Common use of LIMITS ON CONFIDENTIALITY Clause in Contracts

LIMITS ON CONFIDENTIALITY. The law protects the privacy of all communications between a patient and a psychotherapist. In most situations, I can only release information about your treatment to others if you sign a written authorization form that meets certain legal requirements imposed by HIPAA. There are other situations that require only that you provide written, advance consent. Your signature on this Agreement provides consent for those activities, as follows: • 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 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 important to our work together. I will note all consultations in your Clinical Record (which is called “PHI” in my Notice of Psychotherapist’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 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 my permission. • I also have a contract with a billing service. As required by HIPAA, I have a formal business associate contract with this business, in which it promises to maintain the confidentiality of this data except as specifically allowed in the contract or otherwise required by law. If you wish, I can provide you the name of this organization and/or a blank copy of this contract. I also will ask for your permission before having the billing service contact you. • 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 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 court proceeding and a request is made for information concerning my professional services, such information is protected by the psychotherapist-patient privilege law. I cannot provide any information without your (or your legal representative’s) written authorization, or a court order, or a subpoena of which you have been officially notified and failed to inform me that you are opposing the subpoena. 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 required to provide it for them. • If a patient files a complaint or lawsuit against me, I may disclose relevant information regarding that patient in order to defend myself. • If a patient files a worker’s compensation claim, information that is directly related to that claim must, upon appropriate request, be provided to the Workers’ Compensation 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 patient’s treatment. These situations are unusual in my practice. § If I have reason to know or suspect that a child has been abused or neglected, or has been a victim of sexual abuse by another child, the law requires that I file a report with the Department for Children, Youth and Families. Once such a report is filed, I may be required to provide additional information. § If I believe that a patient presents a risk to a person or his/her family, I may be required to take protective actions including warning the potential victim(s), contacting the police, or seeking 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. While this written summary of exceptions to confidentiality should prove helpful in informing you about potential problems, it is important that we discuss any questions or concerns that you may have 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 ON CONFIDENTIALITY. The law protects the privacy of all communications between a patient and a psychotherapist. In most situations, I can only release information about your treatment to others if you sign a written authorization form that meets certain legal requirements imposed by HIPAA. There are other situations that require only that you provide written, advance consent. Your signature on this Agreement provides consent for those activities, as follows: • 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 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 important to our work together. I will note all consultations in your Clinical Record (which is called “PHI” in my Notice of Psychotherapist’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 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 my permission. • I also have a contract with a billing service. As required by HIPAA, I have a formal business associate contract with this business, in which it promises to maintain the confidentiality of this data except as specifically allowed in the contract or otherwise required by law. If you wish, I can provide you the name of this organization and/or a blank copy of this contract. I also will ask for your permission before having the billing service contact you. • 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 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 court proceeding and a request is made for information concerning my professional services, such information is protected by the psychotherapist-patient privilege law. I cannot provide any information without your (or your legal representative’s) written authorization, or a court order, or a subpoena of which you have been officially notified and failed to inform me that you are opposing the subpoena. 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 required to provide it for them. • If a patient files a complaint or lawsuit against me, I may disclose relevant information regarding that patient in order to defend myself. • If a patient files a worker’s compensation claim, information that is directly related to that claim must, upon appropriate request, be provided to the Workers’ Compensation 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 patient’s treatment. These situations are unusual in my practice. § ▪ If I have reason to know or suspect that a child has been abused or neglected, or has been a victim of sexual abuse by another child, the law requires that I file a report with the Department for Children, Youth and Families. Once such a report is filed, I may be required to provide additional information. § ▪ If I believe that a patient presents a risk to a person or his/her family, I may be required to take protective actions including warning the potential victim(s), contacting the police, or seeking 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. While this written summary of exceptions to confidentiality should prove helpful in informing you about potential problems, it is important that we discuss any questions or concerns that you may have 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 ON CONFIDENTIALITY. The law protects the privacy of all communications between a patient and a psychotherapistpsychologist. In most situations, I we can only release information about your treatment to others if you sign a written authorization Authorization form that meets certain legal requirements imposed by HIPAA. There are other situations that require only that you provide written, advance consent. Your signature on this Agreement provides consent for those activities, as follows: • I  We may 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 important to our work together. I We will note all consultations in your Clinical Record (which is called “PHI” in my Notice of PsychotherapistPsychologist’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 we need to share protected information with these individuals for both clinical and administrative purposes, such as scheduling, billing, 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 my permissionthe permission of a professional staff member. • I also have a contract with a billing service. As required by HIPAA, I have a formal business associate contract with this business, in which it promises to maintain the confidentiality of this data except as specifically allowed in the contract or otherwise required by law. If you wish, I can provide you the name of this organization and/or a blank copy of this contract. I also will ask for your permission before having the billing service contact you. •  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 we 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 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 my professional servicesyour diagnosis and treatment, such information is protected by the psychotherapistpsychologist-patient privilege law. I We cannot provide any information without your (or your legal representative’s) written authorization, or a court order, or a subpoena of which you have been officially notified and failed to inform me that you are opposing the subpoena. 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 we are required to provide it for them. •  If a patient files a complaint or lawsuit against meus, I we may disclose relevant information regarding that patient in order to defend myself. • If a patient files a worker’s compensation claim, information that is directly related to that claim must, upon appropriate request, be provided to the Workers’ Compensation Commissionourselves. There are some situations in which I am we are legally obligated to take actions, which I we believe are necessary to attempt to protect others from harm and I we may have to reveal some information about a patient’s treatment. These situations are unusual in my practice. §  If I we have reason reasonable cause to know or suspect that a child has been abused suffered harm as a result of child abuse or neglected, or has been a victim of sexual abuse by another childneglect, the law requires that I we file a report with the appropriate governmental agency, usually the Alaska Department for Children, Youth of Health and FamiliesSocial Services. Once such a report is filed, I we may be required to provide additional information. §  If I we have reasonable cause to believe that a vulnerable adult suffers from abandonment, exploitation, abuse, neglect, or self-neglect; or that a disabled person has been abused, the law requires that we file a report with the Alaska Department of Administration. Once such a report is filed, we may be required to provide additional information.  If a patient presents a risk communicates an immediate threat of serious physical harm to a person or his/her familyan identifiable victim, I we may be required to take protective actions. These actions including warning may include notifying the potential victim(s)victim, contacting the police, or seeking hospitalization of for the patient. If such a situation arises, I we will make every effort to fully discuss it with you before taking any action and I we will try to limit my our disclosure to what is necessary. While this written summary of exceptions to confidentiality should prove helpful in informing you about potential problems, it is important that we discuss any questions or concerns that you may have 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 ON CONFIDENTIALITY. The law protects the privacy of all communications between a patient and a psychotherapistpsychologist. In most situations, I we can only release information about your treatment to others if you sign a written authorization Authorization form that meets certain legal requirements imposed by HIPAA. There are other situations that require only that you provide written, advance consent. Your signature on this Agreement provides consent for those the following, among other, activities, as follows: • I We may 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 important to our work together. I will note all consultations in your Clinical Record (which is called “PHI” in my Notice of Psychotherapist’s Policies and Practices to Protect the Privacy of Your Health Information). • You should be aware that I we practice with other mental health professionals and that I employ clinical and administrative staff. In most cases, I we need to share protected information with these individuals for both clinical and administrative purposes, such as scheduling, billing, referral and quality assurance. All of the mental health professionals are bound by the same similar 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 my permissionthe permission of a professional staff member. • I We also have a contract contracts with a billing servicevarious healthcare and human services organizations. As required by HIPAA, I we have a formal business associate contract with this businessthis/these business(es), in which it promises they promise to maintain the confidentiality of this data except as specifically allowed in the contract or otherwise required by law. If you wish, I we can provide you with the name names of this organization these organizations and/or a blank copy of this contract. I also will ask for your permission before having the billing service contact you. • 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 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 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 my the professional servicesservices we provided to you, such information is protected by the psychotherapistpsychologist-patient privilege law. I We cannot provide any information without your (or your legal representative’s) ’s written authorization, or a court order, or a subpoena of which you have been officially notified and failed to inform me that you are opposing the subpoena. 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 us to disclose information. • If a government agency is requesting the information for health oversight activities, I we may be required to provide it for them. • If a patient files a complaint or lawsuit against meus, I we may disclose relevant information regarding that patient patient, or other patients receiving services relevant to the complaint or lawsuit, in order to defend myself. • If a patient files a worker’s compensation claim, information that is directly related to that claim must, upon appropriate request, be provided to the Workers’ Compensation Commissionourselves. There are some situations in which I am we are legally obligated to take actions, which I we believe are necessary to attempt to protect others from harm and I we may have to reveal some information about a patient’s treatment. These situations are unusual in my our practice. § • If I we have reason reasonable cause to know or suspect believe that a child has been abused or neglected, or has been a victim of sexual abuse by another child, the law requires that I we file a report with the Department for Children, Youth and Familiesappropriate government officials. Once such a report is filed, I we may be required to provide additional information. § • If I we have received information or have reason to suspect that any elderly or disabled adult, or who has reason to suspect that any elderly or disabled adult has been abused, neglected or exploited, the law requires that we file a report with the appropriate governmental agency, usually the Commissioner of the Department of Aging and Disabilities. Once such a report is filed, we may be required to provide additional information. • If we believe that a patient presents poses a serious risk of danger to a person an identifiable victim, or his/her familyto the property of the identifiable individual, I we may be required have to take protective actions including warning contacting the potential victim(s)victim, contacting the police, police or seeking hospitalization of taking steps to hospitalize the patient. • If we believe that a patient poses a serious, imminent risk to him/herself, we may be obligated to seek hospitalization for him/her or to contact family members or others who can help provide protection. If such a situation arises, I we will make every effort to fully discuss it with you before taking any action and I we will limit my our disclosure to what is necessary. • If a patient files a workers’ compensation claim, we may release all relevant records to the patient’s employer upon the patient executing a Workers’ Compensation Medical Authorization. While this written summary of exceptions to confidentiality should prove helpful in informing you about potential problems, it is important that we discuss any questions or concerns that you may have 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 ON CONFIDENTIALITY. The law protects the privacy and confidentiality of all communications communication between a patient client and a psychotherapistthe client’s mental health professional. In most situations, circumstances I can only release information about you only with your treatment to others if you sign a written authorization form that meets certain legal requirements imposed by HIPAAauthorization. There are other a few exceptions to confidentiality and situations that require in which information may be released without authorization or consent. Under HIPAA, use or disclosure of your PHI for the purposes of treatment, payment, or health care operations, requires only that you provide written, advance your consent. Your signature on this Agreement the treatment policies form provides consent for those activitiessituations. Treatment refers to services I provide which may include eliciting personal information from you or about you through interview, as follows: • I may occasionally find it helpful testing, documentation, or consultation with other clinicians intended to consult other serve your 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 important to our work togethercare needs. I will note all consultations in your Clinical Record (which is called “PHI” in my Notice am mandated by law to report to the appropriate agencies suspected neglect or abuse of Psychotherapist’s Policies and Practices to Protect the Privacy of Your Health Information). • You should be aware that I practice children under age 18, individuals 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 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 my permission. • I also have a contract with a billing service. As required by HIPAA, I have a formal business associate contract with this business, in which it promises to maintain the confidentiality of this data except as specifically allowed in the contract or otherwise required by law. If you wish, I can provide you the name of this organization and/or a blank copy of this contract. I also will ask for your permission before having the billing service contact you. • 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 obligated to seek hospitalization for him/herphysical disabilities, or to contact family members or others who can help provide protectionelders. 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 my professional services, such information is protected by the psychotherapist-patient privilege law. I cannot provide any information without your (or your legal representative’s) written authorization, or a court order, or a subpoena of which you have been officially notified and failed to inform me that you are opposing the subpoena. 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 required to provide it for them. • If a patient files a complaint or lawsuit against me, I may disclose relevant information regarding that patient in order to defend myself. • If a patient files a worker’s compensation claim, information that is directly related to that claim must, upon appropriate request, be provided to the Workers’ Compensation 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 patient’s treatment. These situations are unusual in my practice. § If I have reason to know or suspect that a child has been abused or neglected, or has been a victim of sexual abuse by another child, the law requires that I file a report with the Department for Children, Youth and Families. Once such a report is filed, I may be required to provide additional information once I have made such a report. If you appear to be at clear or immediate risk of self-harm or of harming an identified person, I must take reasonable precautions to insure safety. These precautions may include warning a potential victim, notification of law enforcement, or arranging for hospitalization. These precautions may involve disclosure of PHI without your consent or authorization, which is permitted under the law in these circumstances. If you file a Worker’s Compensation claim, your records relevant to that claim can be requested and provided to your employer, insurer, or the Department of Worker’s Compensation. Professional Boards of Social Work and Psychology have the power to subpoena relevant records when necessary, should I be the focus of an inquiry. If you are involved in court proceedings, unless there is a court order, your written authorization is required from you or your legal representative in order for me to release information. § If I believe that your evaluation is court-ordered, or there is a patient presents a risk to a person or his/her familycourt order for your information, I may be required am obligated to take protective actions including warning the potential victim(s), contacting the police, or seeking 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. While this written summary of exceptions to confidentiality should prove helpful in informing you about potential problems, it is important that we discuss any questions or concerns that you may have 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 neededrelease your information.

LIMITS ON CONFIDENTIALITY. The law protects the privacy of all communications between a patient and a psychotherapisttherapist. In most situations, I can only release information about your treatment to others if you sign a written authorization form that meets certain legal requirements imposed by HIPAAform. There are other some situations that require only that you provide written, advance consentwhere I am permitted or required to disclose information without either your consent or Authorization. Your signature on this Agreement provides consent Please see the GCA Notice of Privacy Practices for those activities, as followsmore information. A brief summary is provided below: • 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 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 important to our work together. I will note all consultations in your Clinical Record (which is called “PHI” in my Notice of Psychotherapist’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 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 my permission. • I also have a contract with a billing service. As required by HIPAA, I have a formal business associate contract with this business, in which it promises to maintain the confidentiality of this data except as specifically allowed in the contract or otherwise required by law. If you wish, I can provide you the name of this organization and/or a blank copy of this contract. I also will ask for your permission before having the billing service contact you. • 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 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 court proceeding and a request is made for information concerning my professional servicesyour diagnosis and treatment, such information is protected by the psychotherapistpsychologist-patient privilege law. I cannot provide any information without your (or your legal representative’s) written authorization, or a court order, or a subpoena of which you have been officially notified and failed to inform me that you are opposing the subpoena. 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 I am required to comply if a government agency is requesting the requests information for health oversight activities, I may be required to provide it for them. • If a patient files a complaint or lawsuit against me, I may disclose relevant information regarding that patient in order to defend myself. • If a patient files a worker’s compensation claim, information that is directly related to that claim must, upon appropriate request, be provided to the Workers’ Compensation Commission. There are some situations in which I am legally obligated to take actionsaction, such as making a report to a protective agency or warning a potential victim, which I believe are is necessary to attempt to protect others from harm harm, and I may have to reveal some thereby revealing information about a patient’s treatment. These situations are unusual in my practice. § ▪ If I have reason reasonable cause to know or suspect that a child has been abused suffered harm as a result of child abuse or neglectedneglect. ▪ If I have reasonable cause to believe a vulnerable adult suffers from abandonment, exploitation, abuse, neglect, or self-neglect; or a disabled person has been abused. ▪ If a victim patient communicates an immediate threat of sexual abuse by another child, the law requires that I file a report with the Department for Children, Youth and Families. Once such a report is filedserious harm to an identifiable victim, I may be required to provide additional information. § If I believe that a patient presents a risk to a person or his/her family, I may be required to take protective actions including warning notify the potential victim(s)victim, contacting contact the police, or seeking seek hospitalization of for the patient. If any such a situation arises, I will make every effort to fully discuss it with you before taking any action action, and I will try to limit my disclosure to what is necessary. While this written summary of exceptions to confidentiality should prove helpful in informing you about potential problems, it is important that we discuss any questions or concerns that you may have 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. Consultation with other GCA Professionals One of the many benefits of working as a therapist in a clinic setting is the availability of other experienced professionals. I may consult with other GCA professionals about your care in an effort to provide the best treatment possible.

LIMITS ON CONFIDENTIALITY. The law protects the privacy of all communications between a patient and a psychotherapistclinician. 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 certain legal requirements imposed by HIPAA. There are other situations that require only that you provide written, advance consent. Your signature on this Agreement provides consent for those the activities, as follows: • I A clinician may occasionally find it helpful to consult other health and mental health professionals about a case. During a consultation, I make every effort is made 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 you will not tell you be informed about these consultations unless I feel that it is important to our work togetherdeemed important. I All consultations will note all consultations be noted in your Clinical Record Records (which is called referenced as the “PHI” in my the Notice of Psychotherapist’s Policies and Practices to Protect the Privacy of Your Health Information). • You should be aware that I this practice with includes other mental health professionals and that I employ administrative staff. In most cases, I need it is necessary to share protected information with these individuals for both clinical and administrative purposes, such as scheduling, billing, 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 my permissionthe permission of a professional staff member. • I also have a contract This practice has contracts with a billing servicean answering service and collection agency. As required by HIPAA, I have a formal business associate contract with this businessthis/these business(s), in which it promises it/they promise to maintain the confidentiality of this data except as specifically allowed in the contract or otherwise required by law, has been established. If you wish, I you can provide you be provided the name names of this organization these organizations and/or a blank copy of this the contract. I also will ask for your permission before having the billing service contact you. • Disclosures required by health insurers or to collect overdue fees are discussed elsewhere in this the Agreement. • 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 whereby the clinician is 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 my professional servicesyour evaluation, diagnosis or treatment, such information is protected by the psychotherapist-patient privilege privileged communication law. I The clinician cannot provide any information without your (or your personal or legal representative’s) written authorization, or a court order, or a subpoena of which you have been officially notified and failed to inform me that you are opposing the subpoena. If you are involved in or are contemplating litigation, you should consult with your attorney to determine whether a court would be likely to order me the clinician to disclose information. • If a government agency is requesting the information for health oversight activities, I the clinician may be required to provide it for them. • If a patient client files a complaint or lawsuit against methe clinician, I that clinician may disclose relevant information regarding that patient the client in order to defend myself. • If a patient files a worker’s compensation claim, information that is directly related to that claim must, upon appropriate request, be provided to the Workers’ Compensation Commissionhim/herself. There are some situations in which I am the clinician is legally obligated to take actions, which I believe he/she believes are necessary to attempt to protect others from harm and I harm. In doing so, the clinician may have to reveal some information about a patientclient’s treatment. These situations are unusual in my practice. § • If I have the clinician knows or has reason to know or suspect that a child has been abused or neglectedunder 18 years of age, or a mentally retarded, developmentally disabled, or physically impaired individual under the age of 21 years of age, has been suffered or faces a victim threat of sexual suffering any physical or mental wound, injury, disability, or condition of a nature that reasonably indicates abuse by another or neglect of the child/individual, the law requires that I the clinician file a report with the Department for Childrenappropriate government agency, Youth and Familiesusually the Public Children Services Agency. Once such a report is filed, I the clinician may be required to provide additional information. § • If I the clinician has reasonable cause to believe that an adult is being abused, neglected, or exploited, or is in a condition which is the result of abuse, neglect, or exploitation, the law requires that the clinician report such belief to the county Department of Job and Family Services. Once such a report has been filed, the clinician may be required to provide additional information. • If the clinician knows or has reasonable cause to believe that a client has been the victim of domestic violence, he/she must note that knowledge or belief and the basis for it in the client’s record. • If the clinician believes that a patient presents a clear and substantial risk of imminent serious harm to a person him/herself or hissomeone else, and he/her familyshe believes that disclosure of certain information may serve to protect that individual, I may be required then the clinician must disclose that information to take protective actions including warning the appropriate public authorities, and/or the potential victim(s)victim, contacting and/or professional workers, and/or the police, or seeking hospitalization family of the patientclient. If such a situation arises, I the clinician will make every effort to fully discuss it with you before taking any action and I will limit my the disclosure to what is necessary, if the clinician feels that is appropriate. By signing below, you consent to our releasing information about your claim(s) to the Ohio Department of Insurance in connection with any insurance company’s failure to properly pay a claim in a timely manner, as well as the Ohio Department of Commerce, which requires certain reporting of unclaimed funds. In those instances, only the minimal, required, information will be supplied. In addition, by signing below, you are consenting to the fact that from time to time, we may have the need to consult our practice attorney regarding legal issues involving your care (this is an infrequent occurrence, but does happen from time to time.) Our practice attorney is bound by confidentiality rules also. In addition, we will reveal only the information that we need to reveal to receive appropriate legal advice in connection with those contacts. While this written summary of exceptions to confidentiality should prove helpful in informing you about potential problems, it is important that we you discuss with the clinician any questions or concerns that you may have now or in the future. The laws governing confidentiality can be quite complex, and I am clinicians are not an attorneyattorneys. In situations where specific advice is required, formal legal advice may be needed.

LIMITS ON CONFIDENTIALITY. The law protects the privacy of all communications between a patient client and a psychotherapistclinician. In most situations, I the Counseling Center can only release information about your treatment to others if you sign a written authorization Authorization form that meets certain legal requirements imposed by HIPAA. There are other situations that require only that you provide written, advance consentconsent which is provided by signing that you received this document. Your signature on acknowledging that you received this Agreement provides consent for those the following activities, as follows: • I may occasionally find it helpful Although you will probably meet with only one clinician, you are receiving services from the Counseling Center. Consequently, you will have a file in our office 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 patientwhich all staff will have necessary access. The clinicians on staff consult with each other professionals are also legally bound to keep about our work. Our staff includes the information confidential. If you don’t object, I will not tell you about these consultations unless I feel that it is important to our work together. I will note all consultations in your Clinical Record (which is called “PHI” in my Notice of Psychotherapist’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 staffreceptionist. In most cases, I we need to share protected information with these individuals within the Counseling Center for both clinical and administrative purposes, such as scheduling, billingrecords management, and quality assurance. All of the mental health professionals are bound by the same rules of confidentiality. All staff members have The receptionist has been given training about protecting your privacy and have has agreed not to release any information outside of the practice Counseling Center without my permissionthe permission of a professional staff member. • I In providing, coordinating, or managing your treatment and other services related to your psychological care, the Counseling Center sometimes interacts with various other professionals, on or off campus, concerning your well-being, such as other health care providers or relevant University officials, for example the Office of Accessibility Services. • Records are stored electronically in a secure server maintained by the University of Central Missouri Office of Technology. In conducting routine maintenance activities, the Office of Technology does not ordinarily view individually identifiable information. In a circumstance in which they would view individually identifiable data, Information Services personnel are bound by the same confidentiality rules as the Counseling Center. • The Counseling Center may also have a contract with a billing serviceuse some psychological test-scoring services. As required by HIPAA, I have a the Counseling Center has formal business associate contract contracts with this businessthese businesses, in which it promises they promise to maintain the confidentiality of this data except as specifically allowed in the contract or otherwise required by law. If you wish, I the Counseling Center can provide you with the name names of this organization these organizations and/or a blank copy of this contract. I also will ask for your permission before having the billing service contact you. • 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 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 the Counseling Center is 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 my professional servicesyour diagnosis and treatment, such information is protected by the psychotherapistclinician-patient privilege law. I The Counseling Center cannot provide any information without a) your (or your legal representative’s) written authorization, or b) a court order, or a subpoena of which you have been officially notified and failed to inform me that you are opposing the subpoena. 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 the Counseling Center to disclose information. • If a government agency is requesting the information for health oversight activities, I the Counseling Center may be required to provide it for them. • If a patient client files a complaint or lawsuit against methe Counseling Center, I we may disclose relevant information regarding that patient client in order to defend myselfourselves. • If a patient client files a worker’s compensation claim, information that is directly related to that claim the Counseling Center must, upon appropriate request, be provided provide a copy of the client’s record to the Labor and Industrial Commission or the Workers’ Compensation CommissionDivision of the Missouri Department of Labor and Industrial Relations, or the client’s employer. There are some situations in which I am legally the Counseling Center is obligated to take actions, either by law or by our professional judgment, which I we believe are necessary to attempt to protect others you, others, or the University community from harm harm, and I we may have to reveal some information about a patient’s your condition or your treatment. These situations are unusual in my practice. § • If I we have reason reasonable cause to know or suspect that a child has been abused or neglected, may be subjected to abuse or has been neglect or observe a victim of sexual child being subjected to conditions or circumstances that would reasonably result in abuse by another childor neglect, the law requires that I the Counseling Center file a report with the Department for Children, Youth and FamiliesMissouri Division of Family Services. Once such a report is filed, I we may be required to provide additional information. § • If I we have reasonable cause to suspect that an elderly, disabled, or vulnerable adult presents a likelihood of suffering serious physical harm and is in need of protective services, the law requires that the Counseling Center file a report with Department of Social Services. Once such a report is filed, we may be required to provide additional information. • If we believe that a patient presents it is necessary to disclose information to protect against a risk of serious harm being inflicted by you upon yourself, another person, or to a person or his/her familythe University community, I the Counseling Center may be required to take protective action. Depending on the situation, these actions including warning the may include initiating hospitalization and/or contacting significant others (for example, relatives) and/or a potential victim(s), contacting the police, or seeking hospitalization of the patientvictim and/or law enforcement and/or other University officials. If such a situation arises, I your clinician will make every effort to fully discuss it with you before taking any action and I we will limit my our disclosure to what is necessary. While this written summary of exceptions to confidentiality should prove helpful in informing you about potential problems, it is important that we discuss any questions or concerns that you may have 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. PROFESSIONAL RECORDS Your Clinical Record is maintained electronically. The electronic records are stored on a secure dedicated server maintained by the University’s Information Services department. Access to the contents of your file is limited to the Counseling Center clinical staff. The laws and standards of our profession require that the Counseling Center keep Protected Health Information (PHI) about you in 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, any information about substance use and diagnostic impressions of Substance-Related and Addictive Disorders, the goals that we set for treatment, your progress towards those goals, your medical and social history including any HIV/AIDS (Human Immunodeficiency Virus/Acquired Immunodeficiency Syndrome) related information, your treatment history, any past treatment records that we receive from other providers, reports of any professional consultations, and any reports that have been sent to anyone. Your record may include information from others who contact the Counseling Center expressing concern about you. For example, your record may include contacts we receive from faculty, staff, Public Safety, or other students. In certain situations, we may access additional information such as reports about students of concern or disciplinary reports. You may examine and/or receive a copy of your Clinical Record if you request it in writing, except in the unusual circumstance where disclosure is reasonably likely to endanger you and/or others or when another individual (other than another health care provider) is referenced and we believe disclosing that information puts the other person at risk of substantial harm. Because these are professional records, they can be misinterpreted by and/or be upsetting to untrained readers. For this reason, the Counseling Center recommends that you initially review them in your clinician’s presence, or have them forwarded to another mental health professional so you can discuss the contents. In most circumstances, the Counseling Center is allowed to charge a fee of 40 cents per page (and for certain other expenses). The exceptions to this policy are also contained in the Privacy Notice Form you were offered.

LIMITS ON CONFIDENTIALITY. The law protects the privacy of all communications between a patient and a psychotherapistpsychologist. In most situations, I can only release information about your treatment to others if you sign a written authorization Authorization form that meets certain legal requirements imposed by HIPAA. There are other situations that require only that you provide written, advance consent. Your signature on this Agreement provides consent for those activities, as follows: • *I may occasionally find it helpful to consult other health and mental health professionals about a case. During a the 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 important to our work together. I will note all consultations in your Clinical Record (which is called referred to as “PHI” in my Notice of Psychotherapist’s Policies and Practices to Protect the Privacy of Your 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 personnel for both clinical and administrative purposes, such as scheduling, billing, administrative purposes and quality assurance. All of the mental health professionals are bound by the same rules of confidentiality. All staff members These individuals have been given training about protecting your privacy and have agreed not to release any information outside of the practice without my permission. • I also have a contract with a billing service. As required by HIPAA, I have a formal business associate contract with this business, in which it promises to maintain the confidentiality of this data except as specifically allowed in the contract or otherwise required by law. If you wish, I can provide you the name of this organization and/or a blank copy of this contract. I also will ask for your permission before having the billing service contact you. • *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 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 court proceeding and a request is made for information concerning my professional servicesyour diagnosis and treatment, such information is protected by the psychotherapistpsychologist-patient privilege law. I cannot provide any information without your (or your legal representative’s) written authorization, or a court order, or if a subpoena is served on me with appropriate notices. I may have to release information in a sealed envelope to the clerk of which you have been officially notified and failed to inform me that you are opposing the court issuing the subpoena. 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 required to provide it for them. • *If a patient files a complaint or lawsuit against me, I may disclose relevant information regarding that the patient in order to defend myself. • *If a patient files a worker’s compensation claim, information that is directly related to that claim I must, upon appropriate request, be provided to the Workers’ Compensation Commissionprovide a copy of any mental health report. 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 highly unusual in my practice. § *If I have reason to know or suspect that a child has been is abused or neglected, or has been a victim of sexual abuse by another child, the law requires that I file a report with the appropriate governmental agency, usually the Department for Children, Youth and Familiesof Social services. Once such a report is filed, I may be required to provide additional information. § *If I believe have reason to suspect than an adult is abused, neglected or exploited, the law requires that I report to the Department of Welfare or Social Services. Once such a patient presents a risk to a person or his/her familyreport is filed, I may be required to provide additional information. *If a patient communicates a specific threat of immediate physical harm to an identifiable victim, and I believe he/she has the intent and the ability to carry out the threat, I am required to take protective actions. These actions including warning may include notifying the potential victim(s)victim or his/her guardian, contacting the police, or seeking hospitalization of for 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. While this written summary of the exceptions to confidentiality should prove helpful in informing you about potential problems, it is important that we discuss any questions or concerns that you may have either 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 ON CONFIDENTIALITY. The law protects the privacy of all communications between a patient and a psychotherapistpsychologist. In most situations, I can only release information about your treatment to others if you sign a written authorization Authorization form that meets certain legal requirements imposed by HIPAA. There are other situations that require only that you provide written, advance consent. Your signature on this Agreement provides consent for those activities, as follows: • 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 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 important to our work together. I will note all consultations in your Clinical Record (which is called “PHI” in my Notice of PsychotherapistPsychologist’s Policies and Practices to Protect the Privacy of Your Health Information). • You should be aware that I practice with other mental health professionals If you can’t make your appointment in person and that I employ administrative staff. In most casesrequest to have a videoconference, I need to share protected information with these individuals for both clinical sometimes use FaceTime. While it reports end-to-end encryption, it isn’t a commercial product so they don’t offer a business agreement and administrative purposes, such as scheduling, billing, and quality assurance. All of the mental health professionals are bound by the same rules of I cannot guarantee your 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 my permission. • I also have a contract with a billing service. As required by HIPAA, I have a formal business associate contract with this business, in which it promises to maintain the confidentiality of this data except as specifically allowed in the contract or otherwise required by law. If you wish, I can provide you the name of this organization and/or a blank copy of this contract. I also will ask for your permission before having the billing service contact you. • Disclosures required by health insurers or to collect overdue fees are discussed elsewhere in this Agreement. • If a patient client threatens to seriously 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 I am directed by a judge in a court of law to reveal information, then I must do so. However, if you are involved in a court proceeding and a request is made for information concerning my professional services, such information is protected by the psychotherapist-psychologist- patient privilege law. I cannot provide any information without your (or your legal representative’s) written authorization, or a court order, or a subpoena of which you have been officially notified and failed to inform me that you are opposing the subpoena. 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 am required to provide it for them. • If a patient client files a complaint or lawsuit against me, I may disclose relevant information regarding that patient client in order to defend myself. • If a patient client files a worker’s compensation claim, information that is directly related I am required to that claim must, upon appropriate request, be provided submit a report to the Workers’ Compensation CommissionDivision. 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 patientclient’s treatment. These situations are unusual in my practice. § * If I have reason reasonable cause to know or suspect that a child child/adolescent client under 18 has been or may be abused or neglectedneglected (including physical injury, substantial threat of harm, mental or emotional injury, or has been any kind of sexual contact or conduct), or that a child is a victim of a sexual abuse by another childoffense, the law requires that I file a report with the Department for Children, Youth and Familiesappropriate governmental agency. Once such a report is filed, I may be required to provide additional information. § * If I have reasonable cause to believe that an at-risk adult such as an elderly or disabled person has been or is at imminent risk of being mistreated, self-neglected, or financially exploited, the law requires that I file a patient presents report with the appropriate governmental agency. Once such a risk to a person or his/her familyreport is filed, I may be required to provide additional information * If a client communicates a serious threat of imminent physical violence against a specific person or persons, I must make an effort to notify such person; and/or notify an appropriate law enforcement agency; and/or take protective actions other appropriate action including warning the potential victim(s), contacting the police, or seeking 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. While this written summary of exceptions to confidentiality should prove helpful in informing you about potential problems, it is important that we discuss any questions or concerns that you may have 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 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 forwarded to another mental health professional so you can discuss the contents. In most situations, I am allowed to charge a copying fee (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. CLIENT 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. I am happy to discuss any of these rights with you. MINORS & PARENTS In order to treat your child/adolescent, it is important that all parents/legal guardians are informed and approve of treatment. In the treatment of individuals under the age of 18, it is my practice to invite parents or legal guardians to meet with me in order to collect information that may be helpful to your son’s or daughter’s care. You are also welcome to attend the first 10 minutes of a session in order to report any information you feel I should know. Please do not give me information that you do not want me to share with your son or daughter. If you feel it is pertinent that I know something that hasn’t been shared with him or her, please alert me as to discuss this topic further. At times, you may be invited to participate in a session. If the issue appears to require more intensive family therapy, I will be happy to make an additional referral to a family therapist. 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. However, because privacy in psychotherapy is often crucial to successful progress, particularly with teenagers, it is my policy to request an agreement from the child’s parent(s)/ guardian(s) that they consent to give up access to their child’s 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. Any other communication will require the child’s authorization unless I learn of activity which poses a clear and present danger of immediate and severe risk to the child’s health/safety (e.g., being involved in drunk driving, using I.V. drugs) or if he or she is a danger to someone else; in these cases, I will inform parent(s)/guardian(s). 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 I am considered an out-of-network provider with all insurance companies. If you have out- of-network mental health benefits you may be able to be reimbursed for a percentage based on your plan. Please contact your insurance directly if you have any questions about your out- of-network coverage. You will be expected to pay me directly for each session at the time it is held. If you would like to access your out-of- network benefits, I am happy to provide you with an insurance reimbursement form called a “Superbill” at the end of each month. However, I will not become involved in disputes between you and your insurance company. Ultimately, you are responsible for the timely payment of your account. Payment schedules for other professional services will be agreed to when they are requested. In circumstances of unusual financial hardship, I may be willing to negotiate a fee adjustment. A service fee will be assessed for all returned checks, typically $35.00. 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 collection action is necessary a 25% charge may be added to your bill in order to recover the cost of this service. COLORADO MANDATORY DISCLOSURE STATEMENT

LIMITS ON CONFIDENTIALITY. The law protects the privacy of all communications between a patient and a psychotherapistpsychologist. In most situations, I we can only release information about your treatment to others if you sign a written authorization Authorization form that meets certain legal requirements imposed by HIPAA. There are other situations that require only that you provide written, advance consent. Your signature on this Agreement provides consent for those activities, as follows: • I Your therapist may 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 patientyour identity. 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 feel your therapist feels that it is important to our the work togetheryou are doing. I Your therapist will note all consultations in your Clinical Record (which is called “PHI” in my the Notice of PsychotherapistPsychologist’s Policies and Practices to Protect the Privacy of Your Health Information). • You should be aware that I we practice with other mental health professionals and that I we employ both clinical and administrative staff. In most cases, I your therapist will need to share 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 my permissionthe permission of a professional staff member. • I We also have contracts with Utah Health Information Network for electronic billing and a contract with a billing servicecollection agency. As required by HIPAA, I we have a formal business associate contract with this businessthese businesses, in which it promises they promise to maintain the confidentiality of this data except as specifically allowed in the contract or otherwise required by law. If you wish, I the staff can provide you the name of this organization and/or with a blank copy of this the contract. I also will ask for your permission before having the billing service contact you. • 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 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 your therapist is permitted or required to disclose information without either your consent or Authorization: . • If you are involved in a court proceeding and proceeding, the patient-psychologist privilege provides a request is made degree of protection. However, if a judge issues an order for information concerning my professional servicesthe records, such information is protected by the psychotherapist-patient privilege lawwe are required to release those records. I canOtherwise, your records will not provide any information be released without your (a signed Authorization for you or your legal representative’s) written authorization, or a court order, or a subpoena of which you have been officially notified and failed to inform me that you are opposing the subpoena. 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 us to disclose information. • If a government agency is requesting the information for health oversight activities, I may be we are required to provide it for them. • If a patient files a complaint or lawsuit against meany individual therapist or Corner Canyon Counseling and Psychological Services, I we may disclose relevant information regarding that patient in order to defend myselfthe therapist or the group. • If a patient files a worker’s compensation claim, information that is directly related to that claim we must, upon appropriate request, be provided provide a copy of the patient’s record to the Workersappropriate parties, the patient’s employer, the workers’ Compensation compensation insurance carrier or the Labor Commission. There are some situations in which I am your therapist is legally obligated to take actions, which I believe are action. Whenever your therapist judges that it is necessary to attempt to protect the patient or others from harm and I harm, we may have to reveal some information about a patient’s treatment. These situations are unusual in my our practice. § • If I have your therapist has reason to know or suspect believe that a child has been abused or neglectedis likely to be subjected to incest, molestation, sexual exploitation, sexual abuse, physical abuse, witnessing domestic violence, or has been a victim of sexual abuse by another childneglect, the law requires that I file a report with we immediately notify the Department for Children, Youth Division of Child and FamiliesFamily Services or an appropriate law enforcement agency. Once such a report is filed, I we may be required to provide additional information. § • If I your therapist has reason to believe that any vulnerable adult has been the subject of abuse, neglect, abandonment or exploitation, we are required to immediately notify Adult Protective Services intake. Once such a patient presents a risk to a person or his/her familyreport is filed, I we may be required to provide additional information. • If a patient communicates an actual threat of physical violence against an identifiable victim, we are required to take protective actions. These actions including warning may include notifying the potential victim(s), victim and contacting the policeappropriate law enforcement agency, and/or seeking hospitalization for the patient. In choosing to work with Corner Canyon Counseling and Psychological Services, you also agree to and understand that if there is an identifiable class of victims we will also notify law enforcement of the danger. • If a patient threatens to harm himself/herself, your therapist may be obligated to seek hospitalization for him/her, and/or to contact family members, law enforcement, or seeking hospitalization others who can help provide protection. • If communicable disease is reported to your therapist, we are required to report that disease to the Utah State Department of the patientHealth. Reportable communicable diseases include, but are not limited to: AIDS, Hepatitis, Sexual Transmitted Diseases, and Smallpox. If such a situation arises, I your therapist will make every effort to fully discuss it with you before taking any action and I we will limit my our disclosure to what is necessary. While this written summary of exceptions to confidentiality should prove helpful in informing you about potential problems, it is important that we discuss any questions or concerns that you may have 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 ON CONFIDENTIALITY. The law protects the privacy of all communications between a patient and a psychotherapistpsychologist. In most situations, I can only release information about your treatment to others if you sign a written authorization Authorization form that meets certain legal requirements imposed by state law and/or HIPAA. There But there are other some situations that require only that you provide written, advance consent. Your signature on this Agreement provides where I am permitted or required to disclose information without either your consent for those activities, as followsor Authorization: • ✓ I may occasionally find it helpful to consult with 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 important to our work together. I will note all consultations in your Clinical Record (which is called “PHI” in my Notice of Psychotherapist’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 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 my permission. • I also have a contract with a billing service. As required by HIPAA, I have a formal business associate contract with this business, in which it promises to maintain the confidentiality of this data except as specifically allowed in the contract or otherwise required by law. If you wish, I can provide you the name of this organization and/or a blank copy of this contract. I also will ask for your permission before having the billing service contact you. • ✓ Disclosures required by health insurers or to collect overdue fees are discussed discusses elsewhere in this Agreement. • ✓ If a patient threatens to harm himself/herself, I may be obligated to seek hospitalization for him/herthe patient, 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 my about the professional servicesservices that I have provided to you and/or the records thereof, such information is protected by the psychotherapistpsychologist-patient privilege law. I cannot provide any information without your (you or your legal legally-appointed representative’s) ’s written authorization, or a court order, or compulsory process (a subpoena of which 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 been officially notified and failed instructed me not to inform me that you are opposing the subpoenaobject). 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 activitiesactivities pursuant to their legal authority, I may be required to provide it for them. • ✓ If a patient files a complaint or lawsuit against me, I may disclose relevant information regarding that patient in order to defend myself. • ✓ If a patient files a worker’s compensation claim, information that is directly related to that claim I must, upon appropriate request, be provided disclose information relevant to the Workers’ Compensation Commissionclaimant’s condition, to the worker’s compensation 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. These situations are unusual in my practice. § ➢ If I have reason to know knowledge of a child under 18 or I reasonably suspect that a child under 18 that I have observed has been abused or neglected, or has been a the victim of sexual child abuse by another childor neglect, the law requires that I file a report with the Department for Childrenappropriate governmental agency. I also may make a report if I know or suspect that mental suffering has been inflicted upon a child or that his or her emotional well-being is endangered in any other way (other than physical or sexual abuse, Youth and Familiesor neglect). Once such a report is filed, I may be required to provide additional information. § ➢ If I believe 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 credible reports that he or she has experienced behavior including an act or omission constituting the above, or reasonably suspects that abuse, the law requires that I report to the appropriate governmental agency. Once such a patient presents a risk to a person or his/her familyreport is filed, I may be required to provide additional information. ➢ If a patient communicates a serious threat of physical violence against an identifiable victim, I must take protective actions actions, including warning notifying the potential victim(s), victim and contacting the police, or seeking . I may also seek hospitalization of the patient, or contact others who can assist in protecting the victim. ➢ If I have reasonable cause to believe that the patient is in such mental or emotional 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 who can provide protection. 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. While this written summary of exceptions to confidentiality should prove helpful in informing you about potential problems, it is important that we discuss any questions or concerns that you may have 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 ON CONFIDENTIALITY. The law protects the privacy of all communications between a patient and a psychotherapistclinician. In most situations, I can we only release information about your treatment to others if you sign a written authorization form that meets certain legal requirements imposed by HIPAAform. There are other situations that require only that you provide written, advance consent. Your signature on this Agreement contract provides consent for those activities, as follows: • I may ✓ We occasionally find it helpful to consult with 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 objectTypically, I we will not tell you about these consultations unless I only if we feel that it is important to our work together. I We will note chart all consultations in your Clinical Record (which is called “PHI” in my Notice of Psychotherapist’s Policies and Practices to Protect the Privacy of Your Health Information)consultations. • ✓ You should be aware that I our practice with other includes numerous mental health professionals and that I employ administrative staffprofessionals. In most cases, I need to share protected information PHI is shared with these individuals for both clinical and administrative purposes, such as scheduling, billing, billing and quality assurance. All of the mental health professionals and staff members 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 my permission. • I also have a contract with a billing service. As required by HIPAA, I have a formal business associate contract with this business, in which it promises to maintain the confidentiality of this data except as specifically allowed in the contract or otherwise required by law. If you wish, I can provide you the name of this organization and/or a blank copy of this contract. I also will ask for your permission before having the billing service contact you. • ✓ Disclosures required by health insurers or to collect overdue fees are discussed elsewhere in this Agreementcontract. • ✓ If we believe that a patient threatens presents an imminent danger to harm himselfhis/herselfher health or safety, I we 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 we are permitted or required to disclose information without either your consent or Authorizationconsent: • ❑ If you are involved in a court proceeding and a request is made for information concerning my professional servicesthe services that we provided you, such information is protected by the psychotherapisttherapist-patient privilege law. I We cannot provide any information without your (or your legal representative’s) written authorization, or a court order, or a subpoena of which you have been officially notified and failed to inform me that you are opposing the subpoena. 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 us to disclose information. • ❑ If a government agency is requesting the requests information for health oversight activities, I we may be required to provide it for them. • ❑ If a patient client files a complaint or lawsuit against meus, I we may disclose relevant information regarding that patient client in order to defend myselfourselves. • ❑ If a patient client files a worker’s compensation claimclaim and our services are being compensated through workers compensation benefits, information that is directly related to that claim we must, upon appropriate request, be provided provide a copy of the patient’s record to the Workers’ Compensation patient’s employer or the North Carolina Industrial Commission. There are some situations in which I am we are legally obligated to take actionsaction, which I we believe are necessary to attempt to protect others from harm and I we may have to reveal some information about a patientclient’s treatment. These situations are unusual in my our practice. § ⮚ If I we have reason cause to know or suspect that a child has been under 18 is abused or neglected, or has been if we have reasonable cause to believe that a victim disabled adult is in need of sexual abuse by another childprotective services, the law requires that I we file a report with the Department for Children, Youth THHS Client’s Rights Committee and FamiliesCounty Director of Social Services. Once such a report is filed, I we may be required to provide additional information. § ⮚ If I we believe that a patient client presents a risk an imminent danger to a person or his/her familythe health and safety of another, I we may be required to disclose information in order to take protective actions actions, including initiating hospitalization, warning the potential victim(svictim (if identifiable), contacting and/or calling the police, or seeking hospitalization of the patient. If such a situation arises, I we will make every effort to fully discuss it with you before taking any action and I we will limit my disclosure to what is necessary. While this written summary of exceptions to confidentiality should prove helpful in informing you about potential problems, it is important that we discuss any questions or concerns that you may have 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 ON CONFIDENTIALITY. The law protects the privacy of all communications between a patient and a psychotherapistpsychologist. In most situations, I can only release information about your treatment to others if you sign a written authorization Authorization form that meets certain legal requirements imposed by HIPAA. There are other situations that require only that you provide written, advance consent. Your signature on this Agreement provides consent for those activities, as follows: • 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 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 important to our work together. I will note all consultations in your Clinical Record (which is called “PHI” in my Notice of PsychotherapistPsychologist’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 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 my permission. • I also have a contract contracts with a billing servicePeachtree Professional Services, LLC and Xxxxxxxxxxxxxxxxxxx.xxx. As required by HIPAA, I have a formal business associate contract with this businessthis/these business(es), in which it promises it/they promise to maintain the confidentiality of this data except as specifically allowed in the contract or otherwise required by law. If you wish, I can provide you with the name names of this organization these organizations and/or a blank copy of this contract. I also will ask for your permission before having the billing service contact you. • 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 obligated to seek hospitalization for him/her, 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 my professional services, such information is protected by the psychotherapistpsychologist-patient privilege law. I cannot provide any information without your (or your legal representative’s) written authorization, or a court order, or a subpoena of which you have been officially notified and failed to inform me that you are opposing the subpoena. 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 required to provide it for them. • If a patient files a complaint or lawsuit against me, I may disclose relevant information regarding that patient in order to defend myself. • If a patient files a worker’s compensation claim, information that is directly and I am providing treatment related to that claim the claim, I must, upon appropriate request, be provided to the Workers’ Compensation Commissionfurnish copies of all medical reports and bills. 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 know or suspect believe that a child has been abused or neglected, or has been a victim of sexual abuse by another childabused, the law requires that I file a report with the appropriate governmental agency, usually the Department for Children, Youth and Familiesof Human Resources. Once such a report is filed, I may be required to provide additional information. § § If I have reasonable cause to believe that a disabled adult or elder person has had a physical injury or injuries inflicted upon such disabled adult or elder person, other than by accidental means, or has been neglected or exploited, I must report to an agency designated by the Department of Human Resources. Once such a report is filed, I may be required to provide additional information. § If I determine that a patient presents a risk serious danger of violence to a person or his/her familyanother, I may be required to take protective actions. These actions including warning may include notifying the potential victim(s)victim, and/or contacting the police, or and/or seeking hospitalization of for 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. While this written summary of exceptions to confidentiality should prove helpful in informing you about potential problems, it is important that we discuss any questions or concerns that you may have 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, I keep Protected Health Information about you in two sets of professional records. One set constitutes your Clinical Record. It includes information about your reasons for seeking therapy, a description of the ways in which your problem impacts on your life, your diagnosis, the goals that we set for treatment, your progress towards those goals, your medical and social history, your treatment history, any past treatment records that I receive from other providers, reports of any professional consultations, your billing records, and any reports that have been sent to anyone, including reports to your insurance carrier. Except in unusual circumstances that involve danger to yourself or others or 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 or if information is supplied to me confidentially by others, you or your legal representative 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. Therefore, you are generally not given a copy of notes, psychological reports, etc. However, I can discuss the results with you. 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 situations, I am allowed to charge a copying fee of $0.20. The exceptions to this policy are contained in the attached Notice Form. If I refuse your request for access to your records, you have a right of review (except for information provided to me confidentially by others) which I will discuss with you upon request. Release of reports or other documents from your file can be held until your balance has been paid in full. In addition, I 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 client to client, they can include the contents of our conversations, my analysis of those conversations, and how they impact on your therapy. They also contain particularly sensitive information that you may reveal to me that is not required to be included in your Clinical Record and information supplied to me confidentially by others. 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 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. I am happy to discuss any of these rights with you. MINORS & PARENTS Patients under 18 years of age who are not emancipated and their parents should be aware that the law allows parents to examine their child’s treatment records unless I believe that doing so would endanger the child or we agree otherwise. Because privacy in psychotherapy is often crucial to successful progress, particularly with teenagers, it is [sometimes] my 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, 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 or unless you have insurance coverage that requires another arrangement. If your account has not been paid for more than 30 days after a date of service 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. If such legal action is necessary, its costs will be included in the claim. For example, if an account is sent to a collection agency there is a $100 charge for this in addition to whatever fee is charged by the collection service; these fees become your responsibility. 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. While I will usually discuss your benefits with you, it is your responsibility to 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 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. 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. CREDIT CARD PAYMENTS I do accept credit card payments. However, please be aware if you choose to challenge or dispute a credit card charge you will be charged $30, a fee I must pay my credit card processor, Xxxxxxxxxxxxxxxxxxx.xxx, for the dispute. Also, information such as session dates and fees might be released to settle the dispute. EMAIL COMMUNICATION Sometimes clients like to communicate through email or texting. My standard policy is not to initiate communication with a client via email or texting as I do not have a secured email system and I cannot guarantee confidentiality. However, if I client wishes to cancel a session, etc., through email, I typically respond. However, please be aware I cannot guarantee confidentiality. In addition, please do not send elaborate emails or texts about your situation given the lack of security that accompanies email communications. Patient’s Consent to Treatment

LIMITS ON CONFIDENTIALITY. The law protects the privacy of all communications between a patient client and a psychotherapistpsychologist. In most situations, I can only release information about your treatment to others if you sign a written authorization Authorization form that meets certain legal requirements imposed by HIPAA. There are other situations that require only that you provide written, advance consent. Your signature on this Agreement provides consent for those activities, as follows: • 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 will not reveal 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 important to our work together. I will note all consultations in your Clinical Record (which is called “PHI” in my Notice of PsychotherapistPsychologist’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 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 my permission. • I also have a may contract with various insurance companies and a billing servicecredit bureau. As required by HIPAA, I must have a formal business associate contract with this businessthese businesses, in which it promises they promise to maintain the confidentiality of this data except as specifically allowed in the contract or otherwise required by law. If you wish, I can provide you with the name names of this organization and/or these organizations or a blank copy of this contract. I also will ask for your permission before having the billing service contact you. • Disclosures required by health insurers or to collect overdue fees are discussed elsewhere in this Agreement. • If a patient client threatens to harm himself/herselfhim or her self, I may be obligated to seek hospitalization for him/him or 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 my the professional servicesservices that I provided you, such information is protected by the psychotherapist-patient psychologist- client privilege law. I cannot provide any information without your (or your legal representative’s) written authorization, or a court order, or a subpoena of which you have been officially notified and failed to inform me that you are opposing the subpoena. 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 required to provide it for them. • If a patient client files a complaint or lawsuit against me, I may disclose relevant information regarding that patient in order client to defend myself. • If a patient files a worker’s compensation claim, information that is directly related to that claim must, upon appropriate request, be provided to the Workers’ Compensation 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 patientclient’s treatment. These situations are unusual in my practice. § :  If I have reason receive information in my professional capacity from a child or the parents or guardian or other custodian of a child that gives me reasonable cause to know or suspect that a child has been is an abused or neglected, or has been a victim of sexual abuse by another neglected child, the law requires that I file a report with to the Department for Childrenappropriate governmental agency, Youth usually the statewide central register of child abuse and Familiesmaltreatment, or the local child protective services office. Once such a report is filed, I may be required to provide additional information. §  If I believe that a patient presents a risk client communicates an immediate threat of serious physical harm to a person or his/her familyan identifiable victim, I may be required to take protective actions including warning action. This may include notifying the potential victim(s)victim, contacting the police, or seeking hospitalization of hospitalizing the patientclient. 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. While this written summary of exceptions to confidentiality should prove helpful in informing you about potential problems, it is important that we discuss any questions or concerns that you may have 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. Some of the exceptions to the general rule of legal confidentiality are listed in the Colorado statutes (C.R.S. 12-43-218) and in the Notice of Privacy Practices you were provided. You should be aware that provisions concerning confidential communications do not apply to any delinquency or criminal proceedings, except as provided in section 00-00-000 C.R.S. I will do my best to identify to you situations where the rule of confidentiality does not apply if such situations arise during therapy.

LIMITS ON CONFIDENTIALITY. The law protects the privacy of all communications between a patient and a psychotherapistprovider. In most situationsSeveral types of communications and the consent they require are discussed below. Generally, I can only release information about your treatment can be released to others only if you sign a written authorization form Authorization Form that meets certain legal requirements imposed by HIPAA. There are other situations situations, however, that require only that you provide written, advance consent. Your signature on this Agreement provides consent for those activities, as followsthe following: • I Your provider may occasionally find it helpful to consult other health and mental health professionals about a case. During a consultation, I make every effort is made to avoid revealing the identity of my patientyour identity. The other professionals are also legally bound to keep the information confidential. If you don’t object, I You will not tell you be told about these consultations unless I feel your provider feels that it is important to our your work together. I will note all consultations in your Clinical Record (which is called “PHI” in my Notice of Psychotherapist’s Policies and Practices to Protect the Privacy of • Your Health Information). • You should be aware that I practice doctor practices with other mental health professionals and that I employ employs administrative staff. In most many cases, I need to share some protected information may be shared with these individuals for both clinical and administrative purposes, such as scheduling, billing, 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 my permissionthe permission of a professional staff member. • I We also have a contract contracts with a billing other vendors such as software providers and an answering service. As required by HIPAA, I we have a formal business associate contract with this businesseach and any of these other businesses, in which it promises they promise to maintain the confidentiality of this data except as specifically allowed in the contract or otherwise required by law. If you wish, I we can provide you with the name names of this organization these organizations and/or a blank copy of this contract. I also will ask for your permission before having the billing service contact you. • Disclosures required by health insurers or to collect overdue fees are discussed elsewhere in this Agreement. • If providers believe that a patient threatens presents an imminent danger to harm himselfhis/herselfher health or safety, I they may be obligated to seek hospitalization for him/her, or to contact family members or others who can help provide protection. There also are some situations where I am providers 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 my the professional servicesservices that are provided to you, such information is protected by the psychotherapistprovider-patient privilege law. I Information cannot provide any information be provided without your (or your legal representative’s) written authorization, or a court order, or a subpoena of which you have been officially notified and failed to inform me that you are opposing the subpoena. 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 your provider to disclose information. • If a government agency is requesting the information for health oversight activities, I we may be required to provide it for them. • If a patient files a complaint or lawsuit against mea provider, I that provider may disclose relevant information regarding that patient in order to defend myselfhim/herself. • If a patient files a worker’s compensation claim, information that is directly related to that claim and services are being compensated through workers compensation benefits, a provider must, upon appropriate request, be provided provide a copy of the patient’s record to the Workers’ Compensation patient’s employer or the North Carolina Industrial Commission. There In addition, there are some situations in which I am we are legally obligated to take actions, which I believe are necessary to attempt to protect others from harm and I which may have to reveal require revealing some information about a patient’s treatment. These situations are unusual in my this practice. § They include the following: • If I have reason there is cause to know or suspect that a child has been under 18 is abused or neglected, or has been reasonable cause to believe that a victim disabled adult is in need of sexual abuse by another childprotective services, the law requires that I file a report be filed with the Department for Children, Youth and FamiliesCounty Director of Social Services. Once such a report is filed, I additional information may be required required. • If there is reason to provide additional information. § If I believe that a patient presents a risk an imminent danger to a person or his/her familythe health and safety of another, I we may be required to disclose information in order to take protective actions actions, including initiating hospitalization, warning the potential victim(s)victim, contacting if identifiable, and/or calling the police, or seeking hospitalization of the patient. If such a situation arises, I your provider will make every effort to fully discuss it with you before taking any action and I will limit my disclosure to only what is necessary. While this written summary of exceptions to confidentiality should prove helpful in informing you about potential problems, it is important that we discuss any questions or concerns that you may have now or in the futurefuture be discussed. 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 ON CONFIDENTIALITY. The law protects the privacy of all communications between a patient and a psychotherapistPsychologist. In most situations, I can only release information about your treatment to others if you sign a written authorization Authorization form that meets certain legal requirements imposed by HIPAA. There are other situations that require only that you provide written, advance consent. Your signature on this Agreement provides consent for those activities, as follows: • 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 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 important to our work together. I will note all consultations in your Clinical Record (which is called “PHI” in my Notice of PsychotherapistPsychologist’s Policies and Practices to Protect the Privacy of Your Health Information). • You should be aware that I practice with other independent practitioners who also provide mental health professionals and that I employ administrative staffservices. In most some cases, I need to share protected information with these individuals for both clinical and administrative purposes, such as scheduling, billing, answering service 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 my permission. • I also have the permission of a contract with a billing service. As required by HIPAA, I have a formal business associate contract with this business, in which it promises to maintain the confidentiality of this data except as specifically allowed in the contract or otherwise required by law. If you wish, I can provide you the name of this organization and/or a blank copy of this contract. I also will ask for your permission before having the billing service contact youprofessional 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 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 court proceeding and a request is made for information concerning my professional servicesyour diagnosis and treatment, such information is protected by the psychotherapistPsychologist-patient privilege law. I cannot provide any information without your (or your legal representative’s) written authorization, or a court order, or a subpoena of which you have been officially notified and failed to inform me that you are opposing the subpoena. 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 required to provide it for them. • If a patient files a complaint or lawsuit against me, I may disclose relevant information regarding that patient in order to defend myself. • If a patient files a worker’s compensation claim, information that is directly related to that claim I must, upon appropriate request, be provided provide a copy of the patient’s record to the Workers’ Compensation Commission. appropriate regulatory agency or the patient’s employer 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 reasonable cause to know or suspect that a child has been abused or neglected, may be subjected to abuse or has been neglect or observe a victim of sexual child being subjected to conditions or circumstances that would reasonably result in abuse by another childor neglect, the law requires that I file a report with the Department for Children, Youth and Familiesappropriate regulatory agency. Once such a report is filed, I may be required to provide additional information. § ▪ If I have reasonable cause to suspect that an elderly or disabled adult presents a likelihood of suffering serious physical harm and is in need of protective services, the law requires that I file a report with the appropriate regulatory agency. Once such a report is filed, I may be required to provide additional information. ▪ If I believe that it is necessary to disclose information to protect against a clear and substantial risk of imminent serious harm being inflicted by the patient presents a risk to a person on him/herself or his/her familyanother person, I may be required to take protective action. These actions including warning may include, and/or initiating hospitalization and/or contacting the potential victim(s)victim, contacting and/or the police, or seeking hospitalization of police and/or the patient’s family. 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. While this written summary of exceptions to confidentiality should prove helpful in informing you about potential problems, it is important that we discuss any questions or concerns that you may have 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, I keep Protected Health Information about you in two sets of professional records. One set constitutes your Clinical Record. It includes information about your reasons for seeking therapy, a description of the ways in which your problem impacts on your life, your diagnosis, the goals that we set for treatment, your progress towards those goals, your medical and social history, your treatment history, any past treatment records that I receive from other providers, reports of any professional consultations, your billing records, and any reports that have been sent to anyone, including reports to your insurance carrier. Except in the unusual circumstance where disclosure is reasonably likely to endanger you and/or others or when another individual (other than another health care provider) is referenced and I believe disclosing that information puts the other person at risk of substantial harm, 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 will be charging a copying fee. The exceptions to this policy are contained in the attached Notice Form. If I refuse your request for access to your Clinical Records, you have a right of review, 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 providing you with the best treatment. While the contents of Psychotherapy Notes vary from client to client, they can include the contents of our conversations, my analysis of those conversations, and how they impact on your therapy. They also contain particularly sensitive information that you may reveal to me that is not required to be included in your Clinical Record. 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 or court order. 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 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. BILLING AND PAYMENTS You will be expected to pay for each session at the time it is held. 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.] INSURANCE REIMBURSEMENT You may choose to use your health insurance to cover your treatment costs. There are some specific issues you need to consider in making this decision. 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 patients 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. 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. XXXXXXXX X. XXXXX, LLC, LSCSW INFORMED CONSENT & THERAPIST-PATIENT SERVICES AGREEMENT YOUR SIGNATURE BELOW INDICATES THAT YOU HAVE READ THIS AGREEMENT AND AGREE TO ITS TERMS DURING OUR PROFESSIONAL RELATIONSHIP. IT ALSO SERVES AS AN ACKNOWLEDGEMENT THAT YOU HAVE RECEIVED THE HIPAA NOTICE FORM DESCRIBED ABOVE. PATIENT SIGNATURE DATE SIGNATURE OF PARENT/GUARDIAN DATE

LIMITS ON CONFIDENTIALITY. The law protects the privacy of all communications between a patient and a psychotherapistpsychologist or other mental health professional. In most situations, I we can only release information about your treatment to others if you sign a written authorization form that meets certain legal requirements imposed by HIPAA. There are other situations that require only that HIPAA and/or Maine law, or in some cases, if you provide writtenoral authorization. However, advance consentin the following situations, no authorization is required:  You should be aware that this is a practice with more than one psychologist. Some staff may see some information for the purposes of scheduling, billing, quality assurance, cross-coverage, or archival research. In our practice, there is one chart per patient, and any psychologist who treats that patient will have access to that chart. All psychologists have been given training about confidentiality and protecting your privacy.  Your signature on this Agreement provides consent for those activities, as follows: • I psychologist may occasionally find it helpful to consult with or seek supervision from 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 we will not tell you about these consultations consultations, unless I we feel that it is important to our work together. I will note all consultations in your Clinical Record (which is called “PHI” in my Notice of Psychotherapist’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 Hampden Psychological Consultation, I need to share protected information with these individuals for both clinical and administrative purposesPLLC, such as schedulingreceives services from a computer service professional, billingan accountant, an attorney, a secretary, a housekeeper, an attorney, 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 my permission. • I also have a contract with a billing servicebuilding landlord. As required by HIPAA, I we have a formal business associate contract with this businessthese individuals, in which it promises they promise to maintain the confidentiality of this data data, except as specifically allowed in the contract or otherwise required by law. If you wish, I we can provide you with the name names of this organization these organizations and/or a blank copy of this contract. I also will ask for your permission before having the billing service contact you. • 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 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 court proceeding and a request is made for information concerning my professional servicesyour diagnosis and treatment, such information is protected by the psychotherapistpsychologist-patient privilege law. I We cannot provide any information without your (or your legal representative’s) written authorization, or a court order, or a subpoena of which you have been officially notified and failed to inform me that you are opposing the subpoena. 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 us to disclose information. •  If a government agency is requesting the information for health oversight activities, I we may be required to provide it for them. •  If a patient files a complaint or lawsuit against meus, I we may disclose relevant information regarding that patient in order to defend myselfourselves. •  If you are pursuing medical or mental health disability payments, you may end up signing a patient files a worker’s compensation claim, information document with that is directly related agency or company waiving confidentiality to that claim must, upon appropriate request, be provided to the Workers’ Compensation Commissionyour records. There are some situations in which I am we are legally obligated to take actions, which I we believe are necessary to attempt to protect others from harm harm, and I we may have to reveal some information about a patient’s treatment. These situations are unusual in my practice. §  If I have reason to we know or have reasonable cause to suspect that a child under 18 has been or is likely to be abused or neglected, or that a vulnerable adult has been a victim of sexual abuse by another childabused, neglected, or exploited and is incapacitated or dependent, the law requires that I we file a report with the appropriate government agency, usually the Maine Department for Children, Youth of Health and FamiliesHuman Services. Once such a report is filed, I we may be required to provide additional information. §  If I believe we determine that the patient poses a patient presents a risk direct threat of imminent harm to a person the health or hissafety of any individual, including himself/her familyherself, I we may be required to disclose information in order to take protective action(s). These actions including warning may include notifying the potential victim(s)victim, contacting the police, or seeking hospitalization of for the patient, or contacting family members or others who can assist in providing protection. If such a situation arises, I we will make every effort to fully discuss it with you before taking any action action, and I we will limit my disclosure to what is necessary. While this written summary of exceptions to confidentiality should prove helpful in informing you about potential problems, it is important that we discuss any questions or concerns that you may have 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 ON CONFIDENTIALITY. The law protects the privacy of all communications between a patient and a psychotherapistsocial worker. In most situations, I can only release information about your treatment to others if you sign a written authorization Authorization form that meets certain legal requirements imposed by HIPAA. There are other situations that require only that you provide written, advance consent. Your signature on of this Agreement provides consent for those activities, as follows: • 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 are also legally bound to keep the information confidential. If I you don’t object, I will not tell you about these consultations unless I feel that it is important to our work together. I will note all consultations in your Clinical Record Records (which is called “:PHI” in my Notice of PsychotherapistSocial Worker’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 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 my permission. • I also have a contract with a billing service. As required by HIPAA, I have a formal business associate contract with this business, in which it promises to maintain the confidentiality of this data except as specifically allowed in the contract or otherwise required by law. If you wish, I can provide you the name of this organization and/or a blank copy of this contract. I also will ask for your permission before having the billing service contact you. • 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 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 of Authorization: • If you are involved in a court proceeding and a request is made for information concerning my professional servicesyour diagnosis and treatment, such information is protected by the psychotherapistsocial worker-patient privilege law. I cannot provide any information without your (or your legal representative’s) written authorization, or a court order, or a subpoena of which you have been officially notified and failed to inform me that you are opposing the subpoena. If I 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 required to provide it for themit. • If a patient files a complaint or lawsuit against me, I may disclose relevant information regarding that patient in order to defend myself. • If a patient files a worker’s compensation claim, information that is directly related to that claim must, I must upon appropriate request, be provided furnish all treatment reports to the Workers’ Compensation Commissionpatient’s employer and to the patient or his/her attorney. 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 know suspect or suspect believe that a child under 18 years of age (1) has been abused or neglected, (2) has had non- accidental physical injury, or has been a victim injury which is at variance with the history given of sexual abuse by another such injury, inflicted upon such child, or (3) is placed at imminent risk of serious harm, then I must report this suspicion or belief to the law requires that I file a report with appropriate authority, usually the Department for Children, Youth Commissioner of Children and Families. Once such a report is filed, I may be required to provide additional information. § • If I have reason to believe or suspect that an elderly or disabled or incompetent individual has been abused, I may have to report this to the appropriate authority. Once such a report is filed, I may be required to provide additional information. • If I believe that a patient presents a an imminent risk of personal injury to a person or his/her familyanother identifiable individual, I may be required to take protective actions. These actions including warning may include notifying the potential victim(s)victim, contacting the police, or seeking hospitalization of for the patient. I may also have to take protective action if another’s property is endangered. If a patient presents an imminent risk of personal injury to him/herself, I may be obligated to seek hospitalization of him/her, or to contact family members or others who can help provide protection. 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. While this written summary of exceptions to confidentiality should prove helpful in informing you about potential problems, it is important that we discuss any questions or concerns that you may have 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 ON CONFIDENTIALITY. The law protects the privacy of all communications between a patient and a psychotherapistpsychologist. In most situations, I can only release information about your treatment to others if you sign a written authorization Authorization form that meets certain legal requirements imposed by HIPAAHIPAA and/or Illinois law. There are other situations that require only that you provide writtenHowever, advance consent. Your signature on this Agreement provides consent for those activitiesin the following situations, as followsno authorization is required: • I may occasionally find it helpful to consult other health and mental health professionals about a case. During a such consultation, I will make every effort to avoid revealing the identity of my patientclients. 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 feels that it is important to our work together. I will note all consultations in your Clinical Record (which is called “PHI” in my Notice of Psychotherapist’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 staffuse a billing service. 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 of the mental health professionals staff members 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 my permissionthe permission of a professional staff member. • I also have will make every attempt to safeguard your privacy through any electronic communication, such as electronic billing, e-mails, or record storage to the extent that I am able. While you may attempt to forward information to me via e-mail, be advised that e-mail is not a contract with a billing service. As required by HIPAA, I have a formal business associate contract with this business, in which it promises to maintain the confidentiality secure form of this data except as specifically allowed in the contract or otherwise required by law. If you wish, I can provide you the name of this organization and/or a blank copy of this contract. I also will ask for your permission before having the billing service contact youcommunication. • 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 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 court proceeding and a request is made for information concerning my professional servicesyour diagnosis and treatment, such information is protected by the psychotherapistpsychologist-patient privilege law. I cannot provide disclose any information without your (or your legal representative’s) written authorization, consent or a court order, or a subpoena of which you have been officially notified and failed to inform me that you are opposing the subpoena. 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 Xxxx X. Xxxxx Psy.D. Center for Social Emotional Wellness Ltd. to disclose information. • If a government agency is requesting the information for health oversight activities, I may be required to provide it for themit. • If a patient client files a complaint or lawsuit against me, I may disclose relevant information regarding that patient client in order to defend myself. • If a patient files you file a worker’s compensation claim, information that is directly related to that claim and I am rendering treatment or services in accordance with the provisions of Illinois Workers’ Compensation law, I must, upon appropriate request, provide a copy of your record to your employer or his/her appropriate designee. • The new Conceal and Carry Act requires clinicians to notify the Department of Human Services (DHS) within 24 hours of knowing a person is determined to be provided a Clear and Present Danger to the Workers’ Compensation Commissionthemselves or others, or demonstrates threatening physical or verbal behavior, such as violent, suicidal, or assaultive threats, actions, or other behavior. • There are some situations in which I am legally obligated to take actions, which I believe are may be necessary to attempt to protect others from harm and harm. In the process, I may have to reveal some information about a patientclient’s treatment. These situations are unusual in my practice. § • If I have reason reasonable cause to know or suspect believe that a child has been under 18 years of age known to me in our professional capacity may be an abused child or neglected, or has been a victim of sexual abuse by another neglected child, the law requires that I file a report with the local office of the Department for Children, Youth of Children and FamiliesFamily Services. Once such a report is filed, I may be required to provide additional information. § • If I have reason to believe that an adult over the age of 60 years living in a patient presents domestic situation has been abused or neglected in the preceding 12 months, the law requires that I file a risk report with the agency designated to receive such reports by the Department of Aging. Once such a person or his/her familyreport is filed, I may be required to provide additional information. • If you have made a specific threat or 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 including warning may include notifying the potential victim(s)victim, contacting the police, or seeking your hospitalization. • If I believe that you present a clear, imminent risk of serious physical or mental injury or death to yourself, I may be required to disclose information in order to take protective actions. These actions may include seeking your hospitalization of the patientor contacting family members or others who can assist in protecting you. If such a situation arises, I will make every effort to fully discuss it with you before taking any action and will limit the disclosure to what is necessary. If such situation arises, I will make every effort to fully discuss it with you before taking any action, and I will limit my the disclosure to what is necessary. While this written summary of exceptions to confidentiality should prove helpful in informing you about potential problems, it is important that we discuss any questions or concerns that you may have 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 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 these policies and procedures recorded in your records; and the right to a paper copy of this Agreement, the Notice, and our privacy policies and procedures. PROFESSIONAL RECORDS The laws and standards of my profession require that I keep Protected Health Information about you in your Clinical Record. You may examine 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 with me, or have them forwarded to another mental health professional so you can discuss the contents. Client Registration, Insurance Release, this Client-Therapist Agreement, Payment Authorization, Illinois Notice of Disclosure and History forms are considered part of the record. According to the IL Code of Civil Procedure 735 ILCS, we are allowed to charge the following schedule of copying fees for 2019: Actual postage and shipping charges; Handling charge: $28.44; Copy pages 1-25: $1.07 each; Copy pages 26-50: $.71 each; Copy pages 50+ $.36 each. Electronic format: 50% of copy charges. These fees subject to change by year 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 the fees. It is important that you find out exactly what mental health services your insurance policy covers. If you have questions about the coverage, call your plan administrator.

LIMITS ON CONFIDENTIALITY. The law protects the privacy of all communications communication between a patient and a psychotherapist. In most situations, I can only release information about your treatment to others if is you sign a written authorization Authorization form that meets certain legal requirements imposed by HIPAA. There are other situations that require only that you provide written, advance consent. Your signature on this Agreement provides consent for those activities, as follows: • I may occasionally find it helpful to consult with 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 It you don’t object, I will not tell you about these consultations unless I feel that it is important to our work together. I will note all consultations in your Clinical Record (which is called “PHI” in my Notice of Psychotherapist’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 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 my permission. • I also have a contract with a billing service. As required by HIPAA, I have a formal business associate contract with this business, in which it promises to maintain the confidentiality of this data except as specifically allowed in the contract or otherwise required by law. If you wish, I can provide you the name of this organization and/or a blank copy of this contract. I also will ask for your permission before having the billing service contact you. • Disclosures required by health insurers or to collect overdue fees are discussed elsewhere in this Agreement. • If I believe that a patient threatens presents an imminent danger to harm himselfhis/herselfher health or safety, 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 somme 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 my the professional servicesservices that I provide you, such information is protected by the psychotherapist-psychotherapist- patient privilege law. I cannot provide any information without your (or your legal representative’s) written authorization, or a court order, or a subpoena of which you have been officially notified and failed to inform me that you are opposing the subpoena. 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 required to provide it for them. • If a patient files a complaint or lawsuit against me, I may disclose relevant information regarding that patient in order to defend myself. • If a patient files a worker’s compensation claim, information that is directly related to that claim and my services are being compensated through worker’s compensation benefits, I must, upon appropriate request, be provided to provide a copy of the Workers’ Compensation patient’s 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 patient’s treatment. These situations are unusual in my practice. § • If I have reason cause to know or suspect that a child has been under 18 is abused or neglected, or has been if I have reasonable cause to believe that a victim disabled adult is in need of sexual abuse by another childprotective services, the law requires that I file a report with the Department for Children, Youth and Familiesof Social Services. Once such a report is filed, I may be required to provide additional information. § • If I believe that a patient presents a risk an imminent danger to a person or his/her familythe health and safety of another, I may be required to disclose information in order to take protective actions actions, including initiating hospitalization, warning the potential victim(s)victim, contacting if identifiable, and/or calling the police, or seeking 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. While this written summary of exceptions to confidentiality should prove helpful in informing you about potential problems, it is important that we discuss any questions or concerns that you may have 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 ON CONFIDENTIALITY. The law protects the privacy of all communications between a patient and a psychotherapistPsychologist. In most situations, I can only release information about your treatment to others if you sign a written authorization Authorization form that meets certain legal requirements imposed by HIPAA. There are other situations that require only that you provide written, advance consent. Your signature on this Agreement provides consent for those activities, as follows: • 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 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 important to our work together. I will note all consultations in your Clinical Record (which is called “PHI” in my Notice of PsychotherapistPsychologist’s Policies and Practices to Protect the Privacy of Your Health Information). • You should be aware that I practice with other independent practitioners who also provide mental health professionals and that I employ administrative staffservices. In most some cases, I need to share protected information with these individuals for both clinical and administrative purposes, such as scheduling, billing, answering service 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 my permission. • I also have the permission of a contract with a billing service. As required by HIPAA, I have a formal business associate contract with this business, in which it promises to maintain the confidentiality of this data except as specifically allowed in the contract or otherwise required by law. If you wish, I can provide you the name of this organization and/or a blank copy of this contract. I also will ask for your permission before having the billing service contact youprofessional 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 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 court proceeding and a request is made for information concerning my professional servicesyour diagnosis and treatment, such information is protected by the psychotherapistPsychologist-patient privilege law. I cannot provide any information without your (or your legal representative’s) written authorization, or a court order, or a subpoena of which you have been officially notified and failed to inform me that you are opposing the subpoena. 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 required to provide it for them. • If a patient files a complaint or lawsuit against me, I may disclose relevant information regarding that patient in order to defend myself. • If a patient files a worker’s compensation claim, information that is directly related to that claim I must, upon appropriate request, be provided provide a copy of the patient’s record to the Workers’ Compensation Commission. appropriate regulatory agency or the patient’s employer 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 reasonable cause to know or suspect that a child has been abused or neglected, may be subjected to abuse or has been neglect or observe a victim of sexual child being subjected to conditions or circumstances that would reasonably result in abuse by another childor neglect, the law requires that I file a report with the Department for Children, Youth and Familiesappropriate regulatory agency. Once such a report is filed, I may be required to provide additional information. § § If I have reasonable cause to suspect that an elderly or disabled adult presents a likelihood of suffering serious physical harm and is in need of protective services, the law requires that I file a report with the appropriate regulatory agency. Once such a report is filed, I may be required to provide additional information. § If I believe that it is necessary to disclose information to protect against a clear and substantial risk of imminent serious harm being inflicted by the patient presents a risk to a person on him/herself or his/her familyanother person, I may be required to take protective action. These actions including warning may include, and/or initiating hospitalization and/or contacting the potential victim(s)victim, contacting and/or the police, or seeking hospitalization of police and/or the patient’s family. 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. While this written summary of exceptions to confidentiality should prove helpful in informing you about potential problems, it is important that we discuss any questions or concerns that you may have 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, I keep Protected Health Information about you in two sets of professional records. One set constitutes your Clinical Record. It includes information about your reasons for seeking therapy, a description of the ways in which your problem impacts on your life, your diagnosis, the goals that we set for treatment, your progress towards those goals, your medical and social history, your treatment history, any past treatment records that I receive from other providers, reports of any professional consultations, your billing records, and any reports that have been sent to anyone, including reports to your insurance carrier. Except in the unusual circumstance where disclosure is reasonably likely to endanger you and/or others or when another individual (other than another health care provider) is referenced and I believe disclosing that information puts the other person at risk of substantial harm, 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 will be charging a copying fee. The exceptions to this policy are contained in the attached Notice Form. If I refuse your request for access to your Clinical Records, you have a right of review, 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 providing you with the best treatment. While the contents of Psychotherapy Notes vary from client to client, they can include the contents of our conversations, my analysis of those conversations, and how they impact on your therapy. They also contain particularly sensitive information that you may reveal to me that is not required to be included in your Clinical Record. 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 or court order. 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 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. BILLING AND PAYMENTS You will be expected to pay for each session at the time it is held. 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.] INSURANCE REIMBURSEMENT You may choose to use your health insurance to cover your treatment costs. There are some specific issues you need to consider in making this decision. 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 patients 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. 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. XXXXXXX XXXXXXXX, LSCSW, INC. INFORMED CONSENT & THERAPIST-PATIENT SERVICES AGREEMENT YOUR SIGNATURE BELOW INDICATES THAT YOU HAVE READ THIS AGREEMENT AND AGREE TO ITS TERMS DURING OUR PROFESSIONAL RELATIONSHIP. IT ALSO SERVES AS AN ACKNOWLEDGEMENT THAT YOU HAVE RECEIVED THE HIPAA NOTICE FORM DESCRIBED ABOVE. PATIENT SIGNATURE DATE SIGNATURE OF PARENT/GUARDIAN DATE

LIMITS ON CONFIDENTIALITY. The law protects the privacy of all communications between a patient and a psychotherapistpsychologist. In most situations, I we can only release information about your treatment to others if you sign a written authorization Authorization form that meets certain legal requirements imposed by HIPAA. There are other situations that require only that you provide written, advance consent. Your signature on this Agreement provides consent for those activities, as follows: • 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 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 important to our work together. I will note all consultations in your Clinical Record (which is called “PHI” in my Notice of Psychotherapist’s Policies and Practices to Protect the Privacy of Your Health Information). • You should be aware that I practice with the office includes other mental health professionals and that I employ administrative staff. In most cases, I we need to share protected information with these individuals for both clinical and administrative purposes, such as scheduling, billing, 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 my permission. • I also We have a contract with a billing serviceAzalea Health, which administers our electronic health records. As required by HIPAA, I we have a formal business associate contract with this business, in which it promises they promise to maintain the confidentiality of this data except as specifically allowed in the contract or otherwise required by law. If you wish, I we can provide you the name of this organization and/or with a blank copy of this contract. I also will ask for your permission before having the billing service contact you. • 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 the doctor may be obligated to seek hospitalization for him/her, her or to contact family members or others who can help provide protection. There are some situations where I am your doctor is 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 my our professional services, such information is protected by the psychotherapistpsychologist-patient privilege law. I We cannot provide any information without your (or your legal representative’s) written authorization, or a court order, or a subpoena of which you have been officially notified and failed to inform me that you are opposing the subpoena. 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 us to disclose information. If you do request your information to be shared in a legal matter (e.g., Social Security Case, Xxxxxxx'x Comp Case prior to the claim decision, divorce or other proceedings), a charge of $185.00/hour will be applied for preparation of a clinical summary, as it is our policy not to share clinical notes with anyone besides other healthcare professionals. This is for your protection, as they are written in clinical, not legal language, and the information contained in them could be misinterpreted. • If a government agency is requesting the information for health oversight activities, I we may be required to provide it for them. • If a patient files a complaint or lawsuit against meeither doctor or the practice, I we may disclose relevant information regarding that patient in order to defend myselfourselves. • If a patient files a worker’s compensation claim, information that is directly and we are providing treatment related to that claim the claim, we must, upon appropriate request, be provided to the Workers’ Compensation Commissionfurnish copies of all medical reports and bills. There are some situations in which I am we are legally obligated to take actions, which I we believe are necessary to attempt to protect others from harm and I we may have to reveal some information about a patient’s treatment. These situations are unusual in my this practice. § ▪ If I have your doctor has reason to know or suspect believe that a child has been abused or neglected, or has been a victim of sexual abuse by another childabused, the law requires that I she file a report with the appropriate governmental agency, usually the Department for Children, Youth and Familiesof Human Resources. Once such a report is filed, I we may be required to provide additional information. § ▪ If I your doctor has reasonable cause to believe that a disabled adult or elder person has had a physical injury or injuries inflicted upon such disabled adult or elder person, other than by accidental means, or has been neglected or exploited, she must report to an agency designated by the Department of Human Resources. Once such a report is filed, she may be required to provide additional information. ▪ If your doctor determines that a patient presents a risk serious danger of violence to a person or his/her familyanother, I she may be required to take protective actions. These actions including warning may include notifying the potential victim(s)victim, and/or contacting the police, or and/or seeking hospitalization of for the patient. If such a situation arises, I your doctor will make every effort to fully discuss it with you before taking any action and I she will limit my her disclosure to what is necessary. While 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 doctor 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 policies and procedures recorded in your records; and the right to a paper copy of this written summary Agreement, the attached Notice form, and our privacy policies and procedures. We are happy to discuss any of exceptions these rights with you. Billing and Payments You will be expected to confidentiality should prove helpful in informing you about potential problems, pay for each session at the time it is important 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. If your account has not been paid for more than 60 days and arrangements for payment have not been agreed upon, we discuss any questions have the option of using legal means to secure the payment. This may involve hiring a collection agency or concerns that you may have now or in going through small claims court which will require us to disclose otherwise confidential information. In most collection situations, the future. The laws governing confidentiality can be quite complexonly information we release regarding a patient’s treatment is his/her name, the nature of services provided, and I am not an attorneythe amount due. In situations where specific advice is required, formal legal advice may be needed.Internet Contact

LIMITS ON CONFIDENTIALITY. The law Jaw protects the privacy of all communications between a patient and a psychotherapistpsychologist. In most situations, I can only release information about your treatment to others if you sign a written authorization Authorization (consent) form that meets certain legal requirements imposed by HIPAA. There are other situations that require only that you provide written, advance consent. Your signature on this Agreement provides consent for those activitiesacknowledgement, as follows: • 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 are also legally bound to keep the information confidential. If you don’t object, I will probably not tell you about these consultations unless I feel that it is important to our work together. I will note all consultations in your Clinical Record (which is called “PHI” Record. My office may contact your home or other designated location and leave an email, fax, correspondence through the postal service, or a message on voice mail, or in person in reference to any items that assist my Notice of Psychotherapist’s Policies office in carrying out treatment, payment, and Practices to Protect the Privacy of Your Health Information)healthcare operations, such as following up on insurance matters. • 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, billing and quality assurance. All of the mental health professionals are My staff is 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 protected information outside of the practice without my permissionpractice. • I also have a contract contracts with a billing servicethe management company for the building, my accountant, and the document shredding company,). As required by HIPAA, I have a formal business associate contract with this businessthese businesses, in which it promises they promise to maintain the confidentiality of this data except as specifically allowed in the contract or otherwise required by law. If you wish, I can provide you the name of this organization and/or a blank copy of this contract. I also will ask for your permission before having the billing service contact you. • 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 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: • Authorization If you are involved in a court proceeding and a request is made for information concerning my the professional servicesservices I provided, such information is protected by the psychotherapistpsychologist-patient privilege law. I cannot provide any information without your (or your legal representative’s's) written authorization, or a court order, or a subpoena of which you have been officially notified and failed to inform me that you are opposing the subpoena. 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 required to provide it for them. • If a patient files a complaint or lawsuit against me, I may disclose relevant information regarding that patient in order to defend myself. • If a patient files you file a worker’s 's compensation claim, information that is directly related and I have examined or treated you in regard to that claim such claim, I must, upon appropriate request, be provided provide a report to the Workers’ Compensation Commissionpatient's employer or the employer's insurance company. 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 's treatment. These situations are unusual in my practice. § If I have reason to know or suspect that a child has been abused or neglected, or has been a victim of sexual abuse by another child, the law requires that I file a report with the Department for Children, Youth and Families. Once such a report is filed, I may be required to provide additional information. § If I believe that a patient presents a risk to a person or his/her family, I may be required to take protective actions including warning the potential victim(s), contacting the police, or seeking 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. If I have reason to suspect that a child under 18 has been injured as a result or physical, mental or emotional abuse or neglect or sexual abuse, or that an adult has been or is being abused, neglected or exploited or is in need of protective services, the law requires that I file a report with the appropriate government agency, usually the Department of Social and Rehabilitation Services. Once such a report is filed, I may be required to provide additional information If a patient communicates an imminent, specific threat of harm against a specific individual and I believe that there is a substantial risk that the patient will act on that threat in the foreseeable future, I may be required to take protective actions. These actions may include notifying the potential victim, contacting the police, or seeking hospitalization for the patient. PROFESSIONAL RECORDS You should be aware that, pursuant to HIPAA, I keep Protected Health Information about you in two sets of professional records. One set constitutes your Clinical Record. It includes information about your reasons for seeking therapy, a description of the ways in which your problem impacts on your life, your diagnosis, the goals that we set for treatment, your progress towards those goals, your medical and social history, your treatment history, any past treatment records that I receive from other providers, reports of any professional consultations, and any reports that have been sent to anyone, including reports to your insurance carrier. Unless I believe that access is reasonably likely to cause substantial harm [or where information has been supplied to me by others confidentially], 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., I charge a copying fee of $1.00 per page (and for certain other expenses). In addition, I 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 this written summary the contents of exceptions Psychotherapy Notes vary, 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 confidentiality me that is not required to be included in your Clinical Record. These Psychotherapy Notes cannot be sent to anyone else, including insurance companies without your written, signed Authorization PATIENT RIGHTS MINORS & PARENTS Patients under 18 years of age who are not emancipated and their parents should prove helpful be aware that the law may allow parents to examine their child's treatment records. Because privacy in informing you about potential problemspsychotherapy is often crucial to successful progress, particularly with teenagers, it is important sometimes my policy to request an agreement from parents that we discuss any questions or concerns that you may have now or in they consent to give up their access to their child's records. If they agree, during treatment, I will provide them only with general information about the future. The laws governing confidentiality can be quite complexprogress of the child's treatment, and his/her attendance at scheduled sessions. I am not an attorney. In situations where specific advice can also provide parents with a summary of their child's treatment when it is required, formal legal advice may be neededcomplete.

LIMITS ON CONFIDENTIALITY. The law protects the privacy of all communications between a patient and a psychotherapisttherapist. In most situations, I can only release information about your treatment treatment, evaluation, and diagnosis to others if you sign a written authorization form that meets certain legal requirements imposed by HIPAAHIPPA. There are other situations that require only that you provide written, advance consent. Your signature on this Agreement agreement provides consent for those activities, as follows: • I may occasionally find it helpful to consult with other health and mental health professionals about a case. During a consultation, I make every effort to avoid revealing the identity identify 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 isi important to our work together. I will note all consultations consultations, but not supervision notes, in your Clinical Record (which is called “PHI” in my Notice of Psychotherapist’s Policies and Practices to Protect the Privacy of Your Health Information)client record. • You should be aware that I practice with other mental health professionals and that I employ administrative staff and contractual 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 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 my permission. • I also have the permission of a contract with a billing serviceprofessional staff member. As required by HIPAAHIPPA, I have a formal business associate contract with this businessthis/these business(es), in which it promises it/they promise to maintain the confidentiality of this data except as specifically allowed in the contract or otherwise required by law. If you wish, I can provide you the name of this organization and/or a blank copy of this contract. I also will ask for your permission before having the billing service contact you. • Disclosures required by health insurers insures or to collect overdue fees are discussed elsewhere in associated with this Agreement. • If I believe that a patient threatens presents an immediate danger to harm himselfhis/herselfher health or safety, 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 court proceeding and a request is made for information concerning my professional services, such information is protected by the psychotherapist-patient privilege law. I cannot provide any information without your (or your legal representative’s) written authorization, or a court order, or a subpoena of which you have been officially notified and failed to inform me that you are opposing the subpoena. 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 required to provide it for them. • If a patient files a complaint or lawsuit against me, I may disclose relevant information regarding that patient in order to defend myself. • If a patient files a worker’s compensation claim, information that is directly related to that claim must, upon appropriate request, be provided to the Workers’ Compensation 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 patient’s treatment. These situations are unusual in my practice. § If I have reason to know or suspect that a child has been abused or neglected, or has been a victim of sexual abuse by another child, the law requires that I file a report with the Department for Children, Youth and Families. Once such a report is filed, I may be required to provide additional information. § If I believe that a patient presents a risk to a person or his/her family, I may be required to take protective actions including warning the potential victim(s), contacting the police, or seeking 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. While this written summary of exceptions to confidentiality should prove helpful in informing you about potential problems, it is important that we discuss any questions or concerns that you may have 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 ON CONFIDENTIALITY. The law protects the privacy of all communications between a patient and a psychotherapistpsychologist. In most situations, I we can only release information about your treatment to others if you sign a written authorization Authorization form that meets certain legal requirements imposed by HIPAA. There are other situations that require only that you provide written, advance consent. Your signature on this Agreement provides consent for those activities, as follows: • 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 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 important to our work together. I will note all consultations in your Clinical Record (which is called “PHI” in my Notice of Psychotherapist’s Policies and Practices to Protect the Privacy of Your Health Information). • You should be aware that I practice with the office includes other mental health professionals and that I employ administrative staff. In most cases, I we need to share protected information with these individuals for both clinical and administrative purposes, such as scheduling, billing, 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 my permission. • I also We have a contract with a billing serviceMedical Billing Associates. As required by HIPAA, I we have a formal business associate contract with this business, in which it promises they promise to maintain the confidentiality of this data except as specifically allowed in the contract or otherwise required by law. If you wish, I we can provide you the name of this organization and/or with a blank copy of this contract. I also will ask for your permission before having the billing service contact you. • 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 the doctor may be obligated to seek hospitalization for him/her, her or to contact family members or others who can help provide protection. There are some situations where I am your doctor is 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 my our professional services, such information is protected by the psychotherapistpsychologist-patient privilege law. I We cannot provide any information without your (or your legal representative’s) written authorization, or a court order, or a subpoena of which you have been officially notified and failed to inform me that you are opposing the subpoena. 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 us to disclose information. If you do request your information to be shared in a legal matter (e.g., Social Security Case, Xxxxxxx'x Comp Case prior to the claim decision, divorce or other proceedings), a charge of $185.00/hour will be applied for preparation of a clinical summary, as it is our policy not to share clinical notes with anyone besides other healthcare professionals. This is for your protection, as they are written in clinical, not legal language, and the information contained in them could be misinterpreted. • If a government agency is requesting the information for health oversight activities, I we may be required to provide it for them. • If a patient files a complaint or lawsuit against meeither doctor or the practice, I we may disclose relevant information regarding that patient in order to defend myselfourselves. • If a patient files a worker’s compensation claim, information that is directly and we are providing treatment related to that claim the claim, we must, upon appropriate request, be provided to the Workers’ Compensation Commissionfurnish copies of all medical reports and bills. There are some situations in which I am we are legally obligated to take actions, which I we believe are necessary to attempt to protect others from harm and I we may have to reveal some information about a patient’s treatment. These situations are unusual in my this practice. § ▪ If I have your doctor has reason to know or suspect believe that a child has been abused or neglected, or has been a victim of sexual abuse by another childabused, the law requires that I she file a report with the appropriate governmental agency, usually the Department for Children, Youth and Familiesof Human Resources. Once such a report is filed, I we may be required to provide additional information. § ▪ If I your doctor has reasonable cause to believe that a disabled adult or elder person has had a physical injury or injuries inflicted upon such disabled adult or elder person, other than by accidental means, or has been neglected or exploited, she must report to an agency designated by the Department of Human Resources. Once such a report is filed, she may be required to provide additional information. ▪ If your doctor determines that a patient presents a risk serious danger of violence to a person or his/her familyanother, I she may be required to take protective actions. These actions including warning may include notifying the potential victim(s)victim, and/or contacting the police, or and/or seeking hospitalization of for the patient. If such a situation arises, I your doctor will make every effort to fully discuss it with you before taking any action and I she will limit my her disclosure to what is necessary. While 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 doctor 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 policies and procedures recorded in your records; and the right to a paper copy of this written summary Agreement, the attached Notice form, and our privacy policies and procedures. We are happy to discuss any of exceptions these rights with you. Billing and Payments You will be expected to confidentiality should prove helpful in informing you about potential problems, pay for each session at the time it is important 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. If your account has not been paid for more than 60 days and arrangements for payment have not been agreed upon, we discuss any questions have the option of using legal means to secure the payment. This may involve hiring a collection agency or concerns that you may have now or in going through small claims court which will require us to disclose otherwise confidential information. In most collection situations, the future. The laws governing confidentiality can be quite complexonly information we release regarding a patient’s treatment is his/her name, the nature of services provided, and I am not an attorneythe amount due. In situations where specific advice is required, formal legal advice may be needed.Internet Contact

LIMITS ON CONFIDENTIALITY. The law protects the privacy of all communications between a patient and a psychotherapisttherapist. In most situations, I we can only release information about your treatment to others if you sign a written authorization Authorization form that meets certain legal requirements imposed by HIPAAHIPAA and/or Mississippi law. There are other situations that require only that you provide writtenHowever, advance consent. Your signature on this Agreement provides consent for those activitiesin the following situations, as followsno authorization is required: • 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 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 important to our work together. I will note all consultations in your Clinical Record (which is called “PHI” in my Notice of Psychotherapist’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 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 my permission. • I also have a contract with a billing service. As required by HIPAA, I have a formal business associate contract with this business, in which it promises to maintain the confidentiality of this data except as specifically allowed in the contract or otherwise required by law. If you wish, I can provide you the name of this organization and/or a blank copy of this contract. I also will ask for your permission before having the billing service contact youRecord. • 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 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 court proceeding and a request is made for information concerning my professional servicesyour diagnosis and treatment, such information is protected by the psychotherapisttherapist-patient privilege law. I cannot provide disclose any information without your (or your legal representative’s) written authorization, or a court order, or a subpoena of which you have been officially notified and failed to inform me that you are opposing the subpoena. 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 us to disclose information. • If a government agency is requesting the information for health oversight activities, I may be required to provide it for them. • If a patient files a complaint or lawsuit against meus, I may disclose relevant information regarding that patient in order to defend myselfmy practice. • ▪ If a patient files you file a worker’s compensation claim, information that is directly related to that claim and I am rendering treatment or services in accordance with the provisions of Mississippi Workers’ Compensation law, I must, upon appropriate request, be provided provide a copy of your record to the Workers’ Compensation Commissionyour employer or his/her appropriate designee. 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 we may have to reveal some information about a patient’s treatment. These situations are unusual in my our practice. § ▪ If I have reason reasonable cause (does not have to know or suspect be proof) to believe that a child has been under 18 known to me in my professional capacity may be an abused child or neglected, or has been a victim of sexual abuse by another neglected child, the law requires that I file a report with the local office of the Department for Children, Youth of Children and FamiliesFamily Services. Once such a report is filed, I may be required to provide additional information. § ▪ If I have reason to believe that an adult over the age of 60 living in a patient presents domestic situation has been abused or neglected in the preceding 12 months, the law requires that I file a risk report with the agency designated to receive such reports by the Department of Aging. Once such a person or his/her familyreport is filed, I may be required to provide additional information. ▪ 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 disclose information in order to take protective actions. These actions including warning may include notifying the potential victim(s)victim, contacting the police, or seeking your hospitalization. ▪ If I believe that you present a clear, imminent risk of serious physical or mental injury or death to yourself, I may be required to disclose information in order to take protective actions. These actions may include seeking your hospitalization of the patientor contacting family members or others who can assist in protecting you. 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 our disclosure to what is necessary. While this written summary of exceptions to confidentiality should prove helpful in informing you about potential problems, it is important that we discuss any questions or concerns that you may have 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 ON CONFIDENTIALITY. The law Jaw protects the privacy of all communications between a patient and a psychotherapistpsychologist. In most situations, I can only release information about your treatment to others if you sign a written authorization Authorization (consent) form that meets certain legal requirements imposed by HIPAA. There are other situations that require only that you provide written, advance consent. Your signature on this Agreement provides consent for those activitiesacknowledgement, as follows: • 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 are also legally bound to keep the information confidential. If you don’t object, I will probably not tell you about these consultations unless I feel that it is important to our work together. I will note all consultations in your Clinical Record (which is called “PHI” Record. • My office may contact your home or other designated location and leave an email, fax, correspondence through the postal service, or a message on voice mail, or in person in reference to any items that assist my Notice of Psychotherapist’s Policies office in carrying out treatment, payment, and Practices to Protect the Privacy of Your Health Information)healthcare operations, such as following up on insurance matters. • 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, billing and quality assurance. All of the mental health professionals are My staff is 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 protected information outside of the practice without my permissionpractice. • I also have a contract contracts with a billing servicethe management company for the building, my accountant, and the document shredding company,). As required by HIPAA, I have a formal business associate contract with this businessthese businesses, in which it promises they promise to maintain the confidentiality of this data except as specifically allowed in the contract or otherwise required by law. If you wish, I can provide you the name of this organization and/or a blank copy of this contract. I also will ask for your permission before having the billing service contact you. • 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 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 court proceeding and a request is made for information concerning my the professional servicesservices I provided, such information is protected by the psychotherapistpsychologist-patient privilege law. I cannot provide any information without your (or your legal representative’s's) written authorization, or a court order, or a subpoena of which you have been officially notified and failed to inform me that you are opposing the subpoena. 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 required to provide it for them. • If a patient files a complaint or lawsuit against me, I may disclose relevant information regarding that patient in order to defend myself. • If a patient files you file a worker’s 's compensation claim, information that is directly related and I have examined or treated you in regard to that claim such claim, I must, upon appropriate request, be provided provide a report to the Workers’ Compensation Commissionpatient's employer or the employer's insurance company. 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 's treatment. These situations are unusual in my practice. § If I have reason to know or suspect that a child has been abused or neglected, or has been a victim of sexual abuse by another child, the law requires that I file a report with the Department for Children, Youth and Families. Once such a report is filed, I may be required to provide additional information. § If I believe that a patient presents a risk to a person or his/her family, I may be required to take protective actions including warning the potential victim(s), contacting the police, or seeking 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. If I have reason to suspect that a child under 18 has been injured as a result or physical, mental or emotional abuse or neglect or sexual abuse, or that an adult has been or is being abused, neglected or exploited or is in need of protective services, the law requires that I file a report with the appropriate government agency, usually the Department of Social and Rehabilitation Services. Once such a report is filed, I may be required to provide additional information if a patient communicates an imminent, specific threat of harm against a specific individual and I believe that there is a substantial risk that the patient will act on that threat in the foreseeable future, I may be required to take protective actions. These actions may include notifying the potential victim, contacting the police, or seeking hospitalization for the patient. PROFESSIONAL RECORDS You should be aware that, pursuant to HIPAA, I keep Protected Health Information about you in two sets of professional records. One set constitutes your Clinical Record. It includes information about your reasons for seeking therapy, a description of the ways in which your problem impacts on your life, your diagnosis, the goals that we set for treatment, your progress towards those goals, your medical and social history, your treatment history, any past treatment records that I receive from other providers, reports of any professional consultations, and any reports that have been sent to anyone, including reports to your insurance carrier. Unless I believe that access is reasonably likely to cause substantial harm [or where information has been supplied to me by others confidentially], 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. I charge a copying fee of $1.00 per page (and for certain other expenses). In addition, I 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 this written summary the contents of exceptions Psychotherapy Notes vary, 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 confidentiality me that is not required to be included in your Clinical Record. These Psychotherapy Notes cannot be sent to anyone else, including insurance companies without your written, signed Authorization. PATIENT RIGHTS: MINORS & PARENTS Patients under 18 years of age who are not emancipated and their parents should prove helpful be aware that the law may allow parents to examine their child's treatment records. Because privacy in informing you about potential problemspsychotherapy is often crucial to successful progress, particularly with teenagers, it is important sometimes my policy to request an agreement from parents that we discuss any questions or concerns that you may have now or in they consent to give up their access to their child's records. If they agree, during treatment, I will provide them only with general information about the future. The laws governing confidentiality can be quite complexprogress of the child's treatment, and his/her attendance at scheduled sessions. I am not an attorney. In situations where specific advice can also provide parents with a summary of their child's treatment when it is required, formal legal advice may be neededcomplete.

LIMITS ON CONFIDENTIALITY. The law protects the privacy of all communications between a patient client and a psychotherapist. In most situations, I can only release information about your treatment to others if you sign a written authorization Authorization form that meets certain legal requirements imposed by HIPAA. There are other situations that require only that you provide written, advance consent. Your signature on this Agreement provides consent for those activities, as follows: • 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 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 important to our work together. I will note all consultations in your Clinical Record (which is called “PHI” in my Notice of Psychotherapist’s Policies and Practices to Protect the Privacy of Your Health Information). • You should be aware that I practice sometimes collaborate 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 assuranceprofessionals. All of the these mental health professionals are bound by the same rules of confidentialityconfidentiality and are professionally obligated to protect your privacy. All staff members have been given training about protecting your privacy and have agreed not to release any information outside of the practice without my permission. • I also have a contract with a billing service. As required by HIPAA, I have a formal business associate contract with this business, in which it promises to maintain the confidentiality of this data except as specifically allowed in the contract or otherwise required by law. If you wish, I can provide you the name of this organization and/or a blank copy of this contract. I also will ask for your permission before having the billing service contact you. • Disclosures required by health insurers or to collect overdue fees are discussed elsewhere in this Agreement. • If a patient threatens you threaten to harm himself/herselfyourself during the course of your therapy with me, I may be obligated to seek hospitalization for him/heryou, 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 my the professional servicesservices I provided to you, such information is protected by the psychotherapist-psychotherapist- patient privilege law. I cannot provide any information without your (or your legal representative’s) written authorization, authorization or a court order, or a subpoena of which you have been officially notified and failed to inform me that you are opposing the subpoena.  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 am required to provide it for them. •  If a patient files you file a complaint or lawsuit against me, I may disclose relevant information regarding that patient your therapy work with me in order to defend myself. •  If a patient files you threaten to harm yourself during the course of your therapy work with me, I may be obligated to seek hospitalization for you or to contact family members or others who can help provide protection  If you file a worker’s compensation claim, information that is directly related to that claim I must, upon appropriate request, be provided provide a copy of your client record to the Workers’ Compensation appropriate parties, your employer, the workers' compensation insurance carrier or the Labor 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 patientclient’s treatment. These situations are unusual in my practice. §  If I have reason to know or suspect believe that a child has been abused or neglectedis likely to be subjected to incest, molestation, sexual exploitation, sexual abuse, physical abuse, or has been a victim of sexual abuse by another childneglect, the law requires that I file a report with immediately notify the Department for Children, Youth Division of Child and FamiliesFamily Services or an appropriate law enforcement agency. Once such a report is filed, I may be required to provide additional information. §  If I have reason to believe that any vulnerable adult has been the subject of abuse, neglect, abandonment or exploitation, I am required to immediately notify Adult Protective Services intake. Once such a patient presents a risk to a person or his/her familyreport is filed, I may be required to provide additional information.  If a client communicates an actual threat of physical violence against an identifiable victim, I am required to take protective actions. These actions including warning may include notifying the potential victim(s), victim and contacting the police, or and/or seeking hospitalization of the patientfor that client. 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. While this written summary of exceptions to confidentiality should prove helpful in informing you about potential problems, it is important that we discuss any questions or concerns that you may have 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 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. If I refuse your request, you have the right to appeal my decision. 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. I do bill for my regular therapy fee for such review meetings. In most situations, I do charge a copying fee of $.10 per page (and for certain other expenses). If I refuse your request for access to your records, you have a right of review (except for information supplied to me confidentially by others), which I will discuss with you upon request. CLIENT 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. I am happy to discuss any of these rights with you. MINORS & PARENTS Clients under 14 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 unless I decide that such access is likely to injure the child, or we agree otherwise. Since parental involvement in therapy is important, it is my policy to request an agreement between a child client between 14 and 18 and his/her parents, allowing me to share 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. PROFESSIONAL FEES My session fee is $125 (for 50 minutes) and $187 (for 75 minutes). In addition to weekly appointments, I charge this amount for other professional services you may need, though I will break down the hourly cost if I work for periods of less than one hour. Other services include report writing, telephone conversations lasting longer than 10 minutes, consulting with other professionals with your permission, preparation of records or treatment summaries, and the time spent performing any other service you may request of me. If you become involved in legal proceedings that require my participation, you will be expected to pay for all of my professional time, including preparation and transportation costs, even if I am called to testify by another party. Because of the difficulty of legal involvement, I charge $125 per hour for preparation and attendance at any legal proceeding. 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 circumstances of unusual financial hardship, I may be willing 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 client’s treatment is your name, the nature of services provided, and the amount due. If such legal action is necessary, its costs will be included in the claim. THIRD PARTY REIMBURSEMENT In order for us to set realistic treatment goals and priorities, it may be important to evaluate what resources you have available to pay for your treatment. It is important to remember that you always have the right to self-pay for my services, in which case you avoid the potential problems described in this section. I am available to assist you in securing third party reimbursement for my services if your insurance plan reimburses Licensed Professional Counselors. Many indemnity insurance policies routinely provide a percentage reimbursement for the standard therapy fee of a Licensed Professional Counselor. I am not a member of any Managed Care Preferred Provider Panels. If your policy will cover a Licensed Professional Counselor as an “out of network provider” or if your policy will otherwise make an exception to allow reimbursement to me, I am available to work with you to secure third party payment. Within reason, 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.

LIMITS ON CONFIDENTIALITY. The law protects the privacy of all communications between a patient and a psychotherapistpsychologist. In most situations, I can only release information about your treatment to others if you sign a written authorization form that meets certain legal requirements imposed by HIPAA. There are other situations that require only that you provide written, advance consent. Your signature on this Agreement provides consent for those activities, as follows: • 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 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 important to our work together. I will note all consultations in your Clinical Record (which is called “PHI” in my Notice of PsychotherapistPsychologist’s Policies and Practices to Protect the Privacy of Your Health Information). • You should be aware that I practice may also employ or have contracts 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 schedulingaccountants, attorneys or other individuals that help me with data entry or 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 my permission. • I also have a contract with a billing service. As required by HIPAA, I have a formal business associate contract with this businessthis/these business(es), in which it promises it/they promise to maintain the confidentiality of this data except as specifically allowed in the contract or otherwise required by law. If you wish, I can provide you with the name names of this organization these organizations and/or a blank copy of this contract. I also will ask for your permission before having the billing service contact you. • 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 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 court proceeding and a request is made for information concerning my professional servicesyour evaluation, diagnosis or treatment, such information is protected by the psychotherapistpsychologist-patient privilege law. I cannot provide any information without your (or your personal or legal representative’s) written authorization, or authorization unless I receive a court order, or a subpoena of which you have been officially notified and failed to inform me that you are opposing the subpoena. 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 required to provide it for them. • If a patient client files a complaint or lawsuit against me, I may disclose relevant information regarding that patient client in order to defend myself. • If a patient client files a worker’s compensation claim, information the client must execute a release so that is directly related to that claim mustI may release the information, upon appropriate request, be provided records or reports relevant to the Workers’ Compensation Commissionclaim. 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 know or have reason to know or suspect that a child has been abused under 18 years of age or neglecteda mentally retarded, developmentally disabled, or physically impaired child under 21 years of age has been suffered or faces a victim threat of sexual suffering any physical or mental wound, injury, disability, or condition of a nature that reasonably indicates abuse by another or neglect of the child, the law requires that I file a report with the Department for Childrenappropriate government agency, Youth and Familiesusually the Public Children Services Agency. Once such a report is filed, I may be required to provide additional information. § ▪ If I have reasonable cause to believe that an elderly adult is being abused, neglected, or exploited, or is in a patient presents condition which is the result of abuse, neglect, or exploitation, the law requires that I report such belief to the county Department of Job and Family Services. Once such a risk to a person or his/her familyreport is filed, I may be required to take protective actions including warning provide additional information. ▪ If I know or have reasonable cause to believe that a client or client has been the victim of domestic violence, I must note that knowledge or belief and the basis for it in the client’s or client records. ▪ If I believe that a client presents a clear and substantial risk of imminent serious harm to him/herself or someone else and I believe that disclosure of certain information may serve to protect that individual, then I must disclose that information to appropriate public authorities, and/or the potential victim(s)victim, contacting and/or professional workers, and/or the police, or seeking hospitalization family of the patientclient. 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. While this written summary of exceptions to confidentiality should prove helpful in informing you about potential problems, it is important that we discuss any questions or concerns that you may have 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 as of June 2003, pursuant to HIPAA, I keep Protected Health Information about you in two sets of professional records. One set constitutes your Clinical Record. It includes information about your reasons for seeking therapy, a description of the ways in which your problem impacts on your life, your diagnosis, the goals that we set for treatment, your progress towards those goals, your medical and social history, your treatment history, any past treatment records that I receive from other providers, reports of any professional consultations, your billing records, and any reports that have been sent to anyone, including reports to your insurance carrier. Except in unusual circumstances that involve danger to yourself and others, you may examine and/or receive a copy of your Clinical Record if you request it in writing and the request is signed by you and dated not more than 60 days from the date it is submitted. 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 $1 per page for the first ten pages, 50 cents per page for pages 11 through 50, and 20 cents per page for pages in excess of fifty, plus a $15 fee for records search, plus postage. The exceptions to this policy are contained in the attached Notice Form. If I refuse your request for access to your Clinical Record, you have a right of review, which I will discuss with you upon request. In addition, I 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 client to client, they can include the contents of our conversations, my analysis of those conversations, and how they impact on your therapy. They also contain particularly sensitive information that you may reveal to me that is not required to be included in your Clinical Record. These Psychotherapy Notes are now 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 such disclosure would have an adverse effect on you. 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. I am happy to discuss any of these rights with you. MINORS & PARENTS Clients under 14 years of age (who are not emancipated) and their parents should be aware that the law allows parents to examine their child’s treatment records, unless I decide that such access would injure the child or we agree otherwise. Children between 14 and 18 may independently consent to and receive up to 6 sessions of psychotherapy (provided within a 30-day period) and no information about those sessions can be disclosed to anyone without the child’s agreement. While privacy in psychotherapy is often crucial to successful progress, particularly with teenagers, parental involvement is also essential to successful treatment. For children 14 and over, it is my policy to request an agreement between my client and his/her parents allowing me to share 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.

LIMITS ON CONFIDENTIALITY. The law protects the privacy of all communications between a patient and a psychotherapistclinician. 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 certain legal requirements imposed by HIPAA. There are other situations that require only that you provide written, advance consent. Your signature on this Agreement provides consent for those the activities, as follows: • I A clinician may occasionally find it helpful to consult other health and mental health professionals about a case. During a consultation, I make every effort is made 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 you will not tell you be informed about these consultations unless I feel that it is important to our work togetherdeemed important. I All consultations will note all consultations be noted in your Clinical Record Records (which is called referenced as the “PHI” in my the Notice of Psychotherapist’s Policies and Practices to Protect the Privacy of Your Health Information). • You should be aware that I this practice with includes other mental health professionals and that I employ administrative staff. In most cases, I need it is necessary to share protected information with these individuals for both clinical and administrative purposes, such as scheduling, billing, 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 my permissionthe permission of a professional staff member. • I also have a contract This practice has contracts with a billing servicean answering service and collection agency. As required by HIPAA, I have a formal business associate contract with this businessthis/these business(s), in which it promises it/they promise to maintain the confidentiality of this data except as specifically allowed in the contract or otherwise required by law, has been established. If you wish, I you can provide you be provided the name names of this organization these organizations and/or a blank copy of this the contract. I also will ask for your permission before having the billing service contact you. • Disclosures required by health insurers or to collect overdue fees are discussed elsewhere in this the Agreement. • 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 whereby the clinician is 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 my professional servicesyour evaluation, diagnosis or treatment, such information is protected by the psychotherapist-patient privilege privileged communication law. I The clinician cannot provide any information without your (or your personal or legal representative’s) written authorization, or a court order, or a subpoena of which you have been officially notified and failed to inform me that you are opposing the subpoena. If you are involved in or are contemplating litigation, you should consult with your attorney to determine whether a court would be likely to order me the clinician to disclose information. • If a government agency is requesting the information for health oversight activities, I the clinician may be required to provide it for them. • If a patient client files a complaint or lawsuit against methe clinician, I that clinician may disclose relevant information regarding that patient the client in order to defend myself. • If a patient files a worker’s compensation claim, information that is directly related to that claim must, upon appropriate request, be provided to the Workers’ Compensation Commissionhim/herself. There are some situations in which I am the clinician is legally obligated to take actions, which I believe he/she believes are necessary to attempt to protect others from harm and I harm. In doing so, the clinician may have to reveal some information about a patientclient’s treatment. These situations are unusual in my practice. § • If I have the clinician knows or has reason to know or suspect that a child has been abused or neglectedunder 18 years of age, or a mentally retarded, developmentally disabled, or physically impaired individual under the age of 21 years of age, has been suffered or faces a victim threat of sexual suffering any physical or mental wound, injury, disability, or condition of a nature that reasonably indicates abuse by another or neglect of the child/individual, the law requires that I the clinician file a report with the Department for Childrenappropriate government agency, Youth and Familiesusually the Public Children Services Agency. Once such a report is filed, I the clinician may be required to provide additional information. § • If I the clinician has reasonable cause to believe that an adult is being abused, neglected, or exploited, or is in a condition which is the result of abuse, neglect, or exploitation, the law requires that the clinician report such belief to the county Department of Job and Family Services. Once such a report has been filed, the clinician may be required to provide additional information. • If the clinician knows or has reasonable cause to believe that a client has been the victim of domestic violence, he/she must note that knowledge or belief and the basis for it in the client’s record. • If the clinician believes that a patient presents a clear and substantial risk of imminent serious harm to a person him/herself or hissomeone else, and he/her familyshe believes that disclosure of certain information may serve to protect that individual, I may be required then the clinician must disclose that information to take protective actions including warning the appropriate public authorities, and/or the potential victim(s)victim, contacting and/or professional workers, and/or the police, or seeking hospitalization family of the patientclient. If such a situation arises, I the clinician will make every effort to fully discuss it with you before taking any action and I will limit my the disclosure to what is necessary. While this written summary of exceptions to confidentiality should prove helpful in informing you about potential problems, it is important that we you discuss with the clinician any questions or concerns that you may have now or in the future. The laws governing confidentiality can be quite complex, and I am clinicians are not an attorneyattorneys. In situations where specific advice is required, formal legal advice may be needed.

LIMITS ON CONFIDENTIALITY. The law protects the privacy of all communications between a patient and a psychotherapistpsychologist or other mental health professional. In most situations, I we can only release information about your treatment to others if you sign a written authorization form that meets certain legal requirements imposed by HIPAA. There are other situations that require only that HIPAA and/or Maine law, or in some cases, if you provide writtenoral authorization. However, advance consent. Your signature on this Agreement provides consent for those activitiesin the following situations, as followsno authorization is required: • I You should be aware that this is a practice with more than one psychologist. Some staff may see some information for the purposes of scheduling, billing, quality assurance, cross-coverage, or archival research. In our practice, there is one chart per patient, and any psychologist who treats that patient will have access to that chart. All psychologists have been given training about confidentiality and protecting your privacy. • Your psychologist may occasionally find it helpful to consult with or seek supervision from 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 we will not tell you about these consultations consultations, unless I we feel that it is important to our work together. I will note all consultations in your Clinical Record (which is called “PHI” in my Notice of Psychotherapist’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 casesHampden Psychological Consultation, I need to share protected information with these individuals for both clinical and administrative purposesPLLC, such as schedulingreceives services from a computer service professional, billingan accountant, an attorney, a secretary, a housekeeper, an attorney, 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 my permission. • I also have a contract with a billing servicebuilding landlord. As required by HIPAA, I we have a formal business associate contract with this businessthese individuals, in which it promises they promise to maintain the confidentiality of this data data, except as specifically allowed in the contract or otherwise required by law. If you wish, I we can provide you with the name names of this organization these organizations and/or a blank copy of this contract. I also will ask for your permission before having the billing service contact you. • 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 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 court proceeding and a request is made for information concerning my professional servicesyour diagnosis and treatment, such information is protected by the psychotherapistpsychologist-patient privilege law. I We cannot provide any information without your (or your legal representative’s) written authorization, or a court order, or a subpoena of which you have been officially notified and failed to inform me that you are opposing the subpoena. 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 us to disclose information. • If a government agency is requesting the information for health oversight activities, I we may be required to provide it for them. • If a patient files a complaint or lawsuit against meus, I we may disclose relevant information regarding that patient in order to defend myselfourselves. • If you are pursuing medical or mental health disability payments, you may end up signing a patient files a worker’s compensation claim, information document with that is directly related agency or company waiving confidentiality to that claim must, upon appropriate request, be provided to the Workers’ Compensation Commissionyour records. There are some situations in which I am we are legally obligated to take actions, which I we believe are necessary to attempt to protect others from harm harm, and I we may have to reveal some information about a patient’s treatment. These situations are unusual in my practice. § • If I have reason to we know or have reasonable cause to suspect that a child under 18 has been or is likely to be abused or neglected, or that a vulnerable adult has been a victim of sexual abuse by another childabused, neglected, or exploited and is incapacitated or dependent, the law requires that I we file a report with the appropriate government agency, usually the Maine Department for Children, Youth of Health and FamiliesHuman Services. Once such a report is filed, I we may be required to provide additional information. § • If I believe we determine that the patient poses a patient presents a risk direct threat of imminent harm to a person the health or hissafety of any individual, including himself/her familyherself, I we may be required to disclose information in order to take protective action(s). These actions including warning may include notifying the potential victim(s)victim, contacting the police, or seeking hospitalization of for the patient, or contacting family members or others who can assist in providing protection. If such a situation arises, I we will make every effort to fully discuss it with you before taking any action action, and I we will limit my disclosure to what is necessary. While this written summary of exceptions to confidentiality should prove helpful in informing you about potential problems, it is important that we discuss any questions or concerns that you may have 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 ON CONFIDENTIALITY. The law protects the privacy of all communications between a patient and a psychotherapistpsychologist. In most situations, I can only release information about your treatment to others if you sign a written authorization Authorization form that meets certain legal requirements imposed by HIPAA. There are other situations that require only that you provide written, advance advanced consent. Your signature on this Agreement provides consent for those activities, as follows: • I may occasionally find it helpful to consult other health and mental health professionals professions 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 important to our work together. I will note all these consultations in your Clinical Record (which is called “PHI” in my Notice of PsychotherapistPsychologist’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 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 my permission. • I also have a contract with Synergistic Office Solutions, a software company that I use for billing servicepurposes. As required by HIPAA, I have a formal business associate contract with this business, in which it promises to maintain the confidentiality of this the data except as specifically allowed in the contract or otherwise required by law. If you wish, I can provide you the name of this organization and/or with a blank copy of this contract. I also will ask for your permission before having the billing service contact you. • Disclosures required by health insurers or to bill or to collect overdue fees are discussed elsewhere in this the Agreement. • If a patient threatens to harm himself/herself, I may be obligated obliged to seek hospitalization for him/her, or to contact family members or others who can help provide protection. If you are being treated in couple’s therapy, confidentiality belongs to both you and your partner. Therefore, I will only release information if I have a signed release from both you and your partner. 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 my professional servicesyour diagnosis and treatment, such information is protected by the psychotherapistpsychologist-patient privilege law. I cannot provide any information without your (or your legal representative’s) written authorization, or a court order, or if a subpoena is served on me with appropriate notices, I may have to release information in a sealed envelope to the clerk of which you have been officially notified and failed to inform me that you are opposing the court issuing the subpoena. If you are involved in litigation or contemplating litigationit, 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 required to provide it for them. • If a patient files a complaint or lawsuit against me, I may disclose relevant information regarding that patient in order to defend myself. • If a patient files a worker’s compensation claim, information that is directly related to that claim I must, upon appropriate request, be provided to the Workers’ Compensation Commissionprovide a copy of any mental health report. 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 know or suspect that a child has been is abused or neglected, the law requires I file a report with the appropriate governmental agency, usually the Department of Social Services. Once a report is filed, I may be required to provide additional information. If I have reason to suspect that an adult is abused, neglected or has been a victim of sexual abuse by another childexploited, the law requires that I file a report with to the Department for Children, Youth and Familiesof Welfare or Social Services. Once such a report is filed, I may be required to provide additional information. § If a patient communicates a specific threat of immediate serious physical harm to an identifiable victim, and I believe that a patient presents a risk he/she has the intent and ability to a person carry out the threat, I am required to take protective actions. These actions may include notifying the potential victim or his/her family, I may be required to take protective actions including warning the potential victim(s)guardian, contacting the police, or seeking hospitalization of for 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. While this written summary of exceptions to confidentiality should prove helpful in informing you about potential problems, it is important that we discuss any questions or concerns that you may have 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, 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 that have been sent to anyone, including reports to your insurance carrier. Except in unusual circumstances that involve danger to yourself, 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 20 cents per page. The exceptions to this policy are contained in the attached Notice Form. If I refuse your request for access to your Clinical Record, you have a right of review, which I will discuss with you upon your request. In addition, I 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 client to client, they can include the contents of our conversations, my analysis of those conversations, and how they impact on your therapy. They also contain particularly sensitive information that you may reveal to me that is not required to be included in your Clinical Record. These Psychotherapy Notes are kept separate from your Clinical Record. While the 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 such information does not exist or cannot be found, or such disclosures would be injurious to your health or well-being. PATIENT RIGHTS HIPPA provides you with several new and expanded rights regarding 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 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 the 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 after it is completed, unless we agree otherwise. Payment schedules for other professional services will be agreed to when they are requested. You have the option of paying for services directly or enrolling in the client portal. You may discuss with me how you chose to pay for services during the intake process.

LIMITS ON CONFIDENTIALITY. The law protects the privacy of all communications between a patient and a psychotherapistpsychologist. In most situations, I can only release information about your treatment to others if you sign a written authorization Authorization form that meets certain legal requirements imposed by HIPAA. There are other situations that require only that HIPAA and/or Maine law, or in some cases, if you provide writtenoral authorization. However, advance consent. Your signature on this Agreement provides consent for those activitiesin the following situations, as followsno authorization is required: •  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 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 important to our work together. I will note all consultations in your Clinical Record (which is called “PHI” in my Notice of Psychotherapist’s Policies and Practices to Protect the Privacy of Your Health Information). • You should be aware that I practice have contracts 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 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 my permission. • I also have a contract with a billing servicean accountant. As required by HIPAA, I have a formal business associate contract with this businessthis/these business(es), in which it promises it/they promise to maintain the confidentiality of this data except as specifically allowed in the contract or otherwise required by law. If you wish, I can provide you with the name names of this organization these organizations and/or a blank copy of this contract. I also will ask for your permission before having the billing service contact you. •  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 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 court proceeding and a request is made for information concerning my professional servicesyour diagnosis and treatment, such information is protected by the psychotherapistpsychologist-patient privilege law. I cannot provide any information without your (or your legal representative’s) written authorization, or a court order, or a subpoena of which you have been officially notified and failed to inform me that you are opposing the subpoena. 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 required to provide it for them. •  If a patient files a complaint or lawsuit against me, I may disclose relevant information regarding that patient in order to defend myself. •  If a patient files you have filed a worker’s compensation claim, information and I am being compensated for your treatment by your employer or its insurance company as a result that is directly related to that claim mustclaim, I must provide, upon appropriate request, be provided legally required reports and other information related to the Workers’ Compensation Commissionyour condition. 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 know or have reasonable cause to suspect that a child under 18 has been or is likely to be abused or neglected, neglected or that a vulnerable adult has been a victim of sexual abuse by another childabused, neglected or exploited and is incapacitated or dependent, the law requires that I file a report with the appropriate government agency, usually the Maine Department for Children, Youth and Familiesof Human Services. Once such a report is filed, I may be required to provide additional information. §  If I believe determine that the patient poses a patient presents a risk direct threat of imminent harm to a person the health or hissafety of any individual, including himself/her familyherself, I may be required to disclose information in order to take protective action(s). These actions including warning may include notifying the potential victim(s)victim, contacting the police, or seeking hospitalization of for the patient, or contacting family members or others who can assist in providing protection. 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. While this written summary of exceptions to confidentiality should prove helpful in informing you about potential problems, it is important that we discuss any questions or concerns that you may have 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 that disclosure would physically endanger you and/or 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 forwarded to another mental health professional so you can discuss the contents. In most circumstances, I am allowed to charge a copying fee of $.20 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. You should be aware that I sometimes keep Personal Notes, as permitted by Maine law, and these notes are not available to you. 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 Patients and their parents should be aware that Maine law allows minor children to independently consent to and receive mental health treatment without parental consent and, in that situation, information about that treatment cannot be disclosed to anyone without the minor child’s agreement. I will also provide parents with a psychological assessment report 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 or unless you have insurance coverage that requires another arrangement. 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. INSURANCE REIMBURSEMENT I am not on any private health insurance plans. Once the assessment is completed, 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. You should also be aware that your contract with your health insurance company requires that you authorize me to provide it with information relevant to the services that I provide to you. If you are seeking reimbursement for services under your health insurance policy, you will be required to sign an authorization form that allows me to provide such information. 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. This may require an additional authorization. (If you refuse such authorization, the insurance company can deny your claims and you will be responsible for paying for services yourself.) 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. 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 Date

LIMITS ON CONFIDENTIALITY. The law protects the privacy of all communications between a patient and a psychotherapistpsychologist. In most situations, I we can only release information about your treatment to others if you sign a written authorization Authorization form that meets certain legal requirements imposed by HIPAA. There are other situations that require only that you provide written, advance consent. Your signature on There are some situations in which I am legally required to take action to protect others from harm, even though this Agreement provides consent may require revealing some information about a patient’s treatment. • For example, if I believe a child, an elderly person, or a person with a disability is being abused, I may be required to file a report with the appropriate state agency. • If I believe a patient is threatening serious bodily harm to another, I may be required to take protective actions, which may include notifying the potential victim, notifying the police, or seeking appropriate hospitalization. • If a patient threatens to harm him/herself, I may be required to seek hospitalization for those activitiesthe patient, as follows: • notify police, or to contact family members or others who can help provide protection. These situations are unusual in my practice. However, if such a situation develops, I will make every effort to fully discuss it with you before taking 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 the 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 important to our work together. I will note all consultations in your Clinical Record (which is called “PHI” in my Notice of Psychotherapist’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 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 my permission. • I also have a privacy contract with a billing serviceour accountant. As required by HIPAA, I have a formal business associate contract with this businessthem, in which it promises they promise to maintain the confidentiality of this data except as specifically allowed in the contract or otherwise required by law. If you wish, I can provide you the name of this organization and/or a blank copy of this contract. I also will ask for your permission before having the billing service contact you. • 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 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 court proceeding and a request is made for information concerning my professional servicesyour diagnosis and treatment, such information is protected by the psychotherapistpsychologist-patient privilege law. I cannot provide any information without your (or your legal representative’s's) written authorization, or a court order, or a subpoena of which you have been officially notified and failed to inform me that you are opposing the subpoena. 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 required to provide it for them. • If a patient files a complaint or lawsuit against me, I may disclose relevant information regarding that patient in order to defend myself. • If a patient files a worker’s 's compensation claim, information that is directly related to that claim I must, upon appropriate request, be provided provide records relating to the Workers’ Compensation Commission. There are some situations in treatment or hospitalization for 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 know or suspect that a child has been abused or neglected, or has been a victim of sexual abuse by another child, the law requires that I file a report with the Department for Children, Youth and Families. Once such a report compensation is filed, I may be required to provide additional information. § If I believe that a patient presents a risk to a person or his/her family, I may be required to take protective actions including warning the potential victim(s), contacting the police, or seeking 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. While this written summary of exceptions to confidentiality should prove helpful in informing you about potential problems, it is important that we discuss any questions or concerns that you may have 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 neededbeing sought.

LIMITS ON CONFIDENTIALITY. The law protects the privacy of all communications between a patient and a psychotherapistpsychologist. In most situations, I can only release information about your treatment to others if you sign a written authorization form that meets certain legal requirements imposed by HIPAA. There are other situations that require only that you provide written, advance consent. Your signature on this Agreement provides consent for those activities, as follows: • 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 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 important to our work together. I will note all consultations in your Clinical Record (which is called “PHI” in my Notice of PsychotherapistPsychologist’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 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 my permission. • I also have a contract with a billing service. As required by HIPAA, I have a formal business associate contract with this business, in which it promises to maintain the confidentiality of this data except as specifically allowed in the contract or otherwise required by law. If you wish, I can provide you the name of this organization and/or a blank copy of this contract. I also will ask for your permission before having the billing service contact you. • 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 obligated to seek hospitalization for him/her, or to contact family members or others who can help provide protectioninsurers. There are some situations where I am permitted or required to disclose information without either your consent or Authorization: These situations are rare in my practice, but you should still be aware of them. • If you are involved in a court proceeding and a request is made for information concerning my professional servicesyour diagnosis and treatment, such information is protected by the psychotherapistpsychologist-patient privilege law. I cannot provide any information without your (or your legal representative’s) written authorization, or a court order, or a subpoena order for the release of which you have been officially notified and failed to inform me that you are opposing the subpoena. 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 required to provide it for them. • If a patient files a complaint or lawsuit against me, I may disclose relevant information regarding that patient in order to defend myself. • If a patient files a worker’s compensation claim, information that is directly related to that claim I must, upon appropriate request, be provided provide appropriate information, including a copy of the patient’s record, to the Workers’ Compensation 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 patient’s treatmentemployer, the insurer or the Department of Worker’s Compensation. These situations are unusual in my practice. §  If I have reason reasonable cause to know or suspect believe that a child has been abused under age 18 is suffering physical or neglected, emotional injury resulting from abuse or has been a victim of sexual abuse by another childneglect, the law requires that I file a report with the Department for Children, Youth and Familiesof Social Services. Once such a report is filed, I may be required to provide additional information. §  If I have reason to believe an elderly or handicapped individual is suffering from abuse, the law requires that I report to the Department of Elder Affairs. Once such a report is filed, I may be required to provide additional information.  If a patient presents communicates an immediate threat of serious physical harm to an identifiable victim or if a risk patient has a history of violence and the intent and ability to a person or his/her familycarry out the threat, I may be required to take protective actions. These actions including warning may include notifying the potential victim(s)victim, contacting the police, or and/or seeking hospitalization of for the patient.  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. 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 what, in my judgment, is necessary. While this written summary of exceptions to confidentiality should prove helpful in informing you about potential problems, it is important that we discuss any questions or concerns that you may have 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, it may be necessary for you to seek formal legal advice advice. PROFESSIONAL RECORDS The laws and standards of my profession require that I keep Protected Health Information (PHI) about you in your Clinical Record. You may examine and/or receive a copy of your records if you request it in writing, unless I believe that access would endanger you. In those situations, you have a right to a summary and to have your record sent to another mental health provider or your attorney. Because these are professional records, they can be neededmisinterpreted and/or upsetting to untrained readers. For this reason, I recommend that you initially review them in my presence 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. I am happy to discuss any of these rights with you. CONTACTING ME Messages: Messages can be left for me at my Wellesley office (000-000-0000 X0) or my Rhode Island number (401-305-3051), both of which have a voicemail system. The latter is also my fax number. I check this number frequently for messages, and will make every effort to return your call on the same day you make it, with the exception of weekends and holidays or if you call after 6PM, in which case I will generally return your call on the next business day.

LIMITS ON CONFIDENTIALITY. The law protects the privacy of all communications between a patient client and a psychotherapistpsychologist. In most situations, I can only release information about your treatment (or your child’s treatment) to others if you sign a written authorization Authorization form that meets certain legal requirements imposed by HIPAA. There are other situations that require only that you provide written, advance advanced consent. Your signature on this Agreement provides consent for those activities, as follows: • § I may occasionally find it helpful to consult other health and mental health professionals about a caseyour (your minor child’s) treatment. During a consultation, I make every effort to avoid revealing the identity of my patientclients’ identity. 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 important to our work together. I will note all consultations in your (your child’s) Clinical Record (which is called “PHI” in my Notice of Psychotherapist’s Policies and Practices to Protect the Privacy of Your Health Information)Record. • § 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 of the mental health professionals are bound by the same rules of confidentiality. All administrative staff members have been are given training about protecting your privacy and have agreed agree not to release any information outside of the practice without my permissionthe permission of a professional staff member. • I also have a contract with a billing service. As required by HIPAA, I have a formal business associate contract with this business, in which it promises to maintain the confidentiality of this data except as specifically allowed in the contract or otherwise required by law. If you wish, I can provide you the name of this organization and/or a blank copy of this contract. I also will ask for your permission before having the billing service contact you. • 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 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 court proceeding and a request is made for information concerning my professional services, such information is protected by the psychotherapistpsychologist-patient client privilege law. I cannot provide any information without your (or your legal representative’s) written authorization, authorization or a court order, or a subpoena of which you have been officially notified and failed to inform me that you are opposing the subpoena. 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. • § I also may have contracts with website hosting and storage companies. As required by HIPAA, I will have a business associate contract with these companies, in which they promise to maintain the confidentiality of client information/data except as specifically allowed in the contract or otherwise required by law. § If your account is overdue, I reserve the right to employ a collection agency to receive payment. This will result in revealing your name, date of service, and account balance. No additional treatment related information would be shared. § I know that email, text messaging, faxes, and other forms of electronic communication may compromise your privacy. I do occasionally use email. Electronic communications are only used for brief exchanges, typically regarding administrative issues and scheduling. Please notify me at the beginning of testing if you would like to avoid or limit in anyway the use of any or all these communication devices. I do not use social media messaging for client communication. You should also know that any emails and text messages I receive from you become part of your (your child’s) clinical record There are some situations, such as those listed below, where I am permitted or required to disclose information without either your consent or authorization: § If a government agency is requesting the information for health oversight activities, I may be required to provide it for them. • § If a patient client files a complaint or lawsuit against meus, I may disclose relevant information regarding that patient in order client to defend myselfourselves. • § If a patient client files a worker’s workers’ compensation claim, information that and treatment is directly provided related to that claim the claim, I must, upon appropriate request, be provided to the Workers’ Compensation Commissionfurnish copies of all medical reports and bills. 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 patientclient’s treatment. These situations as follows are unusual in my practiceunusual. § If I have reason to know or suspect believe that a child has been abused or neglected, or has been a victim of sexual abuse by another childabused, the law requires that I file a report with the appropriate governmental agency, usually the Department for Children, Youth and Familiesof Human Resources. Once such a report is filed, I may be required to provide additional information. § If I have reasonable cause to believe that a patient disabled adult or elderly person has had a physical injury or injuries inflicted upon them, other than by accidental means, or has been neglected or exploited, I must report to an agency designated by the Department of Human Resources. Once such report is filed, I may be required to provide additional information. § If I determine that a client presents a risk serious danger of violence to a person or his/her familyanother, I may be required to take protective actions. These actions including warning may include notifying the potential victim(s)victim, and/or contacting the police, or and/or seeking hospitalization of for the patientclient. § 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 protection. 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 any disclosure to what is necessary. While this written summary of exceptions to confidentiality should prove helpful in informing you about potential problems, it is important that we discuss any questions or concerns that you may have 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 our profession require that I keep Protected Health Information about you (your child) in a Clinical Record. Following a formal psycho-educational evaluation, you will an extensive written report of the findings, including all scores. I am not permitted to provide copies of tests due to laws protecting this information. Patient Rights HIPAA provides you with several new or expanded rights with regards 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 our policies and procedures recorded in your records; and the right to a paper copy of this agreement and the Notice form on our website and at our office. I am happy to discuss any of these rights with you. Minors & Parents For clients who are under 18 years of age who are not emancipated, their parents are allowed by law to examine their child’s treatment records unless I believe that doing so would endanger the child or we agree otherwise. If at any point during our work together, I feel that the child is in danger or is a danger to someone else, I will notify the parents of our concern. Professional Fees & Payment Clients are required to pay all fess in full at the time service is rendered unless other arrangements have been made with your psychologist. Fees for comprehensive evaluations are calculated based on a rate of $280.00 per 60-minute assessment hour. The time includes total number of in-person testing hours (typically 5-8), scoring and report writing (typically 2.5 hours), and feedback conference (typically 1.5 hours). Total cost for a comprehensive evaluation generally falls between $2800 - $3300. Any necessary school conferences, phone consultations or observations may be additional costs based on the hourly fee. § In some circumstances and when discussed in advance, I must receive a $300 reservation fee before testing is scheduled. § A payment of one-half of the total testing amount is due on the first day of testing. § The remaining balance is due at the final feedback conference. Fees must be paid before the final report is delivered. Payments are generally accepted in the form of cash, check, or major credit cards. Please make checks payable to the Learning Assessment Center, LLC. All returned checks will incur a $38.00 returned check fee. Once a check payment has been returned for insufficient funds, payment will only be accepted by a guaranteed form of payment such as cash or a cashier’s check. Late payments are subject to finance charges. Overdue accounts of more than 60 days may be turned over to collections to obtain payment. When accounts are turned over to collections, your name, date of services, and account balance will be shared. No information related to your (your child’s) treatment will be revealed. I acknowledge the receipt of Learning Assessment Center’s Office Policies and Agreement for Psychological Services, and I understand and agree to comply with these policies. I understand that these policies will always be available to me on the Learning Assessment Center, LLC website, but that I may always request a hard copy if I am unable to access them. I also acknowledge the receipt of the HIPAA GEORGIA PRIVACY NOTICE for my review. I understand that the HIPAA form will remain available on the Learning Assessment Center’s website but that I may always request a hard copy if I am unable to access it. Name of Client Date of Birth Signature of Client/Legal Guardian Date Signature of Minor Child (If Appropriate) Date

LIMITS ON CONFIDENTIALITY. The law protects the privacy of all communications between a patient and a psychotherapistPsychologist. In most situations, I can only release information about your treatment to others if you sign a written authorization Authorization form that meets certain legal requirements imposed by HIPAA. There are other situations that require only that you provide written, advance consent. Your signature on this Agreement provides consent for those activities, as follows: • 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 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 important to our work together. I will note all consultations in your Clinical Record (which is called “PHI” in my Notice of PsychotherapistPsychologist’s Policies and Practices to Protect the Privacy of Your Health Information). • You should be aware that I practice with other independent practitioners who also provide mental health professionals and that I employ administrative staffservices. In most some cases, I need to share protected information with these individuals for both clinical and administrative purposes, such as scheduling, billing, answering service 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 my permission. • I also have the permission of a contract with a billing service. As required by HIPAA, I have a formal business associate contract with this business, in which it promises to maintain the confidentiality of this data except as specifically allowed in the contract or otherwise required by law. If you wish, I can provide you the name of this organization and/or a blank copy of this contract. I also will ask for your permission before having the billing service contact youprofessional 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 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 court proceeding and a request is made for information concerning my professional servicesyour diagnosis and treatment, such information is protected by the psychotherapistPsychologist-patient privilege law. I cannot provide any information without your (or your legal representative’s) written authorization, or a court order, or a subpoena of which you have been officially notified and failed to inform me that you are opposing the subpoena. 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 required to provide it for them. • If a patient files a complaint or lawsuit against me, I may disclose relevant information regarding that patient in order to defend myself. • If a patient files a worker’s compensation claim, information that is directly related to that claim I must, upon appropriate request, be provided provide a copy of the patient’s record to the Workers’ Compensation Commission. appropriate regulatory agency or the patient’s employer 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 reasonable cause to know or suspect that a child has been abused or neglected, may be subjected to abuse or has been neglect or observe a victim of sexual child being subjected to conditions or circumstances that would reasonably result in abuse by another childor neglect, the law requires that I file a report with the Department for Children, Youth and Familiesappropriate regulatory agency. Once such a report is filed, I may be required to provide additional information. § § If I have reasonable cause to suspect that an elderly or disabled adult presents a likelihood of suffering serious physical harm and is in need of protective services, the law requires that I file a report with the appropriate regulatory agency. Once such a report is filed, I may be required to provide additional information. § If I believe that it is necessary to disclose information to protect against a clear and substantial risk of imminent serious harm being inflicted by the patient presents a risk to a person on him/herself or his/her familyanother person, I may be required to take protective action. These actions including warning may include, and/or initiating hospitalization and/or contacting the potential victim(s)victim, contacting and/or the police, or seeking hospitalization of police and/or the patient’s family. 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. While this written summary of exceptions to confidentiality should prove helpful in informing you about potential problems, it is important that we discuss any questions or concerns that you may have 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, I keep Protected Health Information about you in two sets of professional records. One set constitutes your Clinical Record. It includes information about your reasons for seeking therapy, a description of the ways in which your problem impacts on your life, your diagnosis, the goals that we set for treatment, your progress towards those goals, your medical and social history, your treatment history, any past treatment records that I receive from other providers, reports of any professional consultations, your billing records, and any reports that have been sent to anyone, including reports to your insurance carrier. Except in the unusual circumstance where disclosure is reasonably likely to endanger you and/or others or when another individual (other than another health care provider) is referenced and I believe disclosing that information puts the other person at risk of substantial harm, 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 will be charging a copying fee. The exceptions to this policy are contained in the attached Notice Form. If I refuse your request for access to your Clinical Records, you have a right of review, 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 providing you with the best treatment. While the contents of Psychotherapy Notes vary from client to client, they can include the contents of our conversations, my analysis of those conversations, and how they impact on your therapy. They also contain particularly sensitive information that you may reveal to me that is not required to be included in your Clinical Record. 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 or court order. 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 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. BILLING AND PAYMENTS You will be expected to pay for each session at the time it is held. 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.] INSURANCE REIMBURSEMENT You may choose to use your health insurance to cover your treatment costs. There are some specific issues you need to consider in making this decision. 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 patients 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. 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. XXXXXXXX XXXXXX, PH.D. INFORMED CONSENT & PSYCHOLOGIST-PATIENT SERVICES AGREEMENT YOUR SIGNATURE BELOW INDICATES THAT YOU HAVE READ THIS AGREEMENT AND AGREE TO ITS TERMS DURING OUR PROFESSIONAL RELATIONSHIP. IT ALSO SERVES AS AN ACKNOWLEDGEMENT THAT YOU HAVE RECEIVED THE HIPAA NOTICE FORM DESCRIBED ABOVE. PATIENT SIGNATURE DATE SIGNATURE OF PARENT/GUARDIAN DATE

LIMITS ON CONFIDENTIALITY. The law protects the privacy of all communications between a patient and a psychotherapistclinician. In most situations, I can only release information about your treatment to others if you sign a written authorization form that meets certain legal requirements imposed by HIPAA. There are other situations that require only that you provide written, advance consent. Your signature on this Agreement contract provides consent for those activities, as follows: • 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 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 important to our work together. I will note all consultations in your Clinical Record (which is called “PHI” in my Notice of PsychotherapistPsychologist’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, 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 my permissionthe permission of a professional staff member. • I also At times we occasionally have a contract contracts with a billing serviceother mental health providers. As required by HIPAA, I have a formal business associate affiliate contract with this businessthese persons, in which it promises they promise to maintain the confidentiality of this data except as specifically allowed in the contract or otherwise required by law. If you wish, I can provide you with the name names of this organization these individuals and/or a blank copy of this contract. There are some situations where I also will ask for am permitted or required to disclose information without either your permission before having the billing service contact you. • Disclosures required by health insurers consent or to collect overdue fees are discussed elsewhere in this Agreement. Authorization: • 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: protection • If you are involved in a court proceeding and a request is made for information concerning my the professional servicesservices that I provided you and/or the records thereof, such information is protected by the psychotherapistclinician-patient privilege law. I cannot provide any information without your (or your legal representative’s) written authorization, or a court order, or a subpoena of which you have been officially notified and failed to inform me that you are opposing the subpoena. 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 required to provide it for themit. • If a patient files a complaint or lawsuit against me, I may disclose relevant information regarding that patient in order to defend myself. • If a patient files a worker’s compensation claim, information that is directly related to that claim must, upon appropriate request, be provided to the Workers’ Compensation 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 patient’s treatment. These situations are unusual in my practice. § § If I suspect or have a good faith reason to know or suspect believe that a child any incapacitated adult has been abused or neglectedsubjected to abuse, neglect, self-neglect, or has been a victim of sexual abuse by another childexploitation, or is living in hazardous conditions, the law requires that I file a report with the appropriate governmental agency, usually the Department for Children, Youth of Health and FamiliesHuman Services. Once such a report is filed, I may be required to provide additional information. § information § If I believe that a patient presents communicates a risk serious threat of physical violence against a clearly identified or reasonably identifiable victim or victims, or a serious threat of substantial damage to a person or his/her familyreal property, I may be required to take protective actions. These actions including warning may include notifying the potential victim(s)victim, contacting the police, or seeking involuntary hospitalization of for 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. While this written summary of exceptions to confidentiality should prove helpful in informing you about potential problems, it is important that we discuss any questions or concerns that you may have 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. 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. 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. 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, AND THAT YOU HAVE HAD AN OPPORTUNITY TO RAISE ANY QUESTIONS OR CONCERNS ABOUT THIS AGREEMENT WITH YOUR THERAPIST AT YOUR FIRST APPOINTMENT. __________________________________________ _____________________ Patient Date

LIMITS ON CONFIDENTIALITY. The law protects the privacy of all communications between a patient and a psychotherapisttherapist. In most situations, I we can only release information about your treatment to others if you sign a written authorization Authorization form that meets certain legal requirements imposed by HIPAA. There are other situations that require only that you provide written, advance consent. Your signature on this Agreement provides consent for those activities, as follows: • I  Your therapist may 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. 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 important to our work togetherthe therapeutic process. I We will note all consultations in your Clinical Record (which is called “PHI” in my Notice of Psychotherapist’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 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 my permission. • I also have a contract with a billing service. As required by HIPAA, I have a formal business associate contract with this business, in which it promises to maintain the confidentiality of this data except as specifically allowed in the contract or otherwise required by law. If you wish, I can provide you the name of this organization and/or a blank copy of this contract. I also will ask for your permission before having the billing service contact you. • Disclosures required by health insurers or to collect overdue fees are discussed elsewhere in this Agreement. •  If a patient client seriously threatens to harm himself/herself, I the therapist may be obligated 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 client to the client or others, or there is a probability of immediate mental or emotional injury to the client. There are some situations where I am the therapist is 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 my professional servicesyour diagnosis and treatment, such information is protected by the psychotherapistlicensed professional counselor-patient privilege law. I Your therapist cannot provide any information without your (or your legal representative’s) written authorization, or a court order, or a subpoena of which you have been officially notified and failed to inform me that you are opposing the subpoena. 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 your therapist to disclose information. • If a government agency is requesting the information for health oversight activities, I we may be required to provide it for them. •  If a patient client files a complaint or lawsuit against metheir therapist, I the therapist may disclose relevant information regarding that patient in order to defend myselfthem self. •  If a patient files a worker’s compensation claim, information that is directly related to that claim the therapist must, upon appropriate request, be provided provide records relating to the Workers’ Compensation Commissiontreatment or hospitalization for which compensation is being sought. There are some situations in which I we am legally obligated to take actions, which I we believe are necessary to attempt to protect others from harm and I we may have to reveal some information about a patient’s treatment. These situations are unusual in my this practice. §  If I have reason the therapist has cause to know or suspect believe that a child under 18 has been or may be abused or neglectedneglected (including physical injury, substantial threat of harm, mental or emotional injury, or has been any kind of sexual contact or conduct), or that a child is a victim of a sexual abuse by another childoffense, or that an elderly or disabled person is in a state of abuse, neglect or exploitation, the law requires that I file we make a report with to the appropriate governmental agency, usually the Department for Children, Youth of Protective and FamiliesRegulatory Services. Once such a report is filed, I we may be required to provide additional information. §  If I believe a therapist determines that there is a probability that the client will inflict imminent physical injury on another, or that the patient presents a risk to a person will inflict imminent physical, mental or hisemotional harm upon him/her familyherself, I we may be required to take protective actions including warning the potential victim(s), contacting the police, action by disclosing information to medical or seeking law enforcement personnel or by securing hospitalization of the patient. If such a situation arises, I we will make every effort to fully discuss it with you before taking any action and I will limit my any disclosure to what is necessary. While this written summary of exceptions to confidentiality should prove helpful in informing you about potential problems, it is important that we discuss any questions or concerns that you may have 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 ON CONFIDENTIALITY. The law protects the privacy of all communications between a patient and a psychotherapistpsychologist. In most situations, I we can only release information about your treatment to others if you sign a written authorization Authorization form that meets certain legal requirements imposed by HIPAA. There are other situations that require only that you provide written, advance consent. Your signature on this Agreement provides consent for those activities, as follows: • I We may occasionally find it helpful to consult other health and mental health professionals about a case. During a consultationsuch consultations, 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 important to our work together. I We will note all consultations in your Clinical Record (which is called “PHI” in my the “Notice of PsychotherapistPsychologist’s Policies and Practices to Protect the Privacy of Your Health Information”). • You should be aware that I practice MPA also has contracts with other mental health professionals and that I employ administrative staff. In most casesa typist, I need to share protected with an information with these individuals for both clinical and administrative purposes, such as scheduling, billingtechnology specialist, 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 my permission. • I also have a contract with a billing servicecertified public accountant. As required by HIPAA, I we have a formal business associate contract with this businessthese businesses, in which it promises they promise to maintain the confidentiality of this data except as specifically allowed in the contract or otherwise required by law. If you wish, I we can provide you with the name names of this organization these organizations and/or a blank copy of this contract. I also will ask for your permission before having the billing service contact you. • Disclosures required by health insurers or to collect overdue fees are discussed elsewhere in this Agreement. • If we believe that a patient threatens presents an imminent danger to harm himselfhis/herselfher health or safety, I we 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 we are permitted or required to disclose information without either your consent or Authorizationauthorization: • If you are involved in a court proceeding and a request is made for information concerning my the professional servicesservices that we provided you, such information is protected by the psychotherapistpsychologist-patient privilege law. I We cannot provide any information without your (or your legal representative’s) written authorization, or a court order, or a subpoena of which you have been officially notified and failed to inform me that you are opposing the subpoena. 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 us to disclose information. • If a government agency is requesting the information for health oversight activities, I we may be required to provide it for them. • If a patient files a complaint or lawsuit against meMPA, I MPA may disclose relevant information regarding that patient in order to defend myselfitself. • If a patient files a worker’s compensation claim, information that is directly related to that claim and our services are being compensated through workers compensation benefits, we must, upon appropriate request, be provided provide a copy of the patient’s record to the Workers’ Compensation patient’s employer or the North Carolina Industrial Commission. There are some situations in which I am we are legally obligated to take actions, which I we believe are necessary to attempt to protect others from harm and I we may have to reveal some information about a patient’s treatment. These situations are extremely unusual in my our practice. § • If I we have reason cause to know or suspect that a child has been under 18 is abused or neglected, or has been if we have reasonable cause to believe that a victim disabled adult is in need of sexual abuse by another childprotective services, the law requires that I we file a report with the Department for Children, Youth and FamiliesCounty Director of Social Services. Once such a report is filed, I we may be required to provide additional information. § • If I we believe that a patient presents a risk an imminent danger to a person or his/her familythe health and safety of another, I we may be required to disclose information in order to take protective actions actions, including initiating hospitalization, warning the potential victim(s)victim, contacting if identifiable, and/or calling the police, or seeking hospitalization of the patient. If such a situation arises, I we will make every effort to fully discuss it with you before taking any action and I we will limit my our disclosure to what is necessary. While this written summary of exceptions to confidentiality should prove helpful in informing you about potential problems, it is important that we discuss any questions or concerns that you may have 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. PROFESSIONAL RECORDS You should be aware that, pursuant to HIPAA, we 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, a description of the ways in which your problem impacts on your life, your diagnosis, the goals that we set for treatment, your progress towards those goals, your medical and social history, your treatment history, any past treatment records that I receive from other providers, reports of any professional consultations, your billing records, and any reports that have been sent to anyone, including reports to your insurance carrier. Except in unusual circumstances that involve danger to yourself and/or others or if the record makes reference to another person (unless such other person is a health care 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. However, 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 reasonable copying fee. 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, which we will discuss with you upon request. In addition, we may also keep a set of 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 vary from client to client, they can include the contents of our meetings, our analysis of those meetings, and how they impact on your therapy. They also contain particularly sensitive information that you may reveal that is not required to be included in your Clinical Record. These Psychotherapy Notes may be 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 protected health information. These rights include requesting that your record be amended; 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 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 often MPA’s policy to request an agreement from parents that they consent to give up their access to your records. If they agree, we will provide parents only with general information about the progress of the child’s treatment, and his/her attendance at scheduled sessions. If the parent is responsible for payment of sessions and other professional fees, we will communicate with parents as needed regarding financial matters. 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 child, if possible, and do our 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. If your account has not been paid for more than 60 days and arrangements for payment have not been agreed upon, MPA has 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 released regarding a patient’s treatment is his/her name, the nature of services provided, and the amount due. If such legal action is necessary, 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. However, you (not your insurance company) are responsible for full payment of fees. It is 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. 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. Xxxxxxx Xxxxxx, Ph.D.’s services are covered under many health insurance policies. He does not, however, currently participate in any managed care programs. His services are considered “out of network” and you are expected to pay each office visit and file for reimbursement. Insurance benefits vary considerably. Therefore, you are strongly encouraged to review your own POLICY CAREFULLY REGARDING COVERAGE AND LIMITATIONS AND TO CONTACT YOUR INSURANCE CARRIER OR YOUR COMPANY’S HUMAN RESOURCES OR PERSONNEL DEPARTMENT WITH ANY QUESTIONS. Your statement, which will be provided to you at the time of service, contains all of the information necessary for insurance claims. You may simply submit the statement to your insurance carrier in order to seek reimbursement. You should also be aware that your contract with your health insurance company may require that your therapist provide it with information relevant to the services provided 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 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 on computer. Though all insurance companies claim to keep such information confidential, we 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. We will provide you with a copy of any report submitted, if you request it. By signing this Agreement, you agree that MPA can provide requested information to your carrier. Fees are due in full at each session. We accept cash, checks, debit cards, credit cards, health savings account cards and flexible spending account cards. Please make checks payable to “Mendel Psychological Associates.” There is a $25.00 service charge for any returned checks. Fees will be reviewed periodically and may be increased in the future. Fees will be increased no more than once during any year.

LIMITS ON CONFIDENTIALITY. The law protects the privacy of all communications between a patient and a psychotherapistPsychologist. In most situations, I can only release information about your treatment to others if you sign a written authorization Authorization form that meets certain legal requirements imposed by HIPAA. There are other situations that require only that you provide written, advance consent. Your signature on this Agreement provides consent for those activities, as follows: • 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 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 important to our work together. I will note all consultations in your Clinical Record (which is called “PHI” in my Notice of PsychotherapistPsychologist’s Policies and Practices to Protect the Privacy of Your Health Information). • You should be aware that I practice with other independent practitioners who also provide mental health professionals and that I employ administrative staffservices. In most some cases, I need to share protected information with these individuals for both clinical and administrative purposes, such as scheduling, billing, answering service 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 my permission. • I also have the permission of a contract with a billing service. As required by HIPAA, I have a formal business associate contract with this business, in which it promises to maintain the confidentiality of this data except as specifically allowed in the contract or otherwise required by law. If you wish, I can provide you the name of this organization and/or a blank copy of this contract. I also will ask for your permission before having the billing service contact youprofessional 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 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 court proceeding and a request is made for information concerning my professional servicesyour diagnosis and treatment, such information is protected by the psychotherapistPsychologist-patient privilege law. I cannot provide any information without your (or your legal representative’s) written authorization, or a court order, or a subpoena of which you have been officially notified and failed to inform me that you are opposing the subpoena. 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 required to provide it for them. • If a patient files a complaint or lawsuit against me, I may disclose relevant information regarding that patient in order to defend myself. • If a patient files a worker’s compensation claim, information that is directly related to that claim I must, upon appropriate request, be provided provide a copy of the patient’s record to the Workers’ Compensation Commission. appropriate regulatory agency or the patient’s employer 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 reasonable cause to know or suspect that a child has been abused or neglected, may be subjected to abuse or has been neglect or observe a victim of sexual child being subjected to conditions or circumstances that would reasonably result in abuse by another childor neglect, the law requires that I file a report with the Department for Children, Youth and Familiesappropriate regulatory agency. Once such a report is filed, I may be required to provide additional information. § § If I have reasonable cause to suspect that an elderly or disabled adult presents a likelihood of suffering serious physical harm and is in need of protective services, the law requires that I file a report with the appropriate regulatory agency. Once such a report is filed, I may be required to provide additional information. § If I believe that it is necessary to disclose information to protect against a clear and substantial risk of imminent serious harm being inflicted by the patient presents a risk to a person on him/herself or his/her familyanother person, I may be required to take protective action. These actions including warning may include, and/or initiating hospitalization and/or contacting the potential victim(s)victim, contacting and/or the police, or seeking hospitalization of police and/or the patient’s family. 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. While this written summary of exceptions to confidentiality should prove helpful in informing you about potential problems, it is important that we discuss any questions or concerns that you may have 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, I keep Protected Health Information about you in two sets of professional records. One set constitutes your Clinical Record. It includes information about your reasons for seeking therapy, a description of the ways in which your problem impacts on your life, your diagnosis, the goals that we set for treatment, your progress towards those goals, your medical and social history, your treatment history, any past treatment records that I receive from other providers, reports of any professional consultations, your billing records, and any reports that have been sent to anyone, including reports to your insurance carrier. Except in the unusual circumstance where disclosure is reasonably likely to endanger you and/or others or when another individual (other than another health care provider) is referenced and I believe disclosing that information puts the other person at risk of substantial harm, 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 will be charging a copying fee. The exceptions to this policy are contained in the attached Notice Form. If I refuse your request for access to your Clinical Records, you have a right of review, 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 providing you with the best treatment. While the contents of Psychotherapy Notes vary from client to client, they can include the contents of our conversations, my analysis of those conversations, and how they impact on your therapy. They also contain particularly sensitive information that you may reveal to me that is not required to be included in your Clinical Record. 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 or court order. 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 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. BILLING AND PAYMENTS You will be expected to pay for each session at the time it is held. 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.] INSURANCE REIMBURSEMENT You may choose to use your health insurance to cover your treatment costs. There are some specific issues you need to consider in making this decision. 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 patients 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. 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. XXXXXX XXXXXX, PH.D. INFORMED CONSENT & PSYCHOLOGIST-PATIENT SERVICES AGREEMENT YOUR SIGNATURE BELOW INDICATES THAT YOU HAVE READ THIS AGREEMENT AND AGREE TO ITS TERMS DURING OUR PROFESSIONAL RELATIONSHIP. IT ALSO SERVES AS AN ACKNOWLEDGEMENT THAT YOU HAVE RECEIVED THE HIPAA NOTICE FORM DESCRIBED ABOVE. PATIENT SIGNATURE DATE SIGNATURE OF PARENT/GUARDIAN DATE

LIMITS ON CONFIDENTIALITY. The law protects the privacy of all communications between a patient and a psychotherapistpsychologist. In most situations, I can only release information about your treatment to others if you sign a written authorization Authorization form that meets certain legal requirements imposed by HIPAA. This Authorization is on my website as well. There are other situations that require only that you provide written, advance consent. Your signature on this Agreement provides consent for those activities, as follows: • 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 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 important to our work together. I will note all consultations in your Clinical Record (which is called “PHI” in my Notice of Psychotherapist’s Policies and Practices to Protect the Privacy of Your Health Information)Record. • You should be aware that I practice with other mental health professionals and that I occasionally 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, accounting, 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 signed an agreement not to release any information outside of the practice without my specific permission. • I also have a contract contracts with a billing serviceservices, testing services, and other businesses used to run my practice. As required by HIPAA, I have a formal business associate contract with this businessthese businesses, in which it promises they promise to maintain the confidentiality of this data except as specifically allowed in the contract or otherwise required by law. If you wish, I can provide you with the name names of this organization these organizations and/or a blank copy of this contract. I also will ask for your permission before having the billing service contact you. • 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 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 court Court proceeding and a request is made for information concerning my professional services, such information is protected by the psychotherapistpsychologist-patient privilege law. I cannot provide any information without your (or your legal representative’s) written authorization, or a court Court order, or a subpoena of which you have been officially notified and failed to inform me that you are opposing the subpoena. If you are involved in or contemplating litigation, you should consult with your attorney to determine whether a court 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 am required to provide it for them. • If a patient files a complaint or lawsuit against me, I may disclose relevant information regarding that patient in order to defend myself. • If a patient files a worker’s compensation claim, information that is directly related I am required to that claim must, upon appropriate request, be provided submit a report to the Workers’ Compensation CommissionDivision. • 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 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 reasonable cause to know or suspect that a child has been abused subjected to abuse or neglected, neglect or has been if I have observed a victim of sexual child being subjected to circumstances or conditions that would reasonably result in abuse by another childor neglect, the law requires that I file a report with the Department for Children, Youth and Familiesappropriate governmental agency. Once such a report is filed, I may be required to provide additional information. § • If I have reasonable cause to believe that an at-risk adult has been or is at imminent risk of being mistreated, self- neglected, or financially exploited, the law requires that I file a patient presents report with the appropriate governmental agency. Once such a risk to a person or his/her familyreport is filed, I may be required to provide additional information • If a patient communicates a serious threat of imminent physical violence against a specific person or persons, I must make an effort to notify such person and notify an appropriate law enforcement agency; and/or take protective actions other appropriate action including warning the potential victim(s), contacting the police, or seeking hospitalization of the patient. If any 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. While this written summary of exceptions to confidentiality should prove helpful in informing you about potential problems, it is important that we discuss any questions or concerns that you may have 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, you may need to get formal legal advice advice. PROFESSIONAL RECORDS You should be aware that, pursuant to HIPAA, I keep Protected Health Information about you in two sets of professional records. One set constitutes your Clinical Record. It includes information about your reasons for seeking therapy, a description of the ways in which your problem impacts on your life, your diagnosis, the goals that we set for treatment, your progress towards those goals, your medical and social history, your treatment history, any past treatment records that I receive from other providers, reports of any professional consultations, your billing records, all communications to/from you, and any reports that have been sent to anyone, including reports to your insurance carrier. Except in unusual circumstances, you may examine and/or receive a copy of your Clinical Record, if you request it in writing. In most situations, I am allowed to charge a copying fee of $2.50 per page (and for certain other expenses). The exceptions to this policy are contained in the attached Notice Form. If I refuse your request for access to your Clinical Record, you have a right of review, which I will discuss with you upon request. In addition, I also keep a set of Confidential Psychotherapy Notes. These Confidential Psychotherapy Notes are for my own use and are designed to assist me in providing you with the best treatment. While the contents of Confidential Psychotherapy Notes vary from client to client, they can include the contents of our conversations, my analysis of those conversations, and how they impact on your therapy. They also contain particularly sensitive information that you may reveal to me that is not required to be neededincluded in your Clinical Record and/or information that has been supplied to me confidentially by others. These Confidential 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. Insurance companies cannot require your authorization as a condition of coverage nor penalize you in any way for your refusal to provide it. You should know that according to Colorado State Law, I keep a full set of records for seven (7) years after the date of termination, or date of last contact, whichever is later (though there is an exception: When the client is a juvenile, I will keep the record for a period of seven (7) years commencing either upon the last day of treatment, or for seven (7) years after the juvenile reaches eighteen (18) years of age, whichever date comes later. I cannot guarantee that a copy of your record will exist after this record keeping period.

LIMITS ON CONFIDENTIALITY. The law protects the privacy of all communications between a patient and a psychotherapistpsychologist. In most situations, I the therapist can only release information about your treatment to others if you sign a written authorization Authorization form that meets certain legal requirements imposed by HIPAAHIPAA and/or Illinois law. There are other situations that require only that you provide writtenHowever, advance consent. Your signature on this Agreement provides consent for those activitiesin the following situations, as followsno authorization is required: • I The therapist may occasionally find it helpful to consult other health and mental health professionals about a case. During a consultation, I the 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 object• From time to time, I will not tell you about these consultations unless I feel that it is important to our work together. I will note all consultations in your Clinical Record (which is called “PHI” in my Notice of Psychotherapist’s Policies and Practices to Protect the Privacy of Your Health Information). • You should be aware that I practice therapist may have contracts with other mental health professionals and that I employ administrative staff. In most cases, I need vendors to share protected information assist with these individuals for both clinical and administrative purposeshis/her practice, 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 my permission. • I also have a contract with a billing service. As required by HIPAA, I the therapist will have a formal business associate contract with this businessthis/these business(es), in which it promises it/they promise to maintain the confidentiality of this data except as specifically allowed in the contract or otherwise required by law. If you wish, I the therapist can provide you with the name names of this organization these organizations and/or a blank copy of this contract. I also will ask for your permission before having the billing service contact you. • 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 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 court proceeding and a request is made for information concerning my professional servicesyour diagnosis and treatment, such information is protected by the psychotherapistpsychologist-patient privilege law. I cannot provide any , but the therapist may be required to disclose information without your (or your legal representative’s) written authorization, or in the case of a court order, or a subpoena of which you have been officially notified and failed to inform me that you are opposing the subpoena. 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 the therapist to disclose information. • If a government agency is requesting the information for health oversight activities, I the therapist may be required to provide it for them. • If a patient files a complaint or lawsuit against methe therapist, I the therapist may disclose relevant information regarding that patient in order to defend myselfhimself/herself. • If a patient files you file a worker’s compensation claim, information that and the therapist is directly related to that claim rendering treatment or services in accordance with the provisions of Illinois Workers’ Compensation law, the therapist must, upon appropriate request, be provided provide a copy of your record to the Workers’ Compensation Commissionyour employer or his/her appropriate designee. There are some situations in which I am the therapist is legally obligated to take actions, which I actions that the therapist believe are necessary to attempt to protect others from harm and I harm. The therapist may have to reveal some information about a patient’s treatment. These situations are unusual in my his/her practice. § ▪ If I have reason the therapist has reasonable cause to know or suspect believe that a child has been under 18 known to the therapist in his/her professional capacity may be an abused child or neglected, or has been a victim of sexual abuse by another neglected child, the law requires that I the therapist file a report with the local office of the Department for Children, Youth of Children and FamiliesFamily Services. Once such a report is filed, I the therapist may be required to provide additional information. § ▪ If I the therapist has reason to believe that an adult over the age of 60 living in a patient presents domestic situation has been abused or neglected in the preceding 12 months, the law requires that the therapist file a risk report with the agency designated to receive such reports by the Department of Aging. Once such a person or his/her familyreport is filed, I the therapist may be required to provide additional information. ▪ If you have made a specific threat of violence against another or if the therapist believes that you present a clear, imminent risk of serious physical harm to another, the therapist may be required disclose information in order to take protective actions. These actions including warning may include notifying the potential victim(s)victim, contacting the police, or seeking your hospitalization. ▪ If the therapist believes that you present a clear, imminent risk of serious physical or mental injury or death to yourself, the therapist may be required to disclose information in order to take protective actions. These actions may include your hospitalization of the patientor contacting family members or others who can assist in protecting you. If such a situation arises, I the therapist will make every effort to fully discuss it with you before taking any action and I the therapist will limit my his/her disclosure to what is necessary. While this written summary of exceptions to confidentiality should prove helpful in informing you about potential problems, it is important that we discuss any questions or concerns that you may have now or in the future. The laws governing confidentiality can be quite complex, and I am the therapist is not an attorney. In situations where specific advice is required, formal legal advice may be needed.

LIMITS ON CONFIDENTIALITY. The law protects the privacy of all communications between a patient and a psychotherapistpsychologist. In most situations, I can only release information about your treatment to others if you sign a written authorization form Authorization. This Authorization will remain in effect for a length of time you determine. You may revoke the Authorization at any time, unless I have taken action in reliance on it. However, there are some disclosures that meets certain legal requirements imposed by HIPAA. There are other situations that do not require only that you provide written, advance consent. Your signature on this Agreement provides consent for those activitiesyour Authorization, as follows: • 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 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 important to our work together. I will note all consultations in your Clinical Record (which is called “PHI” in my Notice of Psychotherapist’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, 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 my permissionthe permission of a professional staff member. • I also have a contract contracts with a billing servicebusinesses such as bookkeepers, accountants and computer consultants. As required by HIPAA, I have a formal business associate contract with this business, in which it promises These businesses agree to maintain the confidentiality of this data except as specifically allowed in the contract or otherwise required by law. If you wish, I can provide you the name of this organization and/or a blank copy of this contract. I also will ask for your permission before having the billing service contact you. • 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 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 court proceeding and a request is made for information concerning my professional servicesyour diagnosis and treatment, such information is protected by the psychotherapistpsychologist-patient privilege law. I cannot provide any information without your (or your legal representative’s) written authorization, or a court order, or a subpoena of which you have been officially notified and failed to inform me that you are opposing the subpoena. 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 required to provide it for them. • If a patient files a complaint or lawsuit against me, I may disclose relevant information regarding that patient in order to defend myself. • If a patient files a worker’s compensation claim, information that is directly related to that claim I must, upon appropriate request, be provided provide a copy of the patient’s record to the Workers’ Compensation CommissionD.C. Office of Hearings and Adjudications, the patient’s employer or insurer. There are some situations in which I am legally obligated to take actions, which because I believe these actions are necessary to attempt to protect others from harm and harm. In this process, I may have to reveal some information about a patient’s treatment. These situations are unusual in my practice. If such a situation arises, I will make every effort to discuss it fully with you before taking any action and I will limit my disclosure to what is necessary. § If I know or have reason to know or suspect that a child has been or is in immediate danger of being mentally or physically abused or neglected, or has been a victim of sexual abuse by another child, the law requires that I file a report with the appropriate governmental agency, usually the Child Protective Services Division of the Department for Children, Youth and Familiesof Human Services. Once such a report is filed, I may be required to provide additional information. § If I have substantial cause to believe that an adult patient is in need of protective services because of abuse, neglect or exploitation by someone, the law requires that I file a report with the appropriate governmental agency, usually the Department of Human Services. Once such a report is filed, I may be required to provide additional information. § In an emergency, if I believe that a patient presents a substantial risk of imminent and serious injury to a person or hishim/her familyherself, I may be required to take protective actions, including notifying individuals who can protect the patient or initiating emergency hospitalization. § If I believe that a patient presents a substantial risk of imminent and serious injury to another individual, I may be required to take protective actions. These actions including warning may include notifying the potential victim(s)victim, contacting the police, or seeking hospitalization of for the patient. If such a situation arisesIn all other situations, I will make every effort to fully discuss it with ask you for an advance Authorization before taking disclosing any action and I will limit my disclosure to what is necessaryinformation about you. While this written summary of exceptions to confidentiality should prove helpful in informing you about potential problems, it is important that we discuss any questions or concerns that you may have 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 I keep information about you and our sessions. Your Clinical Record may include information about your reasons for seeking therapy, a description of the ways in which your problem impacts on your life, your diagnosis, the goals that we set for treatment, your progress towards those goals, your medical and social history, your treatment history, any past treatment records that I receive from other providers, reports of any professional consultations, your billing records, and any reports that have been sent to anyone, including reports to your insurance carrier. Except in unusual circumstances that involve a substantial risk of imminent psychological impairment or imminent serious physical danger to yourself and 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 forwarded to another mental health professional so you can discuss the contents. In most situations, I am allowed to charge a copying, postage, and handling fee. If I refuse your request for access to your records, you have a right of review, which I will discuss with you upon request. In addition, I may also keep a separate 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 conversations, my analysis of those conversations, and how they affect 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 and 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 or penalize you in any way for your refusal to provide it. In testing, the report is the clinical record. The report summarizes the client’s background information, lists and describes the test results, and provides our conclusions and recommendations. We cannot release raw data or test protocols because of copyright laws and the confidentiality of test materials. MINORS & PARENTS Psychologists can provide psychotherapy to minors age 14 and above without parental consent if the psychologist determines that the minor is knowingly and voluntarily seeking the services and that provision of the services is clinically indicated for the minor’s well being. These services can be provided for only 90 days, but can be continued if the psychologist redetermines that the services are still clinically indicated. Parents do not have access to records of this treatment. Patients under 18 years of age but who are over 14 and who are not emancipated and whose parents have consented to treatment should be aware that parents can review their records only with the written authorization of the patient. Children under 14, whose parents have consented to the treatment, should be aware that their parents can examine their treatment records unless I decide that such access is likely to injure the child, or we all agree otherwise. Because privacy in psychotherapy is often crucial to successful progress, particularly with teenagers, and because it is important for parents to have some information about their child’s treatment, it is usually my policy to request an agreement of both the parents and child about what information parents will receive about their child’s treatment. During treatment, I will provide parents only with general information about the progress of the child’s treatment and/or his/her attendance at scheduled sessions. When requested, 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.

LIMITS ON CONFIDENTIALITY. The law protects the privacy of all communications between a patient client and a psychotherapistpsychologist. In most situations, I can only release information about your treatment to others if you sign a written authorization Authorization form that meets certain legal requirements imposed by HIPAA. There are other situations that require only that you provide written, advance consent. Your signature on this Agreement provides consent for those activities, such as follows: • ● 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 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 important to our work together. I will note all consultations in your Clinical Record (which is called “PHI” in my Notice of Psychotherapist’s Policies and Practices to Protect the Privacy of Your Health Information)Record. • ● 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, 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 my permissionthe permission of a professional staff member. • I also have a contract with a billing service. As required by HIPAA, I have a formal business associate contract with this business, in which it promises to maintain the confidentiality of this data except as specifically allowed in the contract or otherwise required by law. If you wish, I can provide you the name of this organization and/or a blank copy of this contract. I also will ask for your permission before having the billing service contact you. • ● 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 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 Authorizationauthorization: • ● If you are involved in a court proceeding and a request is made for information concerning my the professional servicesservices I provided for you, such information is protected by the psychotherapistpsychologist-patient client privilege law. I cannot provide any information without your (or your legal representative’s) written authorization, or a court order, or a subpoena of which you have been officially notified and failed to inform me that you are opposing the subpoena. 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 agency, pursuant to their lawful authority, is requesting the information for health oversight activities, I may be required to provide it for them. • ● If a patient client files a complaint or lawsuit against me, I may disclose relevant information regarding that patient client in order to defend myself. • ● If a patient client files a worker’s workers compensation claim, information that is directly related to that claim I must, upon appropriate request, be provided disclose information related to the Workers’ Compensation Commissionclaim to appropriate individuals, which may include that client’s employer, the insurer or the Department of Labor and Industry. There are some situations in which I am legally obligated to take actions, which I believe are necessary to attempt to protect a client or others from harm and I may have to reveal some information about a patientclient’s treatment. These situations are unusual in my practice. § : ● If I know or have reason to know or suspect that believe a child has been is being neglected or physically or sexually abused or neglected, have been neglected or has been a victim of sexual abuse by another childphysically or sexually abused within the preceding three years, the law requires that I file a report immediately with the Department for Childrenappropriate government agency, Youth and Familiesusually the county Child Protection Services. Once such a report is filed, I may be required to provide additional information. § This law also includes reporting the use of illegal drugs during pregnancy. ● If I have reason to believe that a patient presents vulnerable adult is being or have been maltreated or if I have knowledge that a risk to vulnerable adult has sustained a person or his/her familyphysical injury which is not reasonably explained, the law requires that I file a report immediately with the appropriate government agency, usually an agency designated by the county. Once such a report is filed, I may be required to provide additional information. ● If I believe that you present a serious and specific threat of physical harm or violence to yourself or another person, I may be required to disclose information necessary to take protective actions. These actions including warning may include notifying the potential victim(s)victim, contacting your family or others who can help provide protection, contacting the police, or seeking hospitalization of the patientyour hospitalization. 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. While this written summary of exceptions to confidentiality should prove helpful in informing you about potential problems, it is important that we discuss any questions or concerns that you may have 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, 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 certain situations, I may charge a copying fee of 25 cents 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 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. I am 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. Because privacy in psychotherapy is often crucial to successful progress, particularly with teenagers, it is sometimes my 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, 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. YOUR SIGNATURE BELOW INDICATES THAT YOU HAVE READ THIS AGREEMENT AND AGREE TO ITS TERMS AND ALSO SERVES AS AN ACKNOWLEDGEMENT WHICH INCLUDES THE HIPAA NOTICE FORM AND THE PATIENT BILLS OF RIGHTS. Signature Date Print Name For Parents of Child Clients: I hereby give consent for my child to receive treatment at (Name) Moxie Incorporated. Signature Date Print Name Signature Date

LIMITS ON CONFIDENTIALITY. The law protects the privacy of all communications between a patient and a psychotherapistpsychologist. In most situations, I can only release information about your treatment to others if you sign a written authorization Authorization form that meets certain legal requirements imposed by HIPAA. There are other situations that require only that HIPAA and/or Maine law, or in some cases, if you provide writtenoral authorization. However, advance consent. Your signature on this Agreement provides consent for those activitiesin the following situations, as followsno authorization is required: • 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 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 important to our work together. I will note all consultations in your Clinical Record (which is called “PHI” in my Notice of Psychotherapist’s Policies and Practices to Protect the Privacy of Your Health Information). • You should be aware that I practice have contracts 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 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 my permission. • I also have a contract with a billing servicean accountant. As required by HIPAA, I have a formal business associate contract with this businessthis/these business(es), in which it promises it/they promise to maintain the confidentiality of this data except as specifically allowed in the contract or otherwise required by law. If you wish, I can provide you with the name names of this organization these organizations and/or a blank copy of this contract. I also will ask for your permission before having the billing service contact you. • 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 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 court proceeding and a request is made for information concerning my professional servicesyour diagnosis and treatment, such information is protected by the psychotherapistpsychologist-patient privilege law. I cannot provide any information without your (or your legal representative’s) written authorization, or a court order, or a subpoena of which you have been officially notified and failed to inform me that you are opposing the subpoena. 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 required to provide it for them. • If a patient files a complaint or lawsuit against me, I may disclose relevant information regarding that patient in order to defend myself. • If a patient files you have filed a worker’s compensation claim, information and I am being compensated for your treatment by your employer or its insurance company as a result that is directly related to that claim mustclaim, I must provide, upon appropriate request, be provided legally required reports and other information related to the Workers’ Compensation Commissionyour condition. 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 know or have reasonable cause to suspect that a child under 18 has been or is likely to be abused or neglected, neglected or that a vulnerable adult has been a victim of sexual abuse by another childabused, neglected or exploited and is incapacitated or dependent, the law requires that I file a report with the appropriate government agency, usually the Maine Department for Children, Youth and Familiesof Human Services. Once such a report is filed, I may be required to provide additional information. § ▪ If I believe determine that the patient poses a patient presents a risk direct threat of imminent harm to a person the health or hissafety of any individual, including himself/her familyherself, I may be required to disclose information in order to take protective action(s). These actions including warning may include notifying the potential victim(s)victim, contacting the police, or seeking hospitalization of for the patient, or contacting family members or others who can assist in providing protection. 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. While this written summary of exceptions to confidentiality should prove helpful in informing you about potential problems, it is important that we discuss any questions or concerns that you may have 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 that disclosure would physically endanger you and/or 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 forwarded to another mental health professional so you can discuss the contents. In most circumstances, I am allowed to charge a copying fee of $.20 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. You should be aware that I sometimes keep Personal Notes, as permitted by Maine law, and these notes are not available to you. 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 Patients and their parents should be aware that Maine law allows minor children to independently consent to and receive mental health treatment without parental consent and, in that situation, information about that treatment cannot be disclosed to anyone without the minor child’s agreement. I will also provide parents with a psychological assessment report 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 or unless you have insurance coverage that requires another arrangement. 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. INSURANCE REIMBURSEMENT I am not on any private health insurance plans. Once the assessment is completed, 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. You should also be aware that your contract with your health insurance company requires that you authorize me to provide it with information relevant to the services that I provide to you. If you are seeking reimbursement for services under your health insurance policy, you will be required to sign an authorization form that allows me to provide such information. 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. This may require an additional authorization. (If you refuse such authorization, the insurance company can deny your claims and you will be responsible for paying for services yourself.) 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. 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 Date

LIMITS ON CONFIDENTIALITY. The law protects the privacy of all communications between a patient and a psychotherapistpsychologist. In most situations, I we can only release information about your treatment you to others if you sign a written authorization Authorization form that meets certain legal requirements imposed by HIPAA. There are other situations that require only that HIPAA and/or Maine State law and Psychologist’ Ethics guidelines, or in some cases, if you provide writtenoral authorization. However, advance consent. Your signature on this Agreement provides consent for those activitiesin the following situations, as followsno authorization is required: • I may occasionally find it helpful NCMA staff members access patient information as appropriate to their job functions. Staff members and their roles are described on the website (xxx.XXXXxxxxx.xxx), with the exception of Xxxxxx Xxxxx, Ph.D., ABPP who is a forensic psychologist in private practice who manages some of our technology and communications systems. • For purposes of clinical consultation and professional development, we consult with other neuropsychologists and other health and mental health professionals about a caseas relevant. During a consultation, I make every effort to avoid revealing the identity of my patient. The other professionals These individuals 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 important to our work together. I will note all consultations in your Clinical Record (which is called “PHI” in my Notice of Psychotherapist’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 of the mental health professionals are bound by the same rules of confidentialitylaws, though ethical standards vary from profession to profession. All staff members have been given training about protecting your privacy and have agreed not Unless authorized to release any information outside of do otherwise (or unless the practice without my permission. • I also have a contract with a billing service. As required by HIPAA, I have a formal business associate contract with this business, in which it promises to maintain the confidentiality of this data except as specifically allowed in the contract or otherwise required by law. If you wish, I can provide you the name of this organization and/or a blank copy of this contract. I also will ask for your permission before having the billing service contact you. • Disclosures required by health insurers or to collect overdue fees are circumstance falls within another condition discussed elsewhere in within this Agreement), we exclude information that could easily identify the specific patient. We disclose only the information necessary to the consultation question. • If a patient threatens to harm himself/herself, I may be obligated to seek hospitalization for him/heryou are, 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 may become, involved in a court proceeding and a request is made for information concerning my professional servicesyour personal health information, such information is protected by the psychotherapistpsychologist-patient privilege law. I We cannot provide any information without your (or your legal representative’s) written authorization, the written authorization of your legal representative or a court order, or a subpoena of which you have been officially notified and failed to inform me that you are opposing order from the subpoenajudge. If you are involved in or contemplating considering litigation, you should consult with your attorney to determine whether a court judge would be likely to order me us to disclose informationinformation and if that would be in your best interest. • If a government agency is requesting the personal health information for health oversight or security activities, I we may be required to provide it for to them. (In our practice, this has never been requested without a signed release by the patient) • If a patient files a complaint or lawsuit against me, I may disclose relevant information regarding that patient in order to defend myself. • If a patient files you have filed a worker’s compensation claim, and we are being compensated for your assessment by your employer’s insurance company as a result of that claim, we must provide legally required reports and other information that is directly related to your condition. These are sent to your insurance adjuster and, if applicable, nurse case manager. We also will provide work notes that claim mustindicate more limited information as relevant for your work related needs, upon appropriate requestand this should be all that your insurance company gives to your employer, be provided but because we do not have control over what the insurance company chooses to share with your employer, you may want to inquire about their practices. The insurance company may at some point in your care request that we answer some specific questions about your condition, beyond our usual report, and we would provide that. • If a patient were to file a lawsuit or a complaint against NCMA, Xx. Xxxxxx, or any of the staff employed by or contracted to provide services for NCMA, we may disclose relevant personal health information about that patient to respond to the Workers’ Compensation Commissioncomplaint or lawsuit. (This has never happened in NCMA or Xx. Xxxxxx’x practice) • Disclosures to health insurers or other payer sources and to collect overdue fees are discussed elsewhere in this agreement. • There are some situations in circumstances under which I am we are legally obligated to take actions, which I believe are necessary actions in order to attempt to protect others people from harm harm, and I may have to reveal in carrying out those actions, some information about of a patient’s treatmentpersonal health information could be disclosed. These situations are very unusual in my practiceour experience. § If I have reason to we know or have reasonable cause to suspect that a child under the age of 18 has been or is likely to be abused or neglected, neglected or that a vulnerable adult has been a victim of sexual abuse abused, neglected or exploited and is incapacitated or dependent, we are required by another child, the law requires that I to file a report with to the Department for Childrenappropriate government agency. If we determine that a patient poses a direct threat of imminent harm to the health and safety of any individual including himself/herself, Youth and Families. Once such a report is filed, I we may be required to provide additional information. § If I believe that a patient presents a risk to a person or his/her family, I may be required disclose information in order to take protective action(s). These actions including warning may include notifying the potential victim(s)victim, contacting the police, or seeking hospitalization of for the patient, or contacting family members or others who can assist in providing protection. If such a situation arisessituations arise, I will and as appropriate, we make every effort to fully discuss it with you the patient and/or parent/guardian before taking any action action, and I will we limit my the disclosure to what we believe is necessaryabsolutely necessary to prevent harm. • In rare cases, when a patient is so impaired in some way that it would be dangerous for that patient to drive until recovered, and if that patient is not agreeable to that limitation, the Department of Motor Vehicles may be notified. While this written summary of exceptions to confidentiality should prove helpful in informing providing you with information about potential problemsyour privacy rights and privileged information, it is important that we discuss any questions or concerns that you may have now or in have. Laws and the futureethical standards of our profession sometimes conflict, with the ethical standards providing the greater level of privacy for the patient. The laws governing confidentiality can be quite are complex, and I am we are not an attorneylegal experts. In situations where specific advice is required, formal legal advice may be needed. For more information, see xxx.xxx.xxx/xxx/xxxxxxx/xxxxx/xxxxxxxxxxxxx/xxxxxxxxx/xxxxx.xxxx Clinical Records (CR) Your CR includes information about the reason for your evaluation and information obtained from you and your health care providers, family members, or friends (if you have authorized this contact or if contact has occurred based on another situation outlined in this Agreement). Your CR could include: discussion of neuropsychological testing data, raw data, observations of your symptoms and behavior, a description of the ways in which your problems may impact on your life, your diagnosis, your medical, social, educational, occupational, family, and treatment histories, any past treatment or evaluation records received from other providers, legal records provided, reports of or notes from professional consultations, insurance and financial information, authorizations you have signed, and letters or reports provided to others regarding your personal health information. Except in the unusual circumstance that disclosure would endanger you or others, you may examine and/or receive a copy of your CR, if you request it in writing, with the exception of copyrighted test material that is meant to be kept confidential so as to avoid rendering the tests useless. Per Maine law Chapter 353 Section 1. 22 MRSA § 1725, we cannot release the raw test data to anyone other than an appropriately trained professional, such as another neuropsychologist. We are happy to do this at your direction (with authorization) if the need arises. You can ask us to correct health information about you that you think is incorrect or incomplete. We may deny your request, but we will tell you why in writing within 60 days and will retain any information that you want to attach to your record for any future releases. Please tell us if you have preferences about how we share information with you and your family, friends, or others involved in your care. If you have given someone medical power of attorney or if someone is your legal guardian, that person can exercise your rights and make choices about your health information. We will make sure the person has this authority and can act for you before we take any action. Data that we collect about you is stored electronically in house and physically secured and/or password protected and is backed up locally and externally in encrypted form. If you are being seen via XxXxxx Xxxxxx Cottage, requests for records are handled by XxXxxx, such that you would request a copy of your neuropsychological report directly from XxXxxx, not NCMA.

LIMITS ON CONFIDENTIALITY. The law protects the privacy of all communications between a patient and a psychotherapistPsychologist. In most situations, I can only release information about your treatment to others if you sign a written authorization Authorization form that meets certain legal requirements imposed by HIPAA. There are other situations that require only that you provide written, advance consent. Your signature on this Agreement provides consent for those activities, as follows: • 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 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 important to our work together. I will note all consultations in your Clinical Record (which is called “PHI” in my Notice of PsychotherapistPsychologist’s Policies and Practices to Protect the Privacy of Your Health Information). • You should be aware that I practice with other independent practitioners who also provide mental health professionals and that I employ administrative staffservices. In most some cases, I need to share protected information with these individuals for both clinical and administrative purposes, such as scheduling, billing, answering service 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 my permission. • I also have the permission of a contract with a billing service. As required by HIPAA, I have a formal business associate contract with this business, in which it promises to maintain the confidentiality of this data except as specifically allowed in the contract or otherwise required by law. If you wish, I can provide you the name of this organization and/or a blank copy of this contract. I also will ask for your permission before having the billing service contact youprofessional 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 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 court proceeding and a request is made for information concerning my professional servicesyour diagnosis and treatment, such information is protected by the psychotherapistPsychologist-patient privilege law. I cannot provide any information without your (or your legal representative’s) written authorization, or a court order, or a subpoena of which you have been officially notified and failed to inform me that you are opposing the subpoena. 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 required to provide it for them. • If a patient files a complaint or lawsuit against me, I may disclose relevant information regarding that patient in order to defend myself. • If a patient files a worker’s compensation claim, information that is directly related to that claim I must, upon appropriate request, be provided provide a copy of the patient’s record to the Workers’ Compensation Commission. appropriate regulatory agency or the patient’s employer 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 reasonable cause to know or suspect that a child has been abused or neglected, may be subjected to abuse or has been neglect or observe a victim of sexual child being subjected to conditions or circumstances that would reasonably result in abuse by another childor neglect, the law requires that I file a report with the Department for Children, Youth and Familiesappropriate regulatory agency. Once such a report is filed, I may be required to provide additional information. § § If I have reasonable cause to suspect that an elderly or disabled adult presents a likelihood of suffering serious physical harm and is in need of protective services, the law requires that I file a report with the appropriate regulatory agency. Once such a report is filed, I may be required to provide additional information. § If I believe that it is necessary to disclose information to protect against a clear and substantial risk of imminent serious harm being inflicted by the patient presents a risk to a person on him/herself or his/her familyanother person, I may be required to take protective action. These actions including warning may include, and/or initiating hospitalization and/or contacting the potential victim(s)victim, contacting and/or the police, or seeking hospitalization of police and/or the patient’s family. 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. While this written summary of exceptions to confidentiality should prove helpful in informing you about potential problems, it is important that we discuss any questions or concerns that you may have 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, I keep Protected Health Information about you in two sets of professional records. One set constitutes your Clinical Record. It includes information about your reasons for seeking therapy, a description of the ways in which your problem impacts on your life, your diagnosis, the goals that we set for treatment, your progress towards those goals, your medical and social history, your treatment history, any past treatment records that I receive from other providers, reports of any professional consultations, your billing records, and any reports that have been sent to anyone, including reports to your insurance carrier. Except in the unusual circumstance where disclosure is reasonably likely to endanger you and/or others or when another individual (other than another health care provider) is referenced and I believe disclosing that information puts the other person at risk of substantial harm, 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 will be charging a copying fee. The exceptions to this policy are contained in the attached Notice Form. If I refuse your request for access to your Clinical Records, you have a right of review, 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 providing you with the best treatment. While the contents of Psychotherapy Notes vary from client to client, they can include the contents of our conversations, my analysis of those conversations, and how they impact on your therapy. They also contain particularly sensitive information that you may reveal to me that is not required to be included in your Clinical Record. 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 or court order. 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 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. BILLING AND PAYMENTS You will be expected to pay for each session at the time it is held. 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.] INSURANCE REIMBURSEMENT You may choose to use your health insurance to cover your treatment costs. There are some specific issues you need to consider in making this decision. 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 patients 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. 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. XXXXXX XXXXXX, LSCSW INFORMED CONSENT & SOCIAL WORKER-PATIENT SERVICES AGREEMENT YOUR SIGNATURE BELOW INDICATES THAT YOU HAVE READ THIS AGREEMENT AND AGREE TO ITS TERMS DURING OUR PROFESSIONAL RELATIONSHIP. IT ALSO SERVES AS AN ACKNOWLEDGEMENT THAT YOU HAVE RECEIVED THE HIPAA NOTICE FORM DESCRIBED ABOVE. PATIENT SIGNATURE DATE SIGNATURE OF PARENT/GUARDIAN DATE

LIMITS ON CONFIDENTIALITY. The law protects the privacy of all communications between a patient and a psychotherapistpsychologist. In most situations, I can only release information about your treatment to others if you sign a written authorization Authorization form that meets certain legal requirements imposed by HIPAA. There are other situations that require only that you provide written, advance consent. Your signature on this Agreement provides consent for those activities, as follows: • 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 are also legally bound to keep the information confidential. If you don’t object, I will not tell you about these consultations consultations. unless I feel that it is important to our work together. I will note all consultations in your Clinical Record (which is called “PHI” in my Notice of PsychotherapistPsychologist’s Policies and Practices to Protect the Privacy of Your Health Information). • You should be aware that that I practice consult with other mental health professionals and that I employ my wife is my administrative staff. In most cases, I need to share protected information with these individuals for both clinical and administrative purposes, such as scheduling, billing, billing and quality assurancecase consultation. All of the mental health professionals are bound by the same rules of confidentiality. All staff members have • My wife, Xxxxxx Xxx, is my xxxxxx and has been given training about protecting your privacy and have has agreed not to release any information outside of the practice without my permission. • I also employ a QEEG technician who works with my patients under my direction. They have a contract with a billing serviceaccess to all information in the clinical record. This individual has been given training about protecting your privacy and has agreed not to release any information outside the practice without my directive to so. ▪ I send insurance claims through an electronic clearinghouse, Anvicare, Inc.. As required by HIPAA, I have a formal business associate contract with this business, in which it promises they promise to maintain the confidentiality of this these data except as specifically allowed in the contract or otherwise required by law. If you wish, I can provide you the name of this organization and/or with a blank copy of this contract. I also will ask for your permission before having the billing service contact you. • 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 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 court proceeding and a request is made for information concerning my professional servicesyour diagnosis and treatment, such information is protected by the psychotherapistpsychologist-patient privilege law. I cannot provide any information without your (or your legal representative’s) written authorization, or a court order, or a subpoena of which you have been officially notified and failed to inform me that you are opposing the subpoena. 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 required to provide it for them. • If a patient files a complaint or lawsuit against me, I may disclose relevant information regarding that patient in order to defend myself. • If I am being compensated for providing treatment to you as a patient files result of your having filed a worker’s compensation claim, information that is directly related to that claim I must, upon appropriate request, be provided to the Workers’ Compensation Commissionprovide information necessary for utilization review purposes. 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 reasonable cause to know suspect child abuse or suspect that a child has been abused or neglected, or has been a victim of sexual abuse by another childneglect, the law requires that I file a report with the Department for Children, Youth and FamiliesFamily Independence Agency. Once such a report is filed, I may be required to provide additional information. § ▪ If I believe that have reasonable cause to suspect the “criminal abuse” of an adult patient, I must report it to the police. Once such a patient presents a risk to a person or his/her familyreport is filed, I may be required to provide additional information. ▪ If a patient communicates a threat of physical violence against a reasonably identifiable third person and the patient has the apparent intent and ability to carry out that threat in the foreseeable future, I may have to disclose information in order to take protective action. These actions including warning may include notifying the potential victim(s)victim (or, if the victim is a minor, his/her parents and the county Department of Social Services) and contacting the police, or and/or seeking hospitalization of for 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. While this written summary of exceptions to confidentiality should prove helpful in informing you about potential problems, it is important that we discuss any questions or concerns that you may have 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, I keep Protected Health Information about you in two sets of professional records. One set constitutes your Clinical Record. It includes information about your reasons for seeking therapy, a description of the ways in which your problem impacts on your life, your diagnosis, the goals that we set for treatment, your progress towards those goals, your medical and social history, your treatment history, any past treatment records that I receive from other providers, reports of any professional consultations, your billing records, and any reports that have been sent to anyone, including reports to your insurance carrier. Except in unusual circumstances that disclosure would physically endanger you and/or others or 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, 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 forwarded to another mental health professional so you can discuss the contents. In most circumstances, I charge a copying fee of $1. per page. The exceptions to this policy are contained in the attached Notice Form. If I refuse your request for access to your 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 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 client to client, they can include the contents of our conversations, my analysis of those conversations, and how they impact on your therapy. They also contain particularly sensitive information that you may reveal to me that is not required to be included in your Clinical Record. [They also include information from others provided to me confidentially.] These Psychotherapy Notes are kept separate from your Clinical Record. Your Psychotherapy Notes are not available to you and cannot be sent to anyone else, including insurance companies without your written, signed Authorization. Insurance companies cannot require your authorization as a condition of coverage nor penalize you in any way for your refusal to provide it. PATIENT RIGHTS HIPAA provides you with several 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 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. They should also be aware that patients over 14 can consent to (and control access to information about) their own treatment, although that treatment cannot extend beyond 12 sessions or 4 months. While privacy in psychotherapy is very important, particularly with teenagers, parental involvement is also essential to successful treatment. Therefore, it is usually my policy to request an agreement from any patient between 14 and 18 and his/her parents allowing me to share general information with parents about the progress of treatment and the child’s attendance at scheduled sessions. I will also provide parents with a verbal 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. Center for Integrative Psychology PSYCHOTHERAPIST-PATIENT SERVICES AGREEMENT Printed Patient Name 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 Date Legal Guardian/Parent if Patient is a minor Date Therapist Date

LIMITS ON CONFIDENTIALITY. The law protects At the base of an effective therapeutic relationship is your right to privacy of all and confidentiality with regards to what you disclose in therapy. Your communications between a patient with your therapist are considered privileged and a psychotherapistlegally protected. In most situationsThis protection is not absolute, I however, as detailed below. Your therapist can only release information about your treatment to others if you sign a written authorization Authorization form that meets certain legal requirements imposed by HIPAAHIPAA and/or Idaho law. There are other situations that require only that you provide writtenHowever, advance consent. Your signature on this Agreement provides consent for those activitiesin the following situations, as followsno authorization is required: • I Your therapist may 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 the 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 important to our work together. I Your therapist will note all consultations in your Clinical Record (which is called “PHI” in my Notice of PsychotherapistPsychologist’s Policies and Practices to Protect the Privacy of Your Health Information). • You should be aware that I practice your therapist practices with other mental health professionals and that I employ employs administrative staff. In most cases, I need your therapist needs to share protected health information with these individuals for both clinical and administrative purposes, such as scheduling, billing, 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 my permissionthe permission of a professional staff member. • I Your therapist may also have a contract contracts with a billing servicetranscriptionist and collection agency. As required by HIPAA, I we have a formal business associate contract with this businessthese businesses, in which it promises they promise to maintain the confidentiality of this data except as specifically allowed in the contract or otherwise required by law. If you wish, I we can provide you with the name names of this organization these organizations and/or a blank copy of this contract. I also will ask for your permission before having the billing service contact you. • 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 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 your therapist is 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 my professional services, such information is protected by the psychotherapist-patient privilege law. I cannot provide any information without your (or your legal representative’s) written authorization, or a court order, or a subpoena of which you have been officially notified and failed to inform me that you are opposing the subpoena. 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 your therapist may be required to provide it for them. • If a patient files a complaint or lawsuit against meyour therapist, I the therapist may disclose relevant information regarding that patient in order to defend myselfthemselves. • If a patient files a worker’s compensation claim, information that is directly related to that claim mustyour therapist may be required, upon appropriate request, be provided to the Workers’ Compensation 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 patient’s treatment. These situations are unusual in my practice. § If I have reason to know or suspect that a child has been abused or neglected, or has been a victim of sexual abuse by another child, the law requires that I file a report with the Department for Children, Youth and Families. Once such a report is filed, I may be required to provide additional information. § If I believe that a patient presents a risk all clinical information relevant to a person or his/her family, I may be required to take protective actions including warning bearing upon the potential victim(s), contacting injury for which the police, or seeking 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. While this written summary of exceptions to confidentiality should prove helpful in informing you about potential problems, it is important that we discuss any questions or concerns that you may have 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 neededclaim was filed.

LIMITS ON CONFIDENTIALITY. The law protects the privacy of all communications between a patient and a psychotherapistpsychologist. In most situations, I can only release information about your treatment to others if you sign a written authorization form HIPAA Authorization Form that meets certain legal requirements imposed by HIPAA. There are other situations that require only that you provide written, advance consent. Your signature on this Agreement provides consent for those activities, as follows: • ● 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 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 important to our work together. I will note all consultations in your Clinical Record (which is called “PHI” in my Notice of PsychotherapistPsychologist’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 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 my permission. • I also have a contract with a billing service. As required by HIPAA, I have a formal business associate contract with this business, in which it promises to maintain the confidentiality of this data except as specifically allowed in the contract or otherwise required by law. If you wish, I can provide you the name of this organization and/or a blank copy of this contract. I also will ask for your permission before having the billing service contact you. • Disclosures required by health insurers or to collect overdue fees are discussed elsewhere in this Agreement. • ● If a patient client seriously 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. 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 client to the client or others, or there is a probability of immediate mental or emotional injury to the client. 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 my professional servicesyour diagnosis and treatment, such information is protected by the psychotherapistpsychologist-patient privilege law. I cannot provide any information without your (or your legal representative’s) written authorization, or a court order, or a subpoena of which you have been officially notified and failed to inform me that you are opposing the subpoena. 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. • You have agreed that it is not in your best interests or your children’s best interests for me to testify in a court proceeding and will request that any attorneys involved in your case refrain from asking me to testify, requesting information regarding you or your children, or subpoenaing my records. ● If a government agency is requesting the information for health oversight activities, I may be required to provide it for them. • ● If a patient files a complaint or lawsuit against me, I may disclose relevant information regarding that patient in order to defend myself. • ● If a patient files a worker’s compensation claim, information that is directly related to that claim I must, upon appropriate request, be provided provide records relating to the Workers’ Compensation Commissiontreatment or hospitalization for which compensation is being sought. 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 cause to know or suspect believe that a child under 18 has been or may be abused or neglectedneglected (including physical injury, substantial threat of harm, mental or emotional injury, or has been any kind of sexual contact or conduct), or that a child is a victim of a sexual abuse by another childoffense, or that an elderly or disabled person is in a state of abuse, neglect or exploitation, the law requires that I file make a report with to the appropriate governmental agency, usually the Department for Children, Youth of Protective and FamiliesRegulatory Services. Once such a report is filed, I may be required to provide additional information. § ● If I believe determine that there is a probability that the patient presents a risk to a person will inflict imminent physical injury on another, or histhat the patient will inflict imminent physical, mental or emotional harm upon him/her familyherself, or others, I may be required to take protective actions including warning the potential victim(s), contacting the police, action by disclosing information to medical or seeking 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. While this written summary of exceptions to confidentiality should prove helpful in informing you about potential problems, it is important that we discuss any questions or concerns that you may have 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, you may need to obtain formal legal advice advice. PROFESSIONAL RECORDS You should be aware that, pursuant to HIPAA, I keep PHI about you in two sets of professional records. One set constitutes your Clinical Record. It includes information about your reasons for seeking my services, a description of the ways in which your problem impacts on your life, your diagnosis, the goals that we set for treatment, your progress towards those goals, your medical and social history, your treatment history, any past treatment records that I receive from other providers, reports of any professional consultations, your billing records, and any reports that have been sent to anyone, including reports to your insurance carrier. Except in unusual circumstances that involve danger to yourself and others, you may examine and/or receive a copy of your Clinical Record if you request it in writing. You should be needed.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 initially review them in my presence, or have them forwarded to another mental health professional so you can discuss the contents. The exceptions to this policy are contained in the attached Notice Form. If I refuse your request for access to your Clinical Record, you have a right of review, which I will discuss with you upon your request. In addition, I 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 client to client, they can include the contents of our conversations, my analysis of those conversations, and how they impact on your therapy. They also contain particularly sensitive information that you may reveal to me that is not required to be included in your Clinical Record. 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 release would be harmful to your physical, mental or emotional health. PATIENT RIGHTS HIPAA provides you with several new or expanded rights with regard to your Clinical Record and disclosures of PHI. These rights include requesting that I amend your record; requesting restrictions on what information from your Clinical Record is disclosed to others; requesting an accounting of most disclosures of PHI that you have neither consented to nor authorized; determining the location to which PHI disclosures are sent; having any complaints you make about my policies and procedures recorded in your records; and the right to a paper copy of this Agreement and the attached Notice form describing my privacy practices. INSURANCE REIMBURSEMENT You are responsible for paying my fee. I do not file insurance for clients, but will provide you or your insurance company with whatever assistance is needed in order for you to be reimbursed by your insurance company. 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. By signing this Agreement, you agree that I can provide requested information to your carrier. 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. Signature Date Signature Date

LIMITS ON CONFIDENTIALITY. The law protects the privacy of all communications between a patient and a psychotherapistpsychologist. In most situations, I can only release information about your treatment to others if you sign a written authorization Authorization form that meets certain legal requirements imposed by HIPAA. There are other situations that require only that you provide written, advance consent. Your signature on this Agreement provides consent for those activities, as follows: • *I may occasionally find it helpful to consult other health and mental health professionals about a case. During a the 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 important to our work together. I will note all consultations in your Clinical Record (which is called referred to as “PHI” in my Notice of Psychotherapist’s Policies and Practices to Protect the Privacy of Your 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 personnel for both clinical and administrative purposes, such as scheduling, billing, administrative purposes and quality assurance. All of the mental health professionals are bound by the same rules of confidentiality. All staff members These individuals have been given giving training about protecting your privacy and have agreed not to release any information outside of the practice without my permission. • I also have a contract with a billing service. As required by HIPAA, I have a formal business associate contract with this business, in which it promises to maintain the confidentiality of this data except as specifically allowed in the contract or otherwise required by law. If you wish, I can provide you the name of this organization and/or a blank copy of this contract. I also will ask for your permission before having the billing service contact you. • *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 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 court proceeding and a request is made for information concerning my professional servicesyour diagnosis and treatment, such information is protected by the psychotherapistpsychologist-patient privilege law. I cannot provide any information without your (or your legal representative’s) written authorization, or a court order, or if a subpoena is served on me with appropriate notices. I may have to release information in a sealed envelope to the clerk of which you have been officially notified and failed to inform me that you are opposing the court issuing the subpoena. 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 required to provide it for them. • *If a patient files a complaint or lawsuit against me, I may disclose relevant information regarding that the patient in order to defend myself. • *If a patient files a worker’s compensation claim, information that is directly related to that claim I must, upon appropriate request, be provided to the Workers’ Compensation Commissionprovide a copy of any mental health report. 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 highly unusual in my practice. § *If I have reason to know or suspect that a child has been is abused or neglected, or has been a victim of sexual abuse by another child, the law requires that I file a report with the appropriate governmental agency, usually the Department for Children, Youth and Familiesof Social services. Once such a report is filed, I may be required to provide additional information. § *If I believe have reason to suspect than an adult is abused, neglected or exploited, the law requires that I report to the Department of Welfare or Social Services. Once such a patient presents a risk to a person or his/her familyreport is filed, I may be required to provide additional information. *If a patient communicates a specific threat of immediate physical harm to an identifiable victim, and I believe he/she has the intent and the ability to carry out the threat, I am required to take protective actions. These actions including warning may include notifying the potential victim(s)victim or his/her guardian, contacting the police, or seeking hospitalization of for 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. While this written summary of the exceptions to confidentiality should prove helpful in informing you about potential problems, it is important that we discuss any questions or concerns that you may have either 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 ON CONFIDENTIALITY. The law protects the privacy of all communications between a patient and a psychotherapistpsychologist. In most situations, I can only release information about your treatment to others if you sign a written authorization Authorization form that meets certain legal requirements imposed by of state law and HIPAA. There are other situations that require only that you provide written, advance consent. Your signature on this the Agreement provides consent for those the following activities, as follows: • As a student trainee, I may occasionally find it helpful routinely receive supervision from a licensed psychologist who has access to consult other health your Clinical Record and mental health professionals about a casePsychotherapy Notes. During a consultationother consultations with student trainees/professionals affiliated with WSPP and any consultations with student professionals outside of WSPP, I will 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 important to our work together. I will note all consultations in conceal your Clinical Record (which is called “PHI” in my Notice of Psychotherapist’s Policies and Practices to Protect the Privacy of Your Health Information)identity. • 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 Center staff may see your records in the course of the mental health professionals are bound by the same rules of confidentialitytheir clerical duties. All staff members have been given training about protecting your privacy and have agreed not to release any information outside of the practice without my permission. • I also have a contract with a billing service. As required by HIPAA, I have a formal business associate contract with this business, in which it promises to maintain the confidentiality of this data Center except as specifically allowed noted in the contract or otherwise required by law. If you wish, I can provide you the name of this organization and/or a blank copy of this contract. I also will ask for your permission before having the billing service contact youAgreement. • Disclosures required by health insurers or to collect overdue fees are discussed elsewhere in this Agreementelsewhere. • If a patient threatens to harm himself/herself, I may be obligated obliged 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 of Authorization: • If you are involved in I receive a court proceeding and a request is made for information concerning my professional services, such information is protected by the psychotherapist-patient privilege law. I cannot provide any information without your (or your legal representative’s) written authorization, or a court order, or a subpoena of which you have been officially notified and failed to inform me that you are opposing the subpoena. 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 required to provide it for them. activities • If I need to defend myself against a patient files a complaint or lawsuit against me, I may disclose relevant • If an employer requests information regarding that patient in order to defend myself. • If a patient files a the worker’s compensation claim, information that is directly related to that claim must, upon appropriate request, be provided to the Workers’ Compensation Commissionof a patient. There are some situations where I may have to reveal information about a patient’s treatment in which I am order to take legally obligated to take actions, which I believe are necessary to attempt action 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 know or suspect believe that a child that I have seen has been abused or neglected, neglected or has been a victim of sexual threatened with abuse by another childor neglect that I believe is likely to occur, the law requires that I file a report with the Department for Childrenappropriate governmental agency • If I have reason to believe or suspect that abuse, Youth and Families. Once such material abuse or neglect of an elder adult has occurred, the law allows me to file a report is filed, I may be required to provide additional information. § with the appropriate government agency • If I believe that a patient presents a foreseeable risk of harm to a person or his/her familyanother, I may be required have to take protective actions including warning notifying the potential victim(s)victim, contacting the police, or seeking hospitalization of for 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 the minimum necessary. MINORS AND 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 unless I decide that such access is likely to injure the child, or we agree otherwise. Because privacy in psychotherapy is often crucial to progress, particularly with teenagers, it is my policy to request an agreement from parents to give up their access to their child’s records. If they agree, I will provide them with general information about the progress of the child’s treatment, and his/her attendance at scheduled sessions. 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. PROFESSIONAL FEES, BILLING, AND PAYMENTS Costs for services were determined prior to this agreement and are indicated on the payment agreement form. (If you become involved in legal proceedings that require participation of Center personnel, there may be additional charges) You will be expected to pay for service at the time it is provided, unless we agree otherwise or unless you have insurance coverage that requires another arrangement. If you account has not been paid for more than 60 days and arrangements for payment have not been agreed upon, I may hire a collection agency. This will require me to disclose confidential information, but I can usually limit this to the patient’s name, the nature of services provided, and the amount due. INSURANCE REIMBURSEMENT If you have a health insurance policy, it will usually provide some coverage for mental health treatment. I will fill out forms and provide you with whatever assistance I can; however, you (not your insurance company) are responsible for full payment of my fees. Your health insurance company requires that I provide information regarding my services to you including a clinical diagnosis. I will make every effort to release only the minimum information that is necessary. While Though all insurance companies claim to keep such information confidential, I have no control over what they do with it. 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. By signing this written summary Agreement, you agree that I can provide requested information to your carrier. YOUR SIGNATURE BELOW INDICATES THAT YOU HAVE READ THE PSYCHOTHERAPISTPATIENT SERVICES AGREEMENT AND AGREE TO ITS TERMS AND ALSO SERVES AS AN ACKNOWLEDGEMENT THAT YOU HAVE RECEIVED THE HIPAA NOTICE FORM AND GRIEVANCE PROCEDURE. Signature of exceptions Patient /Legal Representative Signature of Therapist Date Signature of Patient /Legal Representative Signature of Therapist Date Signature of Patient /Legal Representative Signature of Therapist Date If legal representative, state relationship and authority to confidentiality should prove helpful in informing you about potential problemsact for the patient I realize that the WSPP Psychology Center is a training clinic which serves important educational and research functions. I also realize that without using my name or any information which could identify me, students might use materials from my file for research purposes. When such information is used, it will be for important purposes which can benefit others. I approve of the use of information in my file for educational and research purposes so long as my privacy is 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, protected and I am not can never be identified as an attorneyindividual. In situations where specific advice is required, formal legal advice may be needed.Signature of Patient /Legal Representative Signature of Therapist Date Signature of Patient /Legal Representative Signature of Therapist Date Signature of Patient /Legal Representative Signature of Therapist Date

LIMITS ON CONFIDENTIALITY. The law protects the privacy of all communications between a patient client and a psychotherapisttherapist. In most situations, I we can only release information about your treatment to others if you sign a written authorization Authorization form that meets certain legal requirements imposed by HIPAA. There are other situations that require only that you provide written, advance consent. Your signature on this Agreement provides consent for those activities, as follows: • I may We occasionally find it helpful to consult other health and mental health professionals about a case. During a consultation, I make every effort is made to avoid revealing the identity of my patienta client. The other professionals are also legally bound to keep the information confidential. If you don’t object, I you will not tell you be informed about these consultations unless I feel that it is important to our work together. I All consultations will note all consultations be noted in your Clinical Record (which is called “PHI” .PHI. in my our Notice of PsychotherapistTherapist’s Policies and Practices to Protect the Privacy of Your Health Information). • You should be aware that I practice Xxxxxx Xxxx contracts with other mental health professionals and that I employ administrative staffXxxxx Xxxxxx for billing services. In most cases, I need to share protected information with these individuals for both clinical and administrative purposesProtected information, such as schedulingname, billingdiagnosis, 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 session date, needs to release any information outside of the practice without my permission. • I also have a contract with a be provided to Xxxxx for billing servicepurposes. As required by HIPAA, I we have a formal business associate contract with this businessher, in which it she promises to maintain the confidentiality of this data except as specifically allowed in the contract or otherwise required by law. If you wish, I can provide you the name of this organization and/or a blank copy of this contract. I also will ask for your permission before having the billing service contact you. • Disclosures required by health insurers or required to collect overdue fees are discussed elsewhere in this Agreement. • If a patient client threatens to harm himself/herself, I your therapist may be obligated to seek hospitalization for him/her, or to contact family members or others who can help provide protection. protection There are some situations where I am a therapist is 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 my the professional servicesservices provided to you and/or the records thereof, such information is protected by the psychotherapisttherapist-patient client privilege law. I canThis information can not provide any information be provided without your (or your legal representative’s) written authorization, authorization or a court order, or a subpoena of which you have been officially notified and failed to inform me that you are opposing the subpoena. 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 the disclosure of such information. • If a government agency is requesting the information for health oversight activities, I your therapist may be required to provide it for themit. • If a patient client files a complaint or lawsuit against mea therapist, I may disclose then relevant information regarding that patient in order to defend myself. • If a patient files a worker’s compensation claim, information that is directly related to that claim must, upon appropriate request, client and the treatment may be provided to the Workers’ Compensation Commissiondisclosed for legal defense purposes. There are some situations in which I am a therapist is legally obligated to take actions, which I believe are she/he deems necessary to attempt to protect others from harm harm, and I may have to reveal some information about a patientclient’s treatmenttreatment may need to be revealed to accomplish this. These situations are unusual in my our practice. § • If I have a therapist has reason to know or suspect that a child has been abused or neglected, or has been a victim of sexual abuse by another child, the law requires that I she/he file a report with the Department for Children, Youth Bureau of Child and FamiliesFamily Services. Once such a report is filed, I additional information may be required as well. • If a therapist suspects or has a good faith reason to provide additional information. § If I believe that any incapacitated adult has been subjected to abuse, neglect, self-neglect, or exploitation, or is living in hazardous conditions, the law requires the filing of a patient presents report with the appropriate governmental agency, usually the Department of Health and Human Services. Once such a risk to a person or his/her familyreport is filed, I additional information may be required as well. • If a client communicates a serious threat of physical violence against a clearly identified or reasonably identifiable victim or victims, or a serious threat of substantial damage to take real property, protective actions including warning may be required. These actions may include notifying the potential victim(s)victim, contacting the police, or seeking involuntary hospitalization of for the patientclient. If such a situation arises, I will make every effort will be made to fully discuss it with you before taking any action action, and I any disclosure will limit my disclosure be limited to what is necessary. While this written summary of exceptions to confidentiality should prove helpful in informing you about potential problems, it is important that we discuss any questions or concerns that you may have 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 counsel may be needed. Professional Records The laws and standards of our profession require that Protected Health Information about you be kept in an individual Clinical Record. 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 the event you request the release of a copy of your Clinical Record, there is a charge for copying fee of $15.00 for the first 30 pages or 50 cents per page, whichever is greater. Electronic Communications Increasingly, insurance companies require that we send billing and other information (e.g., treatment plans) electronically. Such communications may be through e-mail, facsimile, and/or a web site. We can not guarantee the confidentiality of such communications. If you do not consent to electronic communications, please inform your therapist immediately so that other arrangements can be made. We do not accept or respond to electronic mail communications about treatment issues. 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 the ability to request an amendment of your record; to request restrictions on what information from your Clinical Records is disclosed to others; to request an accounting of most disclosures of protected health information that you have neither consented to nor authorized; to a determination of the location to which protected information disclosures are sent; to having any complaints you make about our policies and procedures recorded in your records; and to a paper copy of this Agreement, the attached Notice form, and our privacy policies and procedures. Please feel free to discuss any of these rights with your therapist.

LIMITS ON CONFIDENTIALITY. The law protects the privacy of all communications between a patient and a psychotherapistpsychologist. In most situations, I we can only release information about your treatment to others if you sign a written authorization Authorization form that meets certain legal requirements imposed by HIPAA. There are other situations that require only that you provide written, advance consent. Your signature on this Agreement provides consent for those activities, as follows: • I  Your therapist may 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 patientyour identity. 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 feel your therapist feels that it is important to our the work togetheryou are doing. I Your therapist will note all consultations in your Clinical Record (which is called “PHI” in my the Notice of PsychotherapistPsychologist’s Policies and Practices to Protect the Privacy of Your Health Information). •  You should be aware that I we practice with other mental health professionals and that I we employ both clinical and administrative staff. In most cases, I your therapist will need to share 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 my permissionthe permission of a professional staff member. • I  We also have contracts with Utah Health Information Network for electronic billing and a contract with a billing servicecollection agency. As required by HIPAA, I we have a formal business associate contract with this businessthese businesses, in which it promises they promise to maintain the confidentiality of this data except as specifically allowed in the contract or otherwise required by law. If you wish, I the staff can provide you the name of this organization and/or with a blank copy of this the contract. I also will ask for your permission before having the billing service contact you. •  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 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 your therapist is permitted or required to disclose information without either your consent or Authorization: • .  If you are involved in a court proceeding and proceeding, the patient-psychologist privilege provides a request is made degree of protection. However, if a judge issues an order for information concerning my professional servicesthe records, such information is protected by the psychotherapist-patient privilege lawwe are required to release those records. I canOtherwise, your records will not provide any information be released without your (a signed Authorization for you or your legal representative’s) written authorization, or a court order, or a subpoena of which you have been officially notified and failed to inform me that you are opposing the subpoena. 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 us to disclose information. •  If a government agency is requesting the information for health oversight activities, I may be we are required to provide it for them. •  If a patient files a complaint or lawsuit against meany individual therapist or Corner Canyon Counseling and Psychological Services, I we may disclose relevant information regarding that patient in order to defend myselfthe therapist or the group. •  If a patient files a worker’s compensation claim, information that is directly related to that claim we must, upon appropriate request, be provided provide a copy of the patient’s record to the Workersappropriate parties, the patient’s employer, the workers’ Compensation compensation insurance carrier or the Labor Commission. There are some situations in which I am your therapist is legally obligated to take actions, which I believe are action. Whenever your therapist judges that it is necessary to attempt to protect the patient or others from harm and I harm, we may have to reveal some information about a patient’s treatment. These situations are unusual in my our practice. §  If I have your therapist has reason to know or suspect believe that a child has been abused or neglectedis likely to be subjected to incest, molestation, sexual exploitation, sexual abuse, physical abuse, witnessing domestic violence, or has been a victim of sexual abuse by another childneglect, the law requires that I file a report with we immediately notify the Department for Children, Youth Division of Child and FamiliesFamily Services or an appropriate law enforcement agency. Once such a report is filed, I we may be required to provide additional information. §  If I your therapist has reason to believe that any vulnerable adult has been the subject of abuse, neglect, abandonment or exploitation, we are required to immediately notify Adult Protective Services intake. Once such a patient presents a risk to a person or his/her familyreport is filed, I we may be required to provide additional information.  If a patient communicates an actual threat of physical violence against an identifiable victim, we are required to take protective actions. These actions including warning may include notifying the potential victim(s), victim and contacting the policeappropriate law enforcement agency, and/or seeking hospitalization for the patient. In choosing to work with Corner Canyon Counseling and Psychological Services, you also agree to and understand that if there is an identifiable class of victims we will also notify law enforcement of the danger.  If a patient threatens to harm himself/herself, your therapist may be obligated to seek hospitalization for him/her, and/or to contact family members, law enforcement, or seeking hospitalization others who can help provide protection.  If communicable disease is reported to your therapist, we are required to report that disease to the Utah State Department of the patientHealth. Reportable communicable diseases include, but are not limited to: AIDS, Hepatitis, Sexual Transmitted Diseases, and Smallpox. If such a situation arises, I your therapist will make every effort to fully discuss it with you before taking any action and I we will limit my our disclosure to what is necessary. While this written summary of exceptions to confidentiality should prove helpful in informing you about potential problems, it is important that we discuss any questions or concerns that you may have 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 ON CONFIDENTIALITY. The law protects the privacy of all communications between a patient and a psychotherapistpsychologist. In most situations, I we can only release information about your treatment to others if you sign a written authorization Authorization form that meets certain legal requirements imposed by HIPAA. There are other situations that require only that you provide written, advance consent. Your signature on this Agreement provides consent for those activities, as follows: • I We may occasionally find it helpful to consult other health and mental health professionals about a case. During a consultationsuch consultations, 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 important to our work together. I We will note all consultations in your Clinical Record (which is called “PHI” in my the “Notice of PsychotherapistPsychologist’s Policies and Practices to Protect the Privacy of Your Health Information”). • You should be aware that I practice MPA also has contracts with other mental health professionals and that I employ administrative staff. In most casesa typist, I need to share protected with an information with these individuals for both clinical and administrative purposes, such as scheduling, billingtechnology specialist, 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 my permission. • I also have a contract with a billing servicecertified public accountant. As required by HIPAA, I we have a formal business associate contract with this businessthese businesses, in which it promises they promise to maintain the confidentiality of this data except as specifically allowed in the contract or otherwise required by law. If you wish, I we can provide you with the name names of this organization these organizations and/or a blank copy of this contract. I also will ask for your permission before having the billing service contact you. • Disclosures required by health insurers or to collect overdue fees are discussed elsewhere in this Agreement. • If we believe that a patient threatens presents an imminent danger to harm himselfhis/herselfher health or safety, I we 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 we are permitted or required to disclose information without either your consent or Authorizationauthorization: • If you are involved in a court proceeding and a request is made for information concerning my the professional servicesservices that we provided you, such information is protected by the psychotherapistpsychologist-patient privilege law. I We cannot provide any information without your (or your legal representative’s) written authorization, or a court order, or a subpoena of which you have been officially notified and failed to inform me that you are opposing the subpoena. 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 us to disclose information. • If a government agency is requesting the information for health oversight activities, I we may be required to provide it for them. • If a patient files a complaint or lawsuit against meMPA, I MPA may disclose relevant information regarding that patient in order to defend myselfitself. • If a patient files a worker’s compensation claim, information that is directly related to that claim and our services are being compensated through workers compensation benefits, we must, upon appropriate request, be provided provide a copy of the patient’s record to the Workers’ Compensation patient’s employer or the North Carolina Industrial Commission. There are some situations in which I am we are legally obligated to take actions, which I we believe are necessary to attempt to protect others from harm and I we may have to reveal some information about a patient’s treatment. These situations are extremely unusual in my our practice. § • If I we have reason cause to know or suspect that a child has been under 18 is abused or neglected, or has been if we have reasonable cause to believe that a victim disabled adult is in need of sexual abuse by another childprotective services, the law requires that I we file a report with the Department for Children, Youth and FamiliesCounty Director of Social Services. Once such a report is filed, I we may be required to provide additional information. § • If I we believe that a patient presents a risk an imminent danger to a person or his/her familythe health and safety of another, I we may be required to disclose information in order to take protective actions actions, including initiating hospitalization, warning the potential victim(s)victim, contacting if identifiable, and/or calling the police, or seeking hospitalization of the patient. If such a situation arises, I we will make every effort to fully discuss it with you before taking any action and I we will limit my our disclosure to what is necessary. While this written summary of exceptions to confidentiality should prove helpful in informing you about potential problems, it is important that we discuss any questions or concerns that you may have 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. PROFESSIONAL RECORDS You should be aware that, pursuant to HIPAA, we 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, a description of the ways in which your problem impacts on your life, your diagnosis, the goals that we set for treatment, your progress towards those goals, your medical and social history, your treatment history, any past treatment records that I receive from other providers, reports of any professional consultations, your billing records, and any reports that have been sent to anyone, including reports to your insurance carrier. Except in unusual circumstances that involve danger to yourself and/or others or if the record makes reference to another person (unless such other person is a health care 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. However, 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 reasonable copying fee. 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, which we will discuss with you upon request. In addition, we may also keep a set of 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 vary from client to client, they can include the contents of our meetings, our analysis of those meetings, and how they impact on your therapy. They also contain particularly sensitive information that you may reveal that is not required to be included in your Clinical Record. These Psychotherapy Notes may be 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 protected health information. These rights include requesting that your record be amended; 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 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 often MPA’s policy to request an agreement from parents that they consent to give up their access to your records. If they agree, we will provide parents only with general information about the progress of the child’s treatment, and his/her attendance at scheduled sessions. If the parent is responsible for payment of sessions and other professional fees, we will communicate with parents as needed regarding financial matters. 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 child, if possible, and do our 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. If your account has not been paid for more than 60 days and arrangements for payment have not been agreed upon, MPA has 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 released regarding a patient’s treatment is his/her name, the nature of services provided, and the amount due. If such legal action is necessary, 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. However, you (not your insurance company) are responsible for full payment of fees. It is 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. 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. XXXXXXX XXXXXX, PH.D.’S SERVICES ARE COVERED UNDER MANY HEALTH INSURANCE POLICIES. HE DOES NOT, HOWEVER, CURRENTLY PARTICIPATE IN ANY MANAGED CARE PROGRAMS. HIS SERVICES ARE CONSIDERED “OUT OF NETWORK” AND YOU ARE EXPECTED TO PAY EACH OFFICE VISIT AND FILE FOR REIMBURSEMENT. INSURANCE BENEFITS VARY CONSIDERABLY. THEREFORE, YOU ARE STRONGLY ENCOURAGED TO REVIEW YOUR OWN POLICY CAREFULLY REGARDING COVERAGE AND LIMITATIONS AND TO CONTACT YOUR INSURANCE CARRIER OR YOUR COMPANY’S HUMAN RESOURCES OR PERSONNEL DEPARTMENT WITH ANY QUESTIONS. Your statement, which will be provided to you at the time of service, contains all of the information necessary for insurance claims. You may simply submit the statement to your insurance carrier in order to seek reimbursement. You should also be aware that your contract with your health insurance company may require that your therapist provide it with information relevant to the services provided 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 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 on computer. Though all insurance companies claim to keep such information confidential, we 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. We will provide you with a copy of any report submitted, if you request it. By signing this Agreement, you agree that MPA can provide requested information to your carrier. Fees are due in full at each session. We accept cash, checks, debit cards, credit cards, health savings account cards and flexible spending account cards. Please make checks payable to “Mendel Psychological Associates.” There is a $25.00 service charge for any returned checks. Fees will be reviewed periodically and may be increased in the future. Fees will be increased no more than once during any year.

LIMITS ON CONFIDENTIALITY. The law protects the privacy of all communications between a patient and a psychotherapistpsychologist. In most situations, I can only release information about your treatment to others if you sign a written authorization form HIPAA Authorization Form that meets certain legal requirements imposed by HIPAA. There are other situations that require only that you provide written, advance consent. Your signature on this Agreement provides consent for those activities, as follows: • 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 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 important to our work together. I will note all consultations in your Clinical Record (which is called “PHI” in my Notice of PsychotherapistPsychologist’s Policies and Practices to Protect the Privacy of Your Health Information). • You should be aware that I practice share space with other another mental health professionals professional and that I employ use shared 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 of the mental Mental health professionals are bound by the same rules of confidentiality. All administrative staff members have been given training about protecting your privacy and have agreed not to release any information outside of the practice without my permissioninformation. • I also have a contract with a billing service. As required by HIPAAIn addition, although I have security measures in place, the following business practices may constitute a formal business associate contract with this businesspotential risk to your confidentiality: use of a cell phone, in which it promises to maintain the confidentiality of this data except as specifically allowed in the contract or otherwise required by law. If you wishcomputer, I can provide you the name of this organization and/or a blank copy of this contract. I also will ask for your permission before having the billing service contact you. • Disclosures required by health insurers or to collect overdue fees are discussed elsewhere in this Agreementelectronic calendar, email, credit card processing services, and online backup services. • If a patient client seriously 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. 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 client to the client or others, or there is a probability of immediate mental or emotional injury to the client. 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 my professional servicesyour diagnosis and treatment, such information is protected by the psychotherapistpsychologist-patient privilege law. I cannot provide any information without your (or your legal representative’s) written authorization, or a court order, or a subpoena of which you have been officially notified and failed to inform me that you are opposing the subpoena. 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. You have agreed that it is not in your best interests or your children’s best interests for me to testify in a court proceeding and will request that any attorneys involved in your case refrain from asking me to testify, requesting information regarding you or your children, or subpoenaing my records. • If a government agency is requesting the information for health oversight activities, I may be required to provide it for them. • If a patient files a complaint or lawsuit against me, I may disclose relevant information regarding that patient in order to defend myself. • If a patient files a worker’s compensation claim, information that is directly related to that claim I must, upon appropriate request, be provided provide records relating to the Workers’ Compensation Commissiontreatment or hospitalization for which compensation is being sought. 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 cause to know or suspect believe that a child under 18 has been or may be abused or neglectedneglected (including physical injury, substantial threat of harm, mental or emotional injury, or has been any kind of sexual contact or conduct), or that a child is a victim of a sexual abuse by another childoffense, or that an elderly or disabled person is in a state of abuse, neglect or exploitation, the law requires that I file make a report with to the appropriate governmental agency, usually the Department for Children, Youth of Protective and FamiliesRegulatory Services. Once such a report is filed, I may be required to provide additional information. § • If I believe determine that there is a probability that the patient presents a risk to a person will inflict imminent physical injury on another, or histhat the patient will inflict imminent physical, mental or emotional harm upon him/her familyherself, or others, I may be required to take protective actions including warning the potential victim(s), contacting the police, action by disclosing information to medical or seeking 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. While this written summary of exceptions to confidentiality should prove helpful in informing you about potential problems, it is important that we discuss any questions or concerns that you may have 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, you may need to obtain formal legal advice advice. PROFESSIONAL RECORDS You should be aware that, pursuant to HIPAA, I keep PHI about you in two sets of professional records. One set constitutes your Clinical Record. It includes information about your reasons for seeking my services, a description of the ways in which your problem impacts on your life, your diagnosis, the goals that we set for treatment, your progress towards those goals, your medical and social history, your treatment history, any past treatment records that I receive from other providers, reports of any professional consultations, your billing records, and any reports that have been sent to anyone, including reports to your insurance carrier. Except in unusual circumstances that involve danger to yourself and others, you may examine and/or receive a copy of your Clinical Record if you request it in writing. You should be needed.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 initially review them in my presence, or have them forwarded to another mental health professional so you can discuss the contents. The exceptions to this policy are contained in the attached Notice Form. If I refuse your request for access to your Clinical Record, you have a right of review, which I will discuss with you upon your request. In addition, I 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 client to client, they can include the contents of our conversations, my analysis of those conversations, and how they impact on your therapy. They also contain particularly sensitive information that you may reveal to me that is not required to be included in your Clinical Record. 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 release would be harmful to your physical, mental or emotional health. PATIENT RIGHTS HIPAA provides you with several new or expanded rights with regard to your Clinical Record and disclosures of PHI. These rights include requesting that I amend your record; requesting restrictions on what information from your Clinical Record is disclosed to others; requesting an accounting of most disclosures of PHI that you have neither consented to nor authorized; determining the location to which PHI disclosures are sent; having any complaints you make about my policies and procedures recorded in your records; and the right to a paper copy of this Agreement and the attached Notice form describing my privacy practices. INSURANCE REIMBURSEMENT You are responsible for paying my fee. I do not file insurance for clients, but will provide you or your insurance company with whatever assistance is needed in order for you to be reimbursed by your insurance company. 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. By signing this Agreement, you agree that I can provide requested information to your carrier. 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. Signature Date Signature Date

LIMITS ON CONFIDENTIALITY. The law protects the privacy of all communications between a patient client and a psychotherapisttherapist. In most situations, I can only release information about your treatment to others if you sign a written authorization Authorization form that meets certain legal requirements imposed by HIPAA. There are other situations that require only that you provide written, advance consent. Your signature on this Agreement provides consent for those activities, as follows: • 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 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 important to our work together. I will note all consultations in your Clinical Record (which is called “PHI” in my Notice of PsychotherapistPsychologist’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 your protected information with these individuals for both clinical and administrative purposes, such as scheduling, billing, 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 my permissionthe permission of a professional staff member. • I may also have a contract contracts with a business outside of this office (i.e. such as billing serviceand collection services). As required by HIPAA, I have a formal business associate contract with this businessthis/these business (es), in which it promises it/they promise to maintain the confidentiality of this data except as specifically allowed in the contract or otherwise required by law. If you wish, I can provide you with the name names of this organization these organizations and/or a blank copy of this contract. I also will ask for your permission before having the billing service contact you. • Disclosures required by health insurers or to collect overdue fees are discussed elsewhere in this Agreement. • If a patient client seriously 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 court proceeding and a request is made for information concerning my the professional servicesservices I provided to you, such information is protected by the psychotherapistpsychologist-patient client privilege law. I cannot provide any information without your (or your legal representative’s) written authorization, or a court order, or a subpoena of which you have been officially notified and failed to inform me that you are opposing the subpoena. 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 required to provide it for them. • If a patient client files a complaint or lawsuit against me, I may disclose relevant information regarding that patient client in order to defend myself. • If I am treating a patient client who files a worker’s compensation claim, information that is directly related to that claim mustI may, upon appropriate request, be provided required to the Workers’ Compensation Commissionprovide otherwise confidential information to your employer. 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 patientclient’s treatment. These situations are unusual in my practice. § If I have reason to know or suspect believe that a child has been who I am evaluating or treating is an abused or neglected, or has been a victim of sexual abuse by another child, the law requires that I file a report with the appropriate government agency, usually the Department for Children, Youth and Familiesof Public Welfare. Once such a report is filed, I may be required to provide additional information. § If I have reason to believe that an elderly person or other adult is in need of protective services (regarding abuse, neglect, exploitation or abandonment), the law allows me to report this to appropriate authorities, usually the Department of Aging, in the case of an elderly person. Once such a report is filed, I may be required to provide additional information. If I believe that a patient one of my clients presents a risk specific and immediate threat of serious bodily injury regarding a specifically identified or a reasonably identifiable victim and he/she is likely to a person carry out the threat or his/her familyintent, I may be required to take protective actions including actions, such as warning the potential victim(s)victim, contacting the police, or seeking initiating proceedings for 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. While this written summary of exceptions to confidentiality should prove helpful in informing you about potential problems, it is important that we discuss any questions or concerns that you may have 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 ON CONFIDENTIALITY. The law protects the privacy of all communications between a patient and a psychotherapistpsychologist. In most situationsI may use or disclose confidential information (including but not limited to PHI) for purposes of treatment, payment, and healthcare operations when your written informed consent is obtained. I can only release information about your treatment to others if may use or disclose PHI for purposes outside of treatment, payment, and healthcare operations when you sign a appropriate written authorization form that meets certain legal requirements imposed by HIPAA. There are other situations that require only that you provide written, advance consent. Your signature on this Agreement provides consent for those activities, as followsis obtained in the following situations: • 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 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 important to our work together. I will note all consultations in your Clinical Record (which is called “PHI” in my Notice of PsychotherapistPsychologist’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 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 my permission. • I also have a contract with a billing service. As required by HIPAA, I have a formal business associate contract with this business, in which it promises to maintain the confidentiality of this data except as specifically allowed in the contract or otherwise required by law. If you wish, I can provide you the name of this organization and/or a blank copy of this contract. I also will ask for your permission before having the billing service contact you. • 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 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 court proceeding and a request is made for information concerning my professional servicesyour diagnosis and treatment, such information is protected by the psychotherapistpsychologist-patient privilege law. I cannot provide any information without your (or your personal or legal representative’s) written authorization, or a court order, or a subpoena of which you have been officially notified and failed to inform me that you are opposing the subpoena. 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 required to provide it for them. • If a patient files a complaint or lawsuit against me, I may disclose relevant information regarding that patient in order to defend myself. • If a patient files a worker’s compensation claim, he or she automatically authorizes me to release any information that is directly related relevant to that claim must, upon appropriate request, be provided claim. • Disclosures required by health insurers or to the Workers’ Compensation Commissioncollect 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 I have reason to know or suspect that there is a child has been abused or neglectedabuse investigation, or has been a victim I may turn over my patient’s relevant records to the appropriate governmental agency, usually the local office of sexual abuse by another child, the law requires that I file a report with the Department for Children, Youth and Familiesof 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, I may turn over my patient’s relevant records to the appropriate 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 I believe that a patient presents a clear and substantial risk of imminent, serious harm to a person or his/her familyanother person, I may be required to take protective actions. These actions including warning may include notifying the potential victim(s)victim, contacting the police, or seeking hospitalization of for the patient. • If I believe that a patient presents a clear and substantial risk of imminent, serious harm to him/herself, I may be obligated to seek hospitalization for him/her, or to contact family members or others who can help provide protection. 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. • While this written summary of exceptions to confidentiality should prove helpful in informing you about potential problems, it is important that we discuss any questions or concerns that you may have 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.. Records That I Maintain You should be aware that, pursuant to HIPAA, I keep Protected Health Information (PHI) about you in two sets of professional records. One set constitutes your Clinical Record. It includes information about your reasons for seeking therapy, a description of the ways in which your problem impacts on your life, your diagnosis, the goals that we set for treatment, your progress towards those goals, your medical and social history, your treatment history, any past treatment records that I receive from other providers, reports of any professional consultations, your billing records, and any reports that have been sent to anyone, including reports to your insurance carrier. Except in unusual circumstances that involves danger or harm to yourself or others, you may examine and/or receive a copy of your Clinical Record, if your 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 $30 for the first 10 pages and 50 cents/page thereafter. The exceptions to this policy are contained in the attached Notice Form. I refuse your request for access to your Clinical Record, you have a right of review, which I will discuss with you upon request. In addition, I 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 client to client, they can include the contents of our conversations, my analysis of those conversations, and how they impact on your therapy. They also contain particularly sensitive information that you may reveal to me that is not required to be included in your Clinical Record. 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 such disclosure would be injurious to you. In the case of relationship of family counseling, or when multiple family members are present in the therapy session, the clinical records may contain information on all members present. If anyone in the family requests that clinical information be released to another party, for any reason, I require all those present to sign a release of information before that information can be released. Patient Rights HIPAA provides you with several new or expanded rights regarding 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. I am happy to discuss any of these rights with you. AGREEMENT TO THE ABOVE POLICIES YOUR SIGNATURE BELOW INDICATES THAT YOU HAVE READ THIS AGREEMENT AND AGREE TO ITS TERMS AND SERVES AS AN ACKNOWLEDGEMENT THAT YOU HAVE RECEIVED THE HIPAA PRIVACY NOTICE FORM DESCRIBED ABOVE. Signature Date Signature (if seen with another family member)

LIMITS ON CONFIDENTIALITY. The law protects the privacy of all communications between a patient and a psychotherapistpsychologist. In most situations, I can only release information about your treatment to others if you sign a written authorization form HIPAA Authorization Form that meets certain legal requirements imposed by HIPAA. There are other situations that require only that you provide written, advance consent. Your signature on this Agreement provides consent for those activities, as follows: • 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 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 important to our work together. I will note all consultations in your Clinical Record (which is called “PHI” in my Notice of PsychotherapistPsychologist’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 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 my permission. • I also have a contract with a billing service. As required by HIPAA, I have a formal business associate contract with this business, in which it promises to maintain the confidentiality of this data except as specifically allowed in the contract or otherwise required by law. If you wish, I can provide you the name of this organization and/or a blank copy of this contract. I also will ask for your permission before having the billing service contact you. • Disclosures required by health insurers or to collect overdue fees are discussed elsewhere in this Agreement. • If a patient client seriously 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. 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 client to the client or others, or there is a probability of immediate mental or emotional injury to the client. 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 my professional servicesyour diagnosis and treatment, such information is protected by the psychotherapistpsychologist-patient privilege law. I cannot provide any information without your (or your legal representative’s) written authorization, or a court order, or a subpoena of which you have been officially notified and failed to inform me that you are opposing the subpoena. 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. You have agreed that it is not in your best interests or your children’s best interests for me to testify in a court proceeding and will request that any attorneys involved in your case refrain from asking me to testify, requesting information regarding you or your children, or subpoenaing my records. • If a government agency is requesting the information for health oversight activities, I may be required to provide it for them. • If a patient files a complaint or lawsuit against me, I may disclose relevant information regarding that patient in order to defend myself. • If a patient files a worker’s compensation claim, information that is directly related to that claim I must, upon appropriate request, be provided provide records relating to the Workers’ Compensation Commissiontreatment or hospitalization for which compensation is being sought. 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 cause to know or suspect believe that a child under 18 has been or may be abused or neglectedneglected (including physical injury, substantial threat of harm, mental or emotional injury, or has been any kind of sexual contact or conduct), or that a child is a victim of a sexual abuse by another childoffense, or that an elderly or disabled person is in a state of abuse, neglect or exploitation, the law requires that I file make a report with to the appropriate governmental agency, usually the Department for Children, Youth of Protective and FamiliesRegulatory Services. Once such a report is filed, I may be required to provide additional information. § • If I believe determine that there is a probability that the patient presents a risk to a person will inflict imminent physical injury on another, or histhat the patient will inflict imminent physical, mental or emotional harm upon him/her familyherself, or others, I may be required to take protective actions including warning the potential victim(s), contacting the police, action by disclosing information to medical or seeking 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. While this written summary of exceptions to confidentiality should prove helpful in informing you about potential problems, it is important that we discuss any questions or concerns that you may have 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, you may need to obtain formal legal advice advice. PROFESSIONAL RECORDS You should be aware that, pursuant to HIPAA, I keep PHI about you in two sets of professional records. One set constitutes your Clinical Record. It includes information about your reasons for seeking my services, a description of the ways in which your problem impacts on your life, your diagnosis, the goals that we set for treatment, your progress towards those goals, your medical and social history, your treatment history, any past treatment records that I receive from other providers, reports of any professional consultations, your billing records, and any reports that have been sent to anyone, including reports to your insurance carrier. Except in unusual circumstances that involve danger to yourself and others, you may examine and/or receive a copy of your Clinical Record if you request it in writing. You should be needed.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 initially review them in my presence, or have them forwarded to another mental health professional so you can discuss the contents. The exceptions to this policy are contained in the attached Notice Form. If I refuse your request for access to your Clinical Record, you have a right of review, which I will discuss with you upon your request. In addition, I 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 client to client, they can include the contents of our conversations, my analysis of those conversations, and how they impact on your therapy. They also contain particularly sensitive information that you may reveal to me that is not required to be included in your Clinical Record. 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 release would be harmful to your physical, mental or emotional health. PATIENT RIGHTS HIPAA provides you with several new or expanded rights with regard to your Clinical Record and disclosures of PHI. These rights include requesting that I amend your record; requesting restrictions on what information from your Clinical Record is disclosed to others; requesting an accounting of most disclosures of PHI that you have neither consented to nor authorized; determining the location to which PHI disclosures are sent; having any complaints you make about my policies and procedures recorded in your records; and the right to a paper copy of this Agreement and the attached Notice form describing my privacy practices. INSURANCE REIMBURSEMENT You are responsible for paying my fee. I do not file insurance for clients, but will provide you or your insurance company with whatever assistance is needed in order for you to be reimbursed by your insurance company. 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. By signing this Agreement, you agree that I can provide requested information to your carrier. 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. Signature Date Signature Date

LIMITS ON CONFIDENTIALITY. The law protects the privacy of all communications between a patient and a psychotherapisttherapist. In most situations, I can only release information about your treatment to others if you sign a written authorization Authorization form that meets certain legal requirements imposed by HIPAA. There are other situations that require only that you provide written, advance consent. Your signature on this Agreement provides consent for those activities, activities as follows: • ● 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 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 important to our work together. I will note all consultations in your Clinical Record (which is called “PHI” in my Notice of Psychotherapist’s Physicians 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 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 my permission. • I also have a contract with a billing service. As required by HIPAA, I have a formal business associate contract with this business, in which it promises to maintain the confidentiality of this data except as specifically allowed in the contract or otherwise required by law. If you wish, I can provide you the name of this organization and/or a blank copy of this contract. I also will ask for your permission before having the billing service contact you. • ● Disclosures required by health insurers or to collect overdue fees are discussed elsewhere in this Agreement. • ● If you threaten to harm yourself or others, I may be obligated to seek hospitalization for you or to contact family members or others who can help provide support. 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 my professional services, such information is protected by the physician-patient privilege law. I cannot provide any information without your written authorization, or a court order. ● If a government agency is requesting the information for health oversight activities, I may be required to provide it for them. ● If a patient files a complaint or lawsuit against me, I may disclose relevant information regarding the patient in order to respond to the complaint. ● If a patient files a workers’ compensation claim, and I am providing treatment related to the claim, I must, upon appropriate request, provide information including a copy of the patient’s record, to the patient’s employer, the insurer or the Department of Industrial Accidents. Some situations may occur in which I am legally obligated to take actions that I believe are necessary to attempt to protect yourself and/or others from harm. These situations are very unusual in my practice, and if they should arise, I will discuss it with you fully before taking action, and will limit my disclosure to only what is necessary. ● If I have reason to believe that a child (under 18 years of age), a disabled adult, or an elderly person has been abused or neglected, the law requires that I file a report with the appropriate governmental agency. Once such a report is filed, I may be required to provide additional information. ● If, in my professional opinion, a patient poses a serious danger of violence to another, I may be required to take protective actions. These actions may include, but are not limited to, notifying the potential victim, and/or contacting the police. ● 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. PROFESSIONAL RECORDS The laws and standards of my profession require that I keep Protected Health Information about you in your clinical record. You may examine and/or receive a copy of your records if you request it in writing, unless I believe that access would endanger you. In that situation, you have a right to a summary and to have your record sent to another mental health provider or your attorney. 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. PATIENT RIGHTS HIPAA provides you with several new or expanded rights regarding your Clinical Record and disclosures of Protected Health Information (PHI). These rights include requesting that I amend your record; requesting restrictions on what information from your Clinical Record is disclosed to others; requesting an accounting of most disclosures of 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 AND PARENTS Patients under 18 years of age and their parents should be aware that the law allows parents to examine their child’s treatment records, unless I believe that this review would be harmful to the patient and his/her treatment. I typically provide parents with only general information about the progress of the child’s treatment. If I feel that the child is in danger or is a danger to someone else, 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 concerns he/she may have. RISKS AND BENEFITS Psychotherapy has benefits and risks. Since therapy may involve discussing unpleasant aspects of your life, you may experience uncomfortable feelings like sadness, guilt, anger, frustration, loneliness, and helplessness. On the other hand, psychotherapy has also been shown to have many benefits, often leading to better relationships, solutions to specific problems, and significant reductions in feelings of distress. There are some situations where I am permitted or required to disclose information without either not guarantees of what you will experience. PROFESSIONAL FEES / FINANCIAL AGREEMENT My fee is $160 per 50 minute session ($200 per initial evaluation session). In the event that your consent or Authorization: • If insurance coverage lapses, you are involved responsible for the entire fee. It is important that you advise us of any change in a court proceeding and a request is made your insurance coverage. You are responsible for information concerning my professional servicesany co-pays, such information is protected by the psychotherapistco-patient privilege law. I cannot provide any information without your (or your legal representative’s) written authorizationinsurance, or a court orderdeductible amounts. All co-payments are due at the beginning of each session. Most of our patients prefer the convenience of paying by credit/debit card, or a subpoena of which you have been officially notified and failed to inform me that but you are opposing the subpoenawelcome pay by cash or check if you prefer. If you are involved in or contemplating litigationarrive without your co-pay, your credit/debit card will automatically be charged. If and when you decide to discontinue therapy with me, you should consult with are responsible for paying any outstanding balance on your attorney to determine whether a court would be likely to order me to disclose informationaccount. • If a government agency personal check is requesting returned due to insufficient funds, we will charge your credit/debit card a $25 processing fee, in addition to the information amount of the returned check. Credit/debit cards: Patients are required to provide a credit/debit card upon registering with Xxxx Counseling. We will use this card to charge you for health oversight activitiesany fees per the above rules. If your card is cancelled or declined, I may you will be required to provide it for them. • If us with a patient files a complaint or lawsuit against me, I may disclose relevant information regarding that patient valid card in order to defend myselfcontinue receiving therapy. • Cancellations/Missed Appointments: Once an appointment is scheduled, you are expected to pay for it unless 24 hours advance notice of cancellation is given. If you miss a patient files scheduled appointment or cancel with less than 24 hours’ notice (aside from a worker’s compensation claimgenuine emergency), information that there is directly related to that claim must, upon appropriate request, be provided to the Workers’ Compensation Commissionan $85 fee. There are some situations in which This is because I am legally obligated unable to take actionsoffer the time to another client without advance notice. Please note that this fee is not billable to your insurance company, which I believe and will be charged to your credit/debit card. Other services (e.g. report writing, extended telephone conversations) 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 charged based on our private pay rate of $160/hour, in my practice. § If I have reason to know or suspect that a child has been abused or neglected, or has been a victim of sexual abuse by another child, the law requires that I file a report with the Department for Children, Youth and Families. Once such a report is filed, I may be required to provide additional information. § If I believe that a patient presents a risk to a person or his/her family, I may be required to take protective actions including warning the potential victim(s), contacting the police, or seeking hospitalization of the patient15-minute increments. If services are needed outside the office, such a situation arisesas school consultations or legal proceedings, I you are expected to pay for all my professional time, including travel and waiting time. My fees are subject to periodic change, and you will make every effort be notified in advance of such changes. INSURANCE REIMBURSEMENT For us to fully discuss it with you before taking any action set realistic treatment goals and I will limit my disclosure to what is necessary. While this written summary of exceptions to confidentiality should prove helpful in informing you about potential problemspriorities, it is important that we discuss any questions or concerns 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 assist you in receiving 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 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 neededfind out exactly what mental health services your insurance policy covers.

LIMITS ON CONFIDENTIALITY. The law protects the privacy of all communications between a patient client and a psychotherapisttherapist. In most situations, I can only release information about your treatment to others if you sign a written authorization Authorization form that meets certain legal requirements imposed by HIPAA. There are other situations that require only that you provide written, advance consent. Your signature on this Agreement provides consent for those activities, as follows: •  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 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 important to our work together. I will note all consultations in your Clinical Record (which is called “PHI” in my Notice of PsychotherapistPsychologist’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 your protected information with these individuals for both clinical and administrative purposes, such as scheduling, billing, 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 my permissionthe permission of a professional staff member. •  I may also have a contract contracts with a business outside of this office (i.e. such as billing serviceand collection services). As required by HIPAA, I have a formal business associate contract with this businessthis/these business (es), in which it promises it/they promise to maintain the confidentiality of this data except as specifically allowed in the contract or otherwise required by law. If you wish, I can provide you with the name names of this organization these organizations and/or a blank copy of this contract. I also will ask for your permission before having the billing service contact you. •  Disclosures required by health insurers or to collect overdue fees are discussed elsewhere in this Agreement. •  If a patient client seriously 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 court proceeding and a request is made for information concerning my the professional servicesservices I provided to you, such information is protected by the psychotherapist-patient psychologist- client privilege law. I cannot provide any information without your (or your legal representative’s) written authorization, or a court order, or a subpoena of which you have been officially notified and failed to inform me that you are opposing the subpoena. 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 required to provide it for them. •  If a patient client files a complaint or lawsuit against me, I may disclose relevant information regarding that patient client in order to defend myself. •  If I am treating a patient client who files a worker’s compensation claim, information that is directly related to that claim mustI may, upon appropriate request, be provided required to the Workers’ Compensation Commissionprovide otherwise confidential information to your employer. 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 patientclient’s treatment. These situations are unusual in my practice. §  If I have reason to know or suspect believe that a child has been who I am evaluating or treating is an abused or neglected, or has been a victim of sexual abuse by another child, the law requires that I file a report with the appropriate government agency, usually the Department for Children, Youth and Familiesof Public Welfare. Once such a report is filed, I may be required to provide additional information. §  If I have reason to believe that an elderly person or other adult is in need of protective services (regarding abuse, neglect, exploitation or abandonment), the law allows me to report this to appropriate authorities, usually the Department of Aging, in the case of an elderly person. Once such a report is filed, I may be required to provide additional information.  If I believe that a patient one of my clients presents a risk specific and immediate threat of serious bodily injury regarding a specifically identified or a reasonably identifiable victim and he/she is likely to a person carry out the threat or his/her familyintent, I may be required to take protective actions including actions, such as warning the potential victim(s)victim, contacting the police, or seeking initiating proceedings for 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. While this written summary of exceptions to confidentiality should prove helpful in informing you about potential problems, it is important that we discuss any questions or concerns that you may have 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 ON CONFIDENTIALITY. The law protects the privacy of all communications between a patient and a psychotherapistpsychologist. In most situations, I the therapist can only release information about your treatment to others if you sign a written authorization Authorization form that meets certain legal requirements imposed by HIPAAHIPAA and/or Illinois law. There are other situations that require only that you provide writtenHowever, advance consent. Your signature on this Agreement provides consent for those activitiesin the following situations, as followsno authorization is required: • I The therapist may occasionally find it helpful to consult other health and mental health professionals about a case. During a consultation, I the 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 object• From time to time, I will not tell you about these consultations unless I feel that it is important to our work together. I will note all consultations in your Clinical Record (which is called “PHI” in my Notice of Psychotherapist’s Policies and Practices to Protect the Privacy of Your Health Information). • You should be aware that I practice therapist may have contracts with other mental health professionals and that I employ administrative staff. In most cases, I need vendors to share protected information assist with these individuals for both clinical and administrative purposeshis/her practice, 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 my permission. • I also have a contract with a billing service. As required by HIPAA, I the therapist will have a formal business associate contract with this businessthis/these business(es), in which it promises it/they promise to maintain the confidentiality of this data except as specifically allowed in the contract or otherwise required by law. If you wish, I the therapist can provide you with the name names of this organization these organizations and/or a blank copy of this contract. I also will ask for your permission before having the billing service contact you. • 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 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 court proceeding and a request is made for information concerning my professional servicesyour diagnosis and treatment, such information is protected by the psychotherapistpsychologist-patient privilege law. I cannot provide any , but the therapist may be required to disclose information without your (or your legal representative’s) written authorization, or in the case of a court order, or a subpoena of which you have been officially notified and failed to inform me that you are opposing the subpoena. 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 the therapist to disclose information. • If a government agency is requesting the information for health oversight activities, I the therapist may be required to provide it for them. • If a patient files a complaint or lawsuit against methe therapist, I the therapist may disclose relevant information regarding that patient in order to defend myselfhimself/herself. • If a patient files you file a worker’s compensation claim, information that and the therapist is directly related to that claim rendering treatment or services in accordance with the provisions of Illinois Workers’ Compensation law, the therapist must, upon appropriate request, be provided provide a copy of your record to the Workers’ Compensation Commissionyour employer or his/her appropriate designee. There are some situations in which I am the therapist is legally obligated to take actions, which I actions that the therapist believe are necessary to attempt to protect others from harm and I harm. The therapist may have to reveal some information about a patient’s treatment. These situations are unusual in my his/her practice. § § If I have reason the therapist has reasonable cause to know or suspect believe that a child has been under 18 known to the therapist in his/her professional capacity may be an abused child or neglected, or has been a victim of sexual abuse by another neglected child, the law requires that I the therapist file a report with the local office of the Department for Children, Youth of Children and FamiliesFamily Services. Once such a report is filed, I the therapist may be required to provide additional information. § § If I the therapist has reason to believe that an adult over the age of 60 living in a patient presents domestic situation has been abused or neglected in the preceding 12 months, the law requires that the therapist file a risk report with the agency designated to receive such reports by the Department of Aging. Once such a person or his/her familyreport is filed, I the therapist may be required to provide additional information. § If you have made a specific threat of violence against another or if the therapist believes that you present a clear, imminent risk of serious physical harm to another, the therapist may be required disclose information in order to take protective actions. These actions including warning may include notifying the potential victim(s)victim, contacting the police, or seeking your hospitalization. § If the therapist believes that you present a clear, imminent risk of serious physical or mental injury or death to yourself, the therapist may be required to disclose information in order to take protective actions. These actions may include your hospitalization of the patientor contacting family members or others who can assist in protecting you. If such a situation arises, I the therapist will make every effort to fully discuss it with you before taking any action and I the therapist will limit my his/her disclosure to what is necessary. While this written summary of exceptions to confidentiality should prove helpful in informing you about potential problems, it is important that we discuss any questions or concerns that you may have now or in the future. The laws governing confidentiality can be quite complex, and I am the therapist is not an attorney. In situations where specific advice is required, formal legal advice may be needed.

LIMITS ON CONFIDENTIALITY. The law protects the privacy of all communications between a patient client and a psychotherapistcounselor. In most situations, I your information can only release information about your treatment to others be released if you sign a written authorization form that meets certain legal requirements imposed by HIPAA. There are other situations that require only that you to provide written, advance advanced consent. Your signature on this Agreement agreement provides consent for those activities, as follows: • I Consultation with other professionals may occasionally find it helpful be necessary for this therapist to consult other health and mental health professionals about a caseprovide the best services. During a consultation, I make every effort is made to avoid revealing the identity of my patienta client. The other professionals are also legally bound to keep the information confidential. If you don’t object, I will you may not tell you be told about these consultations unless I feel that it is important to our work together. I will note all consultations in your Clinical Record (which is called “PHI” in my Notice of Psychotherapist’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 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 my permission. • I also have a contract with a billing service. As required by HIPAA, I have a formal business associate contract with this business, in which it promises to maintain the confidentiality of this data except as specifically allowed in the contract or otherwise required by law. If you wish, I can provide you the name of this organization and/or a blank copy of this contract. I also will ask for your permission before having the billing service contact you. • Disclosures required by health insurers or to collect overdue fees are discussed elsewhere in this Agreementagreement. • If a patient client threatens to harm herself/himself, Omaha OB/herself, I XXX may be obligated to seek hospitalization for her/him/her, or to contact family members or others who can help provide protection. There are some situations where I am your therapist may be required or permitted or required to disclose information without either your consent or Authorizationprivate health information: • If you are involved in a court proceeding and a request is made for information concerning my professional servicesyour diagnosis and treatment, such information is protected by the psychotherapistcounselor-patient client privilege law. I Your therapist cannot provide any information without your (or your legal representative’s) written authorization, or a court order, or a subpoena of which you have been officially notified and failed to inform me that you are opposing the subpoena. 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 your therapist to disclose information. • If a government agency is requesting the information for health oversight activities, I your therapist may be required to provide it for them. • If a patient files a complaint or lawsuit against me, I may disclose relevant information regarding that patient in order to defend myself. • If a patient files a worker’s compensation claim, your therapist may disclose information that is directly related relevant to that claim must, upon appropriate request, be provided to the Workers’ Compensation Commissionpatient’s employer or the insurer. There are some situations in which I am your therapist is legally obligated to take actions, which I believe are necessary to attempt to protect self and others from harm harm, and I may have to reveal some information about a patient’s your treatment. These situations are unusual in my practicenot a common occurrence and are only enacted if there are immediate safety concerns. § • If I have reason to know your therapist knows or suspect suspects that a child under the age of 18 has been abused abuse or neglected, or has been a victim of sexual abuse by another child, the law requires that I therapists file a report with the appropriate governmental agency, usually the Nebraska Department for Children, Youth of Health and FamiliesHuman Services. Once such a report is filed, I therapists may be required to provide additional information. § • If I believe your therapist knows or suspects that an elderly or disabled adult has been abused, neglected, exploited, sexually or emotionally abused, the law requires that therapists file a patient presents report with the appropriate governmental agency, usually the Nebraska Department of Health and Human Services. Once such a risk to a person or his/her familyreport is filed, I therapists may be required to take protective actions including warning provide additional information. • If your therapist believes that disclosing information about you is necessary to prevent or lessen a serious and imminent threat to the potential victim(shealth and safety of an identifiable person(s), contacting disclosure may occur, but only to those reasonably able to prevent or lessen the police, or seeking hospitalization of the patientthreat. If such a situation one of these situations arises, I your therapist will make every effort to fully discuss it with you before taking any action action, and I will try to limit my any disclosure to what is necessary. While this written summary Teenagers: Confidentiality and trust are the most important aspects of exceptions working with you. Therefore, specific information will not be shared with parents or others, unless you give the therapist specific to confidentiality should prove do so. Your therapist may however, share generalities with your parents and offer helpful in informing guidance to them and other supportive persons. Exceptions: To protect you about potential problemsand help both you and your family to address and change destructive behavior, it your therapist is important that we discuss any questions or concerns that you may have now or responsible to report to the appropriate agencies in the future. The laws governing confidentiality can be quite complexfollowing events: • Sexual activities if you are under the age of 18 • Abuse: physical, sexual, emotional and I am not an attorney. In situations where specific advice psychological • Potential for suicide • Potential for homicide Should the need to report arise, your therapist will try their best to discuss it with you at the time, as honesty is required, formal legal advice may be neededcrucial to our work together.

LIMITS ON CONFIDENTIALITY. The law protects the privacy of all communications between a patient client and a psychotherapisttherapist. In most situations, I can only release information about your treatment to others if you sign a written authorization Authorization form that meets certain legal requirements imposed by HIPAA. There are other situations that require only that you provide written, advance consent. Your signature on this Agreement provides consent for those activities, as follows: • ➢ I may occasionally find it helpful to consult other health and mental health professionals about a caseyour care. During a consultation, I make every effort to avoid revealing the identity of my patientclients. 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 important to our work together. I will note all consultations consultation in your Clinical Record (which is called “PHI” in my Notice of Psychotherapist’s Policies and Practices to Protect the Privacy of Your Health Information)Record. • You should be aware that ➢ I practice with am an independent practitioner. There are other mental health professionals that work in this same building. Protected Health Information is not shared with those mental health professionals, and that records are separately stored. I employ administrative staff. In most cases, I need to only share protected information with these individuals my secretary for both clinical and administrative purposes, such as scheduling, billing, and quality assurance. All of the mental health professionals are My secretary is bound by the same rules of confidentiality. All staff members have , and she has been given training about protecting your privacy and have has agreed not to release any information outside of the practice without my permission. • There are some situations where I also have am permitted or required to disclose information without either your consent or Authorization: ➢ If you are involved in a contract with court proceeding and a billing servicerequest is made for information concerning the professional services I provided you, such information is protected by therapist-client privilege. As required by HIPAAI cannot provide any information without your written authorization, I have or a formal business associate contract with this business, in which it promises to maintain the confidentiality of this data except as specifically allowed in the contract or otherwise required by lawcourt order. If you wishare 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 can am required to provide you the name of this organization and/or a blank copy of this contractit to them. I also will ask for your permission before having the billing service contact you. • Disclosures required by health insurers or to collect overdue fees are discussed elsewhere in this Agreement. • ➢ If a patient client files a complaint or lawsuit against me, I may disclose relevant information regarding the client in order to defend myself. ➢ If I am treating a client who files a worker’s compensation claim, I may, upon appropriate request, be required to provide otherwise confidential information to the patient’s employer, the insurer, or the Worker’s Compensation Commission. There are some situations in which I am legally obligated to take actions, which I believe are necessary to attempt to protect others form harm and I may have to reveal some information about a client’s treatment. These situations are unusual in my practice. ➢ If I receive information that gives me reason to believe that a child’s physical or mental health or welfare has been or may be adversely affected by abuse or neglect, or by acts or omissions that would be abuse or neglect if committed by a parent or caretaker, the law requires that I file a report with the county Department of Social Services. If I believe that a child has been or may be abused or neglected by another person, I must report that to the appropriate law enforcement agency. Once such a report is filed, I may be required to provide additional information. ➢ If I have reason to believe that a vulnerable adult has been or is likely to be abused, neglected, or exploited, the law requires that I file a report to the Adult Protective Services Program. Once such a report is filed, I may be required to provide additional information. ➢ If I believe that a client presents a clear and substantial risk of imminent, serious harm to another, I may be required to take protective action, including notifying the potential victim, contacting the police, and/ or seeking hospitalization for the client. ➢ 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 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 my professional services, such information is protected by the psychotherapist-patient privilege law. I cannot provide any information without your (or your legal representative’s) written authorization, or a court order, or a subpoena of which you have been officially notified and failed to inform me that you are opposing the subpoena. 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. • protection ➢ If a government agency is requesting the information for health oversight activities, I may be required client reveals his or her intent to provide it for them. • If commit a patient files a complaint or lawsuit against me, I may disclose relevant information regarding that patient in order to defend myself. • If a patient files a worker’s compensation claim, information that is directly related to that claim must, upon appropriate request, be provided to the Workers’ Compensation 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 patient’s treatment. These situations are unusual in my practice. § If I have reason to know or suspect that a child has been abused or neglected, or has been a victim of sexual abuse by another child, the law requires that I file a report with the Department for Children, Youth and Families. Once such a report is filed, I may be required to provide additional information. § If I believe that a patient presents a risk to a person or his/her familycrime, I may be required to take protective actions including warning the potential victim(s)preventative action, contacting such as calling the police, or seeking 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. While this written summary of exceptions to confidentiality should prove helpful in informing you about potential problems, it is important that we discuss any questions or concerns that you may have 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 I am required to keep treatment records. All records are locked and kept confidential. If you wish to see your records, I would prefer you review them in my presence so that we may discuss the contents. Client 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 restriction 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 of this Agreement, the Notice form, and my privacy policies and procedures. I am happy to discuss any of these rights with you. Minor and Parents Clients under 18 years of age who are not emancipated from their parents should be aware that the law allows parents to examine their child’s Clinical Records, unless I decide that such access is likely to injure the child, or we agree otherwise. Because privacy in psychotherapy is often crucial to successful progress, particularly, with teenagers, it is sometimes my policy to request an agreement form parents that they consent to give up their access to their child’s 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. 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 to handle any objections he/she may have. Billings and Payments You will be expected to pay for each session at the time it is held. Payment schedules for other professional services will be agreed to when they are requested. I currently do not accept insurance. YOUR SIGNATURE BELOW INDICATES THAT YOU HAVE RED THIS AGREEMENT AND AGREE TO ITS TERMS AND ALSO SERVES AS AN ACKNOWLEDGEMENT THAT YOU HAVE RECEIVED THE HIPAA NOTICE FORM DESCRIBED ABOVE. Print Name Date: Client’s Signature Print Name Date: