information in two sets of professional records. One set is your clinical record. It includes information about your reasons for seeking therapy and how these and related issues impact on your life, your diagnosis, goals for treatment, progress towards the goals, your medical treatment and social history, past treatment records I receive from other providers, reports of professional consultations, billing records, and any reports to insurance carriers or others. You may choose, in writing, to examine and/or receive a copy of your clinical record. Because professional records can be misinterpreted it would be important to first review them together or with another mental health professional. In very unusual circumstances, such as a situation in which in my professional judgment disclosing information would endanger someone’s life, then clinical records would not be released. In those situations, the person would have a right to a summary and to have their record sent to another mental health provider. A copying fee of $.60 per page will be charged. There may be other associated costs for review of records. The other set I keep in some instances is a set of psychotherapy notes. These notes are for my own use and are designed to 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 conservations, 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. These psychotherapy notes are kept separate from your clinical record. While insurance companies can request and receive a copy of your clinical record, they cannot receive a copy of your psychotherapy notes without your signed, written authorization. Insurance companies cannot require your authorization as a condition of coverage nor penalize you in any way for your refusal. You may examine and/or receive a copy of your psychotherapy notes unless I determine that knowledge of the health care information would be injurious to your health. Patient Rights HIPAA provides you with expanded rights regarding clinical records and disclosures of protected health information. These include requesting that I amend your record; requesting restrictions on what information from your clinical record is disclosed; requesting an accounting of disclosures; determining where protected information disclosures are sent; having any complaints you make about my policies recorded in your records; and the right to a paper copy of this agreement, my policies and procedures, and the attached HIPAA notice form. Minors & Parents Parents of clients 16 years of age who are not emancipated may be allowed by law to examine their child’s records. While privacy in psychotherapy is very important, particularly with teenager, parental involvement is also essential to successful treatment. Therefore, it is my policy when treating 16- to 18-year-olds to request that they agree to my sharing occasional general information about the progress of treatment with his/her parents. Unless I feel discussing disclosure prior to parental notification is not realistic, such as when the child is in danger or is a danger to someone else, I will discuss with the child, what I think is in their best interest to discuss with the parents and preferably both the child and I will talk with the parents together.

Limits of Confidentiality. The law protects the privacy of all communications between a patient and a psychologistpsychologist or mental health counselor. In most situations, I we can only release information about your treatment to others if you sign a written Authorization form that meets specific certain legal requirements imposed by state law and and/or HIPAA. But But, there are some situations where I we am permitted or required to disclose information without either your consent or authorization: • If a patient threatens Authorization. We may find it helpful and that it be in your best interest to harm themselfconsult with your physician, I may be obligated psychiatrist or other professional to seek hospitalization for them or contact family members or others who can help provide protection. ▪ If a patient communicates a serious threat of physical violence against an identifiable victim, I must take protective actions, including notifying the potential victim and contacting the police. I may also seek hospitalization of the patient or contact others who can assist in protecting the victim. ▪ Disclosures may be required to health insurers or to collect overdue fees. • I coordinate your treatment.We occasionally find it helpful to consult other health and mental health professionals about a case. During a consultation, I we make every effort to avoid revealing the identity of my patient. client’s identity.The other professionals are also legally bound to keep the any information we share confidential. If Unless you don’t object, I we will not tell you about these consultations unless I we feel that it is essential important to our work together. I .We will note all consultations in your Clinical Record. • I We practice in a group setting with several mental health professionals and we employ administrative staff. In most cases, we share protected information among these individuals for both clinical supervision and administrative purposes, such as scheduling, billing and to ensure that all of our clients receive the highest possible quality of care. All of the mental health professionals are bound by the same rules of confidentiality. All staff members have been given training about protecting your privacy and have agreed not to release any information outside of the practice. Disclosures required by health insurers or to collect overdue fees are discussed below. If a client threatens to harm him or herself, we may be courtobligated to seek hospitalization for him or her, or to contact family members or others who can help provide protection. If you are involved in a court proceeding and a request is made for information about the professional services that we have provided you and/or the records thereof, such information is protected by psychotherapist-ordered client privilege law. We cannot provide any information without your (or your legally appointed representative’s) written authorization, a court order, or compulsory process (a subpoena)or discovery request from another party to release treatment the court proceeding where that party has given you proper notice (when required) and has stated valid legal grounds for obtaining PHI, and we do not have grounds for objecting under state law (or you have instructed me not to object). If you are involved in or contemplating litigation, you should consult with your attorney to determine whether a court would be likely to order me to disclose information. If a government agency is requesting the information and records in alleged criminal or civil liability cases. In additionfor health oversight activities pursuant to their legal authority, if we may be required to provide it for them If a client files a complaint or lawsuit against meus, I we may disclose relevant information regarding that client in order to defend myselfourself. • If a government agency requests the information for health oversight activities under their legal authority, I may be required to provide it. • If a patient client files a worker’s compensation claim, I we must, upon appropriate request, disclose information relevant to the claimant's condition condition, to the worker’s compensation insurer. ▪ I am There are some situations in which we are legally obligated to take actions, which we believe are necessary to attempt to protect others from harm and we may have to reveal some information about a client’s treatment.These situations are highly rare in our practice. If we have reasonable cause to suspect that a child under 18 is abused or neglected, the law requires that we file a report with the appropriate governmental agency, usually Department of Public Health and Human Services. Once such a report is filed, we may be required by law to report any suspected child provide other information. If we know or have reasonable cause to suspect that an older person or person with a developmental disability has been subjected to abuse, sexual abuse, neglect, or sexual abuse exploitation, the law requires that we file a report with the appropriate governmental agency, usually Department of Public Health and Human Services. Once such a report is filed, we may be required to provide additional information. If a client communicates an actual threat of immediate threat of physical violence by specific means against a clearly identified or reasonably identifiable victim, we may be required to disclose protected information in order to protect the child/children involved. ▪ I am obligated by law to report any suspected abusethreatened victim.These actions may include notifying the potential victim, neglectcontacting the police, or sexual abuse of an older adult or dependent adult to protect seeking hospitalization for the older adult or dependent adult involved. ▪ Please be aware that information shared with me will be disclosed to your partner or family if they participate in couples or family treatment. I will not agree to hold secrets on any one partner’s behalfclient. If such a situation arises, we will make every effort to fully discuss it with you feel something should not be shared with your partner, please do not tell me your secret(s). At such times, it may be most appropriate for you before taking any action and we will limit our disclosure to seek the support of an individual therapist who what is independent of your couple’s treatment and who will consult with me regarding the broad issues and not the specifics of your secret(s)necessary. While this written summary of exceptions to confidentiality should prove helpful in informing you about potential problems, it is essential important that we discuss any questions or concerns that you may have now or in the future. .The laws governing confidentiality can be quite complex, and I am not an attorney. In in situations where specific advice is required, formal legal advice may be needed. Professional Records You should be aware that, in accordance with HIPAA laws, we 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 we 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. In addition, we also keep a set of Psychotherapy Notes.These Notes are for our own personal use and are designed to assist us in providing you with the best treatment. While the contents of Psychotherapy Notes vary from client to client, they may include the contents of our conversations and our analysis of those conversations.They may contain particularly sensitive information that you may reveal that is not required to be included in your Clinical Record.These Psychotherapy Notes are kept separate from your Clinical Record.While insurance companies can request and receive a copy of your Clinical Record, they cannot receive a copy of your Psychotherapy Notes without your signed, written Authorization. Insurance companies cannot require your Authorization as a condition of coverage nor penalize you in any way for your xxxxxxx.Xxx may examine and/or receive a copy of both sets of records if you request it in writing, except for information provided by an individual (other than another health care provider) in confidence under circumstances in which confidentiality was appropriate and the access requested would be reasonably likely to reveal the source of the information. Because these are professional records, they can be misinterpreted and/or upsetting to untrained readers. For this reason, we recommend that you initially review them in your psychotherapist’s presence, or have them forwarded to another mental health professional so you can discuss the contents.We charge a copying fee not to exceed 50 cents per page, and an administrative fee that not to exceed $25 for searching and handling recorded health care information.We may withhold your records until the fees are paid.The exceptions to this policy are contained in the attached Notice Form. If we refuse your request for access to your records, you have a right of review (except for information provided in confidence by another individual other than another health care provider), which we will discuss with you upon request. Patient Rights HIPAA provides you with several new or expanded rights with regard to your Clinical Records and disclosures of protected health information.These rights include requesting that we amend your record; requesting restrictions on what information from your Clinical Records is disclosed to others; requesting an accounting of most disclosures of protected health information that you have neither consented to nor authorized; determining the location to which protected information disclosures are sent; having any complaints you make about our policies and procedures recorded in your records; and the right to a paper copy of this Agreement, the attached Notice form, and our privacy policies and procedures.We are happy to discuss any of these rights with you. Minors & Parents Patients under 18 years of age who are not emancipated from their parents should be aware that the law may allow parents to examine their child’s treatment records. Because privacy in psychotherapy is often crucial to successful progress, particularly with teenagers, it is sometimes our policy to request an agreement from parents that they consent to give up their access to their child’s records. If they agree, during treatment, we will provide them only with general information about the progress of the child’s treatment, and his/her attendance at scheduled sessions.We will also provide parents with a summary of their child’s treatment when it is complete. Any other communication will require the child’s Authorization, unless we feel that the child is in danger or is a danger to someone else, in which case, we will notify the parents of our concern. Before giving parents any information, we will discuss the matter with the client, if possible, and do our best to handle any objections he or she may have. Billing and Payments You are expected to pay for each session at the time it is held. If you have insurance, you must pay for your session in advance, with the exception of Blue Cross Blue Shield, Tricare, Medicare and Medicaid, in which case you are expected to pay you copayment and any deductible at the time of each session. Monthly bills are sent to notify you of any outstanding charges. In circumstances of financial hardship, we will be willing to negotiate a payment installment plan. If your account has not been paid for more than 60 days and arrangements for payment have not been agreed upon, we have the option of using legal means to secure the payment.This may involve a collection agency or going through small claims court which will require us to disclose otherwise confidential information. In most collection situations, the only information we release regarding a client’s treatment is his or her name, the nature of services provided, and the amount due. Insurance Reimbursement In order for us to set realistic treatment goals and priorities, it is important to evaluate what resources you have available to pay for your treatment. If you have a health insurance policy, it will usually provide some coverage for mental health treatment.We will fill out and submit insurance claims and provide you with whatever assistance we 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 very important that you find out exactly what mental health services your insurance policy covers.We advise you to carefully read the section in your insurance coverage booklet that describes mental health services. If you have questions about the coverage, call your plan administrator. Of course, we will provide you with whatever information we can based on our experience and will be happy to help you in understanding the information you receive from your insurance company. If it is necessary to clear confusion, we will be willing to call the company on your behalf. Due to the rising costs of health care, insurance benefits have increasingly become more complex. It is sometimes difficult to determine exactly how much mental health coverage is available. “Managed Health Care” plans such as HMOs and PPOs often require authorization before they provide reimbursement for mental health services. These plans are often limited to short-term treatment approaches designed to work out specific problems that interfere with a person’s usual level of functioning. It may be necessary to seek approval for more therapy after a certain number of sessions. While much can be accomplished in short-term therapy, many clients feel that they need more services after insurance benefits end. Your contract with your health insurance company requires that we provide it with information relevant to the services that we provide to you.We are required to provide a clinical diagnosis. Sometimes we are required to provide additional clinical information such as treatment plans or summaries, or copies of your entire Clinical Record. In such situations, we will inform you and make every effort to release only the minimum information about you that is necessary for the purpose requested.This information will become part of the insurance company files and will probably be stored in a computer.Though all insurance companies licensed in Montana claim to keep such information confidential and protect its privacy, we have no control over what they do with it once it is in their hands.We will provide you with a copy of any report we submit, if you request it. By signing this Agreement, you agree that we can provide requested information to your insurance carrier. Once we have all of the information about your insurance coverage, we will discuss what we can expect to accomplish with the benefits that are available and what will happen if they run out before you feel ready to end your sessions. It is important to remember that you always have the right to pay for our services yourself to avoid the problems described above. YOUR SIGNATURE BELOW INDICATES THAT YOU HAVE READ THIS AGREEMENT AND AGREE TO ITS TERMS AND ALSO SERVES AS AN ACKNOWLEDGEMENT THAT YOU HAVE RECEIVED THE HIPAA NOTICE FORM DESCRIBED ABOVE. Printed Name Signature Date

Limits of Confidentiality. The law protects the privacy of all communications between a patient client and a psychologist. In most situations, I can only release information about you and/or your child’s treatment to others if you sign a written Authorization form that meets specific legal requirements imposed by state law and HIPAAauthorization form. But there are some situations where However, in certain situations, I am permitted or required to disclose information without either your consent or authorization: • If a patient threatens to harm themself, I may be legally obligated to seek hospitalization for them or contact family members take actions in order to protect you and/or your child or others who can help provide protection. ▪ If a patient communicates a serious threat of physical violence against an identifiable victim, I must take protective actions, including notifying the potential victim and contacting the police. I may also seek hospitalization of the patient or contact others who can assist in protecting the victim. ▪ Disclosures may be required to health insurers or to collect overdue fees. • I occasionally find it helpful to consult other health and mental health professionals about a case. During a consultation, I make every effort to avoid revealing the identity of my patient. The other professionals are also legally bound to keep the information confidential. If you don’t object, I will not tell you about these consultations unless I feel it is essential to our work together. I will note all consultations in your Clinical Record. • I may be court-ordered to release treatment information and records in alleged criminal or civil liability cases. In addition, if a client files a complaint or lawsuit against me, I may disclose relevant information regarding that client to defend myselffrom harm. • If I have reasonable cause to believe a government child under the age of 18 has suffered abuse or neglect, I am legally mandated to make a report to the proper law enforcement agency requests or to the information for state department of social and health oversight activities under their legal authorityservices. Once such a report is filed, I may be required to provide itadditional information. • If I have reason to believe that a patient files a worker’s compensation claimvulnerable adult is being abandoned, abused, financially exploited or neglected, I mustam legally mandated to make a report to the proper law enforcement agency or to the state department of social and health services. Once such a report is filed, upon appropriate requestI may be required to provide additional information. • If I believe that you present a clear, imminent risk of serious harm to yourself, I may be required to disclose information relevant in order to take protective actions These actions may include contacting family members or others who can assist in protecting you, or seeking your hospitalization. • If you have made a specific threat of violence against another or if I believe that you present a clear, imminent risk of serious physical harm to another, I may be required to disclose information in order to take protective actions. These actions may include notifying the potential victim, contacting the police or seeking your hospitalization. Further, the law allows the release of confidential information without your authorization in the following situations: a) to a person who I believe is providing healthcare to my identified client, b) to any healthcare provider who I believe has previously provided my identified client healthcare to the claimant's condition extent necessary for me to provide healthcare to you and/or your child, unless you instruct me in writing not to make such disclosure, and finally c) to an immediate family member or any other individual with whom you have a close personal relationship if the worker’s compensation insurerdisclosure is appropriate within good professional practice, unless you instruct me in writing not to make the disclosure. ▪ If you are under the age of 18, I am required by law may have to report any suspected child abuse, neglect, share information with your legal guardian about what we discuss in therapy or sexual abuse to protect the child/children involved. ▪ I am obligated by law to report any suspected abuse, neglect, or sexual abuse of during an older adult or dependent adult to protect the older adult or dependent adult involved. ▪ Please be aware that information shared with me will be disclosed to your partner or family if they participate in couples or family treatmentevaluation. I will not agree act in your best interest when disclosing information to hold secrets on your legal guardian. If any one partner’s behalfof these situations arise, I will make every effort to fully discuss it with you before taking any action, and I will limit my disclosure to what is necessary. If you feel something should not be shared have any questions that I haven’t addressed either in this document or with your partneryou personally, please do not tell feel free to ask me your secret(sfor clarification at any time. I look forward to working with you. Agreement for Psychological Services Client’s Name: Date of Birth: The Health Insurance Portability and Accountability Act (HIPAA). At such times, it may be most appropriate requires that you sign this “Agreement for Psychological Services” and that I have provided you to seek with a copy of my “Notice of Information Practices.” This Policy further explains HIPAA and the support of an individual therapist who is independent protection of your couple’s treatment personal health information. Your signature represents an agreement between us. You can revoke this Agreement in writing at any time. I hereby acknowledge that I have received and who will consult with me regarding the broad issues and not the specifics of your secret(s). While this written summary of exceptions have been given an opportunity to confidentiality should prove helpful in informing you about potential problems, it is essential that we discuss any questions or concerns that you may have now or in the future. 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.read copies of:

Limits of Confidentiality. The law protects the privacy of all communications between a patient and a psychologist. In most situations, I can only release information about your treatment to others if you sign a written Authorization to Release Information form that meets specific certain legal requirements imposed by state law and HIPAA. But there There are some other situations where I am permitted or required to disclose information without either your that require only that you provide written, advance consent. Your signature on this Agreement provides consent or authorizationfor those activities, as follows: • ● If a patient threatens to harm themselfhimself/herself, I may be obligated to seek hospitalization for him/her, or to contact family members or others who can help provide protection. ● If I believe that a patient is threatening serious bodily harm to another, I am required to take protective actions. These actions may include notifying the potential victim, contacting the police, or seeking hospitalization for the patient. If the patient threatens to harm themselves, I may be obligated to seek hospitalization for them or to contact family members or others who can help provide protection. ▪ If a patient communicates a serious threat similar situation occurs in the course of physical violence against an identifiable victimour work together, I must take protective actions, including notifying the potential victim and contacting the policewill attempt to fully discuss it with you before taking any action. ● I may also seek hospitalization of the patient or contact others who can assist in protecting the victim. ▪ Disclosures may be required to health insurers or to collect overdue fees. • I occasionally find it helpful to consult other health and mental health professionals about a case. During a consultation, I make every effort to avoid revealing the identity of my patient. The other professionals professions are 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 essential important to our work together. I will note all consultations in your Clinical RecordRecord (which is called “PHI” in my Notice of Psychologist Policies and Practices to Protect the Privacy of Your Health Information). • ● You should be aware that I may employ administrative staff. In those cases, I will need to share protected information with those individuals for administrative purposes, such as billing and quality assurance. All staff members will be court-ordered trained about protecting your privacy and will agree not to release treatment any information outside of the practice without my permission. There are some situations where I am permitted or required to disclose information without either your consent or Authorization. They are as follows: ● If you are involved in a court proceeding and records a request is made for information concerning your diagnosis and treatment, such information is protected by the psychologist-patient privilege law. I cannot provide any information without your (or legal representative’s) written authorization, or a court order. If you are involved or contemplating litigation, you should consult with your attorney to determine where a court would be likely to order me to disclose information. ● If the Alabama Board of Examiners in alleged criminal or civil liability casesPsychology is requesting the information for an investigation of my practice, I am required to provide it for them. In addition, if ● If a client patient files a complaint compliant or lawsuit against me, I may disclose relevant information regarding that client patient in order to defend myself. • If a government agency requests the information for health oversight activities under their legal authority, I may be required to provide it. • ● If a patient files a worker’s compensation claim, I must, upon appropriate request, may disclose information relevant to the claimant's condition that claim to the workerpatient’s compensation employer or the insurer. ▪ There are some situations in which I am legally obligated to take actions, which I believe are necessary to attempt to protect others from harm, and I may have to reveal some information about a patient’s treatment. ● If I know or suspect that a child under the age of 19 has been abused or neglected, the law requires that I file a report with the appropriate government agency, usually the Alabama Department of Human Resources. Once such report is filed, I may be required by law to report any suspected child abuseprovide additional information. ● If I know or suspect that an elderly or disabled adult has been abused, neglectneglected, exploited, sexually, emotionally, or sexual abuse physically abused, the law requires that I file a report with the appropriate governmental agency, usually the Alabama Department of Human Resources. Once such report is filed, I may be required to protect provide additional information. ● If I believe that disclosing information about you is necessary to prevent or lessen a serious and imminent threat to the child/children involved. ▪ I am obligated by law to report any suspected abuse, neglect, or sexual abuse health and safety of an older adult identifiable person(s), I may disclose that information, but only to those reasonably able to prevent or dependent adult to protect lessen the older adult or dependent adult involvedthreat. ▪ Please be aware that information shared with me will be disclosed to your partner or family if they participate in couples or family treatment. If one of these situations arise, I will not agree make every effort to hold secrets on fully discuss it with you before taking any one partner’s behalf. If you feel something should not be shared with your partneraction, please do not tell me your secret(s). At such times, it may be most appropriate for you and I will try to seek the support of an individual therapist who limit my disclosure to what is independent of your couple’s treatment and who will consult with me regarding the broad issues and not the specifics of your secret(s)necessary. While this written summary of exceptions to confidentiality should prove helpful in informing you about potential problems, it is essential important that we discuss any questions or concerns that you may have now or in the future. 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. PATIENT’S RIGHTS HIPAA provided you with several new or expanded rights with regard to your Clinical Record and disclosures of protected health information. 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 protected health information that you have neither consented to nor authorized; determining the location to which protected information disclosures are sent; having any complaints you make about my policies and procedures recorded in your records; and the right to a paper copy of this Agreement, the attached Notice of Psychologist’s Policies and Practices to Protect the Privacy of Your Health Information form, and my privacy policies and procedures. I will be happy to discuss any of these rights with you. 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 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, test results, and any reports that have been sent to anyone, including reports to your insurance carrier. If you provide me with an appropriate written request, you have the right to examine and/or receive a copy of your records for a fee, except in unusual circumstances that involve danger to you or others. In those situations, you have a right to have your record sent to another mental health provider. The exceptions to this policy are contained in the attached Notice of Psychologist’s Policies and Practices to Protect the Privacy of Your Health Information form. If I refuse your request for access to your records, you have a right of review, which we will discuss with you upon request. In addition, I may also keep a set of Psychotherapy Notes. These notes are for my own use and are designed to assist me in providing you with the best treatment. While the contents of Psychotherapy Notes vary from patient to patient, 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. These Psychotherapy Notes are kept separate from your Clinical Record. While insurance companies can request and receive a copy of your Clinical Record, they cannot receive a copy of your Psychotherapy Notes without your Authorization. Insurance companies cannot require your Authorization as a condition of coverage nor penalize you in any way for your refusal. If I die or become incapacitated, there is a probability that a designated Professional Executor may take control of patient’s records and contact them. PROFESSIONAL FEES My fee for the initial consultation is $187.00. Sessions lengths can vary. Sessions between 16 and 37 minutes are billed at $93.00. Sessions between 38 and 52 minutes are billed at $140.00. Sessions over 52 minutes are billed at $187.00. Additional fees may be applied for additional services and interactive complexity, such as brief consultation with family members. Most insurances and managed care organizations require a co-pay and/or deductible for which you are responsible. If you are using your insurance, you are responsible for verification of coverage and for obtaining pre-authorization for these services prior to your first visit. OTHER FEES If we meet more than the usual time, I will charge accordingly. In addition to weekly appointments, I charge this same hourly rate for other professional services you may need, though I will prorate the hourly cost if I work for periods of less than one hour. Other professional services include report writing, telephone conversations lasting longer than 10 minutes, attendance at meetings with other professionals you have authorized, preparation of treatment summaries, and the time spent performing any other service you may request of me. If a check is returned, the returned check fee is $30.00. Any court appearance, or deposition, or the provision of documents for any attorney or for the court will be billed at a rate of $200 per hour, and will include preparation and travel time. You will be responsible for all such fees related to your evaluation or treatment, payable at the time any such court-related services are requested. The fee for Medical/Mental Health Records or written communications to you or on your behalf will be a minimum of $20 and can increase depending on time spent.

Limits of Confidentiality. The law protects the privacy of all communications between a patient and a psychologist. In most situations, I can only release information about your treatment to others if you sign a written Authorization form that meets specific legal requirements imposed by state law and HIPAAForm. But there are some situations where I am permitted or required to disclose information without either your consent or authorization: • If a patient threatens to harm themself, I may be obligated to seek hospitalization for them or contact family members or others who can help provide protection. ▪ If a patient communicates a serious threat of physical violence against an identifiable victim, I must take protective actions, including notifying the potential victim and contacting the police. I may also seek hospitalization of the patient or contact others who can assist in protecting the victim. ▪ Disclosures may be required to health insurers or to collect overdue fees. • I occasionally find it helpful to consult other health and mental health professionals about a case. During a consultation, I make every effort to avoid revealing the identity of my patient. The other professionals are also legally bound to keep the information confidential. If you don’t do not object, I will not tell you about these consultations unless I feel that it is essential important to our work together. I will note all consultations in your Clinical Record. • If you are involved in a court proceeding and a request is made for information about the professional services that I have provided you and/or the records thereof, such information is protected by psychologist-patient privilege law. I cannot provide any information without your (or your legally- appointed representative’s) written authorization, a court order, or compulsory process (a subpoena) or discovery request from another party to the court proceeding where that party has given you proper notice (when required) has stated valid legal grounds for obtaining PHI, and I do not have grounds for objecting under state law (or you have instructed me not to object). If you are involved in or contemplating litigation, you should consult with your attorney to determine whether a court would be likely to order me to disclose information. • If a government agency is requesting the information for health oversight activities pursuant to their legal authority, I may be court-ordered required to release treatment information and records in alleged criminal or civil liability casesprovide it for them. In addition, if • If a client patient files a complaint or lawsuit against me, I may disclose relevant information regarding that client patient in order to defend myself. • If a government agency requests the information for health oversight activities under their legal authority, I may be required to provide it. • If a patient files a worker’s compensation claim, I must, upon appropriate request, disclose information relevant to the claimant's condition condition, to the worker’s compensation insurer. ▪ There are some situations in which I am legally required by to break confidentiality and take actions, necessary to attempt to protect others from harm. • If I have knowledge of a child under 18, or reasonably suspect that a child under 18 that I have observed, has been the victim of child abuse or neglect, the law to requires that I file a report with the appropriate governmental agency, usually the county welfare department. I also may make a report if I know or reasonably suspect that mental suffering has been inflicted upon a child or that his or her emotional well being is endangered in any suspected child other way (other than physical or sexual abuse, or neglect). • If I observe or have knowledge of an incident that reasonably appears to be physical abuse, abandonment, abduction, isolation, financial abuse or neglect of an elder or dependent adult, or if an elder or dependent adult credibly reports that he or she has experienced behavior including an act or omission constituting physical abuse, abandonment, abduction, isolation, financial abuse, or neglect, or sexual abuse to protect the child/children involved. ▪ I am obligated by law to report any suspected reasonably suspects that abuse, neglectthe law requires that I report to the appropriate government agency. • If a patient, or sexual abuse a family member, communicates a serious threat by the patient of physical violence against an older adult identifiable victim, I must take protective actions, including notifying the potential victim and contacting the police. I may also seek hospitalization of the patient, or dependent adult contact others, who can assist in protecting the victim. • If I have reasonable cause to protect believe that the older adult patient is in such mental or dependent adult involvedemotional condition as to be dangerous to him or herself, I may be obligated to take protective action, including seeking hospitalization or contacting family members or others, including the police, who can help provide protection. ▪ Please If such a situation arises, I will make every effort to fully discuss it with you before taking any action and I will limit my disclosure to what is necessary. Professional Records Pursuant to HIPAA, I may 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, presenting problems, diagnosis, treatment goals, progress, medical and social history, treatment history, any past treatment records that I receive from other providers, reports of any professional consultations, billing records, and any reports that have been sent to anyone, including reports to your insurance carrier. Except in unusual circumstances in that disclosure would physically endanger you and/or others or makes reference to another person (unless such other person is a health care provider), you may examine and/or receive a copy of your Clinical Record, if you request it in writing. Because these are professional records, they can be aware misinterpreted and/or upsetting to untrained readers. For this reason, I recommend that information shared with me you initially review them in my presence, or have them forwarded to another mental health professional so you can discuss the contents. There will be disclosed a copying fee of 25 cents per page. If I refuse your request for access to your partner or family if they participate Clinical Records, you have a right of review (except for information supplied to me confidentially by others) which I will discuss with you upon request. In addition, I may also keep a set of Psychotherapy Notes. These Notes are for my own use and are designed to assist me in couples or family providing you with the best treatment. I will not agree While the contents of Psychotherapy Notes vary from client to hold secrets client, they can include the contents of our conversations, my analysis of those conversations, and how they impact on any one partner’s behalfyour therapy. If you feel something should not be shared with your partner, please do not tell me your secret(s). At such times, it may be most appropriate for you to seek the support of an individual therapist who is independent of your couple’s treatment and who will consult with me regarding the broad issues and not the specifics of your secret(s). While this written summary of exceptions to confidentiality should prove helpful in informing you about potential problems, it is essential that we discuss any questions or concerns They also contain particularly sensitive information that you may reveal to me that is not required to be included in your Clinical Record. They may 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 way for your refusal to provide it. Patient Rights HIPAA provides you with several new or expanded rights with regard to your Clinical Records and disclosures of PHI. These rights include requesting that I amend your record; requesting restrictions on what information from your Clinical Records is disclosed to others; requesting an accounting of most disclosures of PHI that you have now or neither consented to nor authorized; determining the location to which PHI disclosures are sent; having any complaints you make about my policies and procedures recorded in your records; and the future. The laws governing confidentiality can be quite complexright to a paper copy of this Agreement, the attached Notice Form, and I am not an attorney. In situations where specific advice is required, formal legal advice may be neededmy Privacy Policies and Procedures.

Limits of Confidentiality. The law protects the privacy of all communications between a patient and a psychologist. In most situations, I can only release information about your treatment to others if you sign a written Authorization form that meets specific legal requirements imposed by state law and HIPAAForm. But But, there are some situations where I am permitted or required to disclose information without either your consent or authorization: • If a patient threatens to harm themself, I may be obligated to seek hospitalization for them or contact family members or others who can help provide protection. ▪ If a patient communicates a serious threat of physical violence against an identifiable victim, I must take protective actions, including notifying the potential victim and contacting the police. I may also seek hospitalization of the patient or contact others who can assist in protecting the victim. ▪ Disclosures may be required to health insurers or to collect overdue fees. • I occasionally find it helpful to consult other health and mental health professionals about a case. During a consultation, I make every effort to avoid revealing the identity of my patient. The other professionals are also legally bound to keep the information confidential. If you don’t do not object, I will not tell you about these consultations unless I feel that it is essential important to our work together. I will note all consultations in your Clinical Record. • If you are involved in a court proceeding and a request is made for information about the professional services that I have provided you and/or the records thereof, such information is protected by psychologist-patient privilege law. I cannot provide any information without your (or your legally- appointed representative’s) written authorization, a court order, or compulsory process (a subpoena) or discovery request from another party to the court proceeding where that party has given you proper notice (when required) has stated valid legal grounds for obtaining PHI, and I do not have grounds for objecting under state law (or you have instructed me not to object). If you are involved in or contemplating litigation, you should consult with your attorney to determine whether a court would be likely to order me to disclose information. • If a government agency is requesting the information for health oversight activities pursuant to their legal authority, I may be court-ordered required to release treatment information and records in alleged criminal or civil liability casesprovide it for them. In addition, if • If a client patient files a complaint or lawsuit against me, I may disclose relevant information regarding that client patient in order to defend myself. • If a government agency requests the information for health oversight activities under their legal authority, I may be required to provide it. • If a patient files a worker’s compensation claim, I must, upon appropriate request, disclose information relevant to the claimant's condition condition, to the worker’s compensation insurer. ▪ There are some situations in which I am legally required by to break confidentiality and take actions, necessary to attempt to protect others from harm. • If I have knowledge of a child under 18, or reasonably suspect that a child under 18 that I have observed, has been the victim of child abuse or neglect, the law to requires that I file a report with the appropriate governmental agency, usually the county welfare department. I also may make a report if I know or reasonably suspect that mental suffering has been inflicted upon a child or that his or her emotional well being is endangered in any suspected child other way (other than physical or sexual abuse, or neglect). • If I observe or have knowledge of an incident that reasonably appears to be physical abuse, abandonment, abduction, isolation, financial abuse or neglect of an elder or dependent adult, or if an elder or dependent adult credibly reports that he or she has experienced behavior including an act or omission constituting physical abuse, abandonment, abduction, isolation, financial abuse, or neglect, or sexual abuse to protect the child/children involved. ▪ I am obligated by law to report any suspected reasonably suspects that abuse, neglectthe law requires that I report to the appropriate government agency. • If a patient, or sexual abuse a family member, communicates a serious threat by the patient of physical violence against an older adult identifiable victim, I must take protective actions, including notifying the potential victim and contacting the police. I may also seek hospitalization of the patient, or dependent adult contact others, who can assist in protecting the victim. • If I have reasonable cause to protect believe that the older adult patient is in such mental or dependent adult involvedemotional condition as to be dangerous to him or herself, I may be obligated to take protective action, including seeking hospitalization or contacting family members or others, including the police, who can help provide protection. ▪ Please If such a situation arises, I will make every effort to fully discuss it with you before taking any action and I will limit my disclosure to what is necessary. Professional Records Pursuant to HIPAA, I may 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, presenting problems, diagnosis, treatment goals, progress, medical and social history, treatment history, any past treatment records that I receive from other providers, reports of any professional consultations, billing records, and any reports that have been sent to anyone, including reports to your insurance carrier. Except in unusual circumstances in that disclosure would physically endanger you and/or others or makes reference to another person (unless such other person is a health care provider), you may examine and/or receive a copy of your Clinical Record, if you request it in writing. Because these are professional records, they can be aware misinterpreted and/or upsetting to untrained readers. For this reason, I recommend that information shared with me you initially review them in my presence, or have them forwarded to another mental health professional so you can discuss the contents. There will be disclosed a copying fee of 25 cents per page. If I refuse your request for access to your partner or family if they participate Clinical Records, you have a right of review (except for information supplied to me confidentially by others) which I will discuss with you upon request. In addition, I may also keep a set of Psychotherapy Notes. These Notes are for my own use and are designed to assist me in couples or family providing you with the best treatment. I will not agree While the contents of Psychotherapy Notes vary from client to hold secrets client, they can include the contents of our conversations, my analysis of those conversations, and how they impact on any one partner’s behalfyour therapy. If you feel something should not be shared with your partner, please do not tell me your secret(s). At such times, it may be most appropriate for you to seek the support of an individual therapist who is independent of your couple’s treatment and who will consult with me regarding the broad issues and not the specifics of your secret(s). While this written summary of exceptions to confidentiality should prove helpful in informing you about potential problems, it is essential that we discuss any questions or concerns They also contain particularly sensitive information that you may reveal to me that is not required to be included in your Clinical Record. They may 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 way for your refusal to provide it. Patient Rights HIPAA provides you with several new or expanded rights with regard to your Clinical Records and disclosures of PHI. These rights include requesting that I amend your record; requesting restrictions on what information from your Clinical Records is disclosed to others; requesting an accounting of most disclosures of PHI that you have now or neither consented to nor authorized; determining the location to which PHI disclosures are sent; having any complaints you make about my policies and procedures recorded in your records; and the future. The laws governing confidentiality can be quite complexright to a paper copy of this Agreement, the attached Notice Form, and I am not an attorney. In situations where specific advice is required, formal legal advice may be neededmy Privacy Policies and Procedures.

Limits of Confidentiality. The law protects the privacy of all communications between a patient and a psychologist. In most situations, I the Practice can only release information about your treatment to others if you sign a written Authorization form that meets specific certain legal requirements imposed by state law and HIPAA. But there There are some other situations where I am permitted or required to disclose information without either your that require only that you provide written, advance consent. Your signature on this Agreement provides consent or authorizationfor those activities, as follows: • If a patient threatens to harm themself, I  We may be obligated to seek hospitalization for them or contact family members or others who can help provide protection. ▪ If a patient communicates a serious threat of physical violence against an identifiable victim, I must take protective actions, including notifying the potential victim and contacting the police. I may also seek hospitalization of the patient or contact others who can assist in protecting the victim. ▪ Disclosures may be required to health insurers or to collect overdue fees. • I occasionally find it helpful to consult other health and mental health professionals about a case. During a consultation, I we make every effort to avoid revealing the identity of my patientour patients. The other professionals are also legally bound to keep the information confidential. If you don’t object, I we will not tell you about these consultations unless I we feel that it is essential important to our work together. I We 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). • I  Disclosures required by health insurers or to collect overdue fees are discussed elsewhere in this Agreement.  If a patient seriously threatens to harm himself/herself, we may be courtobligated to seek hospitalization for him/her, or to contact family members or others who can help provide protection. Texas law provides that a professional may disclose confidential information only to medical or law enforcement personnel if the professional determines that there is a probability of imminent physical injury by the patient to the patient or others, or there is a probability of immediate mental or emotional injury to the patient. There are some situations where we are permitted or required to disclose information without either your consent or Authorization:  If you are involved in a court proceeding and a request is made for information concerning your diagnosis and treatment, such information is protected by the psychologist-ordered patient privilege law. We cannot provide any information without your (or your legal representative’s) written authorization, or a court order. If you are involved in or contemplating litigation, you should consult with your attorney to release treatment determine whether a court would be likely to order us to disclose information.  If a government agency is requesting the information and records in alleged criminal or civil liability casesfor health oversight activities, we may be required to provide it for them. In addition, if  If a client patient files a complaint or lawsuit against methe Practice, I we may disclose relevant information regarding that client patient in order to defend myselfourselves. • If a government agency requests the information for health oversight activities under their legal authority, I may be required to provide it. •  If a patient files a worker’s compensation claim, I we must, upon appropriate request, disclose provide records relating to treatment or hospitalization for which compensation is being sought. There are some situations in which the Practice is legally obligated to take actions, which we believe is necessary to attempt to protect others from harm and we may have to reveal some information relevant about a patient’s treatment. These situations are unusual in our practice.  If we have cause to believe that a child under 18 has been or may be abused or neglected (including physical injury, substantial threat of harm, mental or emotional injury, or any kind of sexual contact or conduct), or that a child is a victim of a sexual offense, or that an elderly or disabled person is in a state of abuse, neglect or exploitation, the law requires that we make a report to the claimant's condition appropriate governmental agency, usually the Department of Protective and Regulatory Services. Once such report is filed, we may be required to provide additional information.  If we determine that there is a probability that the worker’s compensation insurer. ▪ I am required by law to report any suspected child abuse, neglectpatient will inflict imminent physical injury on another, or sexual abuse to protect that the childpatient will inflict imminent physical, mental or emotional harm upon him/children involved. ▪ I am obligated by law to report any suspected abuse, neglectherself, or sexual abuse others, we may be required to take protective action by disclosing information to medical or law enforcement personnel or by securing hospitalization of an older adult or dependent adult to protect the older adult or dependent adult involved. ▪ Please be aware that information shared with me will be disclosed to your partner or family if they participate in couples or family treatment. I will not agree to hold secrets on any one partner’s behalfpatient. If such a situation arises, we will make every effort to fully discuss it with you feel something should not be shared with your partner, please do not tell me your secret(s). At such times, it may be most appropriate for you before taking any action and we will limit our disclosure to seek the support of an individual therapist who what is independent of your couple’s treatment and who will consult with me regarding the broad issues and not the specifics of your secret(s)necessary. While this written summary of exceptions to confidentiality should prove helpful in informing you about potential problems, it is essential important that we you and your clinician discuss any questions or concerns that you may have now or in the future. The laws governing confidentiality can be quite complex, and I am we are not an attorneyattorneys. In situations where specific advice is required, formal legal advice may be needed.

Limits of Confidentiality. The law protects the privacy of all communications between a patient and a psychologistmental health professional. In most situations, I we can only release information about your treatment to others if you sign a written Authorization authorization form that meets specific certain legal requirements imposed by state law and HIPAA. But there There are some situations where I am permitted or required to disclose information without either your that require only that you provide written, advance consent. Your signature on this Agreement provides consent or authorizationfor those activities as follows: • If a patient threatens to harm themself, I  We may be obligated to seek hospitalization for them or contact family members or others who can help provide protection. ▪ If a patient communicates a serious threat of physical violence against an identifiable victim, I must take protective actions, including notifying the potential victim and contacting the police. I may also seek hospitalization of the patient or contact others who can assist in protecting the victim. ▪ Disclosures may be required to health insurers or to collect overdue fees. • I occasionally find it helpful to consult other health and mental health professionals about a case. During a consultation, I we make every effort to avoid revealing the identity of my our patient. The other professionals are also legally bound to keep the information confidential. If you don’t object, I we will not tell you about these consultations unless I we feel that it is essential important to our work together. I We will note all consultations in your Clinical Recordclinical record (which is called “PHI” in our Notice of Psychologist’s Policies and Practices to Protect the Privacy of Your Health Information). • I There are some situations where we are permitted or required to disclose information without either your consent or Authorization:  If you are involved in a court proceeding and a request is made for information concerning your diagnosis and treatment, such information is protected by the clinician-patient privilege law. We cannot provide any information without your (or your legal representative’s) written authorization or a court order. If you are involved in contemplating litigation, you should consult with your attorney to determine whether a court would be likely to order us to disclose information.  If a government agency is requesting the information for health oversight activities, we may be court-ordered required to release treatment information and records in alleged criminal or civil liability casesprovide it for them. In addition, if  If a client patient files a complaint or lawsuit against mehis/her clinician, I that clinicians may disclose relevant information regarding that client patient in order to defend myselfthemselves. • There are some situations in which we are legally obligated to take actions, which we believe are necessary to attempt to protect others from harm and we may have to reveal some information about a patient’s treatment. These situations are unusual in our practice.  If we have cause to believe that a government agency requests child under 18 has been or may be abused or neglected (including physical injury, substantial threat of harm, mental or emotional injury, or any kind of sexual contact or conduct), or that a child is a victim of a sexual offense, or that an elderly or disabled person is in a state of abuse, neglect or exploitation, the information for health oversight activities under their legal authoritylaw requires that we make a report to the appropriate governmental agency, I usually the Department of Family Protective Services. Once such report is filed, we may be required to provide itadditional information. •  If we determine that there is a probability that the patient files will inflict imminent physical injury on another, or that the patient will inflict imminent physical, mental or emotional harm upon himself/herself, or others, we may be required to take protective action by disclosing information to medical or law enforcement personnel or by securing hospitalization of the patient. If such a worker’s compensation claimsituation arises, I mustwe will make every effort to fully discuss it with you before taking any action and we will limit our disclosure to what is necessary. However, upon appropriate request, disclose information relevant to the claimant's condition to the worker’s compensation insurer. ▪ I am required by law to report any suspected in cases that involve child abuse, neglect, Section 611 of the Texas Health and Safety laws allows for clinicians to refuse to disclose information to a parent who may pose substantial harm to a child either physically or sexual abuse to protect the child/children involved. ▪ I am obligated by law to report any suspected abuse, neglect, or sexual abuse of an older adult or dependent adult to protect the older adult or dependent adult involved. ▪ Please be aware that information shared with me will be disclosed to your partner or family if they participate in couples or family treatment. I will not agree to hold secrets on any one partner’s behalf. If you feel something should not be shared with your partner, please do not tell me your secret(s). At such times, it may be most appropriate for you to seek the support of an individual therapist who is independent of your couple’s treatment and who will consult with me regarding the broad issues and not the specifics of your secret(s)emotionally. While this written summary of exceptions to confidentiality should prove helpful in informing you about potential problems, it is essential important that we you discuss any questions or concerns that you may have now or in the futurefuture with your psychologist/therapist. The laws governing confidentiality can be quite complex, and I am the clinicians at MOCE are not an attorneyattorneys. In situations where specific advice is required, formal legal advice may be needed. PROFESSIONAL RECORDS You should be aware that, pursuant to HIPAA, MOCE clinicians keep PHI about you in professional progress records which are collectively referred to as your Clinical Record. Your Clinical Record 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 we 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, you may examine and/or receive a copy of your Clinical Record if you request it in writing. You should be aware that pursuant to Texas law, psychological test data are not part of a patient’s record. Because these are professional records, they can be misinterpreted and/or upsetting to untrained readers. For this reason, we recommend that you initially review them in the presence of your MOCE clinician, or have them forwarded to another mental health professional so you can discuss the contents. Clinicians are sometimes willing to conduct this review meeting without charge. In most circumstances, MOCE is allowed to charge a copying fee of $1.00 per page to cover supply and administrative costs. If your request for access to your Clinical Record is refused, you have a right of review, which your clinician or the MOCE Privacy Officer will discuss with you upon your request. Clinical records are kept electronically via a secure and encrypted online service. If you have any question about the protection of your records please feel free to ask your therapist or the MOCE Privacy Officer, Xxxxx Xxxxx. Minors & Parents Patients under 18 years of age who are not emancipated and their parents should be aware that the law may allow parents to examine their child’s treatment records. However, if the treatment is for suicide prevention, chemical addiction or dependency, or sexual, physical or emotional abuse, the law provides that parents may not access their child’s records. For children between 16 and 18, because privacy in psychotherapy is often crucial to successful progress, particularly with teenagers, this can lead to a potential problem in therapy. The clinician must work very diligently to maintain a balance between a teenagers’ felt need for privacy/confidentiality and a parent’s right to access their child’s records. All therapists will work prudently with their clients to find that balance for the good of the teenager, unless it is determined that the client is in danger or is a danger to someone else, in which case, we will notify the parents immediately of our concern. BILLING & PAYMENTS You will be expected to pay for each session at the time it is held, unless we agree otherwise or unless you have insurance coverage that requires another arrangement. Payment schedules for other professional services will be agreed to when they are requested. You will not be seen by your therapist when your account is in arrears three sessions, unless some prior arrangement has been made between yourself and the therapist. INSURANCE REIMBURSEMENT In order for us to set realistic treatment goals and priorities, it is important to evaluate what resources you have available to pay for your treatment. If you have a health insurance policy, it will usually provide some coverage for mental health treatment. We will fill out forms and provide you with whatever assistance we 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 very important that you find out exactly what mental health services your insurance policy covers. You should carefully read the section in your insurance coverage booklet that describes mental health services. If you have questions about the coverage, call your plan administrator. Of course, MOCE will provide you with whatever information we can based on our experience and will be happy to help you in understanding the information you receive from your insurance company. If it is necessary to clear confusion, we will be willing to call the company on your behalf.

Limits of Confidentiality. The law protects the privacy of all communications between a patient and a psychologist. In most situations, I the Practice can only release information about regarding your treatment to others if you sign we have a written signed Authorization form that meets specific certain legal requirements imposed by state law and HIPAA. But there There are some other situations where I am permitted or required to disclose information without either your that require that you provide written, advance consent. Your signature on this Agreement provides consent or authorizationfor those activities, as follows: • If a patient threatens to harm themself, I We may be obligated to seek hospitalization for them or contact family members or others who can help provide protection. ▪ If a patient communicates a serious threat of physical violence against an identifiable victim, I must take protective actions, including notifying the potential victim and contacting the police. I may also seek hospitalization of the patient or contact others who can assist in protecting the victim. ▪ Disclosures may be required to health insurers or to collect overdue fees. • I occasionally find it helpful to consult other health and mental health professionals about a case. During a consultation, I we make every effort to avoid revealing the identity of my patientour patients. The other professionals are also legally bound to keep the information confidential. If you don’t object, I we will not tell you about these consultations unless I we feel that it is essential important to our work together. I We 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). • I Disclosures required by health insurers or to collect overdue fees are discussed elsewhere in this Agreement. • If a patient seriously threatens to harm himself/herself, we may be courtobligated to seek hospitalization for him/her, or to contact either a medical professional or the police who can help provide protection. Texas law provides that a professional may disclose confidential information only to medical or law enforcement personnel if the professional determines that there is a probability of imminent physical injury by the patient to the patient or others, or there is a probability of immediate mental or emotional injury to the patient. There are some situations where we are permitted or required to disclose information without either your consent or Authorization: • If you are involved in a court proceeding and a request is made for information concerning your diagnosis and treatment, such information is protected by the psychologist-ordered patient privilege law. We cannot provide any information without your (or your legal representative’s) written authorization, or a court order. If you are involved in or contemplating litigation, you should consult with your attorney to release treatment determine whether a court would be likely to order us to disclose information. • If a government agency is requesting the information and records in alleged criminal or civil liability casesfor health oversight activities, we may be required to provide it for them. In addition, if • If a client patient files a complaint or lawsuit against methe Practice, I we may disclose relevant information regarding that client patient in order to defend myself. • If a government agency requests the information for health oversight activities under their legal authority, I may be required to provide itourselves. • If a patient files a worker’s compensation claim, I we must, upon appropriate request, disclose provide records relating to treatment or hospitalization for which compensation is being sought. • There are some situations in which the Practice is legally obligated to take actions, which we believe are necessary to attempt to protect others from harm and we may have to reveal some information relevant about a patient’s treatment. These situations are unusual in our practice. • If we have cause to the claimant's condition to the worker’s compensation insurer. ▪ I am required by law to report believe that a child under 18 has been or may be abused or neglected (including physical injury, substantial threat of harm, mental or emotional injury, or any suspected kind of sexual contact or conduct), or that a child is a victim of a sexual offense, or that an elderly or disabled person is in a state of abuse, neglect, or sexual abuse exploitation, the law requires that we make a report to protect the child/children involvedappropriate governmental agency, usually the Department of Protective and Regulatory Services. ▪ I am obligated by law Once such report is filed, we may be required to report any suspected abuse, neglectprovide additional information. • If we determine that there is a probability that the patient will inflict imminent physical injury on another, or sexual abuse that the patient will inflict imminent physical, mental or emotional harm upon himself/herself, or others, we may be required to take protective action by disclosing information to medical or law enforcement personnel or by securing hospitalization of an older adult or dependent adult to protect the older adult or dependent adult involved. ▪ Please be aware that information shared with me will be disclosed to your partner or family if they participate in couples or family treatment. I will not agree to hold secrets on any one partner’s behalfpatient. If such a situation arises, we will make every effort to fully discuss it with you feel something should not be shared with your partner, please do not tell me your secret(s). At such times, it may be most appropriate for you before taking any action and we will limit our disclosure to seek the support of an individual therapist who what is independent of your couple’s treatment and who will consult with me regarding the broad issues and not the specifics of your secret(s)necessary. While this written summary of exceptions to confidentiality should prove helpful in informing you about potential problems, it is essential important that we you and your clinician discuss any questions or concerns that you may have now or in the future. 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.

Limits of Confidentiality. The law protects the privacy of all communications between a therapist and patient. It protects any information that links back to you (identifiable patient and a psychologistinformation). In most situations, I can only release information about your treatment to others if you sign a written Authorization form authorization for me to do so. There are some exceptions to this, which you will agree to by signing this document. These include: • I may occasionally find it helpful to consult with other health and mental health professionals about a case. I also find it useful to have a clinical supervisor whom I consult with on a regular basis. The purpose of this is to improve the services that meets I am giving you. With the possible exception of my clinical supervisor, I will make every effort to not disclose any information that may be traceable (identifiable) to you. If you don’t object, I will not tell you about these consultations. I will also note specific legal requirements imposed by state law and HIPAAconsultations in your clinical record. But there • If a 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 protections. There are some situations where I am permitted or required to disclose information without either your consent or authorization: • If you are involved in a court proceeding and a request is made for information regarding the professional services that I have provided to you, such information is protected by the psychotherapist-patient threatens privilege law. I cannot provide any information without your consent or a court order. If you are involved or contemplating litigation, you should consult with your attorney to harm themselfdetermine whether a court would be likely to order me to disclose information. • If a government agency is requesting the information for health oversight activities, I may be obligated required to seek hospitalization provide it for them or contact family members or others who can help provide protectionthem. ▪ • If a patient communicates a serious threat of physical violence against an identifiable victim, I must take protective actions, including notifying the potential victim and contacting the police. I may also seek hospitalization of the patient or contact others who can assist in protecting the victim. ▪ Disclosures may be required to health insurers or to collect overdue fees. • I occasionally find it helpful to consult other health and mental health professionals about a case. During a consultation, I make every effort to avoid revealing the identity of my patient. The other professionals are also legally bound to keep the information confidential. If you don’t object, I will not tell you about these consultations unless I feel it is essential to our work together. I will note all consultations in your Clinical Record. • I may be court-ordered to release treatment information and records in alleged criminal or civil liability cases. In addition, if a client files a complaint or lawsuit against me, I may disclose relevant information regarding that client patient in order to defend myself. • If I am providing treatment for conditions directly related to a government agency requests worker’s compensation claim, I may have to submit such records, upon appropriate requests, to the Chairperson of the Worker’s Compensation Board on such forms and at such times as the chairperson may require. There are some situations in which I am legally obligated to take actions, which I believe are necessary to protect others from harm, and I may have to reveal some information for health oversight activities under their legal authorityabout a patient’s treatment. These situations include: • If I receive information in my professional capacity that gives me reasonable cause to suspect that a child is an abused or neglected child, the law requires me to report to the appropriate governmental agency, usually the statewide central registrar of child abuse and maltreatment and/or the local child protective services office. Once such a report is filed, I may be required to provide itadditional information. • If a patient files a worker’s compensation claimcommunicated an immediate threat of serious physical harm to an identifiable victim, I mustmay be required to take protective actions. These actions may include notifying the potential victim, upon appropriate request, disclose information relevant to contacting the claimant's condition to the worker’s compensation insurer. ▪ I am required by law to report any suspected child abuse, neglectpolice, or sexual abuse to protect seeking hospitalization for the child/children involvedpatient. ▪ I am obligated by law to report any suspected abuse• If one of these situations arises, neglect, or sexual abuse of an older adult or dependent adult to protect the older adult or dependent adult involved. ▪ Please be aware that information shared with me will be disclosed to your partner or family if they participate in couples or family treatment. I will not agree make every effort to hold secrets on fully discuss it with you before taking any one partner’s behalf. If you feel something should not be shared with your partneraction, please do not tell me your secret(s). At such times, it may be most appropriate for you and I will limit my disclosure to seek the support of an individual therapist who what is independent of your couple’s treatment and who will consult with me regarding the broad issues and not the specifics of your secret(s)necessary. While this written summary of exceptions to confidentiality should prove provide helpful in informing information to you about potential problems, it is essential important that we discuss any concerns or questions or concerns that you may have now or in the future. The laws governing regarding patient confidentiality can be are quite complex, and I am not an attorney. In ; in situations where specific advice is required, formal legal advice may be needed.. Professional Records The law and standards of my profession require that I keep Protected Health Information about you in your clinical record. As the confidentiality of our therapy sessions is of the utmost importance, these records (electronic and printed are stored in a locked filing cabinet for your protection. Except in unusual circumstances where there is a danger to yourself or others, or where information has been provided to me confidentially by others, you may examine and/or receive a copy of your clinical record, if you request it in writing. Copies are subject to my copy fee ($.25/page), and I require at least a one-week notice to fill this request. As these are clinical records, they can be misinterpreted and/or upsetting to untrained readers. For this reason, I recommend that you initially review them with me, or have them forwarded to another mental health professional so you can discuss the contents. If I refuse your request for access to your records, you have a right to a review, which I will discuss with you upon request. Patient Rights HIPAA provides you with several rights regarding your clinical record and disclosures of protected health information. These rights require written request on your part, and include requesting that I amend your record; requesting restrictions on what information from your clinical record is disclosed to others; determining the location to which protected information disclosures are sent; having any complaints you make about my policies and procedures recorded in your records; the right to a paper copy of this agreement including the notice of my falling under the HIPAA laws, and my privacy policies and procedures; among others; and the right to submit a complaint to myself, HHS (related to HIPAA complaints), or to through the NY State Office of Professions at <xxxx://xxx.xx.xxxxx.xxx/opd/complain.htm> . I am happy to discuss these rights, as well as any concerns or complaints, with you at any time. Minors and Parents Patients under the age of 18 who are not emancipated and their parents should be aware that the law may allow parents to examine their child’s treatment records. Even where parental consent has been given, children over age 12 may have the right to control access to their treatment records. While privacy in psychotherapy is very important, particularly with teenagers, parental involvement is also essential to successful treatment. For most children age 12 and over, your signature below represents an agreement between my patient and his/her parents allowing me to share general information about the progress of the child’s treatment, including treatment plans, and his/her attendance at scheduled sessions. I will also provide parents with a summary of their child’s treatment when it is complete. Any other communication will require the child’s consent, unless I feel that the child is in danger or is a danger to someone else, in which case I will notify the parents of my concern. Before giving parents any information, I will discuss the matter with the child, if possible, and do my best to handle any objections or concerns he or she may have. In cases where the child is under the age of 12, how open the therapy is will be discussed more thoroughly to meet the needs of the child. It is also important that you are aware that if the parents of a client under 18 are no longer together, both parents may have the right to review the client’s records. Please discuss any concerns you have about this with me. Billing and Payments You will be expected to pay for each session at the time it is held, unless we agree otherwise. Payment for other professional services is due at the next session or on an otherwise agreed upon payment schedule. In circumstances of unusual financial hardship, I may be willing to negotiate a fee adjustment or payment installment plan. Please discuss this with me if you feel you are in need of this. If your account has not been paid for more than 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 otherwise confidential information. In most collection situations, the only information necessary for me to release regarding a patient’s treatment is his/her name, the nature of the services provided, and the amount due. If such legal action is necessary, its costs will be included in the claim. Insurance/Reimbursement In order for us to set realistic treatment goals and priorities, it is important to evaluate what resources you have available to pay for your treatment. I do not accept insurance payment at this time. This means that you are fully responsible for payment of my fees at the time of service. Please discuss any questions or concerns you have regarding fees with me, either now or as they arise. Xxxxx Xxxxxxxx, LMFT Marriage and Family Therapy Psychotherapist-Patient Services Agreement YOUR SIGNATURE BELOW INDICATES THAT YOU HAVE RECEIVED A COPY OF THE 5-PAGE PSYCHOTHERAPIST-PATIENT SERVICES AGREEMENT AND AGREE TO ITS TERMS: Signature/Printed: Date: Signature/Printed: Date: Signature/Printed: Date: Signature/Printed: Date: Witness: Date:

Limits of Confidentiality. The law protects the privacy of all communications between a patient and a psychologist. In most situations, I your therapist can only release information about your treatment to others if you sign a written Authorization authorization form that meets specific certain legal requirements imposed by state law and HIPAA. But there There are some other situations where I am permitted or required to disclose information without either that require only that you provide written, advance consent. Your signature on this Agreement provides consent for those activities, as follows: your consent or authorization: • If a patient threatens to harm themself, I therapist may be obligated to seek hospitalization for them or contact family members or others who can help provide protection. ▪ If a patient communicates a serious threat of physical violence against an identifiable victim, I must take protective actions, including notifying the potential victim and contacting the police. I may also seek hospitalization of the patient or contact others who can assist in protecting the victim. ▪ Disclosures may be required to health insurers or to collect overdue fees. • I occasionally find it helpful to consult other health and mental health professionals about a case. During a consultation, I your therapist will make every effort to avoid revealing the identity of my his/her patient. The other professionals are also legally bound to keep the information confidential. If you don’t n't object, I your therapist will not tell you about these consultations unless I feel he/she feels that it is essential important to our your work together. I Your therapist 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). • I It is also important to be aware of other potential limits to confidentiality that include the following: ● All records as well as notes on sessions and phone calls can be subject to court subpoena under certain extreme circumstances. Most records are stored in locked files but some are stored in secured electronic devices. ● Cell phones, portable phones, faxes, and e-mails are used on some occasions. ● All electronic communication compromises your confidentiality. ● If a patient seriously threatens to harm himself/herself, your therapist may be court-ordered obligated to release treatment seek hospitalization for him/her, or to contact family members or others who can help provide protection. Texas law provides that a professional may disclose confidential information only to medical or law enforcement personnel if the professional determines that there is a probability of imminent physical injury by the patient to the patient or others, or there is a probability of immediate mental or emotional injury to the patient. There are some situations where your therapist is permitted or required to disclose information without either your consent or authorization: ● If you are involved in a court proceeding and records in alleged criminal or civil liability casesa request is made for information concerning your diagnosis and treatment, you should consult with your attorney to determine whether a court would be likely to order your therapist to disclose information. In addition● If a government agency is requesting the information for health oversight activities, if your therapist may be required to provide it for them. ● If a client patient files a complaint or lawsuit against meyour therapist, I he/she may disclose relevant information regarding that client patient in order to defend myselfthemselves. • If a government agency requests the information for health oversight activities under their legal authority, I may be required to provide it. • ● If a patient files a worker’s 's compensation claim, I your therapist must, upon appropriate request, provide records relating to treatment or hospitalization for which compensation is being sought. ● If a patient fails to pay for services your therapist has rendered, he/she may disclose relevant information relevant in a suit seeking payment. There are some situations in which your therapist is legally obligated to take actions, which he/she believes are necessary to attempt to protect others from harm, and he/she may have to reveal some information about a patient's treatment. These situations are unusual in our practice. ● If the therapist has cause to believe that a child under 18 has been or may be abused or neglected (including physical injury, substantial threat of harm, mental or emotional injury, or any kind of sexual contact or conduct), or that a child is a victim of a sexual offense, or that an elderly or disabled person is in a state of abuse, neglect or exploitation, the law requires that the therapist make a report to the claimant's condition appropriate governmental agency, usually the Department of Protective and Regulatory Services. Once such a report is filed, the therapist may be required to provide additional information. ● If the therapist determines that there is a probability that the patient will inflict imminent physical injury on him/herself, or another, or that the patient will inflict imminent mental or emotional harm upon others, the therapist may be required to take protective action by disclosing information to medical or law enforcement personnel or by securing hospitalization of the patient. If such a situation arises, he/she will make every effort to fully discuss it with you before taking any action and, I will limit their disclosure to what is necessary. By signing this agreement, you authorize your therapist to contact any person/entity in a position to prevent harm to the worker’s compensation insurer. ▪ I am required by law patient or a third party if he/she determines there is a probability of harm to report any suspected child abuse, neglect, the patient or sexual abuse to protect the child/children involved. ▪ I am obligated by law to report any suspected abuse, neglect, or sexual abuse of an older adult or dependent adult to protect the older adult or dependent adult involved. ▪ Please be aware that information shared with me will be disclosed to your partner or family if they participate in couples or family treatment. I will not agree to hold secrets on any one partner’s behalf. If you feel something should not be shared with your partner, please do not tell me your secret(s). At such times, it may be most appropriate for you to seek the support of an individual therapist who is independent of your couple’s treatment and who will consult with me regarding the broad issues and not the specifics of your secret(s)a third party. While this written summary of exceptions to confidentiality should prove helpful in informing you about potential problems, it is essential important that we you and your therapist discuss any questions or concerns that you may have now or in the future. The laws governing confidentiality can be quite complex, complex and I am your therapist is not an attorney. In situations where specific advice is required, formal legal advice consultation may be needed. PROFESSIONAL RECORDS The laws and standards of our profession require that your therapist keep Protected Health Information about you in your Clinical Record. The Clinical Record includes information about your reasons for seeking therapy, a description of the ways in which the problem impacts on your life, the diagnosis, the goals that that you and your therapist set for treatment, progress towards those goals, medical and social history, treatment history, any past treatment records that your therapist receives from other providers, reports of any professional consultations, billing records, and any reports that have been sent to anyone, including reports to your school (if applicable). Except in unusual circumstances that involve danger to yourself and/or others, you may examine and/or receive a copy of your Clinical Record if you request it in writing. You should be aware that pursuant to Texas law, psychological test data are not part of a patient's record. Because these are professional records, they can be misinterpreted and/or upsetting to untrained readers. For this reason, we recommend that you have them forwarded to another mental health professional so you can discuss the contents. In most circumstances, we charge a copying fee of $.50 per page (and for certain other expenses). If your therapist refuses your request for access to your records, you have a right of review, which he/she 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 protected health information. These rights include requesting that your therapist amend your record; requesting restrictions on what information from your Clinical Record is disclosed to others; requesting an accounting of most disclosures of protected health information that you have neither consented to nor authorized; determining the location to which protected information disclosures are sent; having any complaints you make about our policies and procedures recorded in your records; and the right to a paper copy of this Agreement, the attached Notice form, and our privacy policies and procedures. MINORS & PARENTS Patients 18 years of age and older must consent for their own treatment. In order for therapists to communicate with parents, he/she must have a signed release from the patient. If parents are paying for treatment of their adult son or daughter, the therapist can provide the patient with a receipt after each session that parents may use to file an insurance company claim. In most cases in which a patient has given written permission to speak with his or her parents, the therapist will discuss it with the patient first.

Limits of Confidentiality. The law protects the privacy of all communications between If we believe that a patient and a psychologistclient presents an imminent danger to his/her health or safety, we may be obligated to seek hospitalization for him/her, or to contact family members or others who can help provide protection. In most situations, I can only release information about your treatment to others if you sign a written Authorization form that meets specific legal requirements imposed by state law and HIPAA. But there There are some situations where I am we are permitted or required to disclose information without either your consent or authorizationAuthorization: • If you are involved in a patient threatens court proceeding and a request is made for information concerning the professional services that we provided you, such information is protected by the counselor-client privilege law. We cannot provide any information without your written authorization, or a court order. If y xxxx ou are involved in or contemplating litigation, you should conwith your attorney to harm themself, I may determine whether a court would be obligated likely to seek hospitalization for them or contact family members or others who can help provide protectionorder us to disclose information. ▪ • If a patient communicates a serious threat of physical violence against an identifiable victimgovernment agency is requesting the information for health oversight activities, I must take protective actions, including notifying the potential victim and contacting the police. I may also seek hospitalization of the patient or contact others who can assist in protecting the victim. ▪ Disclosures we may be required to health insurers or to collect overdue fees. • I occasionally find provide it helpful to consult other health and mental health professionals about a case. During a consultation, I make every effort to avoid revealing the identity of my patient. The other professionals are also legally bound to keep the information confidentialfor them. If you don’t object, I will not tell you about these consultations unless I feel it is essential to our work together. I will note all consultations in your Clinical Record. • I may be court-ordered to release treatment information and records in alleged criminal or civil liability cases. In addition, if a client files a complaint or lawsuit against meRHEMA Counseling & Support Services, I PC or an individual provider within the agency, we may disclose relevant information regarding that client to defend myselfclient. • If a government agency requests the information for health oversight activities under their legal authority, I may be required to provide it. • If a patient client files a worker’s compensation claim, I and our services are being compensated through workers compensation benefits, we must, upon appropriate request, provide a copy of the client’s record to the client’s employer or the North Carolina Industrial Commission. There are some situations in which we are legally obligated to take actions, which we believe are necessary to attempt to protect others from harm and we may have to reveal some information about a client’s treatment. Though these situations are unusual in our practice, we would like to make you aware of them: • If we have cause to suspect that a child under 18 is abused or neglected, or if we have reasonable cause to believe that a disabled adult is in need of protective services, the law requires that we file a report with the County Department of Social Services. Once such a report is filed, we may be required to provide additional information. • If we believe that a client presents an imminent danger to the health and safety of another, we may be required to disclose information relevant in order to take protective actions, including initiating hospitalization, warning the claimant's condition to potential victim, if identifiable, and/or calling the worker’s compensation insurer. ▪ I am required by law to report any suspected child abuse, neglect, or sexual abuse to protect the child/children involved. ▪ I am obligated by law to report any suspected abuse, neglect, or sexual abuse of an older adult or dependent adult to protect the older adult or dependent adult involved. ▪ Please be aware that information shared with me will be disclosed to your partner or family if they participate in couples or family treatment. I will not agree to hold secrets on any one partner’s behalfpolice. If such a situation arises, we will make every effort to fully discuss it with you feel something should not be shared with your partner, please do not tell me your secret(s). At such times, it may be most appropriate for you before taking any action and will limit my disclosure to seek the support of an individual therapist who what is independent of your couple’s treatment and who will consult with me regarding the broad issues and not the specifics of your secret(s)necessary. While this written summary of exceptions to confidentiality should prove helpful in informing you about potential problems, it is essential important that we discuss any questions or concerns that you may have now or in the future. The laws governing confidentiality can be quite complex, and I am we are not an attorneyattorneys. In situations where specific advice is required, formal legal advice may be needed. CLIENT RIGHTS HIPAA provides you with several new or expanded rights with regard to your Clinical Records and disclosures of protected health information. These rights include requesting that we amend your record; requesting restrictions on what information from your Clinical Records is disclosed to others; requesting an accounting of most disclosures of protected health information that you have neither consented to nor authorized; determining the location to which protected information disclosures are sent; having any complaints you make about my policies and procedures recorded in your records; and the right to a paper copy of this Agreement and our privacy policies and procedures. We are happy to discuss any of these rights with you. In addition, you will receive a copy of these rights in RHEMA Counseling & Support Services, PC’s Notice of Privacy Practices. We reserve the right to revise the terms of this Notice and make the new Notice effective for all medical information that we maintain. A copy of these revisions will be posted online at xxx.xxxxxxxx.xxx. You may also obtain a copy from our office located at 0000 Xxxxxxxx Xxxxx, Xxxxxx, XX 00000 or you may request a copy by calling (919) 000- 0000.

Limits of Confidentiality. The law protects I respect the privacy of all communications between a patient the information you provide me, and a psychologistI abide by ethical and legal requirements of confidentiality and privacy of records. It is your right that our sessions and my records about you be kept private. In most all but a few rare situations, I can only release information about your treatment to others if you sign a written Authorization form that meets specific legal requirements imposed confidentiality is protected by state law, the rules of my profession, and my personal integrity. Texas state law requires me to inform you that in certain cases your confidentiality is not protected, and HIPAA. But there are some situations where I am permitted or required to disclose your information without either your consent or authorization: • If a patient threatens to harm themself, I may be obligated to seek hospitalization for them or contact family members or others who can help provide protection. ▪ If a patient communicates a serious threat of physical violence against an identifiable victim, I must take protective actions, including notifying the potential victim and contacting the police. I may also seek hospitalization of the patient or contact others who can assist in protecting the victim. ▪ Disclosures may be required to health insurers or to collect overdue fees. • I occasionally find it helpful to consult other health and mental health professionals about a case. During a consultation, I make every effort to avoid revealing the identity of my patient. The other professionals are also legally bound to keep the information confidential. If you don’t object, I will not tell you about these consultations unless I feel it is essential to our work together. I will note all consultations in your Clinical Record. • I may be court-ordered to release treatment information and records in alleged criminal or civil liability cases. In addition, if a client files a complaint or lawsuit against me, I may disclose relevant information regarding that client to defend myself. • If a government agency requests the information for health oversight activities under their legal authority, I may be required to provide it. • If a patient files a worker’s compensation claim, I must, upon appropriate request, disclose information relevant disclosed to the claimant's condition appropriate authorities/agencies. These cases are:  If I have reason to the worker’s compensation insurer. ▪ believe that you may harm yourself or others,  If I am required by law have reason to report any suspected child believe that you are involved in or have knowledge of abuse or neglect of a child; or abuse, neglect, or sexual abuse to protect the child/children involved. ▪ exploitation of a person who is elderly or has a disability, or  If I am obligated ordered to disclose by law state or federal courts. Professional misconduct by a health care professional must be reported by other health care professionals, in which related client records may be released to report any suspected abusesubstantiate disciplinary concerns. Parents or legal guardians of non- emancipated minor clients have the right to access the client’s records. When fees are not paid in a timely manner, neglecta collection agency will be given appropriate billing and financial information about the client, not clinical information. Insurance companies, managed care, and other third-party payers are given information that they request regarding services to the client. Information that may be requested includes type of services, dates/times of services, diagnosis, treatment plan, description of impairment, progress of therapy, and summaries. Information about clients may be disclosed in consultations with other professionals in order to provide the best possible treatment. In such cases the name of the client, or sexual abuse any identifying information, is not disclosed. Clinical information about the client is discussed. Some progress notes and reports are dictated/typed within the clinic or by outside sources specializing in (and held accountable for) such procedures. In the event the clinic or mental health professional must telephone the client for purposes such as appointment cancellations or reminders, or to give/receive other information, efforts are made to preserve confidentiality. You have the right to cancel a release of an older adult or dependent adult information by providing me with a written notice. If you desire to protect have your information sent to a location different than the older adult or dependent adult involvedaddress I have for you on file, you must provide this information in writing. ▪ Please be aware that You have the right to restrict what information shared with me will might be disclosed to your partner or family others. However, if they participate in couples or family treatment. I will do not agree to hold secrets on any one partner’s behalf. If you feel something should not be shared with your partnerthese restrictions, please do not tell me your secret(s). At such times, it may be most appropriate for you to seek the support of an individual therapist who is independent of your couple’s treatment and who will consult with me regarding the broad issues and not the specifics of your secret(s). While this written summary of exceptions to confidentiality should prove helpful in informing you about potential problems, it is essential that we discuss any questions or concerns that you may have now or in the future. The laws governing confidentiality can be quite complex, and I am not an attorneybound to abide by them. In situations where specific advice is requiredYou have the right to request that information about you be communicated by other means or to another location. This request must be made to me in writing. Additionally, formal legal advice I may be neededdisclose information if you sign a release form granting permission to designated third parties to receive information that you request me to share.

Limits of Confidentiality. The law protects Reunification Therapy, when ordered by the privacy of Court, is considered a non-confidential process. Any or all communications between notes, electronic correspondence, observations and recommendations may be disclosed to the court by the reunification therapist. They will not be disclosed to the parties without a patient Court’s order. Additionally, all parties need to sign any and all releases requested by the therapist that are necessary to obtain reports from relevant professionals (e.g. psychiatrist, psychologist, social worker's, teachers school officials, pediatricians, hospitals etc.). This includes past records as well as current records. As a licensed psychologist. In most situations, I can only release information about your treatment to others if you sign am a written Authorization form that meets specific legal requirements imposed by state law mandated reporter and HIPAA. But as such there are some situations (not all listed) where I am permitted legally obligated to take action to protect and share information about treatment. For example, if I believe that a child, elderly person or disabled person is being abused, I must file a report with the appropriate state agency. If you and/or a family member/significant other reports to me that you have stated a threat of serious bodily harm to an identifiable person, I am required to disclose information without either your consent or authorization: • take protective actions which include notifying the potential victim, contacting the police, and/or seeking hospitalization for you. If a patient threatens you threaten to harm themselfyourself, I may be obligated to seek hospitalization for them you or to contact family members or others who can help provide protection. ▪ If Any other laws specific to breaching confidentiality On a patient communicates regular basis I have peer supervision and consult with a serious threat team of physical violence against an identifiable victim, I must take protective actions, including notifying the potential victim and contacting the police. I may also seek hospitalization of the patient or contact others who can assist in protecting the victim. ▪ Disclosures may be required to health insurers or to collect overdue fees. • I occasionally find it helpful to consult other health and mental health professionals about a casecases. During a consultation, I make every effort to avoid revealing the identity of my patient. The other professionals are 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 essential important to our work together. I Fee Policies: My fees are $250 per hour. The following are also billed at $250 per hour and include: interviewing collateral contacts, appointment cancelled without 2 business day advance, preparing reports, copying files, telephonic, facsimile or electronic correspondence. Court appearances, preparation for court, and travel to and from court are billed at a rate of $350 an hour with a minimum of five hours. A subpoena to court must be received a minimum of seven days in advance of the court date. Upon receipt of the subpoena, that date of appearance is reserved. Even with retraction of subpoena or in the case my presence is not required, minimum payment will note all consultations in your Clinical Recordstill be processed. • I may be court-ordered to release treatment information and records in alleged criminal or civil liability cases. In addition, if a client files a complaint or lawsuit against me, I may disclose relevant information regarding that client to defend myself. • If a government agency requests the information for health oversight activities under their legal authority, I may be A retainer of $2500 is required to provide itcommence any court ordered/stipulated treatment. • If a patient files a worker’s compensation claim, I must, upon appropriate request, disclose information relevant It can be paid by credit card or valid check. After commencement of treatment/work when the retainer goes down to the claimant's condition $500 it needs to the worker’s compensation insurerbe replenished by $2500. ▪ I am required by law to report any suspected child abuse, neglect, or sexual abuse to protect the child/children involvedA valid credit card must be on file. ▪ I am obligated by law to report any suspected abuse, neglect, or sexual abuse of an older adult or dependent adult to protect the older adult or dependent adult involved. ▪ Please be aware that information shared with me You will be disclosed advised when your retainer is at $500. Payment of replenishment retainer must be made within 48 hours of advisement. You are welcome to bring a check in or we will xxxx your partner or family if they participate in couples or family treatment. I will not agree to hold secrets credit card on any one partner’s behalffile. If you feel something should not be shared with your partner, please do not tell me respond to the notification, your secret(s)credit card on file will be charged. At such timesXx. Xxxxxxx has the right to suspend work if fees are not up to date, or she may seek the courts assistance in collection of delinquent fees. You will be responsible for all fees incurred in efforts to collect funds. Please note that to collect fees, personal information will be requested and I must provide the necessary information to obtain collection. There may be occasion where the above fee schedule is changed and this will be written as an amendment to this contract at the end. The retainer will be held until Court determines that Reunification Therapist’s appointment is completed. After this time, if there are funds in the retainer, a credit will be issued. Contacting Me: After the initial appointment is scheduled, correspondence (outside of session) will take place principally by email only. Note all emails are entered into your file and charged at a rate of $250/hour. We want to keep emails to scheduling sessions and/or bare minimum of information. Should you have a concern, it may be most appropriate for you will best to seek the support of request an individual therapist who is independent of your couple’s treatment and who will consult with me regarding the broad issues and not the specifics of your secret(s). While this written summary of exceptions to confidentiality should prove helpful in informing you about potential problems, it is essential that we discuss any questions or concerns that you may have now or in the future. The laws governing confidentiality can be quite complex, and I am not an attorneyappointment. In situations where specific advice treatment, I will offer 1 to 2 appointment times and try to reasonably accommodate your families schedule, however, because this is requireda Court order you will need to come in as requested. If you have a psychiatric/clinical emergency, formal legal advice may contact 911 or proceed to the nearest emergency room. If I will be neededunavailable for an extended time, I will provide you with the name of a colleague to contact, if necessary.

Limits of Confidentiality. The law protects In general, the privacy of all communications between a patient client and a psychologist. In most situationstherapist or psychologist is protected by law, I and we can only release information about your treatment our work to others if with your written permission. But, there are a few exceptions: In most legal proceedings, you sign have the right to prevent us from providing any information about your treatment. In some proceedings involving child custody and those in which your emotional condition is an important issue, a written Authorization form that meets specific legal requirements imposed by state law and HIPAAjudge may order our testimony. But there However, such an order is unlikely. We would advise you never to agree to any release of information without first discussing it with us. There are some situations where I am permitted in which we are legally obligated to take action to protect others from harm, even if we have to reveal some information about a client’s treatment. For example, if we believe that a child, elderly person or disabled person is being abused, we must file a report with the appropriate state agency. If we believe that a client is threatening bodily harm to another, we may be required to disclose information without either your consent take protective actions. These actions may include notifying the potential victim, contacting the police, or authorization: • seeking hospitalization for our clients. If a patient client threatens harm to harm themselfherself/himself, I we may be obligated to seek hospitalization for them or a higher level of care including hospitalization, and/or to contact family members or others who can may help provide protection. ▪ If a patient communicates similar situation occurs in the course of our work together, we will attempt to fully discuss it with you before taking any action. The prior situations have rarely occurred in our practice. If a serious threat of physical violence against an identifiable victimsimilar situation occurs, I must take protective actions, including notifying the potential victim and contacting the policewe will make every effort to fully discuss it with you before taking any action. I We may also seek hospitalization of the patient or contact others who can assist in protecting the victim. ▪ Disclosures may be required to health insurers or to collect overdue fees. • I occasionally find it helpful to consult with other health and mental health professionals about a caseclient in order to provide best care. During a consultation, I we make every effort to avoid revealing completely disguise the identity of my patienteach client. The other professionals Consultants are also legally bound to keep the information confidential. If you don’t object, I we typically will not tell you about these consultations unless I feel we believe it is essential important to our work together. I will note all consultations in your Clinical Record. • I may be court-ordered to release treatment information and records in alleged criminal or civil liability cases. In addition, if a client files a complaint or lawsuit against me, I may disclose relevant information regarding that client to defend myself. • If a government agency requests the information for health oversight activities under their legal authority, I may be required to provide it. • If a patient files a worker’s compensation claim, I must, upon appropriate request, disclose information relevant to the claimant's condition to the worker’s compensation insurer. ▪ I am required by law to report any suspected child abuse, neglect, or sexual abuse to protect the child/children involved. ▪ I am obligated by law to report any suspected abuse, neglect, or sexual abuse of an older adult or dependent adult to protect the older adult or dependent adult involved. ▪ Please be aware that information shared with me will be disclosed to your partner or family if they participate in couples or family treatment. I will not agree to hold secrets on any one partner’s behalf. If you feel something should not be shared with your partner, please do not tell me your secret(s). At such times, it may be most appropriate for you to seek the support of an individual therapist who is independent of your couple’s treatment and who will consult with me regarding the broad issues and not the specifics of your secret(s). While this written summary of exceptions to confidentiality should prove helpful in informing you about potential problemsexceptions to confidentiality, it is essential that we important to discuss any questions or concerns that you may have now or in as we go along. We will be more than happy to discuss these issues with you. Please note, however, that we are not an attorneys, and formal legal advice is sometimes warranted because the future. The laws governing confidentiality can be are quite complex, and I am not an attorney. In situations where specific advice is required, formal legal advice may  (type in name) Signature of parent/guardian (responsible party)   Date  (type in name) Signature of client to be needed.tested   Date  (type in name) Signature of psychologist/psychometrician   Date

Limits of Confidentiality. The law protects the privacy of all communications between a patient client and a psychologist. In most situations, I we can only release information about your treatment to others only if you sign a written Authorization form that meets specific certain legal requirements imposed by state law and HIPAA. But there There are some other situations where I am permitted or required to disclose information without either your that require only that you provide written, advance consent. Your signature on this Agreement provides consent or authorizationfor those activities, as follows: • If a patient threatens to harm themself, I We may be obligated to seek hospitalization for them or contact family members or others who can help provide protection. ▪ If a patient communicates a serious threat of physical violence against an identifiable victim, I must take protective actions, including notifying the potential victim and contacting the police. I may also seek hospitalization of the patient or contact others who can assist in protecting the victim. ▪ Disclosures may be required to health insurers or to collect overdue fees. • I occasionally find it helpful to consult other health and mental health professionals about a case. During a consultation, I we make every effort to avoid revealing the identity of my the patient. The other professionals are also legally bound to keep the information confidential. If you don’t object, I we will not tell you about these consultations unless I we feel that it is essential important to our work together. I We will note all consultations in your Clinical Record. • I We may access your Clinical Record with an appropriate purpose including but not limited to, documenting the patient's treatment, billing insurance; conducting peer review or quality assurance activity, supervision, or for a purpose expressly authorized by the patient. • Disclosures required by health insurers or to collect overdue fees are discussed elsewhere in this Agreement. • If a client threatens to harm himself/herself, we may be courtobligated to seek hospitalization for him/her, or to contact family members or others who can help provide protection. There are some situations where we are permitted or required to disclose information without either your consent or Authorization: • If you are involved in a court proceeding and a request is made for information concerning your diagnosis and treatment, such information is protected by the psychologist-ordered client privilege law. We cannot provide any information without your written authorization, or a court order. If you are involved in or contemplating litigation, you should consult with your attorney to release treatment determine whether a court would be likely to order your therapist to disclose information. • If a government agency is requesting the information and records in alleged criminal or civil liability casesfor health oversight activities, we may be required to provide it for them. In addition, if • If a client files a complaint or lawsuit against meus, I we may disclose relevant information regarding that client in order to defend myselfourselves. • If we are being compensated for providing treatment to you as a government agency requests the information for health oversight activities under their legal authority, I may be required to provide it. • If a patient files result of your having filed a worker’s compensation claimclaim or through an automobile insurance plan, I we must, upon appropriate request, provide information necessary for utilization review purposes. There are some situations in which we are legally obligated to take actions which we believe are necessary to attempt to protect others from harm and we may have to reveal some information about a patient’s treatment. These situations are unusual in our practice. • If we have reasonable cause to suspect child abuse or neglect, the law requires that we file a report with the Family Independence Agency. Once such a report is filed, we may be required to provide additional information. • If we have reasonable cause to suspect the “criminal abuse” of an adult client, we must report it to the police. Once such a report is filed, we may be required to provide additional information. • If a client communicates a threat of physical violence against a reasonably identifiable third person and the client has the apparent intent and ability to carry out that threat in the foreseeable future, we may have to disclose information relevant in order to take protective action. These actions may include notifying the claimant's condition to potential victim (or, if the worker’s compensation insurer. ▪ I am required by law to report any suspected child abusevictim is a minor, neglecthis/her parents and the county Department of Social Services) and contacting the police, or sexual abuse to protect and/or seeking hospitalization for the child/children involved. ▪ I am obligated by law to report any suspected abuse, neglect, or sexual abuse of an older adult or dependent adult to protect the older adult or dependent adult involved. ▪ Please be aware that information shared with me will be disclosed to your partner or family if they participate in couples or family treatment. I will not agree to hold secrets on any one partner’s behalfclient. If such a situation arises, we will make every effort to fully discuss it with you feel something should not be shared with your partner, please do not tell me your secret(s). At such times, it may be most appropriate for you before taking any action and we will limit our disclosure to seek the support of an individual therapist who what is independent of your couple’s treatment and who will consult with me regarding the broad issues and not the specifics of your secret(s)necessary. While this written summary of exceptions to confidentiality should prove helpful in informing you about potential problems, it is essential important that we discuss any questions or concerns that you may have now or in the future. 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.

Limits of Confidentiality. The law protects In general, the privacy of all communications between a patient client and a psychologist. In most situationstherapist or psychologist is protected by law, I and we can only release information about your treatment our work to others if with your written permission. But, there are a few exceptions: In most legal proceedings, you sign have the right to prevent us from providing any information about your treatment. In some proceedings involving child custody and those in which your emotional condition is an important issue, a written Authorization form that meets specific legal requirements imposed by state law and HIPAAjudge may order our testimony. But there However, such an order is unlikely. We would advise you never to agree to any release of information without first discussing it with us. There are some situations where I am permitted in which we are legally obligated to take action to protect others from harm, even if we have to reveal some information about a client’s treatment. For example, if we believe that a child, elderly person or disabled person is being abused, we must file a report with the appropriate state agency. If we believe that a client is threatening bodily harm to another, we may be required to disclose information without either your consent take protective actions. These actions may include notifying the potential victim, contacting the police, or authorization: • seeking hospitalization for our clients. If a patient client threatens harm to harm themselfherself/himself, I we may be obligated to seek hospitalization for them or a higher level of care including hospitalization, and/or to contact family members or others who can may help provide protection. ▪ If a patient communicates similar situation occurs in the course of our work together, we will attempt to fully discuss it with you before taking any action. The prior situations have rarely occurred in our practice. If a serious threat of physical violence against an identifiable victimsimilar situation occurs, I must take protective actions, including notifying the potential victim and contacting the policewe will make every effort to fully discuss it with you before taking any action. I We may also seek hospitalization of the patient or contact others who can assist in protecting the victim. ▪ Disclosures may be required to health insurers or to collect overdue fees. • I occasionally find it helpful to consult with other health and mental health professionals about a caseclient in order to provide best care. During a consultation, I we make every effort to avoid revealing completely disguise the identity of my patienteach client. The other professionals Consultants are also legally bound to keep the information confidential. If you don’t object, I we typically will not tell you about these consultations unless I feel we believe it is essential important to our work together. I will note all consultations in your Clinical Record. • I may be court-ordered to release treatment information and records in alleged criminal or civil liability cases. In addition, if a client files a complaint or lawsuit against me, I may disclose relevant information regarding that client to defend myself. • If a government agency requests the information for health oversight activities under their legal authority, I may be required to provide it. • If a patient files a worker’s compensation claim, I must, upon appropriate request, disclose information relevant to the claimant's condition to the worker’s compensation insurer. ▪ I am required by law to report any suspected child abuse, neglect, or sexual abuse to protect the child/children involved. ▪ I am obligated by law to report any suspected abuse, neglect, or sexual abuse of an older adult or dependent adult to protect the older adult or dependent adult involved. ▪ Please be aware that information shared with me will be disclosed to your partner or family if they participate in couples or family treatment. I will not agree to hold secrets on any one partner’s behalf. If you feel something should not be shared with your partner, please do not tell me your secret(s). At such times, it may be most appropriate for you to seek the support of an individual therapist who is independent of your couple’s treatment and who will consult with me regarding the broad issues and not the specifics of your secret(s). While this written summary of exceptions to confidentiality should prove helpful in informing you about potential problemsexceptions to confidentiality, it is essential that we important to discuss any questions or concerns that you may have now or in as we go along. We will be more than happy to discuss these issues with you. Please note, however, that we are not an attorneys, and formal legal advice is sometimes warranted because the future. The laws governing confidentiality can be are quite complex, and I am not an attorney. In situations where specific advice is required, formal legal advice may be needed.  Signature (type in) of client   Date

Limits of Confidentiality. The law protects the privacy of all communications between a patient and a psychologistmental health professional. In most situations, I we can only release information about your treatment to others if you sign a written Authorization authorization form that meets specific certain legal requirements imposed by state law and HIPAAHIPPA. But there There are some situations where I am permitted or required to disclose information without either your that require only that you provide written, advance consent. Your signature on this Agreement provides consent or authorizationfor those activities as follows: • If a patient threatens to harm themself, I We may be obligated to seek hospitalization for them or contact family members or others who can help provide protection. ▪ If a patient communicates a serious threat of physical violence against an identifiable victim, I must take protective actions, including notifying the potential victim and contacting the police. I may also seek hospitalization of the patient or contact others who can assist in protecting the victim. ▪ Disclosures may be required to health insurers or to collect overdue fees. • I occasionally find it helpful to consult other health and mental health professionals about a case. During a consultation, I we make every effort to avoid revealing the identity of my our patient. The other professionals are also legally bound to keep the information confidential. If you don’t object, I we will not tell you about these consultations unless I we feel that it is essential important to our work together. I We will note all consultations in your Clinical Recordclinical record (which is called “PHI” in our Notice of Psychologist’s Policies and Practices to Protect the Privacy of Your Health Information). There are some situations where we are permitted or required to disclose information without either your consent or Authorization: • I may If you are involved in a court proceeding and a request is made for information concerning your diagnosis and treatment, such information is protected by the clinician-patient privilege law. We cannot provide any information without your (or your legal representative’s) written authorization or a court order. If you are involved in contemplating litigation, you should consult with your attorney to determine whether a court would be court-ordered likely to release treatment information and records in alleged criminal or civil liability cases. In addition, if a client files a complaint or lawsuit against me, I may order us to disclose relevant information regarding that client to defend myselfinformation. • If a government agency requests is requesting the information for health oversight activities under their legal authorityactivities, I we may be required to provide itit for them. • If a patient files a workercomplaint or lawsuit against his/her clinician, that clinicians may disclose relevant information regarding that patient in order to defend themselves. There are some situations in which we are legally obligated to take actions, which we believe are necessary to attempt to protect others from harm and we may have to reveal some information about a patient’s compensation claimtreatment. These situations are unusual in our practice. • If we have cause to believe that a child under 18 has been or may be abused or neglected (including physical injury, I mustsubstantial threat of harm, upon appropriate requestmental or emotional injury, disclose information relevant or any kind of sexual contact or conduct), or that a child is a victim of a sexual offense, or that an elderly or disabled person is in a state of abuse, neglect or exploitation, the law requires that we make a report to the claimant's condition appropriate governmental agency, usually the Department of Family Protective Services. Once such report is filed, we may be required to provide additional information. • If we determine that there is a probability that the worker’s compensation insurerpatient will inflict imminent physical injury on another, or that the patient will inflict imminent physical, mental or emotional harm upon himself/herself, or others, we may be required to take protective action by disclosing information to medical or law enforcement personnel or by securing hospitalization of the patient. ▪ I am required by law If such a situation arises, we will make every effort to report fully discuss it with you before taking any suspected action and we will limit our disclosure to what is necessary. However, in cases that involve child abuse, neglect, Section 611 of the Texas Health and Safety laws allows for clinicians to refuse to disclose information to a parent who may pose substantial harm to a child either physically or sexual abuse to protect the child/children involved. ▪ I am obligated by law to report any suspected abuse, neglect, or sexual abuse of an older adult or dependent adult to protect the older adult or dependent adult involved. ▪ Please be aware that information shared with me will be disclosed to your partner or family if they participate in couples or family treatment. I will not agree to hold secrets on any one partner’s behalf. If you feel something should not be shared with your partner, please do not tell me your secret(s). At such times, it may be most appropriate for you to seek the support of an individual therapist who is independent of your couple’s treatment and who will consult with me regarding the broad issues and not the specifics of your secret(s)emotionally. While this written summary of exceptions to confidentiality should prove helpful in informing you about potential problems, it is essential important that we you discuss any questions or concerns that you may have now or in the futurefuture with your psychologist/therapist. The laws governing confidentiality can be quite complex, and I am the clinicians at MOCE are not an attorneyattorneys. In situations where specific advice is required, formal legal advice may be needed.. PROFESSIONAL RECORDS

Limits of Confidentiality. The law protects In general, the privacy of all communications between a patient client and a psychologist. In most situationspsychotherapist is protected by law, and I can only release information about your treatment our work to others if you sign a with your written Authorization form that meets specific legal requirements imposed by state law and HIPAApermission. But there are a few exceptions. In most legal proceedings, you have the right to prevent me from providing any information about your treatment. In some proceedings involving child custody and those in which your emotional condition is an important issue, a judge may order my testimony if he/she determines that the issues demand it. There are some situations where in which I am permitted 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 am required to disclose information without either your consent file a report with the appropriate state agency. If I believe that a client is threatening serious bodily harm to another, I am required to take protective actions. These actions may include notifying the potential victim, contacting the police, or authorization: • seeking hospitalization for the client. If a patient the client threatens to harm themselfhimself/herself, I may be obligated to seek hospitalization for them him/her or to contact family members or others who can help provide protection. ▪ These situations have rarely occurred in my practice. If a patient communicates a serious threat of physical violence against an identifiable victimsimilar situation occurs, I must take protective actions, including notifying the potential victim and contacting the policewill make every effort to fully discuss it with you before taking any action. I may also seek hospitalization of the patient or contact others who can assist in protecting the victim. ▪ Disclosures may be required to health insurers or to collect overdue fees. • I occasionally find it helpful to consult other health and mental health professionals about a case. During a consultation, I make every effort to avoid revealing the identity of my patient. The other professionals are 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 essential important to our work together. I will note all consultations in your Clinical Record. • I may be court-ordered to release treatment information and records in alleged criminal or civil liability cases. In addition, if a client files a complaint or lawsuit against me, I may disclose relevant information regarding that client to defend myself. • If a government agency requests the information for health oversight activities under their legal authority, I may be required to provide it. • If a patient files a worker’s compensation claim, I must, upon appropriate request, disclose information relevant to the claimant's condition to the worker’s compensation insurer. ▪ I am required by law to report any suspected child abuse, neglect, or sexual abuse to protect the child/children involved. ▪ I am obligated by law to report any suspected abuse, neglect, or sexual abuse of an older adult or dependent adult to protect the older adult or dependent adult involved. ▪ Please be aware that information shared with me will be disclosed to your partner or family if they participate in couples or family treatment. I will not agree to hold secrets on any one partner’s behalf. If you feel something should not be shared with your partner, please do not tell me your secret(s). At such times, it may be most appropriate for you to seek the support of an individual therapist who is independent of your couple’s treatment and who will consult with me regarding the broad issues and not the specifics of your secret(s). While this written summary of exceptions to confidentiality should prove helpful in informing you about potential problems, it is essential important that we discuss any questions or concerns that you may have now or in 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 future. The laws governing confidentiality can be are quite complex, and I am not an attorney. In situations where specific advice is requiredIf you request, formal legal advice I will provide you with relevant portions or summaries of the state laws regarding these issues. Communication between your behavioral health provider(s) and your primary care physician (PCP) may be neededimportant to ensure the continuity of care and that all care is complete, comprehensive, and well-coordinated. I however, I will not do so without your consent. HIPPA CONSENT TO USE OR DISCLOSE INFORMATION FOR TREATMENT, PAYMENT AND HEALTHCARE OPERATIONS Federal regulations (HIPPA) allow me to use or disclose Protected Healthcare Information (PHI) from your records in order to provide treatment to you, to obtain payment for the services I provide, and for other professional activities known as “healthcare operations”. Nevertheless, I ask your consent in order to make this permission explicit. The Notice of Privacy Practices describes these disclosures in more detail. You have the right to review the Notice of Privacy Practices before signing this consent. I reserve the right to revise my Notice of Privacy Practices at any time. You may ask me to restrict the use and disclosure of certain information in your record that otherwise would be disclosed for treatment, payment, or health care operations; however, I do not have to agree to these restrictions. If I do agree to a restriction, that agreement is binding. You may revoke this consent at any time by giving written notification. Such revocation will not affect any action taken in reliance on the consent prior to the revocation. This consent is voluntary; you may refuse to sign it. However, I am permitted to refuse to provide healthcare services if this consent is not granted, or if the consent is later revoked. I hereby consent to the use or disclosure of my Protected Health Information as specified above.

Limits of Confidentiality. The law protects the privacy of all communications between a patient and a psychologist. In most situations, I can only release information about your treatment to others if you sign a written Authorization authorization form that meets specific certain legal requirements imposed by state law and HIPAA. But there are some situations where I am permitted or required to disclose information without either your consent or authorizationSome exceptions are: •  If a patient seriously threatens to harm themself, himself/herself or another person  If I have cause to believe that a child under 18 (or person 65 and older) has been or may be abused or neglected  If a court order or other legal proceedings or statute require disclose.  I may be obligated to seek hospitalization for them or contact family members or others who can help provide protection. ▪ If a patient communicates a serious threat of physical violence against an identifiable victim, I must take protective actions, including notifying the potential victim and contacting the police. I may also seek hospitalization of the patient or contact others who can assist in protecting the victim. ▪ Disclosures may be required to health insurers or to collect overdue fees. • I occasionally find it helpful to consult other health and mental health professionals about a case. During a consultation, I make every effort to avoid revealing the identity of my patient. The other professionals are also legally bound to keep the information confidential. If you don’t object You should be aware that I employ administrative staff. In most cases, I will need to share protected information with these individuals for both clinical and administrative purposes, such as scheduling, billing and quality assurance. All staff members have been given training about protecting your privacy and have agreed not tell you about these consultations unless I feel it to release any information outside of the practice without the permission of a professional staff member.  If a government agency is essential to our work together. I will note all consultations in your Clinical Record. • requesting the information for health oversight activities, I may be court-ordered required to release treatment information and records in alleged criminal or civil liability casesprovide it for them. In addition, if  If a client patient files a complaint or lawsuit against me, I may disclose relevant information regarding that client patient in order to defend myself. • If a government agency requests the information for health oversight activities under their legal authority, I may be required to provide it. •  If a patient files a worker’s compensation claim, I must, upon appropriate request, disclose information relevant provide records relating to the claimant's condition treatment or hospitalization for which compensation is being sought.  If your report to the worker’s compensation insurer. ▪ I am required by law to report any suspected child abuse, neglect, or me that you are a victim of sexual abuse to protect by a mental health professional or member of the child/children involvedclergy. ▪ I am obligated by law to report any suspected abuseIf such a situation arises, neglect, or sexual abuse of an older adult or dependent adult to protect the older adult or dependent adult involved. ▪ Please be aware that information shared with me will be disclosed to your partner or family if they participate in couples or family treatment. I will not agree make every effort to hold secrets on fully discuss it with you before taking any one partner’s behalf. If you feel something should not be shared with your partner, please do not tell me your secret(s). At such times, it may be most appropriate for you to seek the support of an individual therapist who is independent of your couple’s treatment and who will consult with me regarding the broad issues and not the specifics of your secret(s). While this written summary of exceptions to confidentiality should prove helpful in informing you about potential problems, it is essential that we discuss any questions or concerns that you may have now or in the future. The laws governing confidentiality can be quite complex, action and I am not an attorney. In situations where specific advice will limit my disclosure to what is required, formal legal advice may be needednecessary.

Limits of Confidentiality. The law protects the privacy of all communications between a patient and a psychologisttherapist. In most situations, I your therapist can only release information about your treatment to others if you sign a written Authorization authorization form that meets specific certain legal requirements imposed by state law HIPAA and/or Iowa law. However, in certain specific situations, no authorization is required, such as:  Your therapist may occasionally find it helpful to consult with other CRCPG therapists about your care. During a consultation, she will conceal your actual identity, as well as any other identifying information. The other CRCPG therapists are also legally bound to keep any information confidential and HIPAAall receive regular training about the rules, regulations, and ethics of confidentiality. But there  If you are some situations where I am permitted involved in or are contemplating a lawsuit or legal action, your records may be subject to a court or administrative order or a subpoena. Your therapist may be required to provide the requested information.  If you communicate an imminent threat of serious physical harm to yourself or to an identifiable victim, the therapist may be required to disclose confidential information without either your consent in order to take protective actions. These actions may include initiating hospitalization, contacting a family physician or authorization: • If psychiatrist, contacting the police for a patient threatens to harm themselfsafety check, I may be obligated to seek hospitalization for them notifying the potential victim, or contact contacting family members or others who can help provide assist in providing protection. ▪  If the therapist has reasonable cause to believe that a patient communicates child or a serious threat dependent adult to whom she has provided professional services has been abused, the law requires that she file a report with the appropriate government agency, usually the Department of physical violence against an identifiable victimHuman Services. Once such a report is filed, I must take protective actions, including notifying the potential victim and contacting the police. I may also seek hospitalization of the patient or contact others who can assist in protecting the victim. ▪ Disclosures may be required to health insurers or to collect overdue fees. • I occasionally find it helpful to consult other health and mental health professionals about a case. During a consultation, I make every effort to avoid revealing the identity of my patient. The other professionals are also legally bound to keep the information confidential. If you don’t object, I will not tell you about these consultations unless I feel it is essential to our work together. I will note all consultations in your Clinical Record. • I may be court-ordered to release treatment information and records in alleged criminal or civil liability cases. In addition, if a client files a complaint or lawsuit against me, I may disclose relevant information regarding that client to defend myself. • If a government agency requests the information for health oversight activities under their legal authority, I she may be required to provide itadditional information. • If  The therapist is legally obligated to release your protected health information in circumstances noted on the Notice of Privacy Practices form. Couples Counseling When I work with a patient files a worker’s compensation claimcouple, I mustconsider your relationship to be the client. During the course of our work, upon appropriate request, disclose information relevant to I may see one of you individually for one or more sessions or for part of a session. These sessions should be viewed as part of the claimant's condition to the worker’s compensation insurer. ▪ work that I am required by law to report any suspected child abuse, neglect, or sexual abuse to protect doing with the child/children involvedcouple unless otherwise indicated. ▪ I am obligated by law to report any suspected abuse, neglect, or sexual abuse of an older adult or dependent adult to protect the older adult or dependent adult involved. ▪ Please be aware know that information shared with me will anything we discuss when your partner is not present may be disclosed to them if, in my best judgment, doing so is necessary to effectively help your partner or family relationship. Thus, if they participate in couples or family treatment. I will not agree to hold secrets on any one partner’s behalf. If you feel something should not it necessary to talk about matters that you absolutely want to be shared with your partnerno one, please do not tell me your secret(s). At such times, it may be most appropriate for you might want to seek the support of consult with an individual therapist who can treat you individually. This “no secrets” policy is independent intended to allow me to continue to treat the couple by preventing, to the extent possible, a conflict of interest to arise. Other than that, I will not disclose confidential information about your couple’s treatment and to anyone else unless all persons who will consult with me regarding the broad issues and not the specifics of your secret(s). While this written summary of exceptions to confidentiality should prove helpful in informing you about potential problems, it is essential that we discuss any questions or concerns that you may have now or participate in the future. 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 neededtreatment provide permission to release such information.

Limits of Confidentiality. The law protects the privacy of all communications between a patient and a psychologist. In most situations, I can only release information about your treatment to others if you sign a written Authorization consent form that meets specific certain legal requirements imposed by state law and HIPAAHIPAA and/or New York law. But there are some situations where I am permitted or required to disclose information without either your consent or authorizationHowever, in the following situations, no authorization is required: • If a patient threatens to harm themself, I may be obligated to seek hospitalization for them or contact family members or others who can help provide protection. ▪ If a patient communicates a serious threat of physical violence against an identifiable victim, I must take protective actions, including notifying the potential victim and contacting the police. I may also seek hospitalization of the patient or contact others who can assist in protecting the victim. ▪ Disclosures may be required to health insurers or to collect overdue fees. • I occasionally find it helpful to consult other health and mental health professionals about a case. During a consultation, I make every effort to avoid revealing the identity of my patient. The other professionals are 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 essential 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. If you are involved in a court proceeding and a request is made for information concerning your diagnosis and treatment, such information is protected by the psychologist-patient privilege law. I cannot provide any information without your written authorization, or a court order. If you are involved in or contemplating litigation, you should consult with your attorney to determine whether a court would be likely to order me to disclose information. If a government agency is requesting the information for health oversight activities, I may be court-ordered required to release treatment information and records in alleged criminal or civil liability casesprovide it for them. In addition, if If a client patient files a complaint or lawsuit against me, I may disclose relevant information regarding that client patient in order to defend myself. • There are some situations in which I am legally obligated to take actions, which I believe are necessary to attempt to protect others from harm and I may have to reveal some information about a patient’s treatment. These situations are unusual in my practice: If I have reason to believe that a child, adolescent, or vulnerable adult has been subjected to abuse or neglect, or that a vulnerable adult has been subjected to self-neglect, or exploitation, the law requires that I file a report with the appropriate government agency requests agency, usually the information for health oversight activities under their legal authoritylocal office of the Department of Social Services. Once such a report is filed, I may be required to provide itadditional information. • If I know that a patient files has a worker’s compensation claimpropensity for violence and the patient indicates that he/she has the intention to inflict imminent physical injury upon a specified victim(s), I mustmay be required to take protective actions. These actions may include establishing and undertaking a treatment plan that is calculated to eliminate the possibility that the patient will carry out the threat, upon appropriate request, disclose information relevant to seeking hospitalization of the claimant's condition to patient and/or informing the worker’s compensation insurerpotential victim or the police about the threat. ▪ If I am required by law to report any suspected child abuse, neglectbelieve that there is an imminent risk that a patient will inflict serious physical harm or death on him/herself, or sexual abuse 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 initiating hospitalizations and/or notifying family members or others who can protect the child/children involvedpatient. ▪ I am obligated by law to report any suspected abuseIf such a situation arises, neglect, or sexual abuse of an older adult or dependent adult to protect the older adult or dependent adult involved. ▪ Please be aware that information shared with me will be disclosed to your partner or family if they participate in couples or family treatment. I will not agree make every effort to hold secrets on fully discuss it with you before taking any one partner’s behalf. If you feel something should not be shared with your partner, please do not tell me your secret(s). At such times, it may be most appropriate for you action and I will limit my disclosure to seek the support of an individual therapist who what is independent of your couple’s treatment and who will consult with me regarding the broad issues and not the specifics of your secret(s)necessary. While this written summary of exceptions to confidentiality should prove helpful in informing you about potential problems, it is essential important that we discuss any questions or concerns that you may have have, now or in the future. 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 The laws and standards of the profession require that I keep Protected Health Information (PHI) about each client in their clinical record. In some circumstances, I may keep some information in two sets of professional records. One set is your clinical record. It includes information about your reasons for seeking therapy and how these and related issues impact on your life, your diagnosis, goals for treatment, progress towards the goals, your medical treatment and social history, past treatment records I receive from other providers, reports of professional consultations, billing records, and any reports to insurance carriers or others. You may choose, in writing, to examine and/or receive a copy of your clinical record. Because professional records can be misinterpreted it would be important to first review them together or with another mental health professional. In very unusual circumstances, such as a situation in which in my professional judgment disclosing information would endanger someone’s life, then clinical records would not be released. In those situations, the person would have a right to a summary and to have their record sent to another mental health provider. A copying fee of $.60 per page will be charged. There may be other associated costs for review of records. The other set I keep in some instances is a set of psychotherapy notes. These notes are for my own use and are designed to 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 conservations, 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. These psychotherapy notes are kept separate from your clinical record. While insurance companies can request and receive a copy of your clinical record, they cannot receive a copy of your psychotherapy notes without your signed, written authorization. Insurance companies cannot require your authorization as a condition of coverage nor penalize you in any way for your refusal. You may examine and/or receive a copy of your psychotherapy notes unless I determine that knowledge of the health care information would be injurious to your health. Patient Rights HIPAA provides you with expanded rights regarding clinical records and disclosures of protected health information. These include requesting that I amend your record; requesting restrictions on what information from your clinical record is disclosed; requesting an accounting of disclosures; determining where protected information disclosures are sent; having any complaints you make about my policies recorded in your records; and the right to a paper copy of this agreement, my policies and procedures, and the attached HIPAA notice form. Minors & Parents Parents of clients 16 years of age who are not emancipated may be allowed by law to examine their child’s records. While privacy in psychotherapy is very important, particularly with teenager, parental involvement is also essential to successful treatment. Therefore, it is my policy when treating 16- to 18-year-olds to request that they agree to my sharing occasional general information about the progress of treatment with his/her parents. Unless I feel discussing disclosure prior to parental notification is not realistic, such as when the child is in danger or is a danger to someone else, I will discuss with the child, what I think is in their best interest to discuss with the parents and preferably both the child and I will talk with the parents together.

Limits of Confidentiality. The law protects the privacy of all communications between a patient and a psychologistpsychiatrist. In most situations, I can only release information about your treatment to others if you sign a written Authorization form that meets specific certain legal requirements imposed by state law and HIPAAHIPPA. But there There are some other situations where I am permitted or required to disclose information without either your that require only that you provide written, advance consent. Your signature on this Agreement provides consent or authorizationfor those activities as follows: • If a patient threatens to harm themself, I may be obligated to seek hospitalization for them or contact family members or others who can help provide protection. ▪ If a patient communicates a serious threat of physical violence against an identifiable victim, I must take protective actions, including notifying the potential victim and contacting the police. I may also seek hospitalization of the patient or contact others who can assist in protecting the victim. ▪ Disclosures may be required to health insurers or to collect overdue fees. • I occasionally find it helpful to consult other health and mental health professionals about a case. During a consultation, I make every effort to avoid revealing the identity of my patient. The other professionals are also legally bound to keep the information confidential. If you don’t object, I will not tell you about these consultations unless I feel it is essential to our work together. I will note all consultations in your Clinical RecordRecord (which is called “PHI” in my Notice of Psychiatrist’s Policies and Practices to Protect the Privacy of your Health Information). • You should be aware that I practice with other mental health professionals and that I employ administrative staff. In most cases, I need to share protected information with these individuals for both clinical and administrative purposes, such as scheduling, billing and quality assurance. All staff members have been given training about protecting your privacy and have agreed not to release any information outside of the practice without the permission of a professional staff member. Disclosures required by health insurers or to collect overdue fees are discussed elsewhere in this Agreement. If a patient threatens to harm himself/herself, I may be courtobligated to seek hospitalization for him/her or to contact family members or others who can help provide protection. There are some situations where I am permitted or required to disclose information without either your consent or Authorization: If you are involved in a court proceeding and a request is made for information concerning the professional services that I provided you, such information is protected by the psychiatrist-ordered patient privilege law. I cannot provide any information without your written authorization, or a court order. If you are involved in or contemplating litigation, you should consult with your attorney to release treatment determine whether a court would be likely to order me to disclose information. If a government agency is requesting information and records in alleged criminal or civil liability casesfor health oversight activities, I may be required to provide it for them. In addition, if If a client patient files a complaint or lawsuit against me, I may disclose relevant information regarding that client patient in order to defend myself. • If I am providing treatment for conditions directly related to worker’s compensation claim, I may have to submit such records, upon appropriate request, to Chairman of the Worker’s Compensations Board on such forms and at such times as the chairman may require. There are some situations in which I am legally obliged to take actions, which I believe are necessary to attempt to protect others from harm and I may have to reveal some information about a government agency requests patient’s treatment. These situations are unusual in my practice. If I receive information in my professional capacity from a child or the information for health oversight activities under their legal authorityparents or guardian or other custodian of a child that gives me reasonable cause to suspect that a child is an abused or neglected child, the law requires that I report to the appropriate governmental agency, usually the statewide central register of child abuse and maltreatment, or the local child protective services office. Once such a report is filed, I may be required to provide itadditional information. • If a patient files a worker’s compensation claimcommunicates an immediate threat of serious physical harm to an identifiable victim, I mustmay be required to take protective actions. These actions may include notifying the potential victim, upon appropriate request, disclose information relevant to contacting the claimant's condition to the worker’s compensation insurer. ▪ I am required by law to report any suspected child abuse, neglectpolice, or sexual abuse to protect seeking hospitalization for the child/children involvedpatient. ▪ I am obligated by law to report any suspected abuseIf such a situation arises, neglect, or sexual abuse of an older adult or dependent adult to protect the older adult or dependent adult involved. ▪ Please be aware that information shared with me will be disclosed to your partner or family if they participate in couples or family treatment. I will not agree make every effort to hold secrets on fully discuss it with you before taking any one partner’s behalf. If you feel something should not be shared with your partner, please do not tell me your secret(s). At such times, it may be most appropriate for you action and I will limit my disclosure to seek the support of an individual therapist who what is independent of your couple’s treatment and who will consult with me regarding the broad issues and not the specifics of your secret(s)necessary. While this written summary of exceptions to confidentiality should prove helpful in informing you about potential problems, it is essential important that we discuss any questions or concerns that you may have now or in the future. The laws governing confidentiality can be quite complex, and I am not an attorney. PROFESSIONAL RECORDS The laws and standard of my profession require that I keep Protected Health Information about you in your Clinical Record. Except in unusual circumstances that involve danger to yourself and/or others or where information has been supplied to me confidentially by others, you may examine and/or receive a copy of your Clinical Record, if you request it in writing. Because these are professional records, they can be misinterpreted and/or upsetting to untrained readers. For this reason, I recommend that you initially review them in my presence, or have them or have them forwarded to another mental health professional so you can discuss the contents. I am allowed to charge a copy fee of 75 cents per page (and for certain other expenses). If I refuse your request for access to your records, you have a right to review, which I will discuss with you upon request. PATIENT RIGHTS HIPAA provides you with several new or expanded rights with regard to your Clinical Records and disclosures of protected health information. These rights include requesting that I amend your record; requesting restrictions on what information from your Clinical Records is disclosed to others; requesting an accounting of most disclosures of protected health information that you have neither consented to not authorize; determining the location to which protected information disclosures are sent; having any complaints you make about my policies and procedures recorded in your records; and the right to a paper copy of this Agreement, the attached Notice form, and my privacy policies and procedures. I am happy to discuss any of these rights with you. BILLING AND PAYMENTS You will be expected to pay for each session at the time it is held, unless we agree otherwise or unless you have insurance coverage that requires another arrangement. Payment schedules for other professional services will be agreed to when they are requested. (In situations where specific advice is requiredcircumstances of unusual financial hardship, formal legal advice I may be neededwilling to negotiate a fee adjustment or payment installment plan.) If your account has not been paid for more than 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 otherwise confidential information. In most collection situations, the only information I release regarding a patient’s treatment is his/her name, the nature of services provided, and the amount due. (If legal action is necessary, its costs will be included in the claim.) INSURANCE REIMBURSEMENT In order for us to set realistic treatment goals and priorities, it is important to evaluate what resources you have available to pay for your treatment. 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 my fees. It is very important that you find out exactly what mental health services your insurance policy covers. You should carefully read the section in your insurance coverage booklet that describes mental health services. If you have questions about the coverage, call your plan administrator. Of course, I will provide you with whatever information I can based on my experience and will be happy to help you in understanding the information you receive from your insurance company. If it is necessary to clear confusion, I will be willing to call the company on your behalf. Due to the rising costs of health care, insurance benefits have increasingly become more complex. It is sometimes difficult to determine exactly how much mental health coverage is available. “Managed Health Care” plans such as HMOs and PPOs often require authorization before they provide reimbursement for mental health services. These plans are often limited to short-term treatment approaches designed to work out specific problems that interfere with a person’s usual level of functioning. It may be necessary to seek approval for more therapy after a certain number of sessions. While much can be accomplished in short-term therapy, some patients feel that they need more services after insurance benefits end. (Some managed-care plans will not allow me to provide services to you once your benefits end. If this is the case, I will do my best to find another provider who will help you continue your psychotherapy.) You should also be aware that your contract with your health insurance company requires that I provide it with information relevant to the services that I provide additional clinical information such as treatment plans or summaries, or copies of your entire Clinical Record. In such situations, I will make every effort to release only the minimum information about you that is necessary for the purpose requested. This information will become part of the insurance company files and will probably be stored in our computer. Though all insurance companies claim to keep such information confidential, I have no control over what they do with it once it is in their hands. In some cases, they may share the information with the national medical information database. I will provide you with a copy of any report I submit, if you request it. By signing this Agreement, you agree that I can provide requested information to your carrier. Once we have all of the information about your insurance coverage, we will discuss what we can expect to accomplish with the benefits that are available and what will happen if they run out before you feel ready to end your sessions. It is important to remember that you always have the right to pay for my services yourself to avoid the problems described above (unless prohibited by contract). YOUR SIGNATURE BELOW INDICATES THAT YOU HAVE READ THIS AGREEMENT AND AGREE TO ITS TERMS AND ALSO SERVES AS AN ACKNOWLEDGEMENT THAT YOU HAVE RECEIVED THE HIPAA NOTICE FORM DESCRIBED ABOVE. _______________________________ _____________________________________ Patient Signature Witness _______________________________ ______________________________________

Limits of Confidentiality. The law protects the privacy of all communications between a patient and a psychologist. In most situations, I can only release information about your treatment to others if you sign a written Authorization form that meets specific certain legal requirements imposed by state law and and/or HIPAA. But But, there are some situations where I am permitted or required to disclose information without either your consent or authorization: • If a patient threatens to harm themselfhimself/herself, I may be obligated to seek hospitalization for them him/ her, or to contact family members or others who can help provide protection. ▪ If a patient communicates a serious threat of physical violence against an identifiable victim, I must take protective actions, including notifying the potential victim and contacting the police. I may also seek hospitalization of the patient patient, or contact others who can assist in protecting the victim. ▪ Disclosures may be required to health insurers or to collect overdue fees. • I occasionally find it helpful to consult other health and mental health professionals about a case. During a consultation, I make every effort to avoid revealing the identity of my patient. The other professionals are 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 essential important to our work together. I will note all consultations in your Clinical Record. • In cases of alleged criminal or civil liability, I may be court-court ordered to release treatment information and records in alleged criminal or civil liability casesand/or records. In addition, if a client files a complaint or lawsuit against me, I may disclose relevant information regarding that client in order to defend myself. • If a government agency requests is requesting the information for health oversight activities under pursuant to their legal authority, I may be required to provide itit for them. • If a patient files a worker’s compensation claim, I must, upon appropriate request, disclose information relevant to the claimant's condition to the worker’s compensation insurer. ▪ I am required by law to report any suspected child abuse, neglect, or sexual abuse to protect the child/children involved. ▪ I am obligated by law to report any suspected abuse, neglect, or sexual abuse of an older adult elderly person or dependent adult to protect the older adult elderly person or dependent adult involved. ▪ Please I am obliged under the law to report to the appropriate authorities any instance where a patient discloses they have accessed, streamed, or downloaded material where a child is engaged in an obscene sexual act. ▪ In couples or family treatment, please be aware that information shared with me will be disclosed to your partner or family if they participate are participating in couples or family treatment. I will not agree to hold secrets on any one partner’s behalf. If you feel something should not be shared with your partner, please do not tell me your secret(s). At such times, it may be most appropriate for you to seek the support of an individual therapist who is independent of your couple’s treatment treatment, and who will consult with me regarding the broad issues issues, and not the specifics of your secret(s). While this written summary of exceptions to confidentiality should prove helpful in informing you about potential problems, it is essential important that we discuss any questions or concerns that you may have now or in the future. 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.

Limits of Confidentiality. The law protects the privacy of all communications between a patient and a psychologist. In most situations, I can only release information about your treatment to others if you sign a written Authorization to Release Information form that meets specific certain legal requirements imposed by state law and HIPAA. But there There are some other situations where I am permitted or required to disclose information without either your that require only that you provide written, advance consent. Your signature on this Agreement provides consent or authorizationfor those activities, as follows: • If a patient threatens to harm themselfhimself/herself, I may be obligated to seek hospitalization for him/her, or to contact family members or others who can help provide protection. • If I believe that a patient is threatening serious bodily harm to another, I am required to take protective actions. These actions may include notifying the potential victim, contacting the police, or seeking hospitalization for the patient. If the patient threatens to harm themselves, I may be obligated to seek hospitalization for them or to contact family members or others who can help provide protection. ▪ If a patient communicates a serious threat similar situation occurs in the course of physical violence against an identifiable victimour work together, I must take protective actions, including notifying the potential victim and contacting the police. I may also seek hospitalization of the patient or contact others who can assist in protecting the victim. ▪ Disclosures may be required will attempt to health insurers or to collect overdue feesfully discuss it with you before taking any action. • I may occasionally find it helpful to consult other health and mental health professionals about a case. During a consultation, I make every effort to avoid revealing the identity of my patient. The other professionals professions are 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 essential important to our work together. I will note all consultations in your Clinical RecordRecord (which is called “PHI” in my HIPAA Notice of Psychologist’s Policies and Privacy Practices of Your Health Information). • You should be aware that I may employ administrative staff. In those cases, I will need to share protected information with those individuals for administrative purposes, such as billing and quality assurance. All staff members will be court-ordered trained about protecting your privacy and will agree not to release treatment any information outside of the practice without my permission. There are some situations where I am permitted or required to disclose information without either your consent or Authorization. They are as follows: • If you are involved in a court proceeding and records a request is made for information concerning your diagnosis and treatment, such information is protected by the psychologist-patient privilege law. I cannot provide any information without your (or legal representative’s) written authorization, or a court order. If you are involved or contemplating litigation, you should consult with your attorney to determine where a court would be likely to order me to disclose information. • If the Alabama Board of Examiners in alleged criminal or civil liability casesPsychology is requesting the information for an investigation of my practice, I am required to provide it for them. In addition, if • If a client patient files a complaint compliant or lawsuit against me, I may disclose relevant information regarding that client patient in order to defend myself. • If a government agency requests the information for health oversight activities under their legal authority, I may be required to provide it. • If a patient files a worker’s compensation claim, I must, upon appropriate request, may disclose information relevant to the claimant's condition that claim to the workerpatient’s compensation employer or the insurer. ▪ There are some situations in which I am legally obligated to take actions, which I believe are necessary to attempt to protect others from harm, and I may have to reveal some information about a patient’s treatment. • If I know or suspect that a child under the age of 19 has been abused or neglected, the law requires that I file a report with the appropriate government agency, usually the Alabama Department of Human Resources. Once such report is filed, I may be required by law to report any suspected child abuseprovide additional information. • If I know or suspect that an elderly or disabled adult has been abused, neglectneglected, exploited, sexually, emotionally, or sexual abuse physically abused, the law requires that I file a report with the appropriate governmental agency, usually the Alabama Department of Human Resources. Once such report is filed, I may be required to protect provide additional information. • If I believe that disclosing information about you is necessary to prevent or lessen a serious and imminent threat to the child/children involved. ▪ I am obligated by law to report any suspected abuse, neglect, or sexual abuse health and safety of an older adult identifiable person(s), I may disclose that information, but only to those reasonably able to prevent or dependent adult to protect lessen the older adult or dependent adult involvedthreat. ▪ Please be aware that information shared with me will be disclosed to your partner or family if they participate in couples or family treatment. If one of these situations arise, I will not agree make every effort to hold secrets on fully discuss it with you before taking any one partner’s behalf. If you feel something should not be shared with your partneraction, please do not tell me your secret(s). At such times, it may be most appropriate for you and I will try to seek the support of an individual therapist who limit my disclosure to what is independent of your couple’s treatment and who will consult with me regarding the broad issues and not the specifics of your secret(s)necessary. While this written summary of exceptions to confidentiality should prove helpful in informing you about potential problems, it is essential important that we discuss any questions or concerns that you may have now or in the future. 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. PATIENT’S RIGHTS HIPAA provided you with several new or expanded rights with regard to your Clinical Record and disclosures of protected health information. 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 protected health information that you have neither consented to nor authorized; determining the location to which protected information disclosures are sent; having any complaints you make about my policies and procedures recorded in your records; and the right to a paper copy of this Agreement, the HIPAA Notice of Psychologist’s Policies and Privacy Practices of Your Health Information, and my procedures. I will be happy to discuss any of these rights with you. 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 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, test results, and any reports that have been sent to anyone, including reports to your insurance carrier. If you provide me with an appropriate written request, you have the right to examine and/or receive a copy of your records for a fee, except in unusual circumstances that involve danger to you or others. In those situations, you have a right to have your record sent to another mental health provider. The exceptions to this policy are contained in the attached Notice of Psychologist’s Policies and Practices to Protect the Privacy of Your Health Information form. If I refuse your request for access to your records, you have a right of review, which we will discuss with you upon request. In addition, I may also keep a set of Psychotherapy Notes. These notes are for my own use and are designed to assist me in providing you with the best treatment. While the contents of Psychotherapy Notes vary from patient to patient, 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. These Psychotherapy Notes are kept separate from your Clinical Record. While insurance companies can request and receive a copy of your Clinical Record, they cannot receive a copy of your Psychotherapy Notes without your Authorization. Insurance companies cannot require your Authorization as a condition of coverage nor penalize you in any way for your refusal. If I die or become incapacitated, there is a probability that a designated Professional Executor may take control of patient’s records and contact them. PROFESSIONAL FEES My fee for the initial consultation is $187.00. Sessions lengths can vary. Sessions between 16 and 37 minutes are billed at $93.00. Sessions between 38 and 52 minutes are billed at $140.00. Sessions over 52 minutes are billed at $187.00. Additional fees may be applied for additional services and interactive complexity, such as brief consultation with family members. Most insurances and managed care organizations require a co-pay and/or deductible for which you are responsible. If you are using your insurance, you are responsible for verification of coverage and for obtaining pre- authorization for these services prior to your first visit. OTHER FEES If we meet more than the usual time, I will charge accordingly. In addition to weekly appointments, I charge this same hourly rate for other professional services you may need, though I will prorate the hourly cost if I work for periods of less than one hour. Other professional services include report writing, telephone conversations lasting longer than 10 minutes, attendance at meetings with other professionals you have authorized, preparation of treatment summaries, and the time spent performing any other service you may request of me. If a check is returned, the returned check fee is $30.00. Any court appearance, or deposition, or the provision of documents for any attorney or for the court will be billed at a rate of $200 per hour, and will include preparation and travel time. You will be responsible for all such fees related to your evaluation or treatment, payable at the time any such court-related services are requested. The fee for Medical/Mental Health Records or written communications to you or on your behalf will be a minimum of $20 and can increase depending on time spent.

Limits of Confidentiality. The law protects the privacy of all communications between a patient and a psychologist. In most situations, I the office can only release information about your treatment to others only if you sign a written Authorization authorization form that meets specific legal requirements imposed by state law and HIPAA. But there Further information about these limitations can be found in the Notice posted in the waiting room. Absolute confidentiality and privacy of your medical records cannot be guaranteed, especially when it involves third party payers, such as an insurance carrier. At the outset of treatment, and thereafter, the office submits paperwork to your insurance carrier which may include specific information about your mental health, such as diagnosis, and medical conditions. Insurance carriers frequently conduct a clinical audit which includes chart review. There are some situations where I am when Xx. Xxxxx and Xx. Xxxxxxxxx are permitted or required to disclose information without either your consent or authorization, For example: • ! If a patient threatens to harm themself, I may be obligated to seek hospitalization for them or contact family members or others who can help provide protection. ▪ If a patient communicates you present a serious threat risk to your own health and safety or to that of physical violence against an identifiable victimanother person, I we must take protective actions, including notifying warn the potential victim and contacting victim(s), contact the police, or get you hospitalized. I may also seek hospitalization of the patient or contact others who can assist in protecting the victim. ▪ Disclosures may be required to health insurers or to collect overdue fees. • I occasionally find it helpful to consult other health and mental health professionals about a case. During a consultation, I make every effort to avoid revealing the identity of my patient. The other professionals are also legally bound to keep the information confidential. ! If you don’t object, I will not tell you about these consultations unless I feel it is essential to our work together. I will note all consultations in your Clinical Record. • I may be court-ordered to release treatment information and records in alleged criminal or civil liability cases. In addition, if a client files file a complaint or lawsuit against meXx. Xxxxx or Xx. Xxxxxxxxx, I may then as part of their defense they are permitted to disclose relevant information regarding that client to defend myselfyou. • ! If a government agency requests the information for health oversight activities under their legal authority, I may be required to provide it. • If a patient files you file a worker’s compensation claim, I mustinformation directly related to that claim must be provided to the Workers’ Compensation Commission, upon appropriate written request. ! As clinicians, disclose we are legally obligated to take actions that are necessary to protect others from harm. We may be required to reveal some information relevant about your treatment. For example, if there is reason to the claimant's condition to the worker’s compensation insurer. ▪ I am required know or suspect that a child has been abused or neglected by law to report any suspected child abuse, neglectan adult, or has been a victim of sexual abuse by another child, the law requires that we contact the police and/or the Department of Children, Youth, and Families. Once such a report is filed, we may be required to protect the childprovide additional information. RETURN OF BORROWED ITEMS: Personal books and electronic media are made available to encourage learning. Kindly return them when instructed. If they are lost or misplaced, you should replace them (in-kind or monetarily). Revised Therapy Agreement, January, 2020 [AMF/children involved. ▪ I am obligated by law to report any suspected abuseMSS] Acknowledgement of Therapy Agreement Your signature on this “acknowledgement” page affirms that you have read, neglectunderstood, or sexual abuse of an older adult or dependent adult to protect the older adult or dependent adult involved. ▪ Please be aware that information shared with me will be disclosed to your partner or family if they participate in couples or family treatment. I will not and agree to hold secrets on all our office policies. This document represents an agreement between us, revocable in writing by you at any one partner’s behalftime. If Your signature, and the date you feel something should not be shared with your partnersigned below, please do not tell me your secret(s). At such times, it may be most appropriate for you to seek the support of an individual therapist who is independent of your couple’s treatment and who will consult with me regarding the broad issues and not the specifics of your secret(s). While this written summary of exceptions to confidentiality should prove helpful in informing you about potential problems, it is essential that we discuss any questions or concerns indicates that you may have now or read the information in the futureTherapy Agreement and that you agree to abide by the terms it sets forth. The laws governing confidentiality Patient signature: Date: Please return this signed and dated “Acknowledgement of Therapy Agreement” page to Xx. Xxxxx or Xx. Xxxxxxxxx at your first appointment. Or you can be quite complexsend it back to us: 000 Xxxxxx Xxxx, and I am not an attorney. In situations where specific advice is requiredSuite 12, formal legal advice may be needed.Greenville, R.I. 02828

Limits of Confidentiality. The law protects In general, the privacy of all communications between a patient client and a psychologist. In most situationspsychotherapist is protected by law, and I can only release information about your treatment our work to others if you sign a with your written Authorization form that meets specific legal requirements imposed by state law and HIPAApermission. But there are a few exceptions. In most legal proceedings, you have the right to prevent me from providing any information about your treatment. In some proceedings involving child custody and those in which your emotional condition is an important issue, a judge may order my testimony if he/she determines that the issues demand it. There are some situations where in which I am permitted 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 am required to disclose information without either your consent file a report with the appropriate state agency. If I believe that a client is threatening serious bodily harm to another, I am required to take protective actions. These actions may include notifying the potential victim, contacting the police, or authorization: • seeking hospitalization for the client. If a patient the client threatens to harm themselfhimself/herself, I may be obligated to seek hospitalization for them him/her or to contact family members or others who can help provide protection. ▪ These situations have rarely occurred in my practice. If a patient communicates a serious threat of physical violence against an identifiable victimsimilar situation occurs, I must take protective actions, including notifying the potential victim and contacting the policewill make every effort to fully discuss it with you before taking any action. I may also seek hospitalization of the patient or contact others who can assist in protecting the victim. ▪ Disclosures may be required to health insurers or to collect overdue fees. • I occasionally find it helpful to consult other health and mental health professionals about a case. During a consultation, I make every effort to avoid revealing the identity of my patient. The other professionals are 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 essential important to our work together. I will note all consultations in your Clinical Record. • I may be court-ordered to release treatment information and records in alleged criminal or civil liability cases. In addition, if a client files a complaint or lawsuit against me, I may disclose relevant information regarding that client to defend myself. • If a government agency requests the information for health oversight activities under their legal authority, I may be required to provide it. • If a patient files a worker’s compensation claim, I must, upon appropriate request, disclose information relevant to the claimant's condition to the worker’s compensation insurer. ▪ I am required by law to report any suspected child abuse, neglect, or sexual abuse to protect the child/children involved. ▪ I am obligated by law to report any suspected abuse, neglect, or sexual abuse of an older adult or dependent adult to protect the older adult or dependent adult involved. ▪ Please be aware that information shared with me will be disclosed to your partner or family if they participate in couples or family treatment. I will not agree to hold secrets on any one partner’s behalf. If you feel something should not be shared with your partner, please do not tell me your secret(s). At such times, it may be most appropriate for you to seek the support of an individual therapist who is independent of your couple’s treatment and who will consult with me regarding the broad issues and not the specifics of your secret(s). While this written summary of exceptions to confidentiality should prove helpful in informing you about potential problems, it is essential important that we discuss any questions or concerns that you may have now or in 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 future. The laws governing confidentiality can be are quite complex, and I am not an attorney. In situations where specific advice is requiredIf you request, formal legal advice may be neededI will provide you with relevant portions or summaries of the state laws regarding these issues.

Limits of Confidentiality. The law protects Whatever the privacy concern that brings you to our community counseling clinic, you and your provider will spend time getting to know you and how you view yourself, how you developed through your family of all communications between a patient origin, and a psychologistyour current patterns of interaction with other people. In most situationsorder for us to discover, I can only explore, and help you change, you will need to be very open and honest with your provider. Please familiarize yourself with the section below titled ‘What Therapy Is and What It Is Not’. The things you share with your provider are protected under the confidentiality laws of the State of Texas and the United States of America. Both verbal information and written records about a client cannot be shared with another party without the written consent of the client or the client’s legal guardian. It is the policy of our clinic not to release any information about a client without a signed release of information. However, there are limits to confidentiality that you should know about before we begin therapy. Those exceptions include: • Signed authorization from you to release information about your treatment to others if a specific individual or organization • Counselor or Clinic Director’s determination that you sign a written Authorization form that meets specific legal requirements imposed by state may harm yourself or someone else, at which point we may contact medical or law and HIPAA. But there are some situations where I am permitted or required to disclose information without either your consent or authorization: • If a patient threatens to harm themself, I may be obligated to seek hospitalization for them or contact family members or others who can help provide protection. ▪ If a patient communicates a serious threat of physical violence against an identifiable victim, I must take protective actions, including notifying the potential victim and contacting the police. I may also seek hospitalization of the patient or contact others who can assist in protecting the victim. ▪ Disclosures may be required to health insurers or to collect overdue feesenforcement authorities. • I occasionally find it helpful to consult other health and mental health professionals about a case. During a consultation, I make every effort to avoid revealing the identity Disclosure of my patient. The other professionals are also legally bound to keep the information confidential. If you don’t object, I will not tell you about these consultations unless I feel it is essential to our work together. I will note all consultations in your Clinical Record. • I may be court-ordered to release treatment information and records in alleged criminal or civil liability cases. In addition, if a client files a complaint or lawsuit against me, I may disclose relevant information regarding that client to defend myself. • If a government agency requests the information for health oversight activities under their legal authority, I may be required to provide it. • If a patient files a worker’s compensation claim, I must, upon appropriate request, disclose information relevant to the claimant's condition to the worker’s compensation insurer. ▪ I am required by law to report any suspected child abuse, neglect, or sexual abuse to protect exploitation of a child, the child/children involved. ▪ I am obligated elderly, or a disabled individual • Disclosure of professional misconduct of another mental health professional • Court order or requirement by law to report disclose information • Prenatal exposure to controlled substances • In the event of a client’s death (the spouse or parents of a deceased client may have the right to access their child’s or spouse’s records) • If you are currently a UNT-Dallas Student, should an emergency arise, we may provide information to Xxxx of Student Affairs for further resource development. • Minors/Guardianship (parents or legal guardians of non-emancipated minor clients have the right to access the client’s records) We will devote our sessions, usually 45-50 minutes, once a week, to helping you or your child find new ways to help yourself. Our efforts will always be legal, ethical, and relevant, and might be carried out within our sessions as well as without, in the form of homework. It’s hard to predict how many sessions will be needed to bring about the changes you want; If you like your provider can discuss further with you how many sessions they may think it will take to reach your goals, after they become more familiar with your background. The counseling relationship is a professional relationship rather than a social one. Please do not invite your provider to social gatherings, offer them gifts, and/or ask them to join you in any suspected abuseother way than in the professional context of our therapy sessions. If your provider sees you in public, neglectthey will protect your confidentiality by not approaching you first, nor will they discuss your case with you in public. Please feel free not to acknowledge them, if you so choose. They will not feel disrespected. Please note that it is not possible for our providers to guarantee any specific result or outcome regarding your counseling goals. That will depend on your progress and willingness to make changes in your life and behavior. We will however, work closely with you to achieve the best possible results. For a comprehensive review of the University of North Texas Dallas Community Counseling Clinic Privacy Notice and Clinic Practices please see binder in the waiting room of our clinic or visit our website where you can download additional copies for your records. xxx.xxxxxxxxx.xxx/xxxxxxxxxx PAYMENT Currently our clinic’s fees are as follows: Initial Assessment Session $20, and follow-up sessions are $15. If a financial hardship exists please mention it to our business office manager or your therapist and our office will provide you with alternative options. Please note session fees are payable at the time of service. Our office does not routinely provide emergency services. If an emergency arises please first contact 911 or visit the nearest emergency room. You may then inform our office and allow us to help or modify your treatment plan. LEGAL PROCEEDINGS Please note, the University of North Texas – Dallas Community Counseling Center is an educational clinic offering only therapeutic services to our community. Therefore, if any forensic services, including but not limited to child custody evaluations (social studies), court testimonies that you have filed or are a defendant, reports to be used for legal purposes, or sexual abuse any type of an older adult or dependent adult subpoena is served to protect the older adult or dependent adult involved. ▪ Please any of our graduate student practitioners, please be aware that information shared with me it is the policy of the clinic, that a protective order or a motion to quash will be disclosed filed on behalf of the UNT-Dallas Community Counseling Clinic. In the event that it is ordered by a judge for any of our clinicians or supervisors to your partner appear in court, please know we will abide by every one of our legal obligations. Often that means, simply appearing and acting as a fact-witness. In such an event, please note a legal retainer maybe required before any of our practitioners will appear in court. SESSION RECORDING & SUPERVISION I understand, agree, and consent that under the current set-up and management of the University of North Texas Dallas Community Counseling Clinic, I will be provided counseling services by current Practicum or family if they participate Internship students enrolled in couples the Counseling Program at UNTD, or family treatmentapproved by the Community Counseling Clinic Director. I further understand that each provider in training will not be under the supervision of either a faculty member and/or the Community Counseling Clinic Director. I agree that in order for this supervision to hold secrets on any one partner’s behalfbe complete and valuable that my sessions will be recorded so that the licensed supervisor can review the video and ensure I am being provided the best therapeutic care. If you feel something should not be shared I have been made aware that only those with your partner, please do not tell me your secret(s). At such times, it may be most appropriate for you the need to seek see the support of an individual therapist who is independent of your couple’s treatment and who video will consult with me regarding the broad issues and not the specifics of your secret(s). While this written summary of exceptions to confidentiality should prove helpful in informing you about potential problems, it is essential that we discuss any questions or concerns that you may have now or in the future. The laws governing confidentiality can be quite complexview them, and have been informed that any and all individuals viewing such videos will have been trained with Protected Health Information confidentiality training. I am not an attorney. In situations where specific advice is required, formal legal advice may further understand that all my recording will be neededdestroyed and deleted after the termination of my file at the UNTD Community Counseling Clinic.

Limits of Confidentiality. The law protects the privacy of all communications between a patient client and a psychologisttherapist. In most situations, I can only release information about your treatment to others only if you sign a written Authorization authorization form that meets specific certain legal requirements imposed by state law and HIPAA. But there There are other situations involving uses and disclosures for treatment, payment and healthcare operations that require only that you provide written, advanced consent. The Notice of Privacy Practices also describes these uses and disclosures for treatment, payment and healthcare operations. You have the right to and should review the Notice of Privacy Practices before signing this Agreement. Your signature on this Agreement provides consent for uses and disclosures for treatment, payment and healthcare operations such as the following: • I may occasionally find it helpful to consult with other health and mental health professionals about a case. During consultation, I make every effort to avoid revealing the identity of my client. The other professionals are also legally bound to keep the information confidential. I will note all consultations in your Clinical Record (which is called “PHI” in my Notice of Privacy Practices). I may also need to consult with another health care provider, such as your family physician or another therapist to coordinate or manage your health care and other services related to your health care. • If a patient 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. There are some situations where I am permitted or required to disclose information without either your consent or authorization: • If you are involved in a patient threatens to harm themselfcourt or administrative proceeding and a request is made for information concerning my professional services, I may be obligated to seek hospitalization for them cannot provide any information without your written authorization, or contact family members or others who can help provide protection. ▪ If a patient communicates a serious threat of physical violence against an identifiable victim, I must take protective actions, including notifying the potential victim and contacting the police. I may also seek hospitalization of the patient or contact others who can assist in protecting the victim. ▪ Disclosures may be required to health insurers or to collect overdue fees. • I occasionally find it helpful to consult other health and mental health professionals about a case. During a consultation, I make every effort to avoid revealing the identity of my patient. The other professionals are also legally bound to keep the information confidentialcourt order. If you don’t objectare involved in or contemplating litigation, I will not tell you about these consultations unless I feel it is essential should consult with your attorney to our work together. I will note all consultations in your Clinical Recorddetermine whether a court would be likely to order me to disclose information. • I may be court-ordered to release treatment If a government agency is requesting the information and records in alleged criminal or civil liability cases. In additionfor health oversight activities, if a client files • If you file a complaint or lawsuit against me, • If you file a worker’s compensation claim. There are some situations in which I am legally obligated to take actions, which I believe are necessary to attempt to protect others from harm and I may disclose relevant have to reveal some information regarding that client to defend myselfabout a client’s treatment. • If I have reason to believe that a government agency requests child has been abused, the information for health oversight activities under their legal authoritylaw requires that I file a report with the appropriate governmental agency, usually the Department of Family and Child Services. Once the report is filed, I may be required to provide itadditional information. • If I have reasonable cause to believe that a patient files disabled adult or elder person has been neglected or exploited,. • If I determine that a worker’s compensation claimclient presents a serious danger of violence to another or himself, I mustmay be required to take protective actions. These actions may include notifying the potential victim, upon appropriate requestand/or contacting the police, disclose information relevant to and/or seeking hospitalization for the claimant's condition to the worker’s compensation insurerclient. ▪ I am required by law to report any suspected child abuseIf such a situation arises, neglect, or sexual abuse to protect the child/children involved. ▪ I am obligated by law to report any suspected abuse, neglect, or sexual abuse of an older adult or dependent adult to protect the older adult or dependent adult involved. ▪ Please be aware that information shared with me will be disclosed to your partner or family if they participate in couples or family treatment. I will not agree make every effort to hold secrets on fully discuss it with you before taking any one partner’s behalf. If you feel something should not be shared with your partner, please do not tell me your secret(s). At such times, it may be most appropriate for you action and I will limit my disclosure to seek the support of an individual therapist who what is independent of your couple’s treatment and who will consult with me regarding the broad issues and not the specifics of your secret(s). While this written summary of exceptions to confidentiality should prove helpful in informing you about potential problems, it is essential that we discuss any questions or concerns that you may have now or in the futurenecessary. 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 HIPAA provides you with several new or expanded rights with regard to your Clinical Record and disclosures of Protected Health Information (PHI). These rights are described more fully in the Notice of Privacy Practices. Pursuant to HIPAA, I keep Protected Health Information. Your Clinical Record includes information about reasons for seeking therapy, a description of the ways in which your problem impacts your life, diagnosis, the goals that we set for treatment, progress towards those goals, medical and social history, treatment history, past treatment records that I receive from other providers, reports of any professional consultations, billing records, and any reports that have been sent to anyone. Except in unusual circumstances that involve danger to yourself or others, you may examine and/or receive a copy of your Clinical Record, if requested in writing. Because these are professional records, they can be misinterpreted and/or upsetting to untrained readers. For this reason, I recommend we review them together, or have them forwarded to another mental health professional so you can discuss the contents. Normal hourly charges and/or copying charges will apply.

Limits of Confidentiality. The law protects the privacy of all communications between a patient and a psychologistpsychiatrist. In most situations, I can only release information about your treatment to others if you sign a written Authorization form that meets specific certain legal requirements imposed by state law and HIPAAHIPPA. But there There are some other situations where I am permitted or required to disclose information without either your that require only that you provide written, advance consent. Your signature on this Agreement provides consent or authorizationfor those activities as follows: • If a patient threatens to harm themself, I may be obligated to seek hospitalization for them or contact family members or others who can help provide protection. ▪ If a patient communicates a serious threat of physical violence against an identifiable victim, I must take protective actions, including notifying the potential victim and contacting the police. I may also seek hospitalization of the patient or contact others who can assist in protecting the victim. ▪ Disclosures may be required to health insurers or to collect overdue fees. • I occasionally find it helpful to consult other health and mental health professionals about a case. During a consultation, I make every effort to avoid revealing the identity of my patient. The other professionals are also legally bound to keep the information confidential. If you don’t object, I will not tell you about these consultations unless I feel it is essential to our work together. I will note all consultations in your Clinical RecordRecord (which is called “PHI” in my Notice of Psychiatrist’s Policies and Practices to Protect the Privacy of your Health Information). • You should be aware that I practice with other mental health professionals and that I employ administrative staff. In most cases, I need to share protected information with these individuals for both clinical and administrative purposes, such as scheduling, billing and quality assurance. All staff members have been given training about protecting your privacy and have agreed not to release any information outside of the practice without the permission of a professional staff member. • Disclosures required by health insurers or to collect overdue fees are discussed elsewhere in this Agreement. • If a patient threatens to harm himself/herself, I may be courtobligated to seek hospitalization for him/her or to contact family members or others who can help provide protection. There are some situations where I am permitted or required to disclose information without either your consent or Authorization: • If you are involved in a court proceeding and a request is made for information concerning the professional services that I provided you, such information is protected by the psychiatrist-ordered patient privilege law. I cannot provide any information without your written authorization, or a court order. If you are involved in or contemplating litigation, you should consult with your attorney to release treatment determine whether a court would be likely to order me to disclose information. • If a government agency is requesting information and records in alleged criminal or civil liability casesfor health oversight activities, I may be required to provide it for them. In addition, if • If a client patient files a complaint or lawsuit against me, I may disclose relevant information regarding that client patient in order to defend myself. • If I am providing treatment for conditions directly related to worker’s compensation claim, I may have to submit such records, upon appropriate request, to Chairman of the Worker’s Compensations Board on such forms and at such times as the chairman may require. There are some situations in which I am legally obliged to take actions, which I believe are necessary to attempt to protect others from harm and I may have to reveal some information about a government agency requests patient’s treatment. These situations are unusual in my practice. • If I receive information in my professional capacity from a child or the information for health oversight activities under their legal authorityparents or guardian or other custodian of a child that gives me reasonable cause to suspect that a child is an abused or neglected child, the law requires that I report to the appropriate governmental agency, usually the statewide central register of child abuse and maltreatment, or the local child protective services office. Once such a report is filed, I may be required to provide itadditional information. • If a patient files a worker’s compensation claimcommunicates an immediate threat of serious physical harm to an identifiable victim, I mustmay be required to take protective actions. These actions may include notifying the potential victim, upon appropriate request, disclose information relevant to contacting the claimant's condition to the worker’s compensation insurer. ▪ I am required by law to report any suspected child abuse, neglectpolice, or sexual abuse to protect seeking hospitalization for the child/children involvedpatient. ▪ I am obligated by law to report any suspected abuseIf such a situation arises, neglect, or sexual abuse of an older adult or dependent adult to protect the older adult or dependent adult involved. ▪ Please be aware that information shared with me will be disclosed to your partner or family if they participate in couples or family treatment. I will not agree make every effort to hold secrets on fully discuss it with you before taking any one partner’s behalf. If you feel something should not be shared with your partner, please do not tell me your secret(s). At such times, it may be most appropriate for you action and I will limit my disclosure to seek the support of an individual therapist who what is independent of your couple’s treatment and who will consult with me regarding the broad issues and not the specifics of your secret(s)necessary. While this written summary of exceptions to confidentiality should prove helpful in informing you about potential problems, it is essential important that we discuss any questions or concerns that you may have now or in the future. The laws governing confidentiality can be quite complex, and I am not an attorney. PROFESSIONAL RECORDS The laws and standard of my profession require that I keep Protected Health Information about you in your Clinical Record. Except in unusual circumstances that involve danger to yourself and/or others or where information has been supplied to me confidentially by others, you may examine and/or receive a copy of your Clinical Record, if you request it in writing. Because these are professional records, they can be misinterpreted and/or upsetting to untrained readers. For this reason, I recommend that you initially review them in my presence, or have them or have them forwarded to another mental health professional so you can discuss the contents. I am allowed to charge a copy fee of 75 cents per page (and for certain other expenses). If I refuse your request for access to your records, you have a right to review, which I will discuss with you upon request. PATIENT RIGHTS HIPAA provides you with several new or expanded rights with regard to your Clinical Records and disclosures of protected health information. These rights include requesting that I amend your record; requesting restrictions on what information from your Clinical Records is disclosed to others; requesting an accounting of most disclosures of protected health information that you have neither consented to not authorize; determining the location to which protected information disclosures are sent; having any complaints you make about my policies and procedures recorded in your records; and the right to a paper copy of this Agreement, the attached Notice form, and my privacy policies and procedures. I am happy to discuss any of these rights with you. BILLING AND PAYMENTS You will be expected to pay for each session at the time it is held, unless we agree otherwise or unless you have insurance coverage that requires another arrangement. Payment schedules for other professional services will be agreed to when they are requested. (In situations where specific advice is requiredcircumstances of unusual financial hardship, formal legal advice I may be neededwilling to negotiate a fee adjustment or payment installment plan.) If your account has not been paid for more than 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 otherwise confidential information. In most collection situations, the only information I release regarding a patient’s treatment is his/her name, the nature of services provided, and the amount due. (If legal action is necessary, its costs will be included in the claim.) INSURANCE REIMBURSEMENT In order for us to set realistic treatment goals and priorities, it is important to evaluate what resources you have available to pay for your treatment. 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 my fees. It is very important that you find out exactly what mental health services your insurance policy covers. You should carefully read the section in your insurance coverage booklet that describes mental health services. If you have questions about the coverage, call your plan administrator. Of course, I will provide you with whatever information I can based on my experience and will be happy to help you in understanding the information you receive from your insurance company. If it is necessary to clear confusion, I will be willing to call the company on your behalf. Due to the rising costs of health care, insurance benefits have increasingly become more complex. It is sometimes difficult to determine exactly how much mental health coverage is available. “Managed Health Care” plans such as HMOs and PPOs often require authorization before they provide reimbursement for mental health services. These plans are often limited to short-term treatment approaches designed to work out specific problems that interfere with a person’s usual level of functioning. It may be necessary to seek approval for more therapy after a certain number of sessions. While much can be accomplished in short-term therapy, some patients feel that they need more services after insurance benefits end. (Some managed-care plans will not allow me to provide services to you once your benefits end. If this is the case, I will do my best to find another provider who will help you continue your psychotherapy.) You should also be aware that your contract with your health insurance company requires that I provide it with information relevant to the services that I provide additional clinical information such as treatment plans or summaries, or copies of your entire Clinical Record. In such situations, I will make every effort to release only the minimum information about you that is necessary for the purpose requested. This information will become part of the insurance company files and will probably be stored in our computer. Though all insurance companies claim to keep such information confidential, I have no control over what they do with it once it is in their hands. In some cases, they may share the information with the national medical information database. I will provide you with a copy of any report I submit, if you request it. By signing this Agreement, you agree that I can provide requested information to your carrier. Once we have all of the information about your insurance coverage, we will discuss what we can expect to accomplish with the benefits that are available and what will happen if they run out before you feel ready to end your sessions. It is important to remember that you always have the right to pay for my services yourself to avoid the problems described above (unless prohibited by contract). YOUR SIGNATURE BELOW INDICATES THAT YOU HAVE READ THIS AGREEMENT AND AGREE TO ITS TERMS AND ALSO SERVES AS AN ACKNOWLEDGEMENT THAT YOU HAVE RECEIVED THE HIPAA NOTICE FORM DESCRIBED ABOVE. _ _ Patient Signature Witness

Limits of Confidentiality. The law protects the privacy of all communications between a patient client and a psychologist. In most situations, I can only release information about your treatment to others if you sign a written Authorization form that meets specific certain legal requirements imposed by state law and HIPAA. But there There are some other situations where I am permitted or required to disclose information without either your that require only that you provide written, advance consent. Your signature on this Agreement provides consent or authorizationfor those activities, as follows: • If a patient threatens to harm themself, I may be obligated to seek hospitalization for them or contact family members or others who can help provide protection. ▪ If a patient communicates a serious threat of physical violence against an identifiable victim, I must take protective actions, including notifying the potential victim and contacting the police. I may also seek hospitalization of the patient or contact others who can assist in protecting the victim. ▪ Disclosures may be required to health insurers or to collect overdue fees. • I occasionally find it helpful to consult other health and mental health professionals about a case. During a consultation, I make every effort to avoid revealing the identity of my patientclient. The other professionals are 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 essential 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). . • You should be aware that I share an office with other mental health professionals. I do not share protected information with these people. However, you may see the other mental health professionals in the office or his or her clients. All of the mental health professionals are bound by the same rules of confidentiality. • Disclosures required by health insurers or to collect overdue fees are discussed elsewhere in this Agreement. • If I believe that a client presents an imminent danger to his/her health or safety, I may be courtobligated to seek hospitalization for him/her, or to contact family members or others who can help provide protection. There are some situations where I am permitted or required to disclose information without either your consent or Authorization: • If you are involved in a court proceeding and a request is made for information concerning the professional services that I provided you, such information is protected by the psychologist-ordered patient privilege law. I cannot provide any information without your written authorization, or a court order. If you are involved in or contemplating litigation, you should consult with your attorney to release treatment determine whether a court would be likely to order me to disclose information. • If a government agency is requesting the information and records in alleged criminal or civil liability casesfor health oversight activities, I may be required to provide it for them. In addition, if • If a client files you file a complaint or lawsuit against me, I may disclose relevant information regarding that you or my client in order to defend myself. • If a government agency requests the information for health oversight activities under their legal authority, I may be required to provide it. • If a patient files you file a worker’s compensation claim, and my services are being compensated through workers compensation benefits, I must, upon appropriate request, provide a copy of your record to your employer or the North Carolina Industrial Commission. There are some situations in which I am legally obligated to take actions, which I believe are necessary to attempt to protect others from harm and I may have to reveal some information about a client’s treatment. These situations are unusual in my practice. • If I have cause to suspect that a child under 18 is abused or neglected, or if I have reasonable cause to believe that a disabled adult is in need of protective services, the law requires that I file a report with the County Director of Social Services. Once such a report is filed, I may be required to provide additional information. • If I believe that a client presents an imminent danger to the health and safety of another, I may be required to disclose information relevant in order to take protective actions, including initiating hospitalization, warning the claimant's condition to potential victim, if identifiable, and/or calling the worker’s compensation insurerpolice. ▪ I am required by law to report any suspected child abuseIf such a situation arises, neglect, or sexual abuse to protect the child/children involved. ▪ I am obligated by law to report any suspected abuse, neglect, or sexual abuse of an older adult or dependent adult to protect the older adult or dependent adult involved. ▪ Please be aware that information shared with me will be disclosed to your partner or family if they participate in couples or family treatment. I will not agree make every effort to hold secrets on fully discuss it with you before taking any one partner’s behalf. If you feel something should not be shared with your partner, please do not tell me your secret(s). At such times, it may be most appropriate for you action and I will limit my disclosure to seek the support of an individual therapist who what is independent of your couple’s treatment and who will consult with me regarding the broad issues and not the specifics of your secret(s)necessary. While this written summary of exceptions to confidentiality should prove helpful in informing you about potential problems, it is essential important that we discuss any questions or concerns that you may have now or in the future. 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 The laws and standards of my profession require that I keep Protected Health Information about you in your Clinical Record. Except in unusual circumstances that involve danger to yourself and/or others or the record makes reference to another person (unless such other person is a health care provider) and I believe that access is reasonably likely to cause substantial harm to such other person, you may examine and/or receive a copy of your Clinical Record, if you request it in writing. Because these are professional records, they can be misinterpreted and/or upsetting to untrained readers. For this reason, I recommend that 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, I am allowed to charge a copying fee of $0.25 per page (and for 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 request. PATIENT RIGHTS HIPAA provides you with several new or expanded rights with regard to your Clinical Records and disclosures of protected health information. These rights include requesting that I amend your record; requesting restrictions on what information from your Clinical Records is disclosed to others; requesting an accounting of most disclosures of protected health information that you have neither consented to nor authorized; determining the location to which protected information disclosures are sent; having any complaints you make about my policies and procedures recorded in your records; and the right to a paper copy of this Agreement, the attached Notice form, and my privacy policies and procedures. I am happy to discuss any of these rights with you. MINORS & PARENTS Clients under 18 years of age who are not emancipated and their parents should be aware that the law may allow parents to examine their child’s treatment records. Because privacy in psychotherapy is often crucial to successful progress, particularly with teenagers, it is usually my policy to request an agreement from parents that they consent to give up their access to your records. If they agree, during treatment, I will provide them only with general information about the progress of the child’s treatment, and his/her attendance at scheduled sessions. I will also provide parents with a summary of their child’s treatment when it is complete. Any other communication will require the child’s Authorization, unless I feel that the child is in danger or is a danger to someone else, in which case, I will notify the parents of my concern. Before giving parents any information, I will discuss the matter with the child, if possible, and do my best to handle any objections he/she may have. BILLING AND PAYMENTS You will be expected to pay for each session at the time it is held, unless we agree otherwise. Payment schedules for other professional services will be agreed to when they are requested. If your account has not been paid for more than 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 otherwise confidential information. In most collection situations, the only information I release regarding a patient’s treatment is his/her name, the nature of services provided, and the amount due. If such legal action is necessary, its costs will be included in the claim. For your convenience, I accept cash, check or credit card. I ask that each client keeps a credit card on file that can be charged in the event of a missed session. If this is an issue for you, please let me know and we can discuss it further. Personal checks should be made payable to Xxxxx Psychological Services, PLLC. INSURANCE REIMBURSEMENT Please be aware that I am out of network for most insurance companies. This means that if you choose to use insurance for which I am out of network, you are responsible for my full fee at the time of service and then the insurance company will reimburse you consistent with your plan. I would be happy to help you file the insurance claim and have the reimbursement sent directly to you. I am in network with Blue Cross and Blue Shield and Medicare; you will need to pay your copay at the time of visit. I will file your insurance and they will reimburse in accordance with your plan. In order for us to set realistic treatment goals and priorities, it is important to evaluate what resources you have available to pay for your treatment. 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 my fees. It is very important that you find out exactly what mental health services your insurance policy covers. You should carefully read the section in your insurance coverage booklet that describes mental health services. If you have questions about the coverage, call your plan administrator. Of course, I will provide you with whatever information I can based on my experience and will be happy to help you in understanding the information you receive from your insurance company. Due to the rising costs of health care, insurance benefits have increasingly become more complex. It is sometimes difficult to determine exactly how much mental health coverage is available. “Managed Health Care” plans such as HMOs and PPOs often require authorization before they provide reimbursement for mental health services. These plans are often limited to short-term treatment approaches designed to work out specific problems that interfere with a person’s usual level of functioning. It may be necessary to seek approval for more therapy after a certain number of sessions. While much can be accomplished in short-term therapy, some people feel that they need more services after insurance benefits end. You should also be aware that your contract with your health insurance company requires that I provide it with information relevant to the services that I provide to you. I am required to provide a clinical diagnosis. Sometimes I am required to provide additional clinical information such as treatment plans or summaries, or copies of your entire Clinical Record. In such situations, I will make every effort to release only the minimum information about you that is necessary for the purpose requested. This information will become part of the insurance company files and will probably be stored in a computer. Though all insurance companies claim to keep such information confidential, I have no control over what they do with it once it is in their hands. In some cases, they may share the information with a national medical information databank. I will provide you with a copy of any report I submit, if you request it. If you choose for me to file insurance on your behalf, signing this agreement authorizes me to provide the aforementioned information to your insurance company. Once we have all of the information about your insurance coverage, we will discuss what we can expect to accomplish with the benefits that are available and what will happen if they run out before you feel ready to end your sessions. By signing below, you are indicating that you have read, understood this agreement and have had an opportunity to ask questions and clarify any information in this agreement that is either unclear or concerning. You indicate that you agree to its terms. Your signature indicates that Xxxxx Psychological Services, PLLC is authorized to provide you with therapy, evaluation, and other services that are necessary or recommended. Your signature also serves as an acknowledgement that you have received the HIPAA notice form described above. Additionally, by signing below, you authorize Xxxxx Psychological Services, PLLC to charge your credit card the amount indicated in the Professional Fees section of this agreement any time you owe a balance. Rev. 08/19 Signature Date Printed Name Xxxxx Psychological Services, PLLC 0000 XX Xxxxxxx Rd., Suite 140 Cary, NC 27513 000-000-0000 Client Information Name: How would you like me to address you? Address: Preferred Phone Number: (Home, Cell, Work) May I leave a voicemail at the above number? Preferred method of contact: Email Text Telephone Call Email (if I may use it): Would you like appointment reminders? If so, how? Email Text Birth Sex: Female Male Choose not to answer Gender Identity: Male Female Transgender Male/FTM Transgender Female/MTF Genderqueer, neither exclusively male or female Other (Specify) What pronouns should I use? she/her/hers he/him/his they/them/theirs other Sexual orientation: Lesbian, gay, homosexual Straight, heterosexual Bisexual Other Race: American Indian or Alaska Native Asian Black or African American Hispanic or Latinx Native Hawaiian or Other Pacific Islander Caucasian Marital Status: Married Single Engaged Widow/Widower Employment: Employed Full-time student Part-time student Other Credit Card Billing Address (if different than above address) _ __ How will you pay if you do not keep credit card on file? Xxxxx Psychological Services, PLLC 0000 XX Xxxxxxx Rd., Suite 140 Cary, NC 27513 000-000-0000 Client Name: Date: Primary Policy Xxxxxx’s name: Primary Insurance Company: Your relationship to Policy Holder: Policy Holder Phone: Policy #: Group #: Effective Date: Policy Holder DOB: Policy Holder’s Employer:_

Limits of Confidentiality. The law protects the privacy of all communications between a patient client and a psychologist. In most situations, I can only release information about your treatment to others if you sign a written Authorization form for Release of Information that meets specific certain legal requirements imposed by state law and and/or HIPAA. But However, there are some situations where I am permitted or required to disclose information without either your consent or authorization: • If a patient client threatens to harm themselfhimself/herself, I may be obligated to seek hospitalization for them or him/her, and/or to contact family members or others who can help provide protection. ▪ protection (CA Evidence Code § 1024) • If a patient client communicates a serious threat of physical violence against an identifiable victimOR if a client’s family member reports that a client has made such a threat, I must take protective actions, including notifying noticing the potential victim and contacting the police. I may also seek hospitalization of the patient client or contact others who can assist in protecting the victimvictim (CA Evidence Code § 1024, CA Civil Code § 43.92). ▪ • Disclosures may be required to health insurers or to collections agencies to collect overdue fees. • I occasionally find it helpful to consult other health and mental health professionals about a case. During a consultation, I make every effort to avoid revealing the identity of my patientclient. The other professionals are also legally bound to keep the information confidential. If you don’t n't object, I will not tell you about these consultations unless I feel that it is essential important to our work together. I will note all consultations in your Clinical Record. • In cases of alleged criminal or civil liability, I may be court-court ordered to release treatment information and records in alleged criminal or civil liability casesand/or records. In addition, if a client files a complaint or lawsuit against me, I may disclose relevant information regarding that client in order to defend myself. • If a government agency requests is requesting the information for health oversight activities under pursuant to their legal authority, I may be required to provide itit for them. • If a patient client files a worker’s 's compensation claim, I must, upon appropriate request, disclose information relevant to the claimant's condition to the worker’s 's compensation insurer. ▪ • I am required by law to report any suspected child abuse, neglect, or sexual abuse to protect the child/child/ children involvedinvolved (CA Penal Code § 11164-11174.4; 288; 261-269, Child Abuse; CA Welfare and Institutions Code § 18951 ff.). ▪ • I am obligated by law to report any suspected abuse, neglect, or sexual abuse of an older adult elderly person or dependent adult to protect the older adult elderly person or dependent adult involvedinvolved (CA Welfare and Institutions Code § 15630 – 15632; § 15610 – 15610.65; § 15633 - 15637). ▪ Please • In couples or family treatment, please be aware that information shared with me will be disclosed to your partner or family if they participate are participating in couples or family treatment. I will not agree to hold secrets on any one partner’s 's behalf. If you feel something should not be shared with your partner, please do not tell me your secret(s). At such times, it may be most appropriate for you to seek the support of an individual therapist who is independent of your couple’s treatment 's treatment, and who will consult with me regarding the broad issues issues, and not the specifics of your secret(s). While this written summary of exceptions to confidentiality should prove helpful in informing you about potential problems, it is essential important that we discuss any questions or concerns that you may have now or in the future. 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.

Limits of Confidentiality. The law protects the privacy of all communications Communication between a patient client and a psychologistcounselor is confidential to the extent of the law. In most situationsHowever, I can only release information about your treatment to others if you sign a written Authorization form that meets specific legal requirements imposed by state law and HIPAA. But there are some certain situations where I am permitted or required to disclose that require only that you provide written, advance consent for the release of information without either your concerning what you say in a counseling session. Your signature on this Agreement provides consent or authorizationfor the following activities: • If a patient threatens to harm themself, I may be obligated to seek hospitalization for them or contact family members or others who can help provide protection. ▪ If a patient communicates a serious threat of physical violence against an identifiable victim, I must take protective actions, including notifying the potential victim and contacting the police. I may also seek hospitalization of the patient or contact others who can assist in protecting the victim. ▪ Disclosures may be required to health insurers or to collect overdue fees. • I occasionally find it helpful to consult  Consultation with other health and mental health professionals about a your case. During a consultation, I make every effort to avoid revealing the identity of my patientclient. The other professionals are also legally bound to keep the information discussed confidential. If you don’t object, I will not tell you about these consultations unless if I feel it is essential important to our work together. I will also note all consultations in your Clinical Recordrecord. •  Processing by administrative staff. In most cases, I need to share protected information with these individuals for administrative purposes, such as scheduling and/or billing.  Disclosure required by insurance companies that includes a DSM-5 diagnosis.  Serious danger to yourself or others. If a client seriously threatens to harm himself/herself, I may be court-ordered obligated to release treatment seek hospitalization for him/her, or to contact family members or others who can help provide protection. Texas law provides that a professional may disclose confidential information and records in alleged criminal only to medical or civil liability caseslaw enforcement personnel if the professional determines that there is a probability of imminent physical injury to the patient or others, or there is a probability of immediate mental or emotional injury to the client. In additionthe event that I reasonably believe that you are a danger, if physically or emotionally, to yourself or another person, you specifically consent for me to contact the following individuals, in addition to medical and law enforcement personnel: Name Name Name Phone Number Phone Number Phone Number  While my present or potential clients might conduct online searches about my practice and/or me, I do not search my clients on Google, YouTube, Facebook, other search engines or online social networking sites. If clients ask me to conduct such searches or review their web sites or profiles and I consider that it may be helpful, I will consider it.  If a client files a complaint or lawsuit against me, I may will disclose relevant information regarding that client in order to defend myself. •  I do not accept friend requests from current or former clients on my psychotherapy related profiles or social networking sites due to the fact that these sites can compromise clients' confidentiality and privacy. For the same reason, I request that clients do not communicate with me via any interactive or social networking websites. Disclosure will not be affected by this Agreement in the following situations:  If you are involved in a government agency requests court proceeding and a request is made for information concerning your diagnosis and therapy, such information is protected by law. I cannot provide any information without your written authorization, or a court order. In certain situations I am legally obligated to take action, which I believe are necessary to attempt to protect others from harm and I may have to reveal some information about a client’s therapy. If such a case should arise, I will make every effort to fully discuss it with you before taking any action and I will limit my disclosure to what is necessary. Such a situation would be:  If I have cause to believe a child under the information for health oversight activities under their legal authorityage of 18 has been or may be abused or neglected (including physical injury, substantial threat of harm, mental or emotional injury or any kind of sexual contact or conduct), or that a child is a victim of a sexual offense the law requires that I make a report to the appropriate governmental agency. Once such a report is filed, I may be required to provide itadditional information. •  If I have cause to believe that an elderly or disabled person is in a patient files state of abuse, neglect or exploitation, the law requires that I make a worker’s compensation claimreport to the appropriate governmental agency. Once such a report is filed, I must, upon appropriate request, disclose information relevant to the claimant's condition to the worker’s compensation insurer. ▪ I am required by law to report any suspected child abuse, neglect, or sexual abuse to protect the child/children involved. ▪ I am obligated by law to report any suspected abuse, neglect, or sexual abuse of an older adult or dependent adult to protect the older adult or dependent adult involved. ▪ Please be aware that information shared with me will be disclosed to your partner or family if they participate in couples or family treatment. I will not agree to hold secrets on any one partner’s behalf. If you feel something should not be shared with your partner, please do not tell me your secret(s). At such times, it may be most appropriate for you required to seek the support of an individual therapist who is independent of your couple’s treatment and who will consult with me regarding the broad issues and not the specifics of your secret(s). While this written summary of exceptions to confidentiality should prove helpful in informing you about potential problems, it is essential that we discuss any questions or concerns that you may have now or in the future. 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 neededprovide additional information.

Limits of Confidentiality. The law protects the privacy of all communications between If we believe that a patient and a psychologistclient presents an imminent danger to his/her health or safety, we may be obligated to seek hospitalization for him/her, or to contact family members or others who can help provide protection. In most situations, I can only release information about your treatment to others if you sign a written Authorization form that meets specific legal requirements imposed by state law and HIPAA. But there There are some situations where I am we are permitted or required to disclose information without either your consent or authorizationAuthorization: • If you are involved in a patient threatens court proceeding and a request is made for information concerning the professional services that we provided you, such information is protected by the counselor-client privilege law. We cannot provide any information without your written authorization, or a court order. If y xxxx ou are involved in or contemplating litigation, you should conwith your attorney to harm themself, I may determine whether a court would be obligated likely to seek hospitalization for them or contact family members or others who can help provide protectionorder us to disclose information. ▪ • If a patient communicates a serious threat of physical violence against an identifiable victimgovernment agency is requesting the information for health oversight activities, I must take protective actions, including notifying the potential victim and contacting the police. I may also seek hospitalization of the patient or contact others who can assist in protecting the victim. ▪ Disclosures we may be required to health insurers or to collect overdue fees. • I occasionally find provide it helpful to consult other health and mental health professionals about a case. During a consultation, I make every effort to avoid revealing the identity of my patient. The other professionals are also legally bound to keep the information confidentialfor them. If you don’t object, I will not tell you about these consultations unless I feel it is essential to our work together. I will note all consultations in your Clinical Record. • I may be court-ordered to release treatment information and records in alleged criminal or civil liability cases. In addition, if a client files a complaint or lawsuit against meRHEMA Counseling & Support Services, I PC or an individual provider within the agency, we may disclose relevant information regarding that client to defend myselfclient. • If a government agency requests the information for health oversight activities under their legal authority, I may be required to provide it. • If a patient client files a worker’s compensation claim, I and our services are being compensated through workers compensation benefits, we must, upon appropriate request, provide a copy of the client’s record to the client’s employer or the North Carolina Industrial Commission. There are some situations in which we are legally obligated to take actions, which we believe are necessary to attempt to protect others from harm and we may have to reveal some information about a client’s treatment. Though these situations are unusual in our practice, we would like to make you aware of them: • If we have cause to suspect that a child under 18 is abused or neglected, or if we have reasonable cause to believe that a disabled adult is in need of protective services, the law requires that we file a report with the County Department of Social Services. Once such a report is filed, we may be required to provide additional information. • If we believe that a client presents an imminent danger to the health and safety of another, we may be required to disclose information relevant in order to take protective actions, including initiating hospitalization, warning the claimant's condition to potential victim, if identifiable, and/or calling the worker’s compensation insurer. ▪ I am required by law to report any suspected child abuse, neglect, or sexual abuse to protect the child/children involved. ▪ I am obligated by law to report any suspected abuse, neglect, or sexual abuse of an older adult or dependent adult to protect the older adult or dependent adult involved. ▪ Please be aware that information shared with me will be disclosed to your partner or family if they participate in couples or family treatment. I will not agree to hold secrets on any one partner’s behalfpolice. If such a situation arises, we will make every effort to fully discuss it with you feel something should not be shared with your partner, please do not tell me your secret(s). At such times, it may be most appropriate for you before taking any action and will limit my disclosure to seek the support of an individual therapist who what is independent of your couple’s treatment and who will consult with me regarding the broad issues and not the specifics of your secret(s)necessary. While this written summary of exceptions to confidentiality should prove helpful in informing you about potential problems, it is essential important that we discuss any questions or concerns that you may have now or in the future. The laws governing confidentiality can be quite complex, and I am we are not an attorneyattorneys. In situations where specific advice is required, formal legal advice may be needed. CLIENT RIGHTS HIPAA provides you with several new or expanded rights with regard to your Clinical Records and disclosures of protected health information. These rights include requesting that we amend your record; requesting restrictions on what information from your Clinical Records is disclosed to others; requesting an accounting of most disclosures of protected health information that you have neither consented to nor authorized; determining the location to which protected information disclosures are sent; having any complaints you make about my policies and procedures recorded in your records; and the right to a paper copy of this Agreement and our privacy policies and procedures. We are happy to discuss any of these rights with you. In addition, you will receive a copy of these rights in RHEMA Counseling & Support Services, PC’s Notice of Privacy Practices. We reserve the right to revise the terms of this Notice and make the new Notice effective for all medical information that we maintain. A copy of these revisions will be posted online at xxx.xxxxxxxx.xxx. You may also obtain a copy from our office located at 0000 Xxxxxxxx Xxxxx, Xxxxxx, XX 27713 or you may request a copy by calling (919) 000- 0000.

Limits of Confidentiality. The law protects the privacy of all communications between a patient and a psychologist. In most situations, I can only release information about your treatment to others if you sign a written Authorization form that meets specific certain legal requirements imposed by state law and and/or HIPAA. But there are some situations where I am permitted or required to disclose information without either With your consent or authorization: • If signature on a patient threatens to harm themselfproper Authorization form, I may be obligated to seek hospitalization for them or contact family members or others who can help provide protection. ▪ If a patient communicates a serious threat of physical violence against an identifiable victim, I must take protective actions, including notifying disclose information in the potential victim and contacting the police. following situations:  I may also seek hospitalization of the patient or contact others who can assist in protecting the victim. ▪ Disclosures may be required to health insurers or to collect overdue fees. • I occasionally find it helpful to consult other health and mental health professionals about a case. During a consultation, I make every effort to avoid revealing the identity of my patient. The other professionals are 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 essential important to our work together. I will note all consultations in your Clinical Record. •  You should be aware that I practice with other mental health professionals in some cases and that I sometimes employ administrative staff. You will be notified if that is the case. In most cases, I need to share your protected information with these individuals for both clinical and administrative purposes, such as scheduling, billing and quality assurance. All of the mental health professionals are bound by the same rules of confidentiality. All staff members have been given training about protecting your privacy and have agreed not to release any information outside of the practice without the permission of a professional staff member. There are some situations where I am permitted or required to disclose information without either your consent or Authorization: •If you are involved in a court proceeding and a request is made for information concerning your diagnosis and treatment, such information is protected by the psychologist-patient privilege law. I cannot provide any information without your (or your personal or legal representative’s) written authorization, or a court order. If you are involved in or contemplating litigation, you should consult with your attorney to determine whether a court would be likely to order me to disclose information. •If a government agency is requesting the information for health oversight activities, I may be court-ordered required to release treatment information and records in alleged criminal or civil liability casesprovide it for them. In addition, if •If a client patient files a complaint or lawsuit against me, I may disclose relevant information regarding that client patient in order to defend myself. • If a government agency requests the information for health oversight activities under their legal authority, I may be required to provide it. • If •If a patient files a worker’s compensation claim, I must, upon appropriate request, disclose he/she automatically authorizes me to release any information relevant to that claim. •Disclosures required by health insurers or to collect overdue fees are discussed elsewhere in this Agreement. •There are some situations in which I am legally obligated to take actions, which I believe are necessary to attempt to protect others from harm and I may have to reveal some information about a patient’s treatment. These situations are unusual in my practice. •If there is a child abuse investigation, the claimant's condition law requires that I turn over my patient’s relevant records to the workerappropriate governmental agency, usually the local office of the Department of Human Services. Once such a report is filed, I may be required to provide additional information. •If there is an elder abuse or domestic violence investigation, the law requires that I turn over my patient’s compensation insurerrelevant records to the appropriate governmental agency, usually the local office of the Department of Human Services. ▪ Once such a report is filed, I am may be required by law to report any suspected child abuseprovide additional information. •If I believe that a patient presents a clear and substantial risk of imminent, neglectserious harm to another person, I may be required to take protective actions. These actions may include notifying the potential victim, contacting the police, or sexual abuse seeking hospitalization for the patient. •If I believe that a patient presents a clear and substantial risk of imminent, serious harm to protect the childhim/children involved. ▪ her self, I am may be obligated by law to report any suspected abuse, neglectseek hospitalization for him/her, or sexual abuse to contact family members or others who can help provide protection. •When fees for services are not paid in a timely manner, collection agencies may be utilized in collecting unpaid debts. The specific content of an older adult or dependent adult to protect the older adult or dependent adult involved. ▪ Please be aware that information shared with me will be disclosed to your partner or family if they participate in couples or family treatment. I will services (e.g., diagnosis, treatment plan, case notes, testing) is not agree to hold secrets on any one partner’s behalfdisclosed. If you feel something should not be shared with your partner, please do not tell me your secret(s). At such times, a debt remains unpaid it may be most appropriate for reported to credit agencies, and the client’s credit report may state the amount owed, time frame, and the name of the clinic. •Insurance companies and other third-party payers are given information that they request regarding services to clients. Information that may be requested includes type of services, dates/times of services, diagnosis, treatment plan, description of impairment, progress of therapy, case notes, and summaries. If such a situation arises, I will make every effort to fully discuss it with you before taking any action and I will limit my disclosure to seek the support of an individual therapist who what is independent of your couple’s treatment and who will consult with me regarding the broad issues and not the specifics of your secret(s)necessary. While this written summary of exceptions to confidentiality should prove helpful in informing you about potential problems, it is essential important that we discuss any questions or concerns that you may have now or in the future. The laws governing confidentiality can be quite complex, complex and I am not an attorney. In situations where specific advice is required, formal legal advice may be needed.. HIPAA Notice Notice of Psychologists’ Policies and Practices to Protect the Privacy of Your Health Information

Limits of Confidentiality. The law protects the privacy of all communications between a patient client and a psychologist. In most situations, I we can only release information about your treatment to others only if you sign you’ve signed a written Authorization authorization form that meets specific certain legal requirements imposed by state law and HIPAA. But there There are some other situations where I am permitted or required to disclose information without either your that require only that you provide written, advance consent. Your signature on this agreement provides consent or authorizationfor those activities, as follows: • If a patient threatens to harm themself, I ● We may be obligated to seek hospitalization for them or contact family members or others who can help provide protection. ▪ If a patient communicates a serious threat of physical violence against an identifiable victim, I must take protective actions, including notifying the potential victim and contacting the police. I may also seek hospitalization of the patient or contact others who can assist in protecting the victim. ▪ Disclosures may be required to health insurers or to collect overdue fees. • I occasionally find it helpful to consult other health and mental health professionals about a the case. During a consultation, I we make every effort to avoid revealing the identity of my the patient. The other professionals are also legally bound to keep the information confidential. If you don’t object, I we will not tell you about these consultations unless I we feel it that is essential important to our work together. I We will note all consultations in your Clinical Record. • I ● We may access your clinical record with an appropriate purpose including but not limited to, documenting the patient’s treatment, billing insurance; conducting peer review or quality assurance activity, supervision, or for a purpose expressly authorized by the patient. ● Disclosures are required by health insurers or to collect overdue fees are discussed elsewhere in this agreement. ● If a client threatens to harm himself/herself, we may be court-ordered obligated to release treatment seek hospitalization for him/her, or to contact family members or others who can help provide protection. There are some situations where we are permitted or required to disclose information without either your consent or Authorization: ● If you are involved in a court proceeding in a request is made for Information concerning your diagnosis and records treatment, such information is protected by the psychologist – client privilege log. We cannot provide any information without your written authorization, or a court order. If you are involved in alleged criminal or civil liability casescontemplating litigation, you should consult with your attorney to determine whether a quart will be likely to order your therapist to disclose information. In additionEnt information concerning your diagnosis and treatment, if such information is protected by the psychologist Dash client privilege law. We cannot provide any information without your written authorization, or a court order. If you are involved in or contemplating litigation, you should consult with your attorney to determine whether a quart will be likely to order your therapist to disclose information. ● If a government agency is requesting the information for health oversight activities, we may be required to provide it for them. ● If a client files a complaint or lawsuit against meus, I we may disclose relevant information regarding that the client in order to defend myselfourselves. • ● If we are being compensated for providing treatment to you as a government agency requests result of you having filed a Worker’s Compensation claim or through an automobile insurance plan, we must, Upon appropriate request, provide information necessary for utilization review pre upon appropriate request, provide information necessary for utilization review purposes. There are some situations in which we are legally obligated to take action which we believe are necessary to attempt to protect others from harm and we may have to reveal some information about a patient’s treatment. Do you situations are unusual in our practice. ● If we have reasonable cause to suspect child abuse or neglect, the information for health oversight activities under their legal authoritylaw requires that we file a report with the Family Independence Agency. Once such a report is filed, I we may be required to provide itadditional information. • ● If we have a reasonable cause to suspect the “criminal abuse“ of an adult client, we must report it to the police. Once such a report is filed, we may be required to provide additional information. ● If a patient files client communicates a worker’s compensation claimthreat of physical violence against a reasonably identifiable third person and the client has the apparent intent and ability to carry out that threat in the foreseeable future, I must, upon appropriate request, we may have to disclose information relevant in order to take protective action. These actions may include notifying the claimant's condition to potential victim (or, if the worker’s compensation insurer. ▪ I am required by law to report any suspected child abusevictim is a minor, neglecthis/her parents and the county Department of Social Services) and contacting the police, or sexual abuse to protect and/or seeking hospitalization for the child/children involved. ▪ I am obligated by law to report any suspected abuse, neglect, or sexual abuse of an older adult or dependent adult to protect the older adult or dependent adult involved. ▪ Please be aware that information shared with me will be disclosed to your partner or family if they participate in couples or family treatment. I will not agree to hold secrets on any one partner’s behalfclient. If such a situation arises, we will make every effort to fully discuss it with you feel something should not be shared with your partner, please do not tell me your secret(s). At such times, it may be most appropriate for you before taking any action and we will limit our disclosure to seek the support of an individual therapist who what is independent of your couple’s treatment and who will consult with me regarding the broad issues and not the specifics of your secret(s)necessary. While this written summary of exceptions to confidentiality should prove helpful in informing you about potential problems, it is essential important that we discuss any questions or concerns that you may have now or in the future. 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, We keep Protected Health Information about you and 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 these goals, your medical and social history, your treatment history, and he passed treatment records that we received 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 where disclosure would physically in danger you and/or others or makes reference to another person (unless such other person is a healthcare provider) and we believe that access is reasonably likely to cause substantial harm to such other person, you may examine and/or receive a copy of your Clinical Record If you request it in writing. Because these are professional records, they can be misinterpreted and/or upsetting to untrained readers. For this reason, We recommend that you initially review them in the presence of your therapist, or have them forwarded to another mental health professional so you can discuss the contents. In most circumstances, we are allowed to charge a copying fee of $1 per page. The exceptions to this policy are contained in the attached Notice. If we refuse your request for access to your Clinical Records, do you have a right of review (except for information supplied to us confidentially by others), which we will discuss with you upon request. In addition, we also keep Psychotherapy Notes. These notes are for our own use and are designed to assist us in providing you with the best treatment. While the contents of Psychotherapy Notes very from client to client, they can include the contents of your conversations with your therapist, our analysis of those conversations, and how they impact your therapy. They also contain particularly sensitive information that you may review that is not required to be included in your Clinical Record. They 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 anyway for your refusal to provide it. Client Rights HIPAA provides you with several new or expanded rights with regards to your Clinical Records and disclosures of protected health information. These rights include requesting that we amend your record; requesting restrictions on what information from your Clinical Records Is disclosed to others; requesting an accounting of most disclosures of protected health information that you have neither consented to North authorized; determining the location to which protected information disclosures are sent; having any complaints you make about our policies and procedures recorded in your records; and the right to a paper copy of this agreement, the attached notice, and our privacy policies and procedures. We’re happy to discuss any of these rates is disclosed to others; requesting an accounting of most disclosures of protected health information that you have neither consented to North authorized; determining the location to which protected information disclosures are sent; having any complaints you make about our policies and procedures recorded in your records; and the right to a paper copy of this agreement, the attached notice, and our privacy policies and procedures. We’re happy to discuss any of these rights with you. Minors and Parents Clients under 18 years of age who are not emancipated and their parents should be aware that the law may allow parents to examine their child’s treatment records. They should also be aware that patients over 14 years of age can consent to (and control access to information about) . their own treatment, although that treatment cannot extend beyond 12 sessions or four months. While privacy and psychotherapy is very important, particularly with teenagers, parental involvement is also essential to successful treatment. Therefore, it is usually our policy to request an agreement from any client between 14 and 18 and his/her parents allowing us to share general information with parents about the progress of treatment and the child’s attendance at scheduled sessions. Before giving parents any information, we will discuss the matter with the child, if possible, and do our best to handle any objections he/she may have. Billing and Payments (We ask that you pay for each session at the time it is held. If there have been no payments to your account for more than 45 days and arrangements for payment have not been agreed-upon, we 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 us to disclose otherwise confidential information. In most collection situations, the only information we release regarding a client’s treatment is his/her name, the nature of the services provided, and the amount due. If such legal action is necessary, it’s costs will be included in the claim). Insurance Reimbursement In order for us to set realistic treatment goals and priorities, it is important to evaluate what resources you have available to pay for your treatment. If you have a health insurance policy, it will usually provide some coverage for mental health treatment. We will fill out forms and provide you with whatever assistance we can in helping you receive the benefits to which you are entitled. However, you (not your insurance company) are responsible for full payment of our fees. It is very important that you find out exactly what mental health services your insurance policy covers. You should carefully read the section in your insurance coverage booklet that describes mental health services. If you have questions about the coverage, call your plan administrator. Of course, we will provide you with whatever information we can based on our experience and will be happy to help you and understanding the information you received from your insurance company. If it is necessary to clear confusion, we will be willing to call the company on your behalf. You should also be aware that your contract with your health insurance company requires that we provided with information relevant to the services that we provide you. We are required to provide A clinical diagnosis. Sometimes we are required to provide additional clinical information such as treatment plans or summaries, or copies of your entire Clinical Record. In such situations, we will make every effort to release only the minimum information about you that is necessary for the purpose requested. This information will become part of the insurance company files and will probably be stored in a computer. Though all insurance companies going to keep such information confidential, we have no control over what they will do with it once it is in their hands. In some cases they may share information with a national medical information data bank. Will provide you with a copy of any report we submit, if you requested. By signing this agreement, you agree that we can provide requested information to your carrier.

Limits of Confidentiality. The In general, the law protects the privacy of all communications between a patient and a psychologist. In most situations, I can only release information about your treatment can only be released to others if you sign a written Authorization form that meets specific certain legal requirements imposed by state law and HIPAA. But there There are some other situations where I am permitted or required to disclose information without either that require only that your provide written, advance consent. Your signature on this Agreement provides consent or authorizationfor those activities, as follows: • If a patient threatens to harm themself, I Therapists may be obligated to seek hospitalization for them or contact family members or others who can help provide protection. ▪ If a patient communicates a serious threat of physical violence against an identifiable victim, I must take protective actions, including notifying the potential victim and contacting the police. I may also seek hospitalization of the patient or contact others who can assist in protecting the victim. ▪ Disclosures may be required to health insurers or to collect overdue fees. • I occasionally find it helpful to consult other health and mental health professionals about a case. During a consultation, I therapists make every effort to avoid revealing the identity of my patienttheir client. The other professionals are also legally bound to keep the information confidential. If you don’t object, I clients will not tell you be advised about these consultations unless I feel the therapist feels that it is essential important to our your work together. I All consultations will note all consultations be documented 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”). • I You should be aware that the Counseling Center employs an assistant. In most cases, therapists need to share protected information with the assistant for administrative purposes, such as schedules. All of the mental health professionals are bound by the same rules of confidentiality. The assistant has been trained about protecting your privacy and has agreed not to release any information outside of the Center without the permission of a professional staff member. There are some situations where therapists are permitted or required to disclose information without either your consent or Authorization. • If you are involved in a court proceeding and a request is made for information concerning your diagnosis and treatment, such information is protected by the psychologist-patient privilege law. Mental health professionals cannot provide any information without (or your legal representative’s) written authorization, or a court order. If you are involved in or contemplating litigation, you should consult with your attorney to determine whether a court would be likely to order your therapist to disclose information. • If a government agency is requesting the information for health oversight activities, your therapist may be court-ordered required to release treatment information and records in alleged criminal or civil liability casesprovide it for them. In addition, if • If a client files a complaint or lawsuit against mehis/her therapist, I the therapist may disclose relevant information regarding that client in order to defend myselfhim/her. • If a government agency requests the information for health oversight activities under their legal authority, I may be required to provide it. • If a patient client files a worker’s compensation claimclaim related to the services the therapist is providing, I mustthe therapist may, upon appropriate request, disclose protected information relevant to others authorized to receive it by the claimant's condition workers’ compensation law. There are some situations in which mental health professionals are legally obligated to the worker’s compensation insurer. ▪ I am required by law take actions, which they believe are necessary to report any suspected child abuse, neglect, or sexual abuse attempt to protect the child/children involved. ▪ I am obligated by law others from harm and they may have to report any suspected abuse, neglect, or sexual abuse of an older adult or dependent adult to protect the older adult or dependent adult involved. ▪ Please be aware that reveal some information shared with me will be disclosed to your partner or family if they participate in couples or family about a client’s treatment. I will not agree to hold secrets on any one partner’s behalf. If you feel something should not be shared with your partner, please do not tell me your secret(s). At such times, it may be most appropriate for you to seek the support of an individual therapist who is independent of your couple’s treatment and who will consult with me regarding the broad issues and not the specifics of your secret(s). While this written summary of exceptions to confidentiality should prove helpful in informing you about potential problems, it is essential that we discuss any questions or concerns that you may have now or These situations are unusual in the future. 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 neededCounseling Center practice.

Limits of Confidentiality. The law protects the privacy of all communications between a patient and a psychologist. In most situations, I can only release information about your treatment to others if you sign a written Authorization authorization form that meets specific certain legal requirements imposed by state law and HIPAA. But there There are some other situations where I am permitted or required to disclose information without either your that require only that you provide written, advance consent. Your signature on this Agreement provides consent or authorizationfor those activities, as follows: • If a patient threatens to harm themself, I may be obligated to seek hospitalization for them or contact family members or others who can help provide protection. ▪ If a patient communicates a serious threat of physical violence against an identifiable victim, I must take protective actions, including notifying the potential victim and contacting the police. I may also seek hospitalization of the patient or contact others who can assist in protecting the victim. ▪ Disclosures may be required to health insurers or to collect overdue fees. • I occasionally find it helpful to consult other health and mental health professionals about a case. During a consultation, I make every effort to avoid revealing the identity of my patient. The other professionals are also legally bound to keep the information confidential. If you don’t n't object, I will not tell you about these consultations unless I feel that it is essential 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). • If a patient seriously threatens to harm himself/herself, I may be court-ordered obligated to release treatment seek hospitalization for him/her, or to contact family members or others who can help provide protection. Texas law provides that a professional may disclose confidential information only to medical or law enforcement personnel if the professional determines that there is a probability of imminent physical injury by the patient to the patient or others, or there is a probability of immediate mental or emotional injury to the patient. There are some situations where I am permitted or required to disclose information without either your consent or authorization: • If you are involved in a court proceeding and records in alleged criminal or civil liability casesa request is made for information concerning your diagnosis and treatment, you should consult with your attorney to determine whether a court would be likely to order me to disclose information. In addition• If a government agency is requesting the information for health oversight activities, if I may be required to provide it for them. • If a client patient files a complaint or lawsuit against me, I may disclose relevant information regarding that client patient in order to defend myself. • If a government agency requests the information for health oversight activities under their legal authority, I may be required to provide it. • If a patient files a worker’s 's compensation claim, I must, upon appropriate request, provide records relating to treatment or hospitalization for which compensation is being sought. • If a patient fails to pay for services I have rendered, I may disclose relevant information relevant in a suit seeking payment. There are some situations in which I am legally obligated to take actions, which I believe are necessary to attempt to protect others from harm and I may have to reveal some information about a patient's treatment. These situations are unusual in my practice. • If I have cause to believe that a child under 18 has been or may be abused or neglected (including physical injury, substantial threat of harm, mental or emotional injury, or any kind of sexual contact or conduct), or that a child is a victim of a sexual offense, or that an elderly or disabled person is in a state of abuse, neglect or exploitation, the law requires that I make a report to the claimant's condition appropriate governmental agency, usually the Department of Protective and Regulatory Services. Once such a report is filed, I may be required to provide additional information. • If I determine that there is a probability that the patient will inflict imminent physical injury on him/herself, or another, or that the patient will inflict imminent mental or emotional harm upon others, I may be required to take protective action by disclosing information to medical or law enforcement personnel or by securing hospitalization of the patient. If such a situation arises, I will make every effort to fully discuss it with you before taking any action and, I will limit my disclosure to what is necessary. By signing this agreement, you authorize me to contact any person/entity in a position to prevent harm to the worker’s compensation insurer. ▪ patient or a third party if I am required by law determine there is a probability of harm to report any suspected child abuse, neglect, the patient or sexual abuse to protect the child/children involved. ▪ I am obligated by law to report any suspected abuse, neglect, or sexual abuse of an older adult or dependent adult to protect the older adult or dependent adult involved. ▪ Please be aware that information shared with me will be disclosed to your partner or family if they participate in couples or family treatment. I will not agree to hold secrets on any one partner’s behalf. If you feel something should not be shared with your partner, please do not tell me your secret(s). At such times, it may be most appropriate for you to seek the support of an individual therapist who is independent of your couple’s treatment and who will consult with me regarding the broad issues and not the specifics of your secret(s)a third party. While this written summary of exceptions to confidentiality should prove helpful in informing you about potential problems, it is essential important that we discuss any questions or concerns that you may have now or in the future. The laws governing confidentiality can be quite complex, complex and I am not an attorney. In situations where specific advice is required, formal legal advice consultation may be needed. PROFESSIONAL RECORDS The laws and standards of my profession require that I keep Protected Health Information about you or your child in your Clinical Record. The Clinical Record includes information about you or your child's reasons for seeking therapy, a description of the ways in which the problem impacts you or your child's life, the diagnosis, the goals that we set for treatment, progress towards those goals, medical and social history, treatment history, any past treatment records that I receive from other providers, reports of any professional consultations, billing records, and any reports that have been sent to anyone, including reports to your child's school. Except in unusual circumstances that involve danger to yourself and/or others, you may examine and/or receive a copy of your Clinical Record if you request it in writing. You should be aware that pursuant to Texas law, psychological test data are not part of a patient's record. Because these are professional records, they can be misinterpreted and/or upsetting to untrained readers. For this reason, I recommend that you have them forwarded to another mental health professional so you can discuss the contents. In most circumstances, I charge a copying fee of $.50 per page (and for 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 protected health information. 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 protected health information that you have neither consented to nor authorized; determining the location to which protected information disclosures are sent; having any complaints you make about my policies and procedures recorded in your records; and the right to a paper copy of this Agreement, the attached Notice form, and my privacy policies and procedures. MINORS & PARENTS Patients under 18 years of age who are not emancipated from their parents should be aware that the law may allow parents to examine their child's treatment records. However, if the treatment is for suicide prevention, chemical addiction or dependency, or sexual, physical or emotional abuse, the law provides that parents may not access their child's records. For children and adolescents, because privacy in psychotherapy is often critical in building rapport with the therapist, which is crucial to successful progress, it is my policy to discuss the manner in which I will communicate with the son or daughter and the parents. This discussion will typically take place early on in therapy so that all parties are informed as to how we will work together.

Limits of Confidentiality. The law protects the privacy of all communications between a patient and a psychologist. In most situations, I can only release information about your treatment to others if you sign a written Authorization consent form that meets specific certain legal requirements imposed by state law and HIPAAHIPAA and/or Maryland law. But there are some situations where I am permitted or required to disclose information without either your consent or authorizationHowever, in the following situations, no authorization is required: • If a patient threatens to harm themself, I may be obligated to seek hospitalization for them or contact family members or others who can help provide protection. ▪ If a patient communicates a serious threat of physical violence against an identifiable victim, I must take protective actions, including notifying the potential victim and contacting the police. I may also seek hospitalization of the patient or contact others who can assist in protecting the victim. ▪ Disclosures may be required to health insurers or to collect overdue fees. • I occasionally find it helpful to consult other health and mental health professionals about a case. During a consultation, I make every effort to avoid revealing the identity of my patient. The other professionals are 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 essential 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. If you are involved in a court proceeding and a request is made for information concerning your diagnosis and treatment, such information is protected by the psychologist-patient privilege law. I cannot provide any information without your written authorization, or a court order. If you are involved in or contemplating litigation, you should consult with your attorney to determine whether a court would be likely to order me to disclose information. If a government agency is requesting the information for health oversight activities, I may be court-ordered required to release treatment information and records in alleged criminal or civil liability casesprovide it for them. In addition, if If a client patient files a complaint or lawsuit against me, I may disclose relevant information regarding that client patient in order to defend myself. • There are some situations in which I am legally obligated to take actions, which I believe are necessary to attempt to protect others from harm and I may have to reveal some information about a patient’s treatment. These situations are unusual in my practice: If I have reason to believe that a child, adolescent, or vulnerable adult has been subjected to abuse or neglect, or that a vulnerable adult has been subjected to self-neglect, or exploitation, the law requires that I file a report with the appropriate government agency requests agency, usually the information for health oversight activities under their legal authoritylocal office of the Department of Social Services. Once such a report is filed, I may be required to provide itadditional information. • If I know that a patient files has a worker’s compensation claimpropensity for violence and the patient indicates that he/she has the intention to inflict imminent physical injury upon a specified victim(s), I mustmay be required to take protective actions. These actions may include establishing and undertaking a treatment plan that is calculated to eliminate the possibility that the patient will carry out the threat, upon appropriate request, disclose information relevant to seeking hospitalization of the claimant's condition to patient and/or informing the worker’s compensation insurerpotential victim or the police about the threat. ▪ If I am required by law to report any suspected child abuse, neglectbelieve that there is an imminent risk that a patient will inflict serious physical harm or death on him/herself, or sexual abuse 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 initiating hospitalizations and/or notifying family members or others who can protect the child/children involvedpatient. ▪ I am obligated by law to report any suspected abuseIf such a situation arises, neglect, or sexual abuse of an older adult or dependent adult to protect the older adult or dependent adult involved. ▪ Please be aware that information shared with me will be disclosed to your partner or family if they participate in couples or family treatment. I will not agree make every effort to hold secrets on fully discuss it with you before taking any one partner’s behalf. If you feel something should not be shared with your partner, please do not tell me your secret(s). At such times, it may be most appropriate for you action and I will limit my disclosure to seek the support of an individual therapist who what is independent of your couple’s treatment and who will consult with me regarding the broad issues and not the specifics of your secret(s)necessary. While this written summary of exceptions to confidentiality should prove helpful in informing you about potential problems, it is essential important that we discuss any questions or concerns that you may have have, now or in the future. 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 The laws and standards of the profession require that I keep Protected Health Information (PHI) about each client in their clinical record. In some circumstances, I may keep some information in two sets of professional records. One set is your clinical record. It includes information about your reasons for seeking therapy and how these and related issues impact on your life, your diagnosis, goals for treatment, progress towards the goals, your medical treatment and social history, past treatment records I receive from other providers, reports of professional consultations, billing records, and any reports to insurance carriers or others. You may choose, in writing, to examine and/or receive a copy of your clinical record. Because professional records can be misinterpreted it would be important to first review them together or with another mental health professional. In very unusual circumstances, such as a situation in which in my professional judgment disclosing information would endanger someone’s life, then clinical records would not be released. In those situations, the person would have a right to a summary and to have their record sent to another mental health provider. A copying fee of $.60 per page will be charged. There may be other associated costs for review of records. The other set I keep in some instances is a set of psychotherapy notes. These notes are for my own use and are designed to 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 conservations, 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. These psychotherapy notes are kept separate from your clinical record. While insurance companies can request and receive a copy of your clinical record, they cannot receive a copy of your psychotherapy notes without your signed, written authorization. Insurance companies cannot require your authorization as a condition of coverage nor penalize you in any way for your refusal. You may examine and/or receive a copy of your psychotherapy notes unless I determine that knowledge of the health care information would be injurious to your health. Patient Rights HIPAA provides you with expanded rights with regard to clinical records and disclosures of protected health information. These include requesting that I amend your record; requesting restrictions on what information from your clinical record is disclosed; requesting an accounting of disclosures; determining where protected information disclosures are sent; having any complaints you make about my policies recorded in your records; and the right to a paper copy of this agreement, my policies and procedures, and the attached HIPAA notice form. Minors & Parents Parents of clients 16 years of age who are not emancipated may be allowed by law to examine their child’s records. While privacy in psychotherapy is very important, particularly with teenager, parental involvement is also essential to successful treatment. Therefore, it is my policy when treating 16 to 18-year olds to request that they agree to my sharing occasional general information about the progress of treatment with his/her parents. Unless I feel discussing disclosure prior to parental notification is not realistic, such as when the child is in danger or is a danger to someone else, I will discuss with the child, what I think is in their best interest to discuss with the parents and preferably both the child and I will talk with the parents together.