Common use of Location Based Services Clause in Contracts

Location Based Services. If you used location-based services on your mobile phone, you may wish to be aware of the privacy issues related to using these services. I do not place my practice as a check-in location on various sites such as Foursquare, Gowalla, Loopt, etc. However, if you have GPS tracking enabled on your device, it is possible that others may surmise that you are a therapy client due to regular check-ins at my office on a weekly basis. Please be aware of this risk if you are intentionally “checking in,” from my office or if you have a passive LBS app enabled on your phone. Email I prefer using email only to arrange or modify appointments. Please do not email me content related to your therapy sessions, as email is not completely secure or confidential. If you choose to communicate with me by email, be aware that all emails are retained in 24-Hour Crisis Lines the logs of your and my Internet service providers. While it is unlikely that someone will 800-273-TALK drhanzy@myfaithcs .org xxx.xxxxxxxxx.xxx be looking at these logs, they are, in theory, available to be read by the system administrator(s) of the Internet service provider. You should also know that any emails I receive from you and any responses that I send to you become a part of your legal record. My Private Practice Social Media Policy XXXXXXX X XXXXX, PHD, LMFT Owner MYFAITH COMMUNITY & Conclusion Thank you for taking the time to review my Social Media Policy. If you have questions or concerns about any of these policies and procedures or regarding our potential interactions on the Internet, do bring them to my attention so that we can discuss them. COUNSELING SERVICES 0000 Xxxx Xxxx Xxx Xxx X Xxxxxxx, Xx 00000 P: 000-000-0000 E: drhanzy@ xxxxxxxx.xxx Contra Costa Mental Health Access Line 0-000-000-0000 24-Hour Crisis Lines 800-273-TALK drhanzy@myfaithcs .org xxx.xxxxxxxxx.xxx Signature Date AUTHORIZATION TO RELEASE CONFIDENTIAL INFORMATION XXXXXXX X XXXXX, PHD, LMFT Owner MYFAITH COMMUNITY & COUNSELING SERVICES Since all communications made within the confines of a psychotherapeutic relationship are confidential, it is necessary for this office to request a signed authorization in order to release or obtain any information related to this type of confidential relationship. I, [Name of Patient] (“Patient”) hereby authorize Xxxxxxx X Xxxxx, LMFT, PhD, (Provider”) to release confidential information obtained during the course of my treatment to [name or function of the person(s) or entities to whom information is to be released] 3105 Lone Tree Way Ste B Antioch, Ca 94509 P: 000-000-0000 (“Recipient”). This Authorization permits the release of the following information: E:drhanzy@myf Diagnosis Treatment Plan Progress to Date xxxxx.xxx Prognosis Clinical Test Results Dates of Treatment Any and All Information Necessary Other (specify) I authorize the release of the information described above for the following purpose(s): The specific uses and limitations on the types of information to be released are as follows: The specific uses and limitations on the use of the information by Recipient are as follows: Contra Costa Mental Health Access Line 0-000-000-0000 24-Hour Crisis Lines 800-273-TALK drhanzy@myfaithcs .org xxx.xxxxxxxxx.xxx I authorize the release of any medical or other health information necessary to process Medi-Cal or other insurance claims. I also request payment of government benefits either to myself or the party who accepts payment on my behalf. I understand that I have a right to receive a copy of this Authorization, and that any modification or revocation of this Authorization must be in writing. The Authorization shall remain valid until: (“Expiration Date”) (Patient or Patient’s Representative) Name: Date: (Patient or Patient’s Representative) Signature: Date: Authorization to Exchange Confidential Information XXXXXXX X XXXXX, PHD, LMFT Owner I, [Name of Patient] hereby authorize [Name of Provider]_ to exchange confidential information regarding my treatment with [name and function of the person(s) or entities to which information is to be exchanged] MYFAITH COMMUNITY & COUNSELING SERVICES This Authorization permits the exchange of the following information: 3105 Lone Tree Any and All Information Necessary Way Ste B Antioch, Ca 94509 Diagnosis Treatment Plan Prognosis P:000-000-0000 E:drhanzy@myf Progress to Date Clinical Test Results _ Dates of Treatment xxxxx.xxx Patient Records Summary of Treatment Other I authorize the exchange of the information described above for the following purpose(s): The recipient may use the information described above solely for the following purpose(s): I understand that I have a right to receive a copy of this authorization. I also understand that any cancellation or modification of this authorization must be in writing. Contra Costa Mental Health Access Line 0-000-000-0000 This Authorization shall remain valid until: (“Expiration Date”) 24-Hour Crisis Lines 800-273-TALK By: (Patient or Patient’s Representative*) Date: drhanzy@myfaithcs .org xxx.xxxxxxxxx.xxx *If signed by other than Patient, please indicate the relationship between Patient and his/her Representative: Adult Symptom Checklist of Concerns XXXXXXX X XXXXX, PHD, LMFT Owner MYFAITH COMMUNITY & COUNSELING SERVICES 0000 Xxxx Xxxx Xxx Xxx X Xxxxxxx, Xx 00000 P: 000-000-0000 E:drhanzy@ xxxxxxxx.xxx Contra Costa Mental Health Access Line 0-000-000-0000 24-Hour Crisis Lines 800-273-TALK drhanzy@myfaithcs .org xxx.xxxxxxxxx.xxx Name: Date: Please mark all of the items below that apply, and feel free to add any others at the bottom under “Any other concerns or issues.” You may add a note or details in the space next to the concerns checked. ❑ I have no problem or concern bringing me here ❑ Abuse—physical, sexual, emotional, neglect (of children or elderly persons), cruelty to animals ❑ Aggression, violence ❑ Alcohol use ❑ Anger, hostility, arguing, irritability ❑ Anxiety, nervousness ❑ Attention, concentration, distractibility ❑ Career concerns, goals, and choices ❑ Childhood issues (your own childhood) ❑ Codependence ❑ Confusion ❑ Compulsions ❑ Custody of children ❑ Decision making, indecision, mixed feelings, putting off decisions ❑ Delusions (false ideas) ❑ Dependence ❑ Depression, low mood, sadness, crying ❑ Divorce, separation ❑ Drug use—prescription medications, over-the-counter medications, street drugs ❑ Eating problems—overeating, undereating, appetite, vomiting (see also “Weight and diet issues”) ❑ Emptiness ❑ Failure ❑ Fatigue, tiredness, low energy ❑ Fears, phobias ❑ Financial or money troubles, debt, impulsive spending, low income ❑ Friendships ❑ Gambling ❑ Xxxxxxxx, mourning, deaths, losses, divorce ❑ Guilt ❑ Headaches, other kinds of pains ❑ Health, illness, medical concerns, physical problems ❑ Housework/chores—quality, schedules, sharing duties ❑ Inferiority feelings ❑ Interpersonal conflicts ❑ Impulsiveness, loss of control, outbursts ❑ Irresponsibility ❑ Judgment problems, risk taking ❑ Legal matters, charges, suits ❑ Loneliness Adult Symptom Checklist of Concerns XXXXXXX X XXXXX, PHD, LMFT Owner MYFAITH COMMUNITY & COUNSELING SERVICES 0000 Xxxx Xxxx Xxx Xxx X Antioch, Ca 94509 P: 000-000-0000 E: drhanzy@ xxxxxxxx.xxx Contra Costa Mental Health Access Line 0-000-000-0000 24-Hour Crisis Lines 800-273-TALK xxxxxxx@xxxxxxxxx.xxx xxx.xxxxxxxxx.xxx ❑ Marital conflict, distance/coldness, infidelity/affairs, remarriage, different expectations, disappointments ❑ Memory problems ❑ Menstrual problems, PMS, menopause ❑ Mood swings ❑ Motivation, laziness ❑ Nervousness, tension ❑ Obsessions, compulsions (thoughts or actions that repeat themselves) ❑ Oversensitivity to rejection ❑ Pain, chronic ❑ Panic or anxiety attacks ❑ Parenting, child management, single parenthood ❑ Perfectionism ❑ Pessimism ❑ Procrastination, work inhibitions, laziness ❑ Relationship problems (with friends, with relatives, or at work) ❑ School problems (see also “Career concerns ...”) ❑ Self-centeredness ❑ Self-esteem ❑ Self-neglect, poor self-care ❑ Sexual issues, dysfunctions, conflicts, desire differences, other (see also “Abuse”) ❑ Xxxxxxx, oversensitivity to criticism ❑ Sleep problems—too much, too little, insomnia, nightmares ❑ Smoking and tobacco use ❑ Spiritual, religious, moral, ethical issues ❑ Stress, relaxation, stress management, stress disorders, tension ❑ Suspiciousness, distrust ❑ Suicidal thoughts ❑ Temper problems, self-control, low frustration tolerance ❑ Thought disorganization and confusion ❑ Threats, violence ❑ Weight and diet issues ❑ Withdrawal, isolating ❑ Work problems, employment, workaholism/overworking, can’t keep a job, dissatisfaction, ambition

Location Based Services. If you used location-based services on your mobile phone, you may wish to be aware of the privacy issues related to using these services. I do not place my practice as a check-in location on various sites such as Foursquare, Gowalla, Loopt, etc. However, if you have GPS tracking enabled on your device, it is possible that others may surmise that you are a therapy client due to regular check-ins at my office on a weekly basis. Please be aware of this risk if you are intentionally “checking in,” from my office or if you have a passive LBS app enabled on your phone. Email I prefer using email only to arrange or modify appointments. Please do not email me content related to your therapy sessions, as email is not completely secure or confidential. If you choose to communicate with me by email, be aware that all emails are retained in 24-Hour Crisis Lines the logs of your and my Internet service providers. While it is unlikely that someone will 800-273-TALK drhanzy@myfaithcs .org xxx.xxxxxxxxx.xxx be looking at these logs, they are, in theory, available to be read by the system administrator(s) of the Internet service provider. You should also know that any emails I receive from you and any responses that I send to you become a part of your legal record. My Private Practice Social Media Policy XX XXXXXXX X XXXXX, PHDHANZY, LMFT Owner MYFAITH COMMUNITY & Conclusion Thank you for taking the time to review my Social Media Policy. If you have questions or concerns about any of these policies and procedures or regarding our potential interactions on the Internet, do bring them to my attention so that we can discuss them. COUNSELING SERVICES 0000 Xxxx Xxxx Xxx Xxx X Xxxxxxx, Xx 00000 P: 000-000-0000 E: drhanzy@ xxxxxxxx.xxx Contra Costa Mental Health Access Line 0-000-000-0000 24-Hour Crisis Lines 800-273-TALK drhanzy@myfaithcs .org xxx.xxxxxxxxx.xxx Signature Date AUTHORIZATION TO RELEASE CONFIDENTIAL INFORMATION XXXXXXX X XXXXX, PHD, LMFT Owner MYFAITH COMMUNITY & COUNSELING SERVICES Since all communications made within the confines of a psychotherapeutic relationship are confidential, it is necessary for this office to request a signed authorization in order to release or obtain any information related to this type of confidential relationship. I, [Name of Patient] (“Patient”) hereby authorize Xxxxxxx X Xxxxx, LMFT, PhD, (Provider”) to release confidential information obtained during the course of my treatment to [name or function of the person(s) or entities to whom information is to be released] 3105 Lone Tree Way Ste B Antioch, Ca 94509 P: 000-000-0000 (“Recipient”). This Authorization permits the release of the following information: E:drhanzy@myf Diagnosis Treatment Plan Progress to Date xxxxx.xxx Prognosis Clinical Test Results Dates of Treatment Any and All Information Necessary Other (specify) I authorize the release of the information described above for the following purpose(s): The specific uses and limitations on the types of information to be released are as follows: The specific uses and limitations on the use of the information by Recipient are as follows: Contra Costa Mental Health Access Line 0-000-000-0000 24-Hour Crisis Lines 800-273-TALK drhanzy@myfaithcs .org xxx.xxxxxxxxx.xxx I authorize the release of any medical or other health information necessary to process Medi-Cal or other insurance claims. I also request payment of government benefits either to myself or the party who accepts payment on my behalf. I understand that I have a right to receive a copy of this Authorization, and that any modification or revocation of this Authorization must be in writing. The Authorization shall remain valid until: (“Expiration Date”) (Patient or Patient’s Representative) Name: Date: (Patient or Patient’s Representative) Signature: Date: Authorization to Exchange Confidential Information XXXXXXX X XXXXX, PHD, LMFT Owner I, [Name of Patient] hereby authorize [Name of Provider]_ to exchange confidential information regarding my treatment with [name and function of the person(s) or entities to which information is to be exchanged] MYFAITH COMMUNITY & COUNSELING SERVICES This Authorization permits the exchange of the following information: 3105 Lone Tree Any and All Information Necessary Way Ste B Antioch, Ca 94509 Diagnosis Treatment Plan Prognosis P:000-000-0000 E:drhanzy@myf Progress to Date Clinical Test Results _ Dates of Treatment xxxxx.xxx Patient Records Summary of Treatment Other I authorize the exchange of the information described above for the following purpose(s): The recipient may use the information described above solely for the following purpose(s): I understand that I have a right to receive a copy of this authorization. I also understand that any cancellation or modification of this authorization must be in writing. Contra Costa Mental Health Access Line 0-000-000-0000 This Authorization shall remain valid until: (“Expiration Date”) 24-Hour Crisis Lines 800-273-TALK By: (Patient or Patient’s Representative*) Date: drhanzy@myfaithcs .org xxx.xxxxxxxxx.xxx *If signed by other than Patient, please indicate the relationship between Patient and his/her Representative: Adult Symptom Checklist of Concerns XXXXXXX X XXXXX, PHD, LMFT Owner MYFAITH COMMUNITY & COUNSELING SERVICES 0000 Xxxx Xxxx Xxx Xxx X Xxxxxxx, Xx 00000 P: 000-000-0000 E:drhanzy@ xxxxxxxx.xxx Contra Costa Mental Health Access Line 0-000-000-0000 24-Hour Crisis Lines 800-273-TALK drhanzy@myfaithcs .org xxx.xxxxxxxxx.xxx Name: Date: Please mark all of the items below that apply, and feel free to add any others at the bottom under “Any other concerns or issues.” You may add a note or details in the space next to the concerns checked. ❑ I have no problem or concern bringing me here ❑ Abuse—physical, sexual, emotional, neglect (of children or elderly persons), cruelty to animals ❑ Aggression, violence ❑ Alcohol use ❑ Anger, hostility, arguing, irritability ❑ Anxiety, nervousness ❑ Attention, concentration, distractibility ❑ Career concerns, goals, and choices ❑ Childhood issues (your own childhood) ❑ Codependence ❑ Confusion ❑ Compulsions ❑ Custody of children ❑ Decision making, indecision, mixed feelings, putting off decisions ❑ Delusions (false ideas) ❑ Dependence ❑ Depression, low mood, sadness, crying ❑ Divorce, separation ❑ Drug use—prescription medications, over-the-counter medications, street drugs ❑ Eating problems—overeating, undereating, appetite, vomiting (see also “Weight and diet issues”) ❑ Emptiness ❑ Failure ❑ Fatigue, tiredness, low energy ❑ Fears, phobias ❑ Financial or money troubles, debt, impulsive spending, low income ❑ Friendships ❑ Gambling ❑ Xxxxxxxx, mourning, deaths, losses, divorce ❑ Guilt ❑ Headaches, other kinds of pains ❑ Health, illness, medical concerns, physical problems ❑ Housework/chores—quality, schedules, sharing duties ❑ Inferiority feelings ❑ Interpersonal conflicts ❑ Impulsiveness, loss of control, outbursts ❑ Irresponsibility ❑ Judgment problems, risk taking ❑ Legal matters, charges, suits ❑ Loneliness Adult Symptom Checklist of Concerns XXXXXXX X XXXXX, PHD, LMFT Owner MYFAITH COMMUNITY & COUNSELING SERVICES 0000 Xxxx Xxxx Xxx Xxx X Antioch, Ca 94509 P: 000-000-0000 E: drhanzy@ xxxxxxxx.xxx Contra Costa Mental Health Access Line 0-000-000-0000 24-Hour Crisis Lines 800-273-TALK xxxxxxx@xxxxxxxxx.xxx xxx.xxxxxxxxx.xxx ❑ Marital conflict, distance/coldness, infidelity/affairs, remarriage, different expectations, disappointments ❑ Memory problems ❑ Menstrual problems, PMS, menopause ❑ Mood swings ❑ Motivation, laziness ❑ Nervousness, tension ❑ Obsessions, compulsions (thoughts or actions that repeat themselves) ❑ Oversensitivity to rejection ❑ Pain, chronic ❑ Panic or anxiety attacks ❑ Parenting, child management, single parenthood ❑ Perfectionism ❑ Pessimism ❑ Procrastination, work inhibitions, laziness ❑ Relationship problems (with friends, with relatives, or at work) ❑ School problems (see also “Career concerns ...”) ❑ Self-centeredness ❑ Self-esteem ❑ Self-neglect, poor self-care ❑ Sexual issues, dysfunctions, conflicts, desire differences, other (see also “Abuse”) ❑ Xxxxxxx, oversensitivity to criticism ❑ Sleep problems—too much, too little, insomnia, nightmares ❑ Smoking and tobacco use ❑ Spiritual, religious, moral, ethical issues ❑ Stress, relaxation, stress management, stress disorders, tension ❑ Suspiciousness, distrust ❑ Suicidal thoughts ❑ Temper problems, self-control, low frustration tolerance ❑ Thought disorganization and confusion ❑ Threats, violence ❑ Weight and diet issues ❑ Withdrawal, isolating ❑ Work problems, employment, workaholism/overworking, can’t keep a job, dissatisfaction, ambitionxxx.xxxxxxxxx.xxx

Location Based Services. If you used location-based services on your mobile phone, you may wish to be aware of the privacy issues related to using these services. I do not place my practice as a check-in location on various sites such as Foursquare, Gowalla, Loopt, etc. However, if you have GPS tracking enabled on your device, it is possible that others may surmise that you are a therapy client due to regular check-ins at my office on a weekly basis. Please be aware of this risk if you are intentionally “checking in,” from my office or if you have a passive LBS app enabled on your phone. Email I prefer using email only to arrange or modify appointments. Please do not email me content related to your therapy sessions, as email is not completely secure or confidential. If you choose to communicate with me by email, be aware that all emails are retained in 24-Hour Crisis Lines the logs of your and my Internet service providers. While it is unlikely that someone will 800-273-TALK drhanzy@myfaithcs .org xxx.xxxxxxxxx.xxx be looking at these logs, they are, in theory, available to be read by the system administrator(s) of the Internet service provider. You should also know that any emails I receive from you and any responses that I send to you become a part of your legal record. My Private Practice Social Media Policy XX XXXXXXX X XXXXX, PHD, LMFT Owner MYFAITH COMMUNITY & Conclusion Thank you for taking the time to review my Social Media Policy. If you have questions or concerns about any of these policies and procedures or regarding our potential interactions on the Internet, do bring them to my attention so that we can discuss them. COUNSELING SERVICES 0000 Xxxx Xxxx Xxx Xxx X Xxxxxxx, Xx 00000 P: 000-000-0000 E: drhanzy@ xxxxxxxx.xxx Contra Costa Mental Health Access Line 0-000-000-0000 24-Hour Crisis Lines 800-273-TALK drhanzy@myfaithcs .org xxx.xxxxxxxxx.xxx Signature Date AUTHORIZATION TO RELEASE CONFIDENTIAL INFORMATION XXXXXXX X XXXXX, PHD, LMFT Owner MYFAITH COMMUNITY & COUNSELING SERVICES Since all communications made within the confines of a psychotherapeutic relationship are confidential, it is necessary for this office to request a signed authorization in order to release or obtain any information related to this type of confidential relationship. I, [Name of Patient] (“Patient”) hereby authorize Xxxxxxx X Xxxxx, LMFT, PhD, (Provider”) to release confidential information obtained during the course of my treatment to [name or function of the person(s) or entities to whom information is to be released] 3105 Lone Tree Way Ste B Antioch, Ca 94509 P: 000-000-0000 (“Recipient”). This Authorization permits the release of the following information: E:drhanzy@myf Diagnosis Treatment Plan Progress to Date xxxxx.xxx Prognosis Clinical Test Results Dates of Treatment Any and All Information Necessary Other (specify) I authorize the release of the information described above for the following purpose(s): The specific uses and limitations on the types of information to be released are as follows: The specific uses and limitations on the use of the information by Recipient are as follows: Contra Costa Mental Health Access Line 0-000-000-0000 24-Hour Crisis Lines 800-273-TALK drhanzy@myfaithcs .org xxx.xxxxxxxxx.xxx I authorize the release of any medical or other health information necessary to process Medi-Cal or other insurance claims. I also request payment of government benefits either to myself or the party who accepts payment on my behalf. I understand that I have a right to receive a copy of this Authorization, and that any modification or revocation of this Authorization must be in writing. The Authorization shall remain valid until: (“Expiration Date”) (Patient or Patient’s Representative) Name: Date: (Patient or Patient’s Representative) Signature: Date: Authorization to Exchange Confidential Information XXXXXXX X XXXXX, PHD, LMFT Owner I, [Name of Patient] hereby authorize [Name of Provider]_ to exchange confidential information regarding my treatment with [name and function of the person(s) or entities to which information is to be exchanged] MYFAITH COMMUNITY & COUNSELING SERVICES This Authorization permits the exchange of the following information: 3105 Lone Tree Any and All Information Necessary Way Ste B Antioch, Ca 94509 Diagnosis Treatment Plan Prognosis P:000-000-0000 E:drhanzy@myf Progress to Date Clinical Test Results _ Dates of Treatment xxxxx.xxx Patient Records Summary of Treatment Other I authorize the exchange of the information described above for the following purpose(s): The recipient may use the information described above solely for the following purpose(s): I understand that I have a right to receive a copy of this authorization. I also understand that any cancellation or modification of this authorization must be in writing. Contra Costa Mental Health Access Line 0-000-000-0000 This Authorization shall remain valid until: (“Expiration Date”) 24-Hour Crisis Lines 800-273-TALK By: (Patient or Patient’s Representative*) Date: drhanzy@myfaithcs .org xxx.xxxxxxxxx.xxx *If signed by other than Patient, please indicate the relationship between Patient and his/her Representative: Adult Symptom Checklist of Concerns XXXXXXX X XXXXX, PHDHANZY, LMFT Owner MYFAITH COMMUNITY & COUNSELING SERVICES 0000 Xxxx Xxxx Xxxxxx Xx Xxx Xxx X Xxxxxxx, Xx 00000 P: 000-000-0000 E:drhanzy@ xxxxxxxx.xxx Contra Costa Mental Health Access Line 0-000-000-0000 24-Hour Crisis Lines 800-273-TALK drhanzy@myfaithcs .org xxx.xxxxxxxxx.xxx Name: Date: Please mark all of the items below that apply, and feel free to add any others at the bottom under “Any other concerns or issues.” You may add a note or details in the space next to the concerns checked. ❑ I have no problem or concern bringing me here ❑ Abuse—physical, sexual, emotional, neglect (of children or elderly persons), cruelty to animals ❑ Aggression, violence ❑ Alcohol use ❑ Anger, hostility, arguing, irritability ❑ Anxiety, nervousness ❑ Attention, concentration, distractibility ❑ Career concerns, goals, and choices ❑ Childhood issues (your own childhood) ❑ Codependence ❑ Confusion ❑ Compulsions ❑ Custody of children ❑ Decision making, indecision, mixed feelings, putting off decisions ❑ Delusions (false ideas) ❑ Dependence ❑ Depression, low mood, sadness, crying ❑ Divorce, separation ❑ Drug use—prescription medications, over-the-counter medications, street drugs ❑ Eating problems—overeating, undereating, appetite, vomiting (see also “Weight and diet issues”) ❑ Emptiness ❑ Failure ❑ Fatigue, tiredness, low energy ❑ Fears, phobias ❑ Financial or money troubles, debt, impulsive spending, low income ❑ Friendships ❑ Gambling ❑ Xxxxxxxx, mourning, deaths, losses, divorce ❑ Guilt ❑ Headaches, other kinds of pains ❑ Health, illness, medical concerns, physical problems ❑ Housework/chores—quality, schedules, sharing duties ❑ Inferiority feelings ❑ Interpersonal conflicts ❑ Impulsiveness, loss of control, outbursts ❑ Irresponsibility ❑ Judgment problems, risk taking ❑ Legal matters, charges, suits ❑ Loneliness Adult Symptom Checklist of Concerns XXXXXXX X XXXXX, PHD, LMFT Owner MYFAITH COMMUNITY & COUNSELING SERVICES 0000 Xxxx Xxxx Xxx Xxx X 209 Antioch, Ca 94509 P: 000-000-0000 E: drhanzy@ xxxxxxxx.xxx Contra Costa Mental Health Access Line 0-000-000-0000 24-Hour Crisis Lines 800-273-TALK xxxxxxx@xxxxxxxxx.xxx xxx.xxxxxxxxx.xxx ❑ Marital conflict, distance/coldness, infidelity/affairs, remarriage, different expectations, disappointments ❑ Memory problems ❑ Menstrual problems, PMS, menopause ❑ Mood swings ❑ Motivation, laziness ❑ Nervousness, tension ❑ Obsessions, compulsions (thoughts or actions that repeat themselves) ❑ Oversensitivity to rejection ❑ Pain, chronic ❑ Panic or anxiety attacks ❑ Parenting, child management, single parenthood ❑ Perfectionism ❑ Pessimism ❑ Procrastination, work inhibitions, laziness ❑ Relationship problems (with friends, with relatives, or at work) ❑ School problems (see also “Career concerns ...”) ❑ Self-centeredness ❑ Self-esteem ❑ Self-neglect, poor self-care ❑ Sexual issues, dysfunctions, conflicts, desire differences, other (see also “Abuse”) ❑ Xxxxxxx, oversensitivity to criticism ❑ Sleep problems—too much, too little, insomnia, nightmares ❑ Smoking and tobacco use ❑ Spiritual, religious, moral, ethical issues ❑ Stress, relaxation, stress management, stress disorders, tension ❑ Suspiciousness, distrust ❑ Suicidal thoughts ❑ Temper problems, self-control, low frustration tolerance ❑ Thought disorganization and confusion ❑ Threats, violence ❑ Weight and diet issues ❑ Withdrawal, isolating ❑ Work problems, employment, workaholism/overworking, can’t keep a job, dissatisfaction, ambitiondrhanzy@myfaithcs .org xxx.xxxxxxxxx.xxx

Location Based Services. If you used location-based services on your mobile phone, you may wish to be aware of the privacy issues related to using these services. I do not place my practice as a check-in location on various sites such as Foursquare, Gowalla, Loopt, etc. However, if you have GPS tracking enabled on your device, it is possible that others may surmise that you are a therapy client due to regular check-ins at my office on a weekly basis. Please be aware of this risk if you are intentionally “checking in,” from my office or if you have a passive LBS app enabled on your phone. Email I prefer using email only to arrange or modify appointments. Please do not email me content related to your therapy sessions, as email is not completely secure or confidential. If you choose to communicate with me by email, be aware that all emails are retained in 24-Hour Crisis Lines the logs of your and my Internet service providers. While it is unlikely that someone will 800-273-TALK drhanzy@myfaithcs .org xxx.xxxxxxxxx.xxx be looking at these logs, they are, in theory, available to be read by the system administrator(s) of the Internet service provider. You should also know that any emails I receive from you and any responses that I send to you become a part of your legal record. My Private Practice Social Media Policy XX XXXXXXX X XXXXX, PHD, LMFT Owner MYFAITH COMMUNITY & Conclusion Thank you for taking the time to review my Social Media Policy. If you have questions or concerns about any of these policies and procedures or regarding our potential interactions on the Internet, do bring them to my attention so that we can discuss them. COUNSELING SERVICES 0000 Xxxx Xxxx Xxx Xxx X Xxxxxxx, Xx 00000 P: 000-000-0000 E: drhanzy@ xxxxxxxx.xxx Contra Costa Mental Health Access Line 0-000-000-0000 24-Hour Crisis Lines 800-273-TALK drhanzy@myfaithcs .org xxx.xxxxxxxxx.xxx Signature Date AUTHORIZATION TO RELEASE CONFIDENTIAL INFORMATION XXXXXXX X XXXXX, PHD, LMFT Owner MYFAITH COMMUNITY & COUNSELING SERVICES Since all communications made within the confines of a psychotherapeutic relationship are confidential, it is necessary for this office to request a signed authorization in order to release or obtain any information related to this type of confidential relationship. I, [Name of Patient] (“Patient”) hereby authorize Xxxxxxx X Xxxxx, LMFT, PhD, (Provider”) to release confidential information obtained during the course of my treatment to [name or function of the person(s) or entities to whom information is to be released] 3105 Lone Tree Way Ste B Antioch, Ca 94509 P: 000-000-0000 (“Recipient”). This Authorization permits the release of the following information: E:drhanzy@myf Diagnosis Treatment Plan Progress to Date xxxxx.xxx Prognosis Clinical Test Results Dates of Treatment Any and All Information Necessary Other (specify) I authorize the release of the information described above for the following purpose(s): The specific uses and limitations on the types of information to be released are as follows: The specific uses and limitations on the use of the information by Recipient are as follows: Contra Costa Mental Health Access Line 0-000-000-0000 24-Hour Crisis Lines 800-273-TALK drhanzy@myfaithcs .org xxx.xxxxxxxxx.xxx I authorize the release of any medical or other health information necessary to process Medi-Cal or other insurance claims. I also request payment of government benefits either to myself or the party who accepts payment on my behalf. I understand that I have a right to receive a copy of this Authorization, and that any modification or revocation of this Authorization must be in writing. The Authorization shall remain valid until: (“Expiration Date”) (Patient or Patient’s Representative) Name: Date: (Patient or Patient’s Representative) Signature: Date: Authorization to Exchange Confidential Information XXXXXXX X XXXXX, PHD, LMFT Owner I, [Name of Patient] hereby authorize [Name of Provider]_ to exchange confidential information regarding my treatment with [name and function of the person(s) or entities to which information is to be exchanged] MYFAITH COMMUNITY & COUNSELING SERVICES This Authorization permits the exchange of the following information: 3105 Lone Tree Any and All Information Necessary Way Ste B Antioch, Ca 94509 Diagnosis Treatment Plan Prognosis P:000-000-0000 E:drhanzy@myf Progress to Date Clinical Test Results _ Dates of Treatment xxxxx.xxx Patient Records Summary of Treatment Other I authorize the exchange of the information described above for the following purpose(s): The recipient may use the information described above solely for the following purpose(s): I understand that I have a right to receive a copy of this authorization. I also understand that any cancellation or modification of this authorization must be in writing. Contra Costa Mental Health Access Line 0-000-000-0000 This Authorization shall remain valid until: (“Expiration Date”) 24-Hour Crisis Lines 800-273-TALK By: (Patient or Patient’s Representative*) Date: drhanzy@myfaithcs .org xxx.xxxxxxxxx.xxx *If signed by other than Patient, please indicate the relationship between Patient and his/her Representative: Adult Symptom Checklist of Concerns XXXXXXX X XXXXX, PHDHANZY, LMFT Owner MYFAITH COMMUNITY & COUNSELING SERVICES 0000 Xxxx Xxxx Xxxxxx Xx Xxx Xxx X Xxxxxxx, Xx 00000 P: 000-000-0000 E:drhanzy@ xxxxxxxx.xxx Contra Costa Mental Health Access Line 0-000-000-0000 24-Hour Crisis Lines 800-273-TALK drhanzy@myfaithcs .org xxx.xxxxxxxxx.xxx Name: Date: Please mark all of the items below that apply, and feel free to add any others at the bottom under “Any other concerns or issues.” You may add a note or details in the space next to the concerns checked. ❑ I have no problem or concern bringing me here ❑ Abuse—physical, sexual, emotional, neglect (of children or elderly persons), cruelty to animals ❑ Aggression, violence ❑ Alcohol use ❑ Anger, hostility, arguing, irritability ❑ Anxiety, nervousness ❑ Attention, concentration, distractibility ❑ Career concerns, goals, and choices ❑ Childhood issues (your own childhood) ❑ Codependence ❑ Confusion ❑ Compulsions ❑ Custody of children ❑ Decision making, indecision, mixed feelings, putting off decisions ❑ Delusions (false ideas) ❑ Dependence ❑ Depression, low mood, sadness, crying ❑ Divorce, separation ❑ Drug use—prescription medications, over-the-counter medications, street drugs ❑ Eating problems—overeating, undereating, appetite, vomiting (see also “Weight and diet issues”) ❑ Emptiness ❑ Failure ❑ Fatigue, tiredness, low energy ❑ Fears, phobias ❑ Financial or money troubles, debt, impulsive spending, low income ❑ Friendships ❑ Gambling ❑ Xxxxxxxx, mourning, deaths, losses, divorce ❑ Guilt ❑ Headaches, other kinds of pains ❑ Health, illness, medical concerns, physical problems ❑ Housework/chores—quality, schedules, sharing duties ❑ Inferiority feelings ❑ Interpersonal conflicts ❑ Impulsiveness, loss of control, outbursts ❑ Irresponsibility ❑ Judgment problems, risk taking ❑ Legal matters, charges, suits ❑ Loneliness Adult Symptom Checklist of Concerns XXXXXXX X XXXXX, PHD, LMFT Owner MYFAITH COMMUNITY & COUNSELING SERVICES 0000 Xxxx Xxxx Xxx Xxx X 000 Antioch, Ca 94509 P: 000-000-0000 E: drhanzy@ xxxxxxxx.xxx Contra Costa Mental Health Access Line 0-000-000-0000 24-Hour Crisis Lines 800-273-TALK xxxxxxx@xxxxxxxxx.xxx xxx.xxxxxxxxx.xxx ❑ Marital conflict, distance/coldness, infidelity/affairs, remarriage, different expectations, disappointments ❑ Memory problems ❑ Menstrual problems, PMS, menopause ❑ Mood swings ❑ Motivation, laziness ❑ Nervousness, tension ❑ Obsessions, compulsions (thoughts or actions that repeat themselves) ❑ Oversensitivity to rejection ❑ Pain, chronic ❑ Panic or anxiety attacks ❑ Parenting, child management, single parenthood ❑ Perfectionism ❑ Pessimism ❑ Procrastination, work inhibitions, laziness ❑ Relationship problems (with friends, with relatives, or at work) ❑ School problems (see also “Career concerns ...”) ❑ Self-centeredness ❑ Self-esteem ❑ Self-neglect, poor self-care ❑ Sexual issues, dysfunctions, conflicts, desire differences, other (see also “Abuse”) ❑ Xxxxxxx, oversensitivity to criticism ❑ Sleep problems—too much, too little, insomnia, nightmares ❑ Smoking and tobacco use ❑ Spiritual, religious, moral, ethical issues ❑ Stress, relaxation, stress management, stress disorders, tension ❑ Suspiciousness, distrust ❑ Suicidal thoughts ❑ Temper problems, self-control, low frustration tolerance ❑ Thought disorganization and confusion ❑ Threats, violence ❑ Weight and diet issues ❑ Withdrawal, isolating ❑ Work problems, employment, workaholism/overworking, can’t keep a job, dissatisfaction, ambitiondrhanzy@myfaithcs .org xxx.xxxxxxxxx.xxx