Common use of PROFESSIONAL RECORDS Clause in Contracts

PROFESSIONAL RECORDS. You should be aware that, according to the rules of 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. 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 content of Psychotherapy Notes vary from client to client, they can include notes regarding the contents of our conversations, my analysis of those conversations, and how they impact on your therapy. They also can 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 both sets of records, 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 fee for copying records. The exceptions to this policy are contained in the Privacy Notice form. 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 Privacy Notice form, and my privacy policies and procedures. I am happy to discuss any of these rights and/or issues with you. 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 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 typically provide them only with general information about the progress of the child’s treatment, and his/her attendance at scheduled sessions. I also may provide parents with a summary of their child’s treatment when it is complete. Most 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 information, I will discuss the matter with the child, if possible, and do my best to handle any objections he/she may have.

PROFESSIONAL RECORDS. You should be aware that, according to the rules The laws and standards of HIPAA, my profession require that I keep Protected Health Information about you in two sets of professional records. One set constitutes your Clinical Record. It includes Except in unusual circumstances that involve danger to yourself and/or others, or where information about your reasons for seeking therapyhas been supplied to me confidentially by others, or the record makes reference to another person (unless such other person is a description of the ways in which your problem impacts on your lifehealth care provider) and I believe that access is reasonably likely to cause substantial harm to such other person, 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. 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 content of Psychotherapy Notes vary from client to client, they can include notes regarding the contents of our conversations, my analysis of those conversations, and how they impact on your therapy. They also can 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 examine and/or 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 both sets of records, 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 and for copying recordscertain other expenses. The exceptions to this policy are contained in the Privacy Notice form. HIPAA provides you with several new or expanded rights with regard If I refuse your request for access 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 records, you have neither consented a right of review (except for information that has been supplied to nor authorized; determining the location to me confidentially by others) which protected information disclosures are sent; having any complaints I will discuss with you make about my policies and procedures recorded in your records; and the right to a paper copy of this Agreement, the Privacy Notice form, and my privacy policies and procedures. I am happy to discuss any of these rights and/or issues with youupon request. 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 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 typically provide them only with general information about the progress of the child’s treatment, and his/her attendance at scheduled sessions. I will also may provide parents with parents, upon request, a summary of their child’s treatment when it is complete. Most 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.. HIPAA provides you with several 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, and HIPPA Privacy Notice. I am happy to discuss any of these rights with you. Patients who don’t have insurance or who are not using insurance have the right to receive a written Good Faith Estimate of the total expected cost of non-emergency medical services. You can dispute a bill that is at least $400 more than your Good Faith Estimate by contacting xxx.xxx.xxx/xxxxxxxxxxx or call 0-000-000-0000. The law protects the privacy of all communications between a patient and a psychologist. In most situations, I can only release information about your treatment to others if you sign a written Authorization form that meets 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:

PROFESSIONAL RECORDS. You should be aware that, according pursuant to the rules of HIPAA, I your provider 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 are set for treatment, your progress towards those goals, your medical and social history, your treatment history, any past treatment records that I receive received from other providers, reports of any professional consultations, your billing records, and any reports that have been sent to anyone, including reports to your insurance carrier. In additionExcept in unusual circumstances that involve danger to yourself and/or others or the record makes reference to another person (unless such other person is a health care provider) and your provider believes that access is reasonably likely to cause substantial harm to such other person, 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 content of Psychotherapy Notes vary from client to client, they can include notes regarding the contents of our conversations, my analysis of those conversations, and how they impact on your therapy. They also can 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 examine and/or 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 both sets of records, 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 it is recommended that you initially review them in my presencewith your provider, or have them forwarded to another mental health professional so you can discuss the contents. In most circumstances, I am allowed to (There normally will be a charge a fee for copying records). The exceptions to this policy are contained in the Privacy attached Notice formForm. If your request for access to your records is refused, you have a right of review, which will be discussed with you upon request. In addition, your provider may also keep a set of Psychotherapy Notes. These Notes are for your provider’s use and are designed to assist in providing you with the best treatment. While the contents of Psychotherapy Notes vary from client to client, they can include the contents of your conversations with your provider, an analysis of those conversations, and how they impact on your therapy. They may also contain particularly sensitive information that you may reveal to your provider that is not required to be included in your Clinical Record and information revealed to your provider 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 a separate 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 Records and disclosures of protected health information. These rights include requesting that I your provider amend your record; requesting restrictions on what information from your Clinical Record Records is disclosed to others; requesting an accounting of most disclosures of Protected Health Information 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 our policies and procedures recorded in your records; and the right to a paper view and copy of this Agreement, the Privacy Notice form, and my privacy policies and proceduresyour records,. I am Your provider will be happy to discuss any of these rights and/or issues with you. Patients under 18 years of age who These rights are not emancipated and their parents should be aware that explained further in 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 typically provide them only with general information about the progress of the child’s treatment, and his/her attendance at scheduled sessions. I also may provide parents with a summary of their child’s treatment when it is complete. Most 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 information, I will discuss the matter with the child, if possible, and do my best to handle any objections he/she may havePrivacy Notice.

PROFESSIONAL RECORDS. You should be aware that, according to the rules The standards of HIPAA, my profession require that I keep Protected Health Information about you in two sets of professional records. One set constitutes your Clinical Record. It includes Except in unusual circumstances that involve danger to yourself and 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 about your reasons for seeking therapyhas been supplied to me confidentially by others, 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. 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 content of Psychotherapy Notes vary from client to client, they can include notes regarding the contents of our conversations, my analysis of those conversations, and how they impact on your therapy. They also can 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 examine and/or 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 both sets of records, 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 circumstancessituations, I am allowed to charge a copying fee of $.50 cents per page (and for copying certain other expenses like postage). If I refuse your request for access to your records. The exceptions , you have a right of review (except for information provided to this policy are contained in the Privacy Notice formme confidentially by others) which I will discuss with you upon request. 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 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 Privacy attached Notice form, and my privacy policies and procedures. I am happy to discuss any of these rights and/or issues with you. Patients under 18 years You are expected to pay for the session at the beginning 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 recordshour. If they agreeyou have insurance I take, during treatmentthe insurance company may pay for part of this fee. If I take your insurance, I will typically provide file the insurance for you, but you are responsible for assuring that the insurance company pays their part of your bill. I am paid different rates by different insurance companies. If you have questions about any charges or fees, please feel free to discuss these with me. The parts of my fee not covered by insurance (the co-pay and/or coinsurance and deductible) are your responsibility, and I will expect you to pay them only with general information about at the progress time of the child’s treatmentsession. You are required to know how much your part of the fee will be, and his/her attendance to be sure that your sessions are authorized ahead of time by the insurance company or the managed care company administering the benefits for the insurance company. This is usually done by calling the number for mental health services on your insurance card. Please remember that when a managed care company authorizes sessions, the paperwork contains a disclaimer that even though they are authorizing the service, they cannot guarantee payment. This is the responsibility of you and your insurance company. In the event you do not know your co-pay or co-insurance, you will be responsible for the full amount at the time of service and can request reimbursement from your insurance company. If I do not accept your insurance, you may request a bill which you may submit to your insurance company. Some insurance companies will reimburse you with the “out of network” benefit. It is your responsibility to find out if your insurance will pay for an out of network therapist. This is usually accomplished by calling the number for mental health services or behavioral health services on the back of your insurance card. Your therapy appointment time is reserved only for you. This is different from other medical offices, where more than one person may be scheduled sessionsat the same time. If you run late to an appointment, it will still end at the scheduled time, because someone has a scheduled appointment right after yours. If you I accept cash, checks and money orders as payment for your session. Credit cards are not accepted. In the event that you have a check returned to me for non-payment of funds, you will be expected to pay for the associated costs I have. These charges will include a returned check charge and any bank charges that I incur. I may also may provide parents with ask you to pay by cash or money order in the future. I schedule appointments Monday through Friday. My cell phone number is available to you and if I do not answer, I encourage you to leave a summary of their child’s treatment when it is completemessage. Most other communication I check my messages daily and will require the child’s Authorization, unless I feel that the child is in danger or is a danger to someone else, in which casereturn calls as soon as possible. If you call after 6:00pm, I will notify return your call if necessary but will most likely call the parents of my concernfollowing day. Before giving parents informationIf you call on the weekend or when the office is closed, I screen messages and if you do not have an emergency, your call will discuss be returned on the matter with next business day. Please note, even though I have a cell phone I am not always available when the child, if possibleoffice is closed. There can be times when I do not check my phone for hours or I may not have coverage. If you have an emergency, and I do my best not return your call within a few minutes, please contact the emergency room of the hospital covered by your insurance company or call 911. In addition to handle any objections he/she may have911, you can call the following emergency contact numbers: Ridgeview Institute – 000-000-0000 Peachford Hospital – 000-000-0000 Behavioral Health Link (24 hour crisis line) – 0-000-000-0000 Lifeline (National Crisis Line) – 0-000-000-0000.

PROFESSIONAL RECORDS. You should be aware that, according pursuant to the rules of HIPAAHIPPA, I sometimes keep Protected Health Information about you in two sets of professional records. : One set constitutes your you 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, 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. I usually review the records with you and allow you to add a note indicating changes which will become part of your clinical 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. In most circumstances, I am allowed to charge a copying fee. If I refuse your request for access to your Clinical Record, you have a right of review which I will discuss upon request. In addition, I also sometimes 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 content contents of Psychotherapy Notes vary from client to client, they can include notes regarding the contents of our conversations, my analysis of those conversations, conversations and how they impact on your therapy. They may also can 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 request to examine and/or receive a copy of both sets of records, 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 fee for copying records. The exceptions to this policy are contained in the Privacy Notice form. 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 Privacy Notice form, and my privacy policies and procedures. I am happy to discuss any of these rights and/or issues with you. 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 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 typically provide them only with general information about the progress of the child’s treatment, and his/her attendance at scheduled sessions. I also may provide parents with a summary of their child’s treatment when it is complete. Most other communication will require the child’s Authorization, Psychotherapy Notes unless I feel determine that the child is in danger or is a danger such disclosure would be injurious to someone else, in which case, I will notify the parents of my concern. Before giving parents information, I will discuss the matter with the child, if possible, and do my best to handle any objections he/she may haveyou.

PROFESSIONAL RECORDS. You should be aware that, according pursuant to the rules of HIPAA, I keep Protected Personal 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 problems impacts on your life, your diagnosis, the goals that we I have set for treatment, your progress towards those these goals, your medical and social history, your treatment history, any past treatment records that I receive are received from other providers, reports of any other professional consultations, your billing records, and any reports that have been sent to anyone, including reports to your insurance carrier. You may examine and/or receive a copy of your Clinical Record if you request it in writing, unless I believe that access to it would endanger you. In additionthose 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 misinterpreted and/or upsetting to untrained readers. For this reason, we recommend that if you request to examine them, you initially review them with your therapist, or have them forwarded to another mental health professional so you can discuss the contents. In addition to the Clinical Record, I also might keep a set of Psychotherapy Therapy Notes. These Notes notes are for my own use and are designed to assist me in providing you with the best treatment, . While the content contents of Psychotherapy Therapy Notes vary from client to client, they can include notes regarding the contents of our therapy conversations, my analysis of those conversations, and how they impact on your therapy. They also can contain particularly sensitive information that you may reveal to me that but is not required to be included in your Clinical Record. These Psychotherapy Therapy 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 the Therapy Notes without your signed, written Authorization. Insurance companies cannot require your Authorization as a condition of coverage coverage, nor penalize you in any way for your refusal. You may examine and/or receive a copy of both sets of recordsthe Therapy Notes unless I determine that it will adversely affect your well-being. In that case, if you request it in writing. Because these are professional records, they can be misinterpreted and/or upsetting have a right to untrained readers. For this reason, I recommend that you initially review them in my presence, a summary or to have them forwarded your record sent to another mental health professional so you can discuss the contents. In most circumstances, I am allowed to charge a fee for copying records. The exceptions to this policy are contained in the Privacy Notice form. 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 Privacy Notice form, and my privacy policies and procedures. I am happy to discuss any of these rights and/or issues with you. 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 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 typically provide them only with general information about the progress of the child’s treatment, and his/her attendance at scheduled sessions. I also may provide parents with a summary of their child’s treatment when it is complete. Most 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 information, I will discuss the matter with the child, if possible, and do my best to handle any objections he/she may haveattorney.

PROFESSIONAL RECORDS. You should be aware that, according pursuant to the rules of 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, you may examine and/or receive a copy of your Clinical Record if you request it in writing. Because these are professional records, they can be misinterpreted and/or upsetting to untrained readers. For this reason, I recommend that you initially review them in my presence, or have them forwarded to another mental health professional so you can discuss the contents. In most circumstances, I am allowed to charge a copying fee of $0.25 per page (and for certain other expenses). 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 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 content contents of Psychotherapy Notes vary from client to client, they can include notes regarding the contents of our conversations, my analysis of those conversations, and how they impact on your therapy. They also can 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 both sets of records, if you request it in writing. Because these are professional records, they can your Psychotherapy Notes unless I determine that such information does not exist or cannot be misinterpreted and/or upsetting to untrained readers. For this reason, I recommend that you initially review them in my presencefound, or have them forwarded to another mental health professional so you can discuss the contents. In most circumstances, I am allowed to charge a fee for copying records. The exceptions to this policy are contained in the Privacy Notice form. HIPAA provides you with several new or expanded rights with regard such disclosure would be injurious 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 Privacy Notice form, and my privacy policies and procedures. I am happy to discuss any of these rights and/or issues with you. 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 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 typically provide them only with general information about the progress of the child’s treatment, and his/her attendance at scheduled sessions. I also may provide parents with a summary of their child’s treatment when it is complete. Most 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 information, I will discuss the matter with the child, if possible, and do my best to handle any objections he/she may havewell-being.

PROFESSIONAL RECORDS. You should be aware that, according to the rules The laws and standards of HIPAA, I our profession require that we keep Protected Health Information about you in two sets of professional records. One set constitutes your Clinical Record. It includes information about your reasons for seeking therapyservices, 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 we receive from other providers, reports of any professional consultations, your billing records, and any reports that have been sent to anyone, including reports to your insurance carrier. In additionExcept in unusual circumstances that involve danger to yourself and/or others or where information has been supplied to us confidentially by others, 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 content of Psychotherapy Notes vary from client to client, they can include notes regarding the contents of our conversations, my analysis of those conversations, and how they impact on your therapy. They also can 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 both sets of records, your Clinical Record if you request it in writing. This accessibility does not extend to testing protocols, because of test security issues. Because these are professional records, they can be misinterpreted and/or upsetting to untrained readers. For this reason, I we recommend that you initially review them in my our presence, or have them forwarded to another mental health professional so you can discuss the contents. In most circumstancessituations, I am we are allowed to charge a fee for copying recordscopying, postage, and administrative fee. The exceptions to this policy are contained in the Privacy Notice form. HIPAA Health Insurance Portability and Accountability Act (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 we 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 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 our policies and procedures recorded in your records; and the right to a paper copy of this Agreement, the Privacy attached Notice form, and my our privacy policies and procedures. I am We are happy to discuss any of these rights and/or issues with you. Patients under 18 years of age (minors) who are not emancipated and from their parents should be aware that the law may allow parents to examine their child’s treatment records. Because privacy in psychotherapy is often crucial to successful progress, particularly with teenagers, it is sometimes my our policy to request an agreement from parents that they consent to give up their access to their child’s 's records. If they agree, during treatment, I we will typically provide them only with general information about the progress of the child’s 's treatment, and his/her attendance at scheduled sessions. I We will also may provide parents with a summary of their child’s 's treatment when it is complete. Most Any other communication will require the child’s 's Authorization, unless I we feel that the child is in danger or is a danger to someone else, ; in which case, I we will notify the parents of my our concern. Before giving parents any information, I we will discuss the matter with the child, child if possible, and do my our best to handle any objections he/she may have. BILLING AND PAYMENTS (initial) You will be expected to pay for each session at the time it is held. If your account has not been paid for more than 60 days and arrangements for payment have not been agreed upon, we reserve the right to use legal means to secure the payment. This may involve hiring a collection agency or going through small claims court which will require us to disclose otherwise confidential information. In most collection situations, the only information we release regarding a patient's treatment is his/her name, the nature of services provided, and the amount due. If such legal action is necessary, all costs will be included in the claim and be the responsibility of the patient. INSURANCE REIMBURSEMENT (initial) This is a fee for service practice. We do not accept insurance and are not contracted with any insurance companies. We cannot submit paperwork for patients to obtain prior authorizations, as we are not contracted with any insurance companies. If you wish to submit a claim to your insurance company, we will provide you with a diagnosis code, if one is available and CPT codes. All insurance companies claim to keep such information confidential; we have no control over the use of the information once it has been submitted to the insurance company by our clients. If you wish to submit to your insurance company please let us know so that we can make sure to code your receipt(s) accordingly. Please specify your preferred form of contact: Telephone: Type: Email: Our standard practice is to provide patients with appointment reminders via telephone, text message, or email contact. These reminders include: the patient’s name, the name of our practice (Beljan Psychological Services) and/or the name of the professional with whom you have an appointment, the date and time of your appointment, and our telephone number. We will not disclose PHI in voicemail messages left on your cellular, home, or office phones unless you specifically authorize us to do so. By signing this agreement you give us the permission to treat you or your child in accordance with the information stated in this document. This treatment includes but is not limited to neuropsychological assessment, psychoeducational/intellectual assessment, psychotherapy, and other treatments previously discussed and agreed upon with the patient and/or guardian.

PROFESSIONAL RECORDS. You should be aware that, according to the rules The laws and standards of HIPAA, I our profession require that we keep Protected Health Information about you in two sets of professional records. One set constitutes your Clinical Record. It includes information about your reasons for seeking therapyExcept in unusual circumstances where that disclosure would physically endanger you and/or others, 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. 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 content of Psychotherapy Notes vary from client to client, they can include notes regarding the contents of our conversations, my analysis of those conversations, and how they impact on your therapy. They also can 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 examine and/or 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 both sets of records, 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 we recommend that you initially review them in my presence, our presence or have them forwarded to another mental health professional so you can discuss the contents. If you want to review your records and we believe that you seeing your records would be emotionally damaging, we reserve the right to send them to a mental health professional of your choice who can review and explain them to you. In most circumstances, I am we are allowed to charge a copying fee of $0.10 per page (and charge for copying certain other expenses). If we refuse your request for access to your records, you have a right of review, which we will discuss with you upon request. The exceptions In addition to this being able to review your notes, you also may add information to them if you believe they contain inaccurate or incomplete information. It is our office policy are contained to retain clients’ records for fifteen years after the end of our therapy. Please note that in some cases our files may include information from other treatment providers that clients have given me written permission to obtain. If you have given me permission to obtain such records, we cannot provide them to you if you ask to review your files. Instead, we would ask for you to contact the Privacy Notice formprovider who created the records and obtain copies directly from her or him. HIPAA provides you with several new or expanded rights with regard to your Clinical Record Records and disclosures of protected health information. These rights include requesting that I we amend your record; requesting restrictions on what information from your Clinical Record Records is disclosed to others; requesting an accounting of most disclosures of Protected Health Information 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 our policies and procedures recorded in your records; and the right to a paper copy of this Agreement, the Privacy attached Notice form, and my our privacy policies and procedures. I am We are happy to discuss any of these rights and/or issues with you. Patients under 18 years Parent(s) or legal guardians are authorized to provide written informed consent for the evaluation of age who are not emancipated a minor. However, the psychologist will make every effort to explain the nature 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 typically provide them only with general information about the progress purpose of the child’s treatment, evaluation and his/her attendance at scheduled sessions. I also may provide parents with a summary of their child’s treatment when it is complete. Most other communication will require the child’s Authorization, unless I feel that the child is in danger establish assent from your son or is a danger to someone else, in which case, I will notify the parents of my concern. Before giving parents information, I will discuss the matter with the child, if possible, and do my best to handle any objections he/she may havedaughter.

PROFESSIONAL RECORDS. You should be aware that, according pursuant to the rules of HIPAA, I your therapist 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 are set for treatment, your progress towards those goals, your medical and social history, your treatment history, any past treatment records that I receive received from other providerstherapists, reports of any professional consultations, your billing records, and any reports that have been sent to anyone, including reports to your insurance carrier. In additionExcept in unusual circumstances that involve danger to yourself and/or others or the record makes reference to another person (unless such other person is a health care provider) and your therapist believes that access is reasonably likely to cause substantial harm to such other person, 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 content of Psychotherapy Notes vary from client to client, they can include notes regarding the contents of our conversations, my analysis of those conversations, and how they impact on your therapy. They also can 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 examine and/or 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 both sets of records, 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 it is recommended that you initially review them in my presencewith your therapist, or have them forwarded to another mental health professional so you can discuss the contents. In most circumstances, I am allowed to (There normally will be a charge a fee for copying records). The exceptions to this policy are contained in the attached Privacy Notice formNotice. If your request for access to your records is refused, you have a right of review, which will be discussed with you upon request. In addition, your therapist may also keep a set of Psychotherapy Notes. These Notes are for your therapist's use and are designed to assist in providing you with the best treatment. While the contents of Psychotherapy Notes vary from client to client, they can include the contents of your conversations with your therapist, an analysis of those conversations, and how they impact on your therapy. They may also contain particularly sensitive information that you may reveal to your therapist that is not required to be included in your Clinical Record and information revealed to your therapist 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 a separate 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. CLIENT RIGHTS HIPAA provides you with several new or expanded rights with regard to your Clinical Record Records and disclosures of protected health information. These rights include requesting that I your therapist amend your record; requesting restrictions on what information from your Clinical Record Records is disclosed to others; requesting an accounting of most disclosures of Protected Health Information 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 our policies and procedures recorded in your records; and the right to a paper view and copy of this Agreement, the Privacy Notice form, and my privacy policies and proceduresyour records,. I am Your therapist will be happy to discuss any of these rights and/or issues with you. Patients under 18 years of age who These rights are not emancipated and their parents should be aware that explained further in 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 typically provide them only with general information about the progress of the child’s treatment, and his/her attendance at scheduled sessions. I also may provide parents with a summary of their child’s treatment when it is complete. Most 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 information, I will discuss the matter with the child, if possible, and do my best to handle any objections he/she may havePrivacy Notice.

PROFESSIONAL RECORDS. You should be aware that, according to the rules The laws and standards of HIPAA, I our profession require that we keep Protected Health Information about you in two sets of professional records. One set constitutes your Clinical Client 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. 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 content of Psychotherapy Notes vary from client to client, they can include notes regarding the contents of our conversations, my analysis of those conversations, and how they impact on your therapy. They also can 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 both sets of recordsyour Clinical Record, if you request it in writing, with the following unusual exceptions. The exceptions would involve danger to yourself or others. An example would include reference to another person when we believe that your accessing your Clinical Record is reasonably likely to cause substantial harm to that other person. Another example would be when information has been supplied to RCC confidentially by others. Because these are professional records, they can be misinterpreted and/or upsetting to untrained readers. For this reason, I we recommend that you initially review them your treatment records in my your provider’s presence, or have them forwarded to another mental health professional so you can discuss the contents. If we need to refuse your request for access to your records, you have a right of review (except for information provided to us confidentially by others), which we will discuss with you upon request. In most circumstancesaddition, I am allowed your provider may also keep a set of Psychotherapy Notes on your case. These notes are for your provider’s own use and are designed to charge assist them in providing you with the best psychotherapy and counseling. While the contents of Psychotherapy Notes vary from client to client, they generally consist of notes to ourselves about our work that would not be very meaningful to others. They may also contain particularly sensitive information that you or others reveal to us that is not required to be included in your Client Record. These Psychotherapy Notes are kept separate from your Client Record. Psychotherapy Notes regarding you are not available to you and cannot be sent to anyone else, with the possible exception of a fee court order. We are not typically asked to release copies of Psychotherapy Notes, and in virtually all cases, would refuse to do so unless mandated by law, so this information remains highly protected and confidential. Insurance companies cannot require you to authorize us to release Psychotherapy Notes as a condition of coverage nor penalize you in any way for copying records. The exceptions your refusal to this policy are contained in the Privacy Notice formprovide it. HIPAA provides you with several new or expanded rights with regard to your Clinical Client Record and disclosures of protected health information. These rights include requesting that I your provider 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 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 our policies and procedures recorded in your records; and the right to a paper copy of this Agreement, the Privacy attached Notice form, and my RCC privacy policies and procedures. I am happy We are willing to discuss any of these rights and/or issues with you. Patients Clients under 18 years of age who are not emancipated (and their parents parents) should be aware that the law may allow allows parents to examine their child’s treatment recordsrecords (except Psychotherapy notes) unless the provider believes that doing so would endanger the child or we agree otherwise. Because privacy in psychotherapy therapy, specifically, is often crucial to successful progress, particularly with teenagers, it is sometimes my our policy to request an agreement from parents that they consent to give up their access to their child’s records. If they agree, during treatment, I the therapist will typically provide them only with general information about the progress of the child’s treatment, and his/her their attendance at scheduled sessions. I also may provide parents with a summary of their child’s treatment when it is complete. Most Any other communication will require the child’s Authorization, unless I feel the therapist feels that the child is in danger or is a danger to someone else, in which case, I we will notify the parents of my the concern. Before giving parents any information, I the therapist will discuss the matter with the child, if possible, and do my their best to handle any objections he/she the minor may have. For clients under the age of 18 seeking psychiatric services, it is imperative that the Legal Guardian is available (preferably in person, but at minimum by phone) during the appointment time in order to provide consent for beginning new medications if any are prescribed. You will be expected to pay for each appointment 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. We request that all individuals maintain a credit card on file in the event of an unforeseen balance developing. Because we never wish to take our clients to small claims court or turn their accounts over to collections agencies, we work to prevent balances by requiring a credit card on file. In the event of a missed appointment (late cancelation or no-show), or a balance accruing because of insurance deductibles or changes to copays, your card will be charged at the time of the new balance. Disputing valid charges to a credit card on file may be grounds for termination from services and you will continue to be responsible for the balance due even while the disputed charges are under review by your bank. It is our policy that any patient balances must be paid at the time of services or you will be required to reschedule your appointment when the balance has been paid, barring a clinical crisis. This may mean not being seen at the time of your appointment if you have not made your payment and will result in a late cancelation fee (for non-Medicaid members) since your provider has set aside that appointment time only for you. True emergency situations will be evaluated on a case-by-case basis, as we do understand that emergencies can arise. We charge the full session fee if you miss an appointment without giving notice. This is the amount that is billed to insurance if you are using your insurance. In the event of missed appointments, insurance cannot be billed. In the case of licensed therapists, this amount is $160. For our RD, this fee is $120. For our Psychiatric Nurse Practitioner, this would be $330 for an hour; $165 for 30 minutes; and $110 for 20 minutes. If you cancel your appointment with less than 48-hours-notice, then we charge half of the session fee that you would have been paying or that would have been billed to your insurance. In the event that we must utilize a collections agency or law firm to obtain the balance owed to us, you will be responsible for all collections and attorney’s fees. If you are a Medicaid beneficiary, we are prevented as participating providers from billing for a missed appointment. However, we retain the right to terminate our patient relationship with you for one no show and three, or more, late-canceled appointments.

PROFESSIONAL RECORDS. You should be aware that, according pursuant to the rules of HIPAA, I your provider 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 are set for treatment, your progress towards those goals, your medical and social history, your treatment history, any past treatment records that I receive received from other providers, reports of any professional consultations, your billing records, and any reports that have been sent to anyone, including reports to your insurance carrier. In additionExcept in unusual circumstances that involve danger to yourself and/or others or the record makes reference to another person (unless such other person is a health care provider) and your provider believes that access is reasonably likely to cause substantial harm to such other person, 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 content of Psychotherapy Notes vary from client to client, they can include notes regarding the contents of our conversations, my analysis of those conversations, and how they impact on your therapy. They also can 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 examine and/or 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 both sets of records, 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 it is recommended that you initially review them in my presencewith your provider, or have them forwarded to another mental health professional so you can discuss the contents. In most circumstances, I am allowed to (There normally will be a charge a fee for copying records). The exceptions to this policy are contained in the Privacy attached Notice formForm. If your request for access to your records is refused, you have a right of review, which will be discussed with you upon request. In addition, your provider may also keep a set of Psychotherapy Notes. These Notes are for your provider’s use and are designed to assist in providing you with the best treatment. While the contents of Psychotherapy Notes vary from client to client, they can include the contents of your conversations with your provider, an analysis of those conversations, and how they impact on your therapy. They may also contain particularly sensitive information that you may reveal to your provider that is not required to be included in your Clinical Record and information revealed to your provider 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 a separate 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 Records and disclosures of protected health information. These rights include requesting that I your provider amend your record; requesting restrictions on what information from your Clinical Record Records is disclosed to others; requesting an accounting of most disclosures of Protected Health Information 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 our policies and procedures recorded in your records; and the right to a paper view and copy of this Agreement, the Privacy Notice form, and my privacy policies and proceduresyour records. I am Your provider will be happy to discuss any of these rights and/or issues with you. Patients under 18 years of age who These rights are not emancipated and their parents should be aware that explained further in 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 typically provide them only with general information about the progress of the child’s treatment, and his/her attendance at scheduled sessions. I also may provide parents with a summary of their child’s treatment when it is complete. Most 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 information, I will discuss the matter with the child, if possible, and do my best to handle any objections he/she may havePrivacy Notice.

PROFESSIONAL RECORDS. You should be aware that, according to the rules The laws and standards of HIPAA, I our profession require that we keep Protected Health Information about you in two sets of professional records. One set constitutes your Clinical Record. It includes information about your reasons for seeking therapyservices, 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 we receive from other providers, reports of any professional consultations, your billing records, and any reports that have been sent to anyone, including reports to your insurance carrier. In additionExcept in unusual circumstances that involve danger to yourself and/or others or where information has been supplied to us confidentially by others, 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 content of Psychotherapy Notes vary from client to client, they can include notes regarding the contents of our conversations, my analysis of those conversations, and how they impact on your therapy. They also can 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 both sets of records, your Clinical Record if you request it in writing. This accessibility does not extend to testing protocols, because of test security issues. Because these are professional records, they can be misinterpreted and/or upsetting to untrained readers. For this reason, I we recommend that you initially review them in my our presence, or have them forwarded to another mental health professional so you can discuss the contents. In most circumstancessituations, I am we are allowed to charge a fee for copying recordscopying, postage, and administrative fee. The exceptions to this policy are contained in the Privacy Notice form. HIPAA Health Insurance Portability and Accountability Act (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 we 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 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 our policies and procedures recorded in your records; and the right to a paper copy of this Agreement, the Privacy attached Notice form, and my our privacy policies and procedures. I am We are happy to discuss any of these rights and/or issues with you. Patients under 18 years of age (minors) who are not emancipated and from their parents should be aware that the law may allow parents to examine their child’s treatment records. Because privacy in psychotherapy is often crucial to successful progress, particularly with teenagers, it is sometimes my our policy to request an agreement from parents that they consent to give up their access to their child’s 's records. If they agree, during treatment, I we will typically provide them only with general information about the progress of the child’s 's treatment, and his/her attendance at scheduled sessions. I We will also may provide parents with a summary of their child’s 's treatment when it is complete. Most Any other communication will require the child’s 's Authorization, unless I we feel that the child is in danger or is a danger to someone else, ; in which case, I we will notify the parents of my our concern. Before giving parents any information, I we will discuss the matter with the child, child if possible, and do my our best to handle any objections he/she may have. BILLING AND PAYMENTS (initial) 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, we have the option of using legal means to secure the payment. This may involve hiring a collection agency or going through small claims court which will require us to disclose otherwise confidential information. In most collection situations, the only information we release regarding a patient's treatment is his/her name, the nature of services provided, and the amount due. If such legal action is necessary, all costs will be included in the claim and be the responsibility of the patient. INSURANCE REIMBURSEMENT (initial) This is a fee for service practice. We do not accept insurance. If you wish to submit a claim to your insurance company, we will provide you with a diagnosis code, if one is available and CPT codes. All insurance companies claim to keep such information confidential; we have no control over the use of the information once it has been submitted to the insurance company by our clients.. Please specify your preferred form of contact: Telephone: Type: Email: Mail: Our standard practice is to provide patients with appointment reminders via telephone or email contact. These reminders include: the patient’s name, the name of our practice (Beljan Psychological Services) and/or the name of the professional with whom you have an appointment, the date and time of your appointment, and our telephone number. We will not disclose PHI in voicemail messages left on your cellular, home, or office phones unless you specifically authorize us to do so. If you would like us to leave appointment reminders via voicemail, please specify the telephone number at which appointment reminders may be left. By signing this agreement you give us the permission to treat you or your child in accordance with the information stated in this document. This treatment includes but is not limited to neuropsychological assessment, psychoeducational/intellectual assessment, psychotherapy, and other treatments previously discussed and agreed upon with the patient and/or guardian.

PROFESSIONAL RECORDS. You should be aware that, according to the rules Laws and standards of HIPAA, I our profession require that we keep Protected Health Information about you in two sets of professional recordsyour clinical record. One set constitutes your Clinical Record. It includes information about your reasons for seeking therapyExcept in unusual circumstances where disclosure would physically endanger you and/or others, 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. 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 content of Psychotherapy Notes vary from client to client, they can include notes regarding the contents of our conversations, my analysis of those conversations, and how they impact on your therapy. They also can 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 both sets of recordsyour 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 we recommend that you initially review them in my our presence, or have them forwarded to another mental health professional professional, so you can discuss the contents. In most circumstances, I am allowed to charge a clients will be charged an appropriate fee for copying any time spent preparing information requests. If we refuse your request for access to your records, you have a right of review, which we will discuss with you upon request. The exceptions In addition to being able to review your notes, you may also add information to them, if you believe they contain inaccurate or incomplete information. Also, please note that in some cases our files may include information from other treatment providers, which clients have given us written permission to obtain. If you have given permission to obtain such records, we cannot provide the records of other professionals to you, if you request. Instead, we would ask for you to contact the provider who created the records and obtain copies directly from her or him. Your mental health records will be maintained through the use of computer and paper filing systems. Hampden Psychological Consultation, PLLC, is committed to making every reasonable effort to ensure the confidentiality of your mental health record. It is our office policy to retain clients’ entire records for seven years after the end of our work together. A summary will be maintained for 15 year from the last contact. For minors, the full record will be maintained until three years after the age of majority. A treatment summary will be maintained for at least 15 years after the age of majority. In the event of the death of a psychologist, medical records can be obtained by contacting another psychologist in this policy are contained in the Privacy Notice formpractice or our legal counsel, Xxxxxxx Xxxxxxx, Esq. HIPAA provides you with several new or expanded rights rights, with regard to your Clinical Record clinical records and disclosures of protected health information. These rights include requesting that I we amend your record; requesting restrictions on what information from your Clinical Record clinical records is disclosed to others; requesting an accounting of most disclosures of Protected Health Information 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 our policies and procedures recorded in your records; and the right to a paper copy of this Agreementagreement, the Privacy Notice attached notice form, and my our privacy policies and procedures. I am We are happy to discuss any of these rights and/or issues with to you. Patients under 18 years Maine has two conflicting sections of age law regarding access to records, when the patient or client is a minor. Therefore, if the patient is a minor, we will probably want to have a discussion with the parent(s) to establish some sort of agreement about who are will have access to what information. One section of 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 emancipated and their parents should be aware that disclosed to anyone, without the law may allow parents to examine their minor child’s treatment recordsagreement. Because While privacy in psychotherapy is often crucial to successful progressvery important, particularly with teenagers, parental involvement is also essential to successful treatment, particularly with younger children. Therefore, it is sometimes my our general policy not to request provide treatment to a child, unless there is agreement about what information may be shared. What generally works well is to have an agreement from between the patient and his/her parents that they consent allowing us to give up their access to their child’s records. If they agree, during treatment, I will typically provide them only with share general information about the progress of the their child’s treatment, and his/her attendance at scheduled sessions. I also may provide parents with a summary of their child’s treatment when it is complete. Most Any other communication will require the child’s Authorizationauthorization, unless I we feel that the child is in danger or is a danger to someone else, in which case, I we will notify the parents of my our concern. Before giving parents any information, I we will discuss the matter with the child, if possible, and do my our best to handle any objections he/she may have. This should be discussed further, preferably at the first session.

PROFESSIONAL RECORDS. You should be aware that, according pursuant to the rules of 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. In addition, I also keep a set of Psychotherapy Notes. These Notes are for my own use Except in unusual circumstances that involve danger to yourself and are designed to assist me in providing you with the best treatment, While the content of Psychotherapy Notes vary from client to client, they can include notes regarding the contents of our conversations, my analysis of those conversations, and how they impact on your therapy. They also can contain particularly sensitive others or where information that you may reveal has been supplied to me by others confidentially, or the record makes reference to another person (unless such other person is a health care provider) and I believe that access is not required reasonably likely 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 Recordcause substantial harm to such other person, 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 both sets of records, 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 am sometimes willing to conduct this review meeting without charge.) In most circumstances, I am allowed to charge a copying fee and for copying recordscertain other expenses. The exceptions to this policy are contained in the Privacy attached Notice formForm. HIPAA provides 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. 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 several new or expanded rights with regard 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 disclosures of protected health informationRecord. These rights include requesting that I amend your record; requesting restrictions on what information Psychotherapy Notes are kept separate 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 Privacy Notice form, and my privacy policies and proceduresRecord. I am happy to discuss any of these rights and/or issues with you. Patients under 18 years of age who Your Psychotherapy Notes are not emancipated available to you and their parents should cannot be aware that the law may allow parents sent 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 typically provide them only with general information about the progress of the child’s treatment, and his/her attendance at scheduled sessions. I also may provide parents with a summary of their child’s treatment when it is complete. Most other communication will require the child’s Authorization, unless I feel that the child is in danger or is a danger to someone 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 which case, I will notify the parents of my concern. Before giving parents information, I will discuss the matter with the child, if possible, and do my best any way for your refusal to handle any objections he/she may haveprovide it.

PROFESSIONAL RECORDS. You should be aware that, according to the rules The laws and standards of HIPAA, my profession require that 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. 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 content of Psychotherapy Notes vary from client to client, they can include notes regarding the contents of our conversations, my analysis of those conversations, and how they impact on your therapy. They also can contain particularly sensitive information that you may reveal to me that is not required to be included in your Clinical Recordclinical record. These Psychotherapy Notes You are kept separate from your Clinical Record. While insurance companies can request and entitled to 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 both sets of records, if or I can prepare a summary for you request it in writinginstead. Because these are professional records, they can be misinterpreted and/or upsetting to untrained readers. For this reasonIf you wish to see your records, I recommend that you initially review them in my presence, or have them forwarded to another mental health professional presence so you that we can discuss the contents. In most circumstances, I am sometimes willing to conduct a review meeting without charge. You are entitled to a free copy of your record; however I am allowed to charge a copying fee of $1 per page (and for copying records. The exceptions to this policy are contained in the Privacy Notice formcertain other expenses) for any subsequent copies. HIPAA provides you with several new or expanded rights with regard to regarding your Clinical Record 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 clinical record is disclosed to others; , requesting an accounting of most disclosures of Protected Health Information 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 Privacy Notice form, agreement and my privacy policies and procedures. I am happy to discuss any of these rights and/or issues with you. Patients I will provide treatment/evaluation to children only with custodial consent to do so. Clients under 18 17 years of age who are not emancipated emancipated, and their parents should be aware that the law may allow parents to examine their child’s 's treatment records. Because privacy in psychotherapy therapy is often crucial to successful progress, particularly with teenagers, it is sometimes my policy to request an agreement from parents that they consent regarding how children's privacy can be honored. Information given to give up their access me by your child which involves risk to their child’s recordslife, incidences of abuse or neglect, or other unlawful activity will be shared with you as soon as reasonably possible, and, if necessary, appropriate actions taken to aid in the protection of your child and any other potential victim. If they agree, during treatment, I will typically provide them only with general information about the progress use my clinical judgment to advise you of the your child’s treatment, and his/her attendance at scheduled sessions. I also may provide parents with a summary of their child’s treatment when it is complete. Most 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 information, I will discuss the matter with the child, if possible, and do my best to handle any objections he/she may have's statements regarding issues outside those stated areas.

PROFESSIONAL RECORDS. You should be aware that, according to the rules of HIPAA, I keep Protected Health Information The AUPSC keeps personal information about you in two sets of one professional records. One set constitutes record, which is referred to as 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 you and your graduate clinician set for treatment, your progress towards those goals, your medical and social history, your treatment history, any past treatment records that I receive AUPSC receives from other providers, reports of any professional consultations, your billing records, and any reports that have been sent to anyone, including reports to your insurance carrier. In additionIf you provide AUPSC with an appropriate written request, I also keep a set of Psychotherapy Notes. These Notes are for my own use and are designed you have the right to assist me in providing you with the best treatment, While the content of Psychotherapy Notes vary from client to client, they can include notes regarding the contents of our conversations, my analysis of those conversations, and how they impact on your therapy. They also can 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 both sets of your records, if except in unusual circumstances that involve danger to you request it in writingor others. In those situations, you have a right to have your record sent to another mental health provider. Because these are professional records, they can be misinterpreted and/or upsetting to untrained readers. For this reason, I recommend XXXXX recommends that you initially review them in my presence, the presence of your graduate clinician as well as the staffed supervisor or have them forwarded to another mental health professional so you can discuss the contents. You will be charged the same hourly rate you pay for a therapy session for this review meeting. In most circumstancessituations, I am AUPSC is allowed to charge a fee of $20 to cover the expense of accessing the file, copying the materials, and forwarding them to the mental health professional of your choice. XXXXX keeps all professional records for copying records10 years after the last attended session. All official documents and reports can be mailed, faxed or provided in person. The exceptions AUPSC does NOT send records by electronic mail (email) due to file security concerns. any records due to email not being a secure delivery method. In addition to keeping records of therapy in your Clinical Record, sessions at AUPSC, whether in person or via telehealth, are recorded for the purposes of supervision and clinical service delivery. Direct observations of in person and telehealth sessions by supervisors may also take place. However, this policy is not done without first discussing the observation with the client or the client’s caregivers recordings will be afforded all of the protection that is given a Clinical Record. Certain forms are contained routinely completed by all clients at AUPSC and their caregivers. One purpose of these forms is to help graduate clinicians make informed decisions regarding evaluations and treatment. The forms are also used for research purposes with your consent. Ongoing research is important so that we can continue to improve the way we provide services at AUPSC. Biographical and psychological data are available to graduate students for research purposes with appropriate permissions. However, to protect the privacy of our clients, all identifying names, places, and events are removed when information from AUPSC records are used in the any research project. AUPSC Privacy Notice form. HIPAA practices provides you with several new or expanded the following rights with regard to your Clinical Record and disclosures of protected health information. These rights include Clinic Record: requesting that I your graduate clinician 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 personal 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 AUPSC policies and procedures recorded in your records; and the right to a paper copy of this Agreement, the accompanied Privacy Notice formForm, and my AUPSC privacy policies and procedures. I am Your graduate clinician or other AUPSC representative will be happy to discuss any of these rights and/or issues with you. Patients Clients under 18 14 years of age age, who are not emancipated emancipated, and their parents caregiver(s), should be aware that the law may allow parents caregivers to examine their child’s treatment recordsrecords unless the child’s graduate clinician or the child’s graduate clinician’s supervisor decides that such access is likely to injure the child, or the child’s graduate clinician, the child, and the child’s caregiver(s) agree otherwise. Because privacy in psychotherapy is often crucial to successful progress, particularly with teenagers, it is sometimes my AUPSC policy to request an agreement from parents caregiver(s) that they consent to give up their access to their child’s records. If they agree, during treatment, I the graduate clinician will typically provide them only with general information about the progress of the child’s treatment, and his/her the client’s attendance at scheduled sessions. I The graduate clinician will also may provide parents caregivers with a summary of their child’s treatment when it is complete. Most Any other communication will require the child’s Authorizationauthorization, unless I feel the graduate clinician feels that the child is in danger or is a danger to someone else, in which case, I the graduate clinician will notify the parents caregivers of my the clinician’s concern. Before giving parents caregiver(s) any information, I the graduate clinician will discuss the matter with the child, if possible, and do my the clinician’s best to handle any objections he/she the child may have. This section contains important information focusing on doing psychotherapy using video conferencing through the internet at AUPSC. Please read carefully and discuss any questions or concerns you may have with your graduate clinician. Telepsychology services can only be delivered to clients within the state of Alabama. Telepsychology services are limited to a case-by-case basis in consideration of access to required settings for secure telehealth delivery and clinician training (see Appropriateness of Telepsychology below).

PROFESSIONAL RECORDS. The laws and standards of our profession require that your therapist keep notes regarding his or her treatment of you in your clinical record. HIPAA mandates that you as a client may have access to PHI in your file, and that while that information belongs to you, the record itself does not. You should be aware thatmay request access to your file, according or copies of your records, though fees will apply. There are some exceptions to the rules of 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. 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 content of Psychotherapy Notes vary from client to client, they can include notes regarding the contents of our conversations, my analysis of those conversations, and how they impact on your therapy. They also can contain particularly sensitive information that you may reveal have access to. For example, you do not have access to me that psychotherapy notes, or to information has been provided in confidence by someone who is not required a health care provider, or to private information about another person that might be included in your Clinical Recordrecord. These Psychotherapy Notes There are kept separate from your Clinical Recordother exceptions as well. While insurance companies can request and receive Please refer to the NPP for a copy more detailed explanation of your Clinical Record, they cannot receive a copy of your Psychotherapy Notes without your signed, written Authorizationthese exceptions. 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 both sets of records, if you request it in writing. Because Please understand that because these are professional records, they may contain information that can be misinterpreted and/or be upsetting to untrained readers. For this reason, I recommend it is our recommendation that you initially review them in my presencethe presence of your therapist, or have them forwarded to another mental health professional so you can discuss the contents. In most circumstances, I am allowed to charge a fee for copying records. The exceptions to this policy are contained in the Privacy Notice form. HIPAA provides you with several new or expanded rights with regard to your Clinical Record clinical record and disclosures of protected health informationPHI. These rights include things such as the following: requesting that I amend your record be amended by you with information that you would like to have included in your record; requesting restrictions on what information from your Clinical Record clinical record is disclosed to others; requesting an accounting of most disclosures of Protected Health Information PHI that you have neither consented is disclosed for purposes other than for treatment, payment or health care operations; registering complaints about failures 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 protect your recordsprivacy; and the right to a paper copy of this Agreement, the Privacy Notice formattached NPP, and my privacy policies and proceduresany Authorizations you have signed. I am There are other rights you have under HIPAA as well. Please refer to your copy of the NPP for greater elaboration. Also, your therapist would be happy to discuss any of these rights and/or issues with you. Patients under 18 years of age who are not emancipated and their parents should be aware that the law If you wish, you may allow parents direct any questions or concerns about your care to examine their child’s treatment recordsour Privacy Officer, Xx. 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 typically provide them only with general information about the progress of the child’s treatment, and his/her attendance at scheduled sessions. I also may provide parents with a summary of their child’s treatment when it is complete. Most 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 information, I will discuss the matter with the child, if possible, and do my best to handle any objections he/she may haveXxxxx Xxxxxxxxx.

PROFESSIONAL RECORDS. You should be aware that, according to the rules The laws and standards of HIPAA, my profession require that I keep Protected Health Information (PHI) about you in two sets of professional recordsyour clinical record. One set constitutes your Clinical Record. It includes Except in unusual circumstances that involve danger to yourself and/or others or where 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 has been sent to anyone, including reports to your insurance carrier. 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 content of Psychotherapy Notes vary from client to client, they can include notes regarding the contents of our conversations, my analysis of those conversations, and how they impact on your therapy. They also can contain particularly sensitive information that you may reveal supplied to me confidentially by others, or the record makes reference to another person (unless such other person is a health care provider) and I believe that access is not required reasonably likely 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 cause substantial harm to such other person you in any way for your refusal. You may examine and/or receive a copy of both sets of records, your clinical record if you request it in writing. Because these are professional profession records, they can be misinterpreted and/or upsetting to untrained readers. For this reason, I recommend ask that you initially review them in my presence, 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 fee copying feel of $2 per page. If I refuse your request for copying access to your records. The exceptions to this policy are contained in the Privacy Notice form, you have a right of review which I will discuss with you upon your request. HIPAA provides you with several new or expanded rights with regard to your Clinical Record clinical record and disclosures of protected health informationPHI. These rights include requesting that I amend your record; requesting restrictions on what information from your Clinical Record clinical record is disclosed to others; requesting an accounting of most disclosures of Protected Health Information PHI that you have neither consented to nor authorized; determining the location to which protected information 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, the Privacy attached Notice form, and my privacy policies and procedures. I am happy to discuss any of these rights and/or issues with you. Patients SC provides the client the opportunity to file inquiries with its Board of Examiners in Psychology. Board offices can be reached at SC Board of Examiners in Psychology, PO Box 11329, Columbia, SC 29211-1329. Please note that Xxxxx Psychology Service, PA and Xxxx Xxxxx Xxxxx, Ph.D. are separate business entities and share no joint liability. Clients under 18 years of age who are not emancipated and their parents should be aware that the law may allow allows parents to examine their child’s treatment 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 from parents that they consent to give up their access to their child’s records. If they agree, during treatment, I will typically provide them only with general information about the progress of the child’s treatment, and his/her attendance at scheduled sessions. I will also may provide parents with a summary of their child’s treatment when it is complete. Most Any other communication will require the child’s Authorizationauthorization, 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 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. If such legal action is necessary, its costs will be included in the claim. Regarding insurance reimbursement, I will discuss fill out forms and provide you with whatever assistance I can in helping you receive the matter benefits to which you are entitled; however, you, not your insurance company, are responsible for full payment of my fees. You should be aware that your contract with your health insurance company requires that I provide it with information relevant to the childservices I provide to you. I am required to provide a clinical diagnosis and sometimes other information as well. I make every effort to release only the minimum information necessary for the purpose requested. I will, if possibleof course, provide you with copies of any information released to an insurance company, at your request. By signing this agreement, you agree that I may file for insurance reimbursement from your insurance carrier, and do my best you agree that I may provide them with requested information. Your signature also indicates you have read the information in this document and agree to handle any objections he/she may haveabide by its terms during our professional relationship. Your signature also serves as an acknowledgement that you have received the HIPAA Notice form.

PROFESSIONAL RECORDS. You should be aware that, according to the rules The laws and standards of HIPAA, my profession require that 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 therapyIf you provide a written request, a description of you have 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 right to anyone, including reports to your insurance carrier. 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 content of Psychotherapy Notes vary from client to client, they can include notes regarding the contents of our conversations, my analysis of those conversations, and how they impact on your therapy. They also can 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 both sets of your records, if you request it in writing. Because these are professional records, they can sometimes be misinterpreted and/or upsetting to untrained readers. For this reason, I recommend that you initially review them in my presence, presence or have them forwarded to another mental health professional so you can discuss to review with you. There may be a charge for reproducing records or for the contents. In most circumstances, I am allowed time required to charge a fee for copying recordsreview them with you. The exceptions law requires that I obtain your signature acknowledging that I have provided you with information regarding your rights to this policy are contained privacy. This information is included in the Notice of Privacy Notice form. HIPAA Practices required by the Health Insurance Portability and Accountability Act (HIPAA), a federal law that provides you with several new or expanded privacy protections and patient rights with regard to the use and disclosure of 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 (PHI). By signing this document, you will be acknowledging that you have neither consented received the privacy notice. Payment is expected at time of service. Please see the Medical Practice Commitments and Expectations form included with your new client paperwork for more detailed information. The hourly fee for regular therapy appointments is $135. The fee for the initial intake session is $285. Examples of other billable services beyond your therapy appointments include report writing, frequent or lengthy telephone conversations, consulting with other professionals (with your permission), and preparation of records or treatment summaries. If you become involved in legal proceedings that require the participation of clinic personnel, you will be expected to nor authorized; determining pay for the location requested services, including preparation and transportation costs. Because of the complexity and difficulty of legal involvement, our fee is $250 per hour for any legal work. Any pre-certification requirements that GCA agrees to which protected do, on your behalf, must be done as a scheduled appointment, and with the client present. This is to ensure that you are fully aware of any information disclosures are sent; having any complaints you make about my policies and procedures recorded in being released to your records; and insurance company. We reserve the right to a paper copy of this Agreement, refuse any pre-certification requirements that we find excessive. Please keep in mind that you will be billed for the Privacy Notice form, and my privacy policies and procedures. I am happy to discuss any of these rights and/or issues with you. 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 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 typically provide them only with general information about the progress of the child’s treatment, and his/her attendance at scheduled sessions. I also may provide parents with a summary of their child’s treatment when it is complete. Most 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 information, I will discuss the matter with the child, if possible, and do my best to handle any objections he/she may havetime spent on "pre-certifications."

PROFESSIONAL RECORDS. You should be aware that, according to the rules The laws and standards of HIPAA, I professional psychologists require that we keep Protected Health Information about you in two sets of professional records. One set constitutes your Clinical RecordRecords. It Your Clinical Record includes information about your reasons for seeking therapytherapy and/or a psychological assessment, a description of the ways in which these problems impact life for your problem impacts on your lifechild and/or family, your the diagnosis, the goals that we set for treatment, your progress towards those these goals, your medical and social history, your treatment history, any past treatment records that I receive we received from other providers, reports of from any professional consultations, your billing records, and any reports that have been sent to anyone. Except in unusual circumstances that involve danger to yourself and/or others or where information has been supplied to us confidentially by others, including reports or the record makes reference to your insurance carrier. In additionanother person and we believe that access is reasonably likely to cause substantial harm to such other person, 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 content of Psychotherapy Notes vary from client to client, they can include notes regarding the contents of our conversations, my analysis of those conversations, and how they impact on your therapy. They also can 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 examine and/or receive a copy of your Clinical Record, they cannot receive a copy of your Psychotherapy Notes without your signed, upon 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 both sets of records, if you request it in writingrequest. Because these are professional records, they can be misinterpreted and/or upsetting to untrained readers. For this reason, I we recommend that you initially review them in my our presence, or have them forwarded to another mental health professional so you can discuss the contents. In most circumstances, I am allowed to we charge a copying fee of $.075 per page (and for copying recordscertain other expenses). The exceptions to this policy are contained in the Privacy Notice form. HIPAA provides you with several new or expanded rights with regard If we refuse your request for access to your Clinical Record and disclosures records, you have a right of protected health informationreview, which we will discuss with you upon your request. In addition, we may also keep a set of psychotherapy notes. These rights notes are for our own use and are designed to assist in providing your child and/or family with the best treatment. While the contents of psychotherapy notes vary from patient to patient, they can include requesting the contents of our conversations, our analysis of those conversations, and how they impact your therapy. They may also contain particularly sensitive information that I amend you, your record; requesting restrictions on what information child and/or family may reveal during sessions that is not required to be included in your Clinical Record. These psychotherapy notes are kept separate 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 Privacy Notice form, and my privacy policies and proceduresRecord. I am happy to discuss any of these rights and/or issues with you. Patients under 18 years of age who They are not emancipated available to you and their parents should cannot be aware that the law may allow parents sent 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 typically provide them only with general information about the progress of the child’s treatment, and his/her attendance at scheduled sessions. I also may provide parents with a summary of their child’s treatment when it is complete. Most other communication will require the child’s Authorization, unless I feel that the child is in danger or is a danger to someone 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 which case, I will notify the parents of my concern. Before giving parents information, I will discuss the matter with the child, if possible, and do my best to handle any objections he/she may haveway for your refusal.

PROFESSIONAL RECORDS. You should be aware that, according pursuant to the rules of HIPAA, I keep Protected Health Information about you in two sets of professional records. One set constitutes your Clinical Record. It includes information about your reasons for seeking therapy, a description of the ways in which your problem impacts on your life, your diagnosis, the goals that we set for treatment, your progress towards those goals, your medical and social history, your treatment history, any past treatment records that I receive from other providers, reports of any professional consultations, your billing records, and any reports that have been sent to anyone, including reports to your insurance carrier. Except in unusual circumstances that involve danger to yourself and others or where information has been supplied to me 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. In most situations, I am allowed to charge a copying fee of $.10 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 records, 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 content contents of Psychotherapy Notes vary from client to client, they can include notes regarding the contents of our conversations, my analysis of those conversations, and how they impact on your therapy. They also can 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 signedwritten, written signed 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 both sets of records, if you request it in writing. Because these are professional records, they can be misinterpreted and/or upsetting to untrained readers. For this reason, your Psychotherapy Notes unless I recommend determine 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 fee for copying records. The exceptions to this policy are contained in the Privacy Notice formsuch access is clinically contraindicated. 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 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 Privacy attached Notice form, and my privacy policies and procedures. I am happy to discuss any of these rights and/or issues with you. 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 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 During treatment, I will typically provide them only with general information about the progress of the child’s treatment, and his/her attendance at scheduled sessions. I will also may provide parents with a summary of their child’s treatment when it is complete. Most 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 RECORDS. You should be aware that, according pursuant to the rules of HIPAA, I am allowed to keep Protected Health Information about you in two sets of professional records. One The major 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. You may examine and/or receive a copy of your Clinical Record, if you request it in writing, except in unusual circumstances which I judge could involve significant physical danger to yourself or others. Should that be the case, I will provide you with an accurate and representative summary of your Record, if you request it in writing. If our therapy has involved more than one person as a client, either person is allowed to request access to or authorize release of the Clinical Record, even though the Record will contain information about the other(s). 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. Generally, I keep your Clinical Record for the 7 years after your treatment ends required by law, or up to 10 years. I have a designated colleague (on record with the State Board) who would take over and properly dispose of my professional records should something happen to me. In most circumstances, legally I am allowed to charge a base fee of $30 for 10 or fewer pages and a copying fee of .50 per page up to 50 pages, then .25 per page thereafter. The law may change these guidelines and if so, I will follow changes made by law. 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 am permitted by law to 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 content contents of Psychotherapy Notes vary from client to client, they can include notes regarding the contents of our conversations, my analysis of those conversations, and how they impact on your therapy. They may also can 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 If I have made them, you may request to examine and/or receive a copy of both sets your Psychotherapy Notes unless I determine that such disclosure would be injurious to you. * Please note, however, that in most cases I do not keep a separate set of recordsPsychotherapy Notes but include all written information, if you request it in writing. Because these are professional recordsrequired and otherwise, 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 fee for copying records. The exceptions to this policy are contained in the Privacy Notice form. 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 Privacy Notice form, and my privacy policies and procedures. I am happy to discuss any of these rights and/or issues with you. 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 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 typically provide them only with general information about the progress of the child’s treatment, and his/her attendance at scheduled sessions. I also may provide parents with a summary of their child’s treatment when it is complete. Most 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 information, I will discuss the matter with the child, if possible, and do my best to handle any objections he/she may havemain Clinical Record.

PROFESSIONAL RECORDS. You should be aware that, according pursuant to the rules of HIPAA, I keep the Practice keeps 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 you and your psychologist set for treatment, your progress towards those goals, your medical and social history, your treatment history, any past treatment records that I we receive from other providers, reports of any professional consultations, your billing records, and any reports that have been sent to anyone, including reports to your insurance carrier. Except in unusual circumstances that involve danger to yourself and others, you may examine and/or receive a copy of your Clinical Record if you request it in writing. You should be aware that pursuant to Texas law, psychological test data are not part of a patient’s record. Because these are professional records, they can be misinterpreted and/or upsetting to untrained readers. For this reason, we recommend that you initially review them in our 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 we refuse your request for access to your Clinical Record, you have a right of review, which we will discuss with you upon your request. In addition, I we also keep a set of Psychotherapy Notes. These Notes are for my our own use and are designed to assist me us in providing you with the best treatment, . While the content contents of Psychotherapy Notes vary from client to client, they can include notes regarding the contents of our conversations, my our analysis of those conversations, and how they impact on your therapy. They also can contain particularly sensitive information that you may reveal to me us 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 both sets of records, if you request it in writing. Because these are professional records, they can your Psychotherapy Notes unless we determine that release would 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 fee for copying records. The exceptions to this policy are contained in the Privacy Notice form. HIPAA provides you with several new or expanded rights with regard harmful 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 Agreementphysical, the Privacy Notice form, and my privacy policies and procedures. I am happy to discuss any of these rights and/or issues with you. 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 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 typically provide them only with general information about the progress of the child’s treatment, and his/her attendance at scheduled sessions. I also may provide parents with a summary of their child’s treatment when it is complete. Most other communication will require the child’s Authorization, unless I feel that the child is in danger mental or is a danger to someone else, in which case, I will notify the parents of my concern. Before giving parents information, I will discuss the matter with the child, if possible, and do my best to handle any objections he/she may haveemotional health.

PROFESSIONAL RECORDS. You should be aware that, according pursuant to the rules of HIPAAHIPPA, I sometimes keep Protected Health Information about you in two sets of professional records. : One set constitutes your you 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, 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, (for which I will provide you with an accurate and representative summary of your Record if you request it), 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. If I refuse your request for access to your Clinical Record, you have a right of review which I will discuss upon request. In addition, I also sometimes 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 content contents of Psychotherapy Notes vary from client to client, they can include notes regarding the contents of our conversations, my analysis of those conversations, conversations and how they impact on your therapy. They may also can 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 request to examine and/or receive a copy of both sets of records, 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 fee for copying records. The exceptions to this policy are contained in the Privacy Notice form. 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 Privacy Notice form, and my privacy policies and procedures. I am happy to discuss any of these rights and/or issues with you. 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 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 typically provide them only with general information about the progress of the child’s treatment, and his/her attendance at scheduled sessions. I also may provide parents with a summary of their child’s treatment when it is complete. Most other communication will require the child’s Authorization, Psychotherapy Notes unless I feel determine that the child is in danger or is a danger such disclosure would be injurious to someone else, in which case, I will notify the parents of my concern. Before giving parents information, I will discuss the matter with the child, if possible, and do my best to handle any objections he/she may haveyou.

PROFESSIONAL RECORDS. You should be aware that, according to the rules The laws and standards of HIPAA, my profession require that I keep Protected Health Information protected health information about you and your clinical record, except in two sets of professional records. One set constitutes your Clinical Record. It includes unusual circumstances that involves danger to yourself and/or others or where 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 has been sent to anyone, including reports to your insurance carrier. 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 content of Psychotherapy Notes vary from client to client, they can include notes regarding the contents of our conversations, my analysis of those conversations, and how they impact on your therapy. They also can contain particularly sensitive information that you may reveal supplied to me that is not required to be included in your Clinical Recordconfidentially by others. These Psychotherapy Notes are kept separate from your Clinical Record. While insurance companies can request and You may examine and/ or 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 both sets of records, clinical record if you request it in writing. Because these are professional records, they can be misinterpreted and/or and/ or upsetting to untrained readers. For this reason, I recommend that you initially review them in my presence, presence or have them forwarded to another mental health professional professional, so you can discuss the contents. In most circumstances, I am allowed to charge a copying fee of 75 cents per page. In certain circumstances, I have the right to refuse your request for copying access to your records. The exceptions You do have a right to review this policy are contained in the Privacy Notice formrefusal, which I will discuss with you upon request. HIPAA HIPPA provides you with several new or expanded rights with regard to your Clinical Record clinical records and disclosures disclosure of protected health information. These rights include requesting that I amend your record; , requesting restrictions on what information from your Clinical Record clinical record is disclosed to others; , requesting an accounting of most disclosures of Protected Health Information 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 Agreementagreement , the Privacy Notice attached notice form, and my privacy policies and procedures. I am happy to discuss any of these rights and/or issues with you. Patients under 18 years New York law give children of any age who the right to independently consent to and receive mental health treatment without parental consent if they request it and I determine that such services are not emancipated necessary and their parents should be aware that requiring parental consent would have a detrimental affect on the law may allow parents to examine their course of a child’s treatment. In that situation, information about the treatment cannot be disclosed to anyone without the child’s agreement. Even where parental consent is given, children over age 12 have the right to control access to their treatment records. Because While privacy in psychotherapy is often crucial to successful progressvery important, particularly with teenagers, parental involvement is also essential to successful treatment, particularly with younger children. Therefore, it is sometimes my policy not to provide treatment to a child under age 12 unless he/she agrees that I can share whatever information I consider necessary with his/her parents. For children age 12 or over, I request an agreement from between my patient and his/her parents that they consent allowing me to give up their access to their child’s records. If they agree, during treatment, I will typically provide them only with share general information about the progress of the child’s treatment, and treatment in his/her attendance at of scheduled sessions. I will also may provide parents with a the summary of their child’s treatment when it is complete. Most Any other communication communications will require the child’s Authorizationauthorization, unless I feel that the child is in danger or is a danger to someone else, in which casecase , 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 RECORDS. You should be aware that, according to the rules of HIPAAunder HIPAA regulations, I keep Xxxxxx Xxxxxxx may store 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 are set for treatment, your progress towards those goals, your medical and social history, your treatment history, any past treatment records that I receive were received from other providers, reports of any professional consultations, your billing records, and any reports that have been sent to anyone, including reports to your insurance carrier. Generally you may review and/or receive a copy of your Clinical Record if you request it in writing. However, because these are professional records, they can be easily misinterpreted and/or be potentially upsetting to untrained readers. For this reason, The Connection Place recommends that you initially review them in the presence of Xxxxxx Xxxxxxx, or have them forwarded to another qualified mental health professional with whom you can discuss the contents. As allowed by law, The Connection Place charges a retrieval/copying fee of 15¢ for the first five pages of a record and 25¢ per page thereafter. In additioncircumstances where The Connection Place feels that your review or receipt of your Clinical Record may result in a danger to yourself or another or when disclosure of your record compromises the privacy of another person, I The Connection Place may deny your request. In addition to your Clinical Record, Xxxxxx Xxxxxxx may also keep a set of Psychotherapy Notes. These Notes are for my his own use and are designed to assist me him in providing you with the best treatment, While the treatment possible. These notes may include more detailed content of Psychotherapy Notes vary from client to clientyour conversations with the therapist, they can include notes regarding the contents of our conversations, my his analysis of those conversations, and how they impact on your therapy. They also can contain particularly sensitive information that you may reveal to me Xxxxxx Xxxxxxx that is not required to be included in your Clinical Record. These Also included may be information from others provided to Xxxxxx Xxxxxxx confidentially. Psychotherapy Notes are kept separate from your Clinical Record. While insurance companies can request Your Psychotherapy Notes are not available to you and receive a copy of your Clinical Record, they cannot receive a copy of your Psychotherapy Notes be sent to anyone else, including insurance companies, without your signed, written signed Authorization. Insurance companies cannot require you to authorize release of your Authorization Psychotherapy Notes as a condition of coverage nor penalize you in any way for your refusalrefusal to provide it. You may examine and/or receive Clients who are minors often need the same privacy and confidentiality in counseling as do adults. Xxxxxx Xxxxxxx makes every effort to maintain necessary privacy in his therapeutic relationships with minor-age clients while keeping parents or guardians appropriately informed about the child’s progress. If the parents of a minor-age client are estranged/divorced, it is the policy of The Connection Place that a copy of both sets of records, if you request it in writingthe court-decreed parenting agreement be on file. 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 fee for copying records. The exceptions to this policy are contained in the Privacy Notice form. 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 Privacy Notice form, and my privacy policies and procedures. I am happy to discuss any of these rights and/or issues with you. Patients under 18 years of age who are not emancipated and their parents Parents should be aware that even non-custodial parents usually have the law may allow parents right to examine access their child’s treatment recordsClinical Record. Because privacy in Parents should also be aware that the state of Tennessee allows 16 and 17 year olds to seek psychotherapy is often crucial without their parents’ consent if they are sufficiently mature to successful progressunderstand and make judgments about the risks and benefits of such treatments. In these cases, particularly with teenagers, it is sometimes my policy to request an agreement from parents that they consent to give up their do not necessarily have access to their older adolescent child’s records. If they agreeIt is, during treatmenthowever, I will typically provide them only the policy of The Connection Place to seek an agreement with the teen on general information about (e.g., reports of progress & attendance) that may be shared with the progress of parents in a way that will allow parental involvement while still safeguarding the childadolescent’s treatmentprivacy. Except where the law allows otherwise (e.g., and his/her attendance at scheduled sessions. I also may provide parents with a summary of their child’s treatment when it is complete. Most danger to self or others), any other communication from the therapist to a parent will require the childminor client’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 information, I will discuss the matter with the child, if possible, and do my best to handle any objections he/she may havewritten authorization.

PROFESSIONAL RECORDS. You should be aware that, according to the rules The laws and standards of HIPAA, my profession require that 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 therapyExcept in circumstances involving potential danger to yourself and/or others, 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. 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 content of Psychotherapy Notes vary from client to client, they can include notes regarding the contents of our conversations, my analysis of those conversations, and how they impact on your therapy. They also can 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 both sets of records, your Clinical Record if you request it in writing. Pursuant to Texas law, psychological test data are not part of a patient’s record. Because these are professional records, they can easily 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 Any request to charge view or obtain a copy of a client’s mental health records must be made in writing and signed and dated by the client or the client’s legal guardian. Records will be made available during regular business hours. My office charges a fee of $25 for copying a client’s records. Should the records request include a request that the records be shipped, the actual cost of shipping the records will be added to the $25 copying fee. Payment must be made by money order or cashier’s check. Personal checks will not be accepted for payment. Once payment is received, the requested records will be mailed by certified mail, return receipt requested. If a Business Records Affidavit is requested, a fee of $15 will be charged, and the Affidavit will not be signed until that fee is paid. Payment of this fee must be by certified check or money order. The exceptions client or client’s legal guardian will be responsible for the cost of the mobile notary. Within 15 days of receipt of the written records request and payment of all applicable fees, records will be provided. If it is determined that having access to the mental health records would be harmful to the client’s physical, mental, or emotional health, the request for access to records will be refused, and a written statement attesting to this policy are contained in the Privacy Notice formwill be provided. HIPAA provides you with several new or expanded rights with regard to your Clinical Record and disclosures of protected health informationProtected Health Information (PHI). These rights include requesting that I your psychologist 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 your PHI that you have neither consented to nor authorized; determining the location to which protected information disclosures are your PHI is 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 Privacy attached Notice formForm, and my privacy policies and procedures. I am happy to discuss any of these rights and/or issues with you. Patients Clients under 18 years of age who are not emancipated and their parents should be aware that the law may allow parents (who have legal custody of their children) to examine their child’s treatment mental health records. Because privacy in psychotherapy is often crucial to successful progressHowever, particularly if the mental health records include information regarding suicide prevention, chemical addiction or dependency, sexual abuse, physical abuse, or emotional abuse, the law provides that parents may not access their child’s records. When working with teenagers, a reasonable guarantee of privacy is often needed in order for the adolescent to be appropriately disclosing. With the aforementioned matter in mind, it is sometimes my policy policy, when working with children between 16 and 18 years of age, to request an agreement from the client and his/her parents that they the parents’ consent to give up their access to their child’s mental health records. If they the parents agree, during treatment, I will typically provide them only with general information about regarding the progress of the child’s treatment, and his/her attendance at scheduled sessions. I also may provide parents with a summary results of their child’s treatment when it is completepsychological evaluation. Most Any other communication will require the child’s Authorization, unless I feel that the child is in danger or is poses a danger to someone else, ; in which casesuch cases, I will notify the parents of my concernconcerns. Before giving Prior to providing parents any information, I will discuss the matter with the child, if possible, and do my best to handle appropriately address any objections he/she concerns the child may have.

PROFESSIONAL RECORDS. You should be aware that, according I am required to the rules of HIPAA, I keep Protected Health Information about you in two sets of professional treatment records. One set constitutes your Clinical Record. It includes information about This includes, for example, your reasons for seeking therapy, a description of the ways in which your problem impacts on your lifeany diagnostic impressions, your diagnosis, the treatment 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 recordsprogress, and any reports that clinical consultations with other professionals. You have been sent the right to anyone, including reports to your insurance carrier. 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 content of Psychotherapy Notes vary from client to client, they can include notes regarding the contents of our conversations, my analysis of those conversations, and how they impact on your therapy. They also can 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 Recordrecords or a treatment summary. I may decline a request for records if I believe it will not be in your best interest or the best interest of others. In the case of family or couples therapy, they canI require that all adults present sign a release of information consent form before information is released. No information will be released if consent is not receive a copy of obtained from all participating adults. If you request 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 both sets of records, 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 ask that you initially we review them in my presence, or have them forwarded together to another mental health professional so you can discuss clarify the contentscontents and avoid any misunderstandings. In most circumstances, I am allowed to charge a fee of $1.00 per page for copying copies of records. The exceptions to this policy are contained in the Privacy Notice form. HIPAA Health Insurance Portability and Accountability Act of 1996 (HIPAA) provides you with several new or expanded rights with regard to your Clinical Record 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 clinical record is disclosed to others; requesting an accounting of most disclosures of Protected Health Information 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 Privacy attached Notice form, and my privacy policies and procedures. I am happy to discuss any of these rights and/or issues with you. Patients Clients under 18 years of age who are not emancipated and their parents should be aware that the law may allow allows parents to examine their child’s treatment recordsrecords 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 from parents that they consent to give up their access to their child’s records. If they agree, during treatment, I will typically provide them parents only with general information about the progress of the child’s treatment, and his/her attendance at scheduled sessions. I also may provide parents with , and a summary of their child’s treatment when it is complete. Most Any other communication will require the child’s Authorizationauthorization, 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. I do not perform court-related evaluations for child custody nor do I testify in hearings involving child custody issues. In addition, I do not appear voluntarily at any court or administrative hearing. From a therapeutic perspective, it is not in your best interest to ask that I testify, no matter what issue is involved. If you, or your attorney, choose to subpoena me for court testimony, including depositions or administrative hearings, please know that I may decline to appear if I believe that it is in your, or your child’s, best interest for me to do so. 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 $400 per hour for preparation and attendance at any legal proceeding. In general, the law protects the confidentiality of all communications between a client and psychologist. 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, however, a few exceptions to the general rule of confidentiality. In addition, there are some situations where I am permitted or required to disclose information without either your consent or authorization: Court order. In most cases, the psychologist-client privilege law protects your treatment records and information, and I can not reveal treatment information without your (or your legal representative’s) written authorization. If, however, the court determines that my testimony or records are required, then I am required to provide the information requested. 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.

PROFESSIONAL RECORDS. You should be aware that, according pursuant to the rules of 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 toward 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. 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 content contents of Psychotherapy Notes vary from client to client, they can include notes regarding the contents of our conversations, my analysis of those conversations, and how they impact on your therapy. They also can 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 or penalize you in any way for your refusal. You may examine and/or receive a copy of both sets of records, records 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, 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 for copying records. The exceptions to this policy are contained in the Privacy Notice form. 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 Privacy Notice form, and my privacy policies and procedures. I am happy to discuss any of these rights and/or issues with you. 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 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 typically provide them only with general information about the progress of the child’s treatment, and his/her attendance at scheduled sessions. I also may provide parents with a summary of their child’s treatment when it is complete. Most $1.00 per page (plus 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 information, I will discuss the matter with the child, if possible, and do my best to handle any objections he/she may haveexpenses such as postage).

PROFESSIONAL RECORDS. You should be aware that, according to The laws and standards of the rules of HIPAA, I mental health professional require that therapists keep Protected Health Information about you in two sets of professional records. One set constitutes your Clinical Record. It includes The Counseling Center maintains your Clinical Record via confidential electronic database and is password-protected. Except in unusual circumstances that involve danger to yourself and/or others or when another individual (other than another heath care provider) is referenced and therapists believe disclosing that information about your reasons for seeking therapyputs the other person at risk of substantial harm, 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. 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 content of Psychotherapy Notes vary from client to client, they can include notes regarding the contents of our conversations, my analysis of those conversations, and how they impact on your therapy. They also can 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 examine and/or 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 both sets of records, 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 therapists recommend that you initially review them in my presencethe presence of your therapist, or have them forwarded to another mental health professional so you can discuss the contents. In most circumstancesIf you therapist refuses your request for access to your records, I am allowed to charge you have a fee for copying records. The exceptions to this policy are contained in right of review, which the Privacy Notice formDirector of Health and Counseling will discuss with you upon request. HIPAA provides you with several new or expanded rights with regard to your Clinical Record Records and disclosures of protected health information. These rights include requesting that I the therapists 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 protected health information that you have neither consented to nor or not authorized; determining the location to which protected information disclosures are sent; having any complaints you make about my this office’s policies and procedures recorded in your records; , and the right to a paper copy of this Agreement, the Privacy posted Notice form, and my the Counseling Center privacy policies and procedures. I am Counseling Center therapists are happy to discuss any of these rights and/or issues with you. Patients under 18 years of age who are not emancipated and their parents should be aware that the law Client Signature Date If your counselor needs to contact you, may allow parents he or she do so: (please circle yes or no) • By telephone (yes/no) • By email? (yes/no) If “yes” to examine their child’s treatment records. Because privacy in psychotherapy is often crucial to successful progresseither or both, 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 typically please provide them only with general information about the progress of the child’s treatment, and his/her attendance at scheduled sessions. I also may provide parents with a summary of their child’s treatment when it is complete. Most 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 your contact information, I will discuss the matter with the child, if possible, and do my best to handle any objections he/she may have.: Phone: email:

PROFESSIONAL RECORDS. You should be aware that, according to The laws and standards of psychology and counseling professions require that the rules of HIPAA, I clinician 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. 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 content of Psychotherapy Notes vary from client to client, they can include notes regarding the contents of our conversations, my analysis of those conversations, and how they impact on your therapy. They also can 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 Except in unusual circumstances that involve danger to yourself and/or others, you may examine and/or 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 both sets of records, if you request it in writingwriting and the request is signed by you and dated not more than 60 days from the date submitted. Because these are professional records, they can be misinterpreted and/or upsetting to untrained readers. For this reason, I recommend it is recommended that you initially review them in my presence, the presence of the clinician or have them forwarded to another mental health professional so you can discuss the contents. In most circumstances, I am allowed the law allows clinicians 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 copying recordsrecords search, plus postage. The exceptions If you request for access to this policy are contained in your records is refused, you have the Privacy Notice formright of review, which will be discussed with you upon request. HIPAA HIPPA provides you with several new or expanded guidelines and policies regarding your rights with regard to your Clinical Record and disclosures of protected health information. These rights include requesting that I the clinician 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 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 Privacy Notice form, and my privacy policies and procedures. I am happy to discuss any of these rights and/or issues with you. 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 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 typically provide them only with general information about the progress of the child’s treatment, and his/her attendance at scheduled sessions. I also may provide parents with a summary of their child’s treatment when it is complete. Most 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 information, I will discuss the matter with the child, if possible, and do my best to handle any objections he/she may have.

PROFESSIONAL RECORDS. You should be aware that, according to the rules The laws and standards of HIPAA, my profession require that I keep Protected Health Information about you in two sets of professional records. One set constitutes your Clinical Record. It includes 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 about your reasons for seeking therapyhas been supplied to me confidentially by others, 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. 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 content of Psychotherapy Notes vary from client to client, they can include notes regarding the contents of our conversations, my analysis of those conversations, and how they impact on your therapy. They also can 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 examine and/or 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 both sets of records, if you request it in writing. Because these there 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 circumstancesThere will be a copying fee of 25 cents per page. 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 am allowed to charge a fee for copying records. The exceptions to this policy are contained in the Privacy Notice formwill discuss with you upon request. HIPAA provides you with several new or expanded rights with regard to your Clinical Record Records and disclosures of protected health information. These rights include requesting that I amend your record; requesting restrictions on what information from your Clinical Record Records is disclosed to others; requesting an accounting of most disclosures of Protected Health Information 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 Privacy Notice form, and my privacy policies and procedures. I am happy to discuss any of these rights and/or issues with you. Patients under 18 years of age who are not emancipated can consent to psychological services subject to the involvement of their parents or guardian unless the psychologist determines that their involvement would be inappropriate. A patient over the age of 12 may consent to psychological services if he or she is mature enough to participate intelligently in such services, and the minor patient either would present a danger of serious physical or mental harm to him or herself or others, or is the alleged victim of incest or child abuse. In addition, patients over age 12 may consent to alcohol and drug treatment in some circumstance. However, unemancipated patients under 18 years of age and their parents should be aware that the law may allow parents to examine their child’s treatment recordsrecords unless I determine that access would have a detrimental effect only professional relationship with the patient, or to his/her physical safety or psychological well-being. Because privacy in psychotherapy is often crucial to successful progress, particularly with teenagers, and parental involvement is also essential, it is sometimes usually my policy to request an agreement from with minors over the age of 12 and their parents that they consent to give up their about access to their child’s recordsinformation. If they agree, This agreement provides that during treatment, I will typically provide them parents with only with general information about the progress of the child’s treatment, and his/her the patient’s attendance at scheduled sessions. I will also may provide parents with a summary of their child’s treatment when it is complete. Most 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 information, I will discuss the matter with the child, if possible, and do my best to handle any objections he/she may have.

PROFESSIONAL RECORDS. You should be aware that, according to The laws and standards of psychology and counseling professions require that the rules of HIPAA, I clinician 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. 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 content of Psychotherapy Notes vary from client to client, they can include notes regarding the contents of our conversations, my analysis of those conversations, and how they impact on your therapy. They also can 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 Except in unusual circumstances that involve danger to yourself and/or others, you may examine and/or 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 both sets of records, if you request it in writingwriting and the request is signed by you and dated not more than 60 days from the date submitted. Because these are professional records, they can be misinterpreted and/or upsetting to untrained readers. For this reason, I recommend it is recommended that you initially review them in my presence, the presence of the clinician or have them forwarded to another mental health professional so you can discuss the contents. In most circumstances, I am allowed the law allows clinicians to charge a copying fee of $3.07 per page for copying recordsthe first ten pages, 64 cents per page for pages 11 through 50, and 26 cents per page for pages in excess of fifty, plus postage, as of 2022. The exceptions If you request for access to this policy are contained in your records is refused, you have the Privacy Notice formright of review, which will be discussed with you upon request and we will provide them to a psychologist or licensed mental health professional designated by you. HIPAA HIPPA provides you with several new or expanded guidelines and policies regarding your rights with regard to your Clinical Record and disclosures of protected health information. These rights include requesting that I the clinician 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 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 Privacy Notice form, and my privacy policies and procedures. I am happy to discuss any Please consult the Notice form for more complete information of these rights and/or issues with yourights. Patients Clients who are under 18 years of age and who are not emancipated and emancipated, along with their parents parents, should be aware that the law may allow allows parents to examine their child’s treatment recordsrecords absent a court order blocking a parent’s access. Because Also, children between the ages of 14 and 18 years of age may independently consent to and receive up to 6 sessions of psychotherapy/counseling services provided it is within a 30 day period and no information will be disclosed to the parent/guardian unless there is a compelling need for disclosure based on a substantial probability of harm to the minor or other persons and the minor is told of the intent of the mental health professional to inform the minor’s parent or guardian. No information about those sessions can be disclosed to anyone without the child’s agreement. Under this option only the minor child is responsible for payment. While the privacy in psychotherapy psychotherapy/counseling is often crucial to successful progress, particularly with teenagers, parental involvement can also be essential to successful treatment. For children 14 and over, it is sometimes my policy to request an agreement from between the client and his/her parents that they consent allowing the clinician to give up their access to their child’s records. If they agree, during treatment, I will typically provide them only with share general information about the progress of the child’s treatment, treatment and his/her attendance at scheduled sessions. I The clinician will also may provide parents with a summary of their child’s treatment when it is complete. Most Any other communication will require the child’s Authorization, unless I feel the clinician feels that the child is in danger danger, or is a danger to someone else, or a threat to property, in which case, I the clinician will notify the parents of my the concern. Before giving parents any information, I the clinician will discuss the matter with the child, if possible, and will do my his/her best to handle any objections he/she that the child may have. However, the parent(s) signing such an agreement may revoke their consent to this agreement, so although it may provide some protection involving the release of information, we cannot guarantee that it will always be effective. Both parents must recognize that if a minor child or children are the only client(s), that typically both parents hold the privilege on all communication involving the child while in therapy and that anything that either of them says in a session is available to the other parent, unless blocked by a court order.

PROFESSIONAL RECORDS. You should be aware that, according pursuant to the rules of HIPAA, I keep Protected Health Information about you in two sets of professional records. One , one set constitutes your Clinical RecordRecords. 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, 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. In additionExcept in unusual circumstances that involve danger to yourself and others or (where information has been supplied to me confidentially by others), 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 content of Psychotherapy Notes vary from client to client, they can include notes regarding the contents of our conversations, my analysis of those conversations, and how they impact on your therapy. They also can 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 examine and/or 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 both sets of records, 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 am sometimes willing to conduct this review meeting without charge.) In most circumstancessituations, I am allowed to charge a copying fee of $0.50/per page (and for copying recordscertain other expenses). The exceptions to this policy are contained in the Privacy attached Notice formForm. 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 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 Records. (They also include information from others provided to me confidentially.) These Psychotherapy Notes are kept separate from your clinical Records. 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. HIPAA provides you with several new or expanded rights with regard to your Clinical Record Records and disclosures of protected health information. These rights include requesting that I amend your record; records, requesting restrictions on what information from your Clinical Record Records is disclosed to others; requesting an accounting of most disclosures of Protected Health Information 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 Privacy attached Notice form, and my privacy policies and procedures. I am happy to discuss any of these rights and/or issues with you. Patients under 18 16 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 recordsrecords unless I decide that such access is likely to injure the child. (There are some circumstances in which I can provide treatment for not more than 6 sessions to a child under 16 without parental consent or notification, but the requirements for such nonconsensual treatment are complicated and can be discussed on request.) 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 hey consent to give up their access to their child’s records. If they agree, during treatment, I will typically provide them only with general information about the progress of the child’s treatment, and his/her attendance at scheduled sessionssession. I will also may provide parents with a summary of their child’s treatment when it is complete. Most Any other communication will require the child’s Authorizationconsent, 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 RECORDS. You should be aware that, according pursuant to the rules of HIPAA, I may keep Protected Health Information about you in two sets of professional records. One set constitutes your Clinical Record. It includes information about your reasons for seeking therapy, 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 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. (I am sometimes willing to conduct this review meeting without charge.) In most circumstances, I am allowed to charge a copying fee of $.20 per page (and for certain other expenses). The exceptions to this policy are contained in the provided 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 may also keep a set of Psychotherapy Notes. These Notes are for my own use and are designed to assist me your treatment provider in providing you with the best treatment, . While the content contents of Psychotherapy Notes vary from client to client, they can include notes regarding the contents of our conversations, my the analysis of those conversations, and how they impact on your therapy. They also can 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 both sets of recordsyour Psychotherapy Notes unless it is determined that release would be harmful to your physical, 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, mental or have them forwarded to another mental health professional so you can discuss the contents. In most circumstances, I am allowed to charge a fee for copying records. The exceptions to this policy are contained in the Privacy Notice formemotional health. 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 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 Privacy provided Notice form, and my our privacy policies and procedures. I am happy to discuss any of these rights and/or issues with you. 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 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 typically provide them only with general information about the progress of the child’s treatment, and his/her attendance at scheduled sessions. I also may provide parents with a summary of their child’s treatment when it is complete. Most 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 information, I will discuss the matter with the child, if possible, and do my best to handle any objections he/she may have.

PROFESSIONAL RECORDS. You should Please be aware that, according pursuant to the rules of HIPAA, I keep Protected Health Information about you in two 2 sets of professional records. One set constitutes is 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 toward those goals, your medical and social history, your our 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. Except in unusual circumstances that involve danger to you/others or where information has been supplied to us by others confidentially, including reports to your insurance carrier. 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 content of Psychotherapy Notes vary from client to client, they can include notes regarding the contents of our conversations, my analysis of those conversations, and how they impact on your therapy. They also can 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 examine and/or receive a copy of your Clinical Record, they cannot receive with 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 both sets of records, 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, presence or have them forwarded to another mental health professional so you can discuss the contents. In most circumstancessituations, I am allowed to charge a fee copying fee. If I refuse your request for copying access to your records, you have a right of review which I will discuss with you upon request. The exceptions All legal services pertaining to this policy legal counsel, release of records, subpoenas, emailing and consultation pertaining to any lawsuits are contained charged $300 per hour. Additional costs may apply. In addition, I keep a set of Psychotherapy Notes. These Notes are for our own use and are designed to assist in providing you with the Privacy Notice formbest treatment. While the contents of Psychotherapy Notes vary from client to client, they can include the contents/analysis of our conversations and how they impact 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. While insurance companies can request a copy of your Clinical Record, they cannot receive a copy of your Psychotherapy Notes 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. You may examine and/or receive your Psychotherapy Notes unless I determine that such access is clinically contraindicated. In the event of my death or incapacitation, I have appointed a professional colleague to act on my behalf to notify you and to make decisions about storing, releasing and/or disposing of my professional records: Xxxxxx Xxxxxx-Xxxxx, LMFT, 00000 X. Xxxxxxxxxx Xx. #155, Scottsdale, AZ 85254; 000-000-0000 HIPAA provides you with several new or expanded rights with regard to your Clinical Record and disclosures of protected health informationPHI. These rights include requesting that I we amend your record; record (must be made in writing), requesting restrictions on of what information from your Clinical Record is disclosed to others; , requesting an accounting of most disclosures of Protected Health Information PHI 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 Privacy Notice form, and my privacy policies and proceduresagreement. I am will be happy to discuss any of these rights and/or issues with you. Patients Clients under 18 years of age (who are not emancipated emancipated) and their parents should be aware that the law may allow parents to examine their child’s treatment records. Because privacy in psychotherapy therapy 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 typically provide them only with general information about the progress of the child’s treatment, and his/her attendance at scheduled sessions. I also may provide parents with a summary of their child’s treatment when it is complete. Most 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 information, I will discuss the matter with the child, if possible, and do my best to handle any objections he/she may have.is

PROFESSIONAL RECORDS. You should be aware that, according pursuant to the rules of HIPAA, I sometimes 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. In addition, Except in unusual circumstances that involve danger to yourself and others (for which I also keep a set of Psychotherapy Notes. These Notes are for my own use and are designed to assist me in providing will provide you with the best treatmentan accurate and representative summary of your Record if you request it), While the content of Psychotherapy Notes vary from client to client, they can include notes regarding the contents of our conversations, my analysis of those conversations, and how they impact on your therapy. They also can 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 examine and/or 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 both sets of records, 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 .10 per page. If I refuse your request for copying records. The exceptions to this policy are contained in the Privacy Notice form. HIPAA provides you with several new or expanded rights with regard access 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 Record, you have neither consented to nor authorized; determining the location to a right of review, 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 Privacy Notice form, and my privacy policies and procedures. I am happy to discuss any of these rights and/or issues with you. 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 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 typically provide them only with general information about the progress of the child’s treatment, and his/her attendance at scheduled sessions. I also may provide parents with a summary of their child’s treatment when it is complete. Most 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 information, I will discuss the matter with you upon request. In addition, I sometimes 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 childbest treatment. While the contents of Psychotherapy Notes vary from client to client, if possiblethey can include the contents of our conversations, my analysis of those conversations, and do my best how they impact on your therapy. They may also contain particularly sensitive information that you may reveal to handle me that is not required to be included in 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 objections he/she way for your refusal. You may haverequest to examine and/or receive a copy of your Psychotherapy Notes unless I determine that such disclosure would be injurious to you.

PROFESSIONAL RECORDS. You should be aware that, according to the rules The laws and standards of HIPAA, my profession require that 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 therapyIf you provide a written request, a description of you have 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 right to anyone, including reports to your insurance carrier. 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 content of Psychotherapy Notes vary from client to client, they can include notes regarding the contents of our conversations, my analysis of those conversations, and how they impact on your therapy. They also can 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 both sets of your records, if you request it in writing. Because these are professional records, they can sometimes be misinterpreted and/or upsetting to untrained readers. For this reason, I recommend that you initially review them in my presence, presence or have them forwarded to another mental health professional so you can discuss to review with you. There may be a charge for reproducing records or for the contents. In most circumstances, I am allowed time required to charge a fee for copying recordsreview them with you. The exceptions law requires that I obtain your signature acknowledging that I have provided you with information regarding your rights to this policy are contained privacy. This information is included in the Notice of Privacy Notice form. HIPAA Practices required by the Health Insurance Portability and Accountability Act (HIPAA), a federal law that provides you with several new or expanded privacy protections and patient rights with regard to the use and disclosure of 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 (PHI). By signing this document, you will be acknowledging that you have neither consented received the privacy notice. Payment is expected at time of service. Please see the Medical Practice Commitments and Expectations form included with your new client paperwork for more detailed information. The hourly fee for regular therapy appointments is $170. The fee for the initial intake session is $350. Examples of other billable services beyond your therapy appointments include report writing, frequent or lengthy telephone conversations, consulting with other professionals (with your permission), and preparation of records or treatment summaries. If you become involved in legal proceedings that require the participation of clinic personnel, you will be expected to nor authorized; determining pay for the location requested services, including preparation and transportation costs. Because of the complexity and difficulty of legal involvement, our fee is $250 per hour for any legal work. Any pre-certification requirements that GCA agrees to which protected do, on your behalf, must be done as a scheduled appointment, and with the client present. This is to ensure that you are fully aware of any information disclosures are sent; having any complaints you make about my policies and procedures recorded in being released to your records; and insurance company. We reserve the right to a paper copy of this Agreement, refuse any pre-certification requirements that we find excessive. Please keep in mind that you will be billed for the Privacy Notice form, and my privacy policies and procedures. I am happy to discuss any of these rights and/or issues with you. 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 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 typically provide them only with general information about the progress of the child’s treatment, and his/her attendance at scheduled sessions. I also may provide parents with a summary of their child’s treatment when it is complete. Most 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 information, I will discuss the matter with the child, if possible, and do my best to handle any objections he/she may havetime spent on "pre-certifications."

PROFESSIONAL RECORDS. You should be aware that, according pursuant to the rules of HIPAA, I your therapist may keep Protected Health Information about you in two (2) sets of professional records. One set constitutes your Clinical Record. It This 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 are set for treatment, your progress towards those goals, your medical and social history, your treatment history, any past treatment records that I receive received from other providerstherapists, reports of any professional consultations, your billing records, and any reports that have been sent to anyone, including reports to your insurance carrier. In additionExcept in unusual circumstances that involve danger to yourself and/or others or the record makes reference to another person (unless such other person is a health care provider) and your therapist believes that access is reasonably likely to cause substantial harm to such other person, 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 content of Psychotherapy Notes vary from client to client, they can include notes regarding the contents of our conversations, my analysis of those conversations, and how they impact on your therapy. They also can 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 examine and/or 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 both sets of records, 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 it is recommended that you initially review them in my presencewith your therapist, or have them forwarded to another mental health professional so you can discuss the contents. In most circumstances, I am allowed to There normally will be a charge a fee for copying records. The exceptions to this policy are contained in the attached Privacy Notice formNotice. HIPAA provides If your request for access to your records is refused, you have a right of review, which will be discussed with you upon request. In addition, your therapist may also keep a set of Psychotherapy Notes. These notes are for your therapist's use and are designed to assist in providing you with several new or expanded rights the best treatment. While the contents of Psychotherapy Notes vary from client to client, they can include the contents of your conversations with regard your therapist, an analysis of those conversations, and how they may have an impact on your therapy. They may also contain particularly sensitive information that you may reveal to your therapist that is not required to be included in your Clinical Record and disclosures of protected health informationinformation revealed to your therapist confidentially by others. These rights include requesting that I amend your record; requesting restrictions on what information Psychotherapy Notes are kept separate 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 Privacy Notice form, and my privacy policies and proceduresRecord. I am happy to discuss any of these rights and/or issues with you. Patients under 18 years of age who Your Psychotherapy Notes are not emancipated available to you and their parents should cannot be aware that the law may allow parents sent 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 typically provide them only with general information about the progress of the child’s treatment, and his/her attendance at scheduled sessions. I also may provide parents with a summary of their child’s treatment when it is complete. Most other communication will require the child’s Authorization, unless I feel that the child is in danger or is a danger to someone anyone else, including insurance companies without a separate written, signed Authorization. Insurance companies cannot require your authorization to release Psychotherapy Notes as a condition of coverage nor penalize you in which case, I will notify the parents of my concern. Before giving parents information, I will discuss the matter with the child, if possible, and do my best any way for your refusal to handle any objections he/she may haveprovide it.

PROFESSIONAL RECORDS. You should be aware that, according to the rules The laws and standards of HIPAA, my profession require that I keep Protected Health Information about you in two sets of professional records. One set constitutes your a Clinical Record. It includes information about your reasons for seeking therapyExcept in unusual circumstances where that disclosure would physically or emotionally endanger you and/or others, 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. 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 content of Psychotherapy Notes vary from client to client, they can include notes regarding the contents of our conversations, my analysis of those conversations, and how they impact on your therapy. They also can 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 examine and/or 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 both sets of records, if you request it in writing. In most circumstances, I am allowed to charge a copying fee of $0.10 per page (and charge for certain other expenses such as postage and envelopes). 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 presence so you can discuss the contents. In most circumstancesIf I refuse your request for access to your records, you have a right of review, which I will discuss with you upon request. You also may add information to your records when I review them with you if you believe they contain inaccurate or incomplete information. It is my office policy to retain clients’ records for seven years after the end of our therapy. Please note that in some cases our files may include information from other treatment providers that clients have given me written permission to obtain. If you have given me permission to obtain such records, I am allowed cannot provide them to charge a fee you if you ask to review your files. Instead, I would ask for copying records. The exceptions you to this policy are contained in contact the Privacy Notice formprovider who created the records and obtain copies directly from her or him. HIPAA provides you with several new or expanded rights with regard to your Clinical Record Records and disclosures of protected health information. The written notice of these HIPAA rights are framed on the wall of the waiting room and a copy can by provided to you if you request it. These rights include requesting that I amend your record; requesting restrictions on what information from your Clinical Record Records is disclosed to others; requesting an accounting of most disclosures of Protected Health Information 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 our policies and procedures recorded in your records; and the right to a paper copy of this Agreement, the Privacy attached Notice form, and my our privacy policies and procedures. I am happy to discuss any of these rights and/or issues with you. Patients For a detailed description of your rights under 18 years of age who are not emancipated HIPAA, go to the Health and their parents should be aware that the law may allow parents to examine their child’s treatment recordsHuman Services web page below. 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 typically provide them only with general information about the progress of the child’s treatment, and hisxxxxx://xxx.xxx.xxx/hipaa/for-professionals/privacy/guidance/privacy-practices-for-protected-health-informati on/her attendance at scheduled sessions. I also may provide parents with a summary of their child’s treatment when it is complete. Most 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 information, I will discuss the matter with the child, if possible, and do my best to handle any objections he/she may haveindex.html.

PROFESSIONAL RECORDS. You should be aware that, according to the rules of HIPAAunder HIPAA regulations, I keep your AGAPE therapist may store 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 are set for treatment, your progress towards those goals, your medical and social history, your treatment history, any past treatment records that I receive were received from other providers, reports of any professional consultations, your billing records, and any reports that have been sent to anyone, including reports to your insurance carrier. Generally you may review and/or receive a copy of your Clinical Record if you request it in writing. However, because these are professional records, they can be easily misinterpreted and/or be potentially upsetting to untrained readers. For this reason, XXXXX recommends that you initially review them in the presence of your therapist, or have them forwarded to another qualified mental health professional with whom you can discuss the contents. As allowed by law, XXXXX charges a retrieval/copying fee of 15¢ for the first five pages of a record and 25¢ per page thereafter. In additioncircumstances where XXXXX feels that your review or receipt of your Clinical Record may result in a danger to yourself or another or when disclosure of your record compromises the privacy of another person, I XXXXX may deny your request. If your request for access to your Clinical Record is refused, you have a right of review, which your therapist or the Clinical Director will discuss with you upon request. The exceptions to this policy are contained in the Notice form. In addition to your Clinical Record, your therapist may also keep a set of Psychotherapy Notes. These Notes are for my his/her own use and are designed to assist me him/her in providing you with the best treatment, While the . These may include more detailed content of Psychotherapy Notes vary from client to clientyour conversations with the therapist, they can include notes regarding the contents of our conversations, my his/her analysis of those conversations, and how they impact on your therapy. They also can contain particularly sensitive information that you may reveal to me the therapist that is not required to be included in your Clinical Record. These Also included may be information from others provided to the therapist confidentially. Psychotherapy Notes are kept separate from your Clinical Record. While insurance companies can request Your Psychotherapy Notes are not available to you and receive a copy of your Clinical Record, they cannot receive a copy of your Psychotherapy Notes be sent to anyone else, including insurance companies, without your signed, written signed Authorization. Insurance companies cannot require you to authorize release of your Authorization Psychotherapy Notes as a condition of coverage nor penalize you in any way for your refusal. You may examine and/or receive a copy of both sets of records, if you request it in writing. Because these are professional records, they can be misinterpreted and/or upsetting refusal 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 fee for copying records. The exceptions to this policy are contained in the Privacy Notice form. 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 Privacy Notice form, and my privacy policies and procedures. I am happy to discuss any of these rights and/or issues with you. 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 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 typically provide them only with general information about the progress of the child’s treatment, and his/her attendance at scheduled sessions. I also may provide parents with a summary of their child’s treatment when it is complete. Most 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 information, I will discuss the matter with the child, if possible, and do my best to handle any objections he/she may haveit.

PROFESSIONAL RECORDS. You should be aware that, according to the rules of 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. 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 content of Psychotherapy Notes vary from client to client, they can include notes regarding the contents of our conversations, my analysis of those conversations, and how they impact on your therapy. They also can 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 both sets of records, 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 fee for copying records. The exceptions to this policy are contained in the Privacy Notice form. 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 Privacy Notice form, and my privacy policies and procedures. I am happy to discuss any of these rights and/or issues with you. 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 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 typically provide them only with general information about the progress of the child’s treatment, and his/her attendance at scheduled sessions. I also may provide parents with a summary of their child’s treatment when it is complete. Most 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 information, I will discuss the matter with the child, if possible, and do my best to handle any objections he/she may have.

PROFESSIONAL RECORDS. You should be aware that, according to the rules The laws and standards of HIPAA, my profession require that 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 therapyExcept in circumstances involving potential danger to yourself and/or others, 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. 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 content of Psychotherapy Notes vary from client to client, they can include notes regarding the contents of our conversations, my analysis of those conversations, and how they impact on your therapy. They also can 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 both sets of records, your Clinical Record if you request it in writing. Pursuant to Texas law, psychological test data are not part of a patient’s record. Because these are professional records, they can easily 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 Any request to charge view or obtain a copy of a client’s mental health records must be made in writing and signed and dated by the client or the client’s legal guardian. Records will be made available during regular business hours. My office charges a fee of $25 for copying a client’s records. Should the records request include a request that the records be shipped, the actual cost of shipping the records will be added to the $25 copying fee. Payment must be made by money order or certified check. Personal checks will not be accepted for payment. Once payment is received, the requested records will be mailed by certified mail, return receipt requested. If a Business Records Affidavit is requested, a fee of $15 will be charged, and the Affidavit will not be signed until that fee is paid. Payment of this fee must be by certified check or money order. The exceptions client or client’s legal guardian will be responsible for the cost of the mobile notary. Within 15 days of receipt of the written records request and payment of all applicable fees, records will be provided. If it is determined that having access to the mental health records would be harmful to the client’s physical, mental, or emotional health, the request for access to records will be refused, and a written statement attesting to this policy are contained in the Privacy Notice formwill be provided. HIPAA provides you with several new or expanded rights with regard to your Clinical Record and disclosures of protected health informationProtected Health Information (PHI). These rights include requesting that I your psychologist 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 your PHI that you have neither consented to nor authorized; determining the location to which protected information disclosures are your PHI is 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 Privacy attached Notice formForm, and my privacy policies and procedures. I am happy to discuss any of these rights and/or issues with you. Patients Clients under 18 years of age who are not emancipated and their parents should be aware that the law may allow parents (who have legal custody of their children) to examine their child’s treatment mental health records. Because privacy in psychotherapy is often crucial to successful progressHowever, particularly if the mental health records include information regarding suicide prevention, chemical addiction or dependency, sexual abuse, physical abuse, or emotional abuse, the law provides that parents may not access their child’s records. When working with teenagers, a reasonable guarantee of privacy is often needed in order for the adolescent to be appropriately disclosing. With the aforementioned matter in mind, it is sometimes my policy policy, when working with children between 16 and 18 years of age, to request an agreement from the client and his/her parents that they the parents’ consent to give up their access to their child’s mental health records. If they the parents agree, during treatment, I will typically provide them only with general information about regarding the progress of the child’s treatment, and his/her attendance at scheduled sessions. I also may provide parents with a summary results of their child’s treatment when it is completepsychological evaluation. Most Any other communication will require the child’s Authorization, unless I feel that the child is in danger or is poses a danger to someone else, ; in which casesuch cases, I will notify the parents of my concernconcerns. Before giving Prior to providing parents any information, I will discuss the matter with the child, if possible, and do my best to handle appropriately address any objections he/she concerns the child may have.

PROFESSIONAL RECORDS. You should I am are required by law to maintain the privacy of and provide individuals with a copy of our “Notice to Privacy Practices” of our ethical and legal duties in regards to your protected health information in all forms (i.e. all paper and/or electronic data). A copy of this notice is on our website, attached with this informed consent and available in paper form. A copy will be aware that, according provided to you at no cost upon your request. If you have any objections to the rules of HIPAANotice, I keep please speak with your therapist. The BROADWAY COUNSELING CENTER keeps your Protected Health Information about you (PHI) in two sets of professional recordsrecords that are kept for seven years for adult clients and for ten years past the 18th birthday of minor clients. 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 toward those goals, your medical and social history, your treatment history, any past treatment records that I we receive from other providers, reports of any professional consultations, your billing records, and any reports that have been sent to anyone. Except in unusual circumstances that involve danger to yourself or others, including reports to your insurance carrier. 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 content of Psychotherapy Notes vary from client to client, they can include notes regarding the contents of our conversations, my analysis of those conversations, and how they impact on your therapy. They also can 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 both sets of records, your Clinical Record if you request it in writing. You should be aware that pursuant to the laws of the State of Texas, psychological test data are not part of a client’s record. Because these are professional records, they can be misinterpreted and/or upsetting to untrained readers. For As mentioned earlier in this reasondocument, I recommend BROADWAY COUNSELING CENTER charges a $25 fee for locating your Clinical Record, a fee of $50 per hour for the time spent gathering and preparing the records, and a 10 cents per page copying fee. If we refuse your request to your Clinical Record, you have a right of review, which we will discuss upon your request. In addition to the Clinical Record, BROADWAY COUNSELING CENTER also keeps a set of psychotherapy notes. These notes are for your therapist’s own use and are designed to assist him/her in providing you with the best treatment possible. While the contents of the notes vary from client to client, they can include the contents of your conversations with your therapist and your therapist’s analysis of those conversations. Psychotherapy notes may also contain particularly sensitive information that you initially review them may reveal to your therapist that is not required to be included in my presence, or have them forwarded to another mental health professional so you can discuss the contentsyour Clinical Record. In most circumstances, I am allowed to charge a fee for copying records. The exceptions to this policy These notes are contained in the Privacy Notice form. HIPAA provides you with several new or expanded rights with regard to kept separate from 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 are not typically released 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 . You may examine and/or receive a paper copy of this Agreement, the Privacy Notice form, and my privacy policies and procedures. I am happy to discuss any of these rights and/or issues with you. 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 your psychotherapy is often crucial to successful progress, particularly with teenagers, notes unless it is sometimes my policy determined that releasing them would be harmful to request an agreement from parents that they consent to give up their access to their child’s records. If they agreeyour physical, during treatmentmental, I will typically provide them only with general information about the progress of the child’s treatment, and his/her attendance at scheduled sessions. I also may provide parents with a summary of their child’s treatment when it is complete. Most 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 information, I will discuss the matter with the child, if possible, and do my best to handle any objections he/she may haveemotional health.

PROFESSIONAL RECORDS. You should be aware that, according pursuant to the rules of HIPAA, I your psychiatrist 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, medications prescribed, type of therapy approach provided, the goals that we are set for treatment, your progress towards those goals, ,your medical and social history, your treatment history, any past treatment records that I receive received from other providerspsychiatrists/psychologists/therapists, reports of any professional consultations, your billing records, and any reports that have been sent to anyone, including reports to your insurance carrier. In additionExcept in unusual circumstances that involve danger to yourself and/or others or the record makes reference to another person (unless such other person is a health care provider) and your psychiatrist believes that access is reasonably likely to cause substantial harm to such other person or to yourself, 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 content of Psychotherapy Notes vary from client to client, they can include notes regarding the contents of our conversations, my analysis of those conversations, and how they impact on your therapy. They also can 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 examine and/or 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 both sets of records, 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 it is recommended that you initially review them in my presencewith your psychiatrist, or have them forwarded to another mental health professional so you can discuss the contents. In most circumstances, I am allowed to (There may be a charge a fee for copying records). The exceptions to this policy are contained in the attached Privacy Notice formNotice. If your request for access to your records is refused, you have a right of review, which will be discussed with you upon request. In addition, your psychiatrist may also keep a set of Psychotherapy Notes. These Notes are for your psychiatrist’s use and are designed to assist in providing you with the best treatment. While the contents of Psychotherapy Notes vary from client to client, they can include the contents of your conversations with your psychiatrist, an analysis of those conversations, and how they impact on your therapy. They may also contain particularly sensitive information that you may reveal to your therapist that is not required to be included in your Clinical Record and information revealed to your therapist 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 a separate 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. CLIENT RIGHTS HIPAA provides you with several new or expanded rights with regard to your Clinical Record Records and disclosures of protected health information. These rights include requesting that I your psychiatrist amend your record; requesting restrictions on what information from your Clinical Record Records is disclosed to others; requesting an accounting of most disclosures of Protected Health Information 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 our policies and procedures recorded in your records; and the right to a paper view and copy of this Agreement, the Privacy Notice form, and my privacy policies and proceduresyour records,. I am Your psychiatrist will be happy to discuss any of these rights and/or issues with you. Patients under 18 years of age who These rights are not emancipated and their parents should be aware that explained further in 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 typically provide them only with general information about the progress of the child’s treatment, and his/her attendance at scheduled sessions. I also may provide parents with a summary of their child’s treatment when it is complete. Most 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 information, I will discuss the matter with the child, if possible, and do my best to handle any objections he/she may havePrivacy Notice.

PROFESSIONAL RECORDS. You should be aware that, according to the rules The laws and standards of HIPAA, I my profession require that we keep Protected Health Information about you in two sets of professional records. One set constitutes your Clinical Record. It includes information about your reasons for seeking therapyExcept in unusual circumstances that disclosure would physically endanger you and/or others or makes reference to another person (other than a health care provider) and we believe that access is reasonably likely to cause substantial harm to such other person, 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. 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 content of Psychotherapy Notes vary from client to client, they can include notes regarding the contents of our conversations, my analysis of those conversations, and how they impact on your therapy. They also can 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 examine and/or 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 both sets of records, 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 we recommend that you initially review them in my our presence, or have them forwarded to another mental health professional so you can discuss the contents. In most circumstances, I am we are allowed to charge a copying fee of $1.00 per page for copying the first 25 pages and 25 cents per page thereafter as well as postage or other costs associated with furnishing you these records. The exceptions We may withhold copies of your records until payment of the copying fees has been made. If we refuse your request for access to this policy are contained your records, you have a right of review, which we will discuss with you upon request. You agree that unless a medical emergency exists, provision of records within 30 days of request will be considered timely. With certain exceptions, such as those involved in the Privacy Notice form. HIPAA forensic, legal or Worker’s Compensation matters, HIPPA provides you with several new or expanded rights with regard to your Clinical Record clinical records and disclosures of protected health information. These rights include requesting that I we amend your record; requesting restrictions on what information from your Clinical Record Records is disclosed to others; requesting an accounting of most disclosures of Protected Health Information 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 our policies and procedures recorded in your records; and the right to a paper copy of this Agreement, the Privacy attached Notice form, and my privacy policies and procedures. I am We are happy to discuss any of these rights and/or issues with you. 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. Children between 13 and 17 may independently consent to (and control access to the records of) diagnosis and treatment in a crisis situation. Because privacy in psychotherapy is often crucial to successful progress, particularly with teenagers, it and parental involvement, is sometimes my policy to also essential, we may request an agreement from with minors [over 12] and their parents that they consent to give up their about access to their child’s recordsinformation. If they agree, This agreement provides that during treatment, I we will typically provide them parents only with general information about the progress of the child’s treatment, and his/her the patient’s attendance at scheduled sessions. I We may also may provide parents with a summary of their child’s treatment when it is complete. Most other communication will In these cases, we may require the child’s Authorization, unless I we feel that the child is in danger or is a danger to someone else, in which case, I we will notify the parents of my concernour concerns. Before giving parents any information, I we will discuss the matter with the child, if possible, and do my our best to handle any objections he/she may have. It is our understanding that Federal laws are more stringent in protecting release of Drug and Alcohol information regarding adults as well as minor children. While we recognize the serious parental concerns in this regard, we cannot release such information without your child’s informed consent. By presenting your minor child for treatment, you are representing and affirming that you have legal parental authority to do so. Unless parental rights have been terminated, or there have been other specific restrictions imposed by the court or law, you are affirming that both parents have equal rights to information about diagnosis and treatment under the law.

PROFESSIONAL RECORDS. You should be aware that, according pursuant to the rules of HIPAA, I keep your therapist sometimes keeps 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 problems impact your life, your diagnosis, the goals that we set for treatment, your progress towards those toward these goals, your medical and social history, your treatment history, any past treatment records that I receive your therapist receives from other providers, reports of any professional consultations, your billing records, and any reports that have been sent to anyone, including reports to your insurance carrier. In addition, I also keep a set of Psychotherapy Notes. These Notes are for my own use and are designed Except in unusual circumstances that involve danger to assist me yourself or others (in providing which case your therapist will provide you with the best treatmentan accurate and representative summary), While the content of Psychotherapy Notes vary from client to client, they can include notes regarding the contents of our conversations, my analysis of those conversations, and how they impact on your therapy. They also can 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 both sets of records, your Clinical Record if you request it in writing. Because these are professional records, they can be misinterpreted and/or may be upsetting to untrained readersa non-professional who reads them. For this reason, I we recommend that you initially review them in my presence, or have them forwarded to another mental health professional the presence of your therapist so that you can may discuss the contents. In most circumstancesaddition to Clinical Records, I am allowed your therapist will sometimes keep a set of Psychotherapy Notes. These notes are for their own use and are designed to charge assist them in providing you with high quality care. Though the contents of these notes may vary, they may include the contents of your conversations, your therapist’s analysis of these conversations, and how their analysis impacts your therapy. They may also contain sensitive information that you share with your therapist that is not required in your Clinical Record. Though insurance companies can request your Clinical Record, they do not have access to my Psychotherapy Notes without your signed, written authorization. Insurance companies cannot require your Authorization as a fee condition of coverage nor penalize you for copying recordsyour refusal. The exceptions You may request to this policy are contained in the Privacy Notice formexamine and/or receive a copy of your Psychotherapy Notes unless your therapist determines that such a disclosure would be injurious to you. HIPAA provides you with several new or expanded rights with regard to regarding your Clinical Record and disclosures of protected health informationPHI. These rights include requesting that I amend your therapist amends your record; requesting restrictions on what , restrict certain information from your Clinical Record is disclosed from disclosure to others; requesting , provide an accounting account of most disclosures of Protected Health Information PHI that you have neither consented to nor not authorized; determining , determine the location to which protected information disclosures PHI are sent; having , record any complaints that you make about my policies and procedures recorded in your records; record, and the right to provide you with a paper copy of this Agreement, the Privacy attached Notice formForm, and my privacy policies and procedurespolicy. I am happy to We can discuss any of these rights and/or issues with youat your request. Should you wish to utilize any of these rights, please put that request in writing. Patients under the age of 18 years of age who are not emancipated and from their parents should be aware that the law may allow parents to examine their child’s treatment records. Because privacy in psychotherapy is often crucial to successful progress, particularly with teenagers, it is sometimes my policy to request an agreement consent from parents that they consent to give up their access to their child’s recordsthe records of patients between the ages of 14 and 18. If they agreethis agreement is established, during treatment, I your therapist will typically only provide them only parents with general information about the patient’s progress of the child’s treatment, and his/her attendance attendance. Your therapist will also provide a verbal or written summary at scheduled sessions. I also may provide parents with a summary the end of their child’s treatment when treatment, if it is completerequested. Most Any other communication will would require the child’s Authorizationauthorization, unless I feel your therapist believes that the child is in danger or is a danger to someone else, self or others (in which case, I will your therapist would notify the parents of my concernparents). Before giving parents information, I your therapist will make every effort to discuss the matter it with the child, if possible, and do my best to handle any objections he/she may have.

PROFESSIONAL RECORDS. You should be aware that, according to the rules of HIPAA, I keep Protected Health Information about you in two sets of professional records. One set constitutes your The Clinical Record. It Record includes information about your reasons for seeking therapy, a description of the ways in which your problem impacts on your lifeproblems, your diagnosis, the goals that we set for treatment, your progress towards those treatment goals, your medical treatment progress, history (medical, social, and social history, your treatment historytreatment), any past treatment records that I receive received from other providers, reports of any professional consultations, your billing records, and any reports that have been sent to anyone, including reports to your insurance carrier. In additionYour therapist records a progress note for each visit which details the problems discussed in that session, I also keep a set of Psychotherapy Notes. These Notes are for my own use treatment plans and are designed to assist me in providing you with the best treatment, While the content of Psychotherapy Notes vary from client to client, they can include notes regarding the contents of our conversations, my analysis of those conversationsgoals, and how they any relevant information that would impact on your therapy. They also can contain particularly sensitive Under no circumstances will your therapist agree to omit information that you may reveal to me that is not required to be included have shared in your Clinical Record. These Psychotherapy Notes are kept separate therapy from your Clinical Recordclinical 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 both sets of recordsyour Clinical Record, if you request it in writing. Because these are professional records, they records can be misinterpreted and/or upsetting to untrained readers. For this reason, I readers we recommend that you initially review them in my presenceyour records with your therapist, or have them forwarded to another mental health professional so you can discuss the contents. In most circumstances, I am allowed to charge • You will be charged a fee of $1.00 a page for copying of your clinical record. • We request you pay your bill in full prior to our releasing your records. The exceptions In order to this policy are contained in avoid misunderstandings your therapist will ask you and those family members (or others) attending your therapy sessions to sign the Privacy Notice form. HIPAA provides you with several new or expanded rights with regard Consent for Multiple Therapy Attendees Release of Information Form, which explains how clinical information about your treatment cannot be released to your Clinical Record another party without the consent of all of those who have attended sessions 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 participated in your records; and the right to a paper copy of this Agreement, the Privacy Notice form, and my privacy policies and procedures. I am happy to discuss any of these rights and/or issues with you. 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 sometimes my policy to request an agreement from parents that they consent to give up their access to their child’s recordstherapy. If they agreeyou wish, during at the end of treatment, I you and those who have attended your therapy, may sign a Consent Form that gives us permission to release the treatment record, on your signature alone. The records of all clients seen at the Centers for Family Change are the property of Centers for Family Change. If your therapist leaves the practice or becomes incapacitated or dies, all your records will typically provide them only with general information about remain in possession of Centers for Family Change. If Centers for Family Change ceases to exist as an independent practice your records will become the progress property of the child’s treatmentanother licensed mental health professional, and his/her attendance at scheduled sessions. I also may provide parents with a summary of their child’s treatment when it is complete. Most 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 information, I will discuss the matter with the child, if possible, and do my best to handle any objections he/she may havepractice.

PROFESSIONAL RECORDS. You should be aware that, according to the rules The laws and standards of HIPAA, my profession require that I keep Protected Health Information about you in two sets of professional records. One set constitutes your Clinical Record. It includes Except in unusual circumstances that involve danger to yourself and/or others or where information about your reasons for seeking therapyhas been supplied to me confidentially by others, 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. 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 content of Psychotherapy Notes vary from client to client, they can include notes regarding the contents of our conversations, my analysis of those conversations, and how they impact on your therapy. They also can 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 examine and/ or 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 both sets of records, 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 75 cents per page (and for copying certain other expenses). If I refuse your request for access to your records. The exceptions , you have a right to this policy are contained in the Privacy Notice forma review. HIPAA provides you with several new or expanded rights with regard to regarding your Clinical Record Records and disclosures of protected health information. These rights include requesting that I amend your record; requesting restrictions on what information from your Clinical Record Records is disclosed to others; requesting an accounting of most disclosures of Protected Health Information 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 Privacy attached Notice form, and my privacy policies and procedures. The Colorado Department of Regulatory Agencies has the general responsibility of regulating the practice of licensed psychologists and other licensed and unlicensed individuals who practice psychotherapy. The agency within the department that has specific responsibility for licensed and unlicensed psychotherapists is the Department of Regulatory Agencies, Mental Health Section. The Board of Psychologist Examiners can be reached at 0000 Xxxxxxxx, Xxxxx 0000, Xxxxxx, Xxxxxxxx 00000, or (000) 000-0000. In a professional relationship such as ours, clear boundaries need to be maintained. For example, sexual intimacy between a therapist and a client is never appropriate. If sexual intimacy occurs, it should be reported to the Department of Regulatory Agencies, Mental Health Section. If you have a health insurance policy, it will usually provide limited coverage for mental health treatment. If I am happy not on the provider panel for the managed care insurance company that covers your mental health treatment, you may still be able to discuss any have your insurance reimburse you for some portion of these rights and/or issues my fees. It is important to understand that there are disadvantages to using managed care insurance benefits to help cover the cost of psychotherapy. 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 youa person’s usual level of functioning. Patients under 18 years It may be necessary to seek approval for more therapy after a certain number of age who are not emancipated and their parents sessions. While much can be accomplished in short-term therapy, some clients 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 law may allow parents services that I provide to examine their child’s you. I am required to provide a clinical diagnosis. In rare cases I am required to provide additional clinical information such as treatment recordsplans or summaries, or copies of your entire Clinical Record. 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 treatmentIn such situations, I will typically provide them make every effort to release only with general the minimum information about you that is necessary for the progress purpose requested. This information will become part of the child’s treatmentinsurance company files and will probably be stored in a computer. Though all insurance companies claim to keep such information confidential, and his/her attendance at scheduled sessionsI 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 also may will provide parents you with a summary copy of their child’s treatment when it any report I submit, if you request it. By signing this Agreement, you agree that I can provide requested information to your carrier. I will help you 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 completevery important that you find out exactly what mental health services your insurance policy covers. Most other communication will require You should carefully read the child’s Authorizationsection in your insurance coverage booklet that describes mental health services. If you have questions about the coverage, unless I feel that the child is in danger or is a danger to someone else, in which casecall your plan administrator. Of course, I will notify provide you with whatever information I can based on my experience and will be happy to help you in understanding the parents of my concerninformation you receive from your insurance company. Before giving parents informationIf it is necessary to clear confusion, I would be willing to call the company on your behalf. Once we have all the information about your insurance coverage, we will discuss the matter what we can expect to accomplish with the childbenefits 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 have the option of paying for my services yourself to avoid many of the complications and problems described above. Increasingly, if possiblepeople are not using insurance to pay for psychotherapy due to concerns about confidentiality, choice of therapist and do my best to handle any objections he/she may havecontrol of treatment decisions.

PROFESSIONAL RECORDS. You should be aware that, according pursuant to the rules of HIPAA, I your psychiatrist 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, medications prescribed, type of therapy approach provided, the goals that we are set for treatment, your progress towards those goals, your medical and social history, your treatment history, any past treatment records that I receive received from other providerspsychiatrists/psychologists/therapists, reports of any professional consultations, your billing records, and any reports that have been sent to anyone, including reports to your insurance carrier. In additionExcept in unusual circumstances that involve danger to yourself and/or others or the record makes reference to another person (unless such other person is a health care provider) and your psychiatrist believes that access is reasonably likely to cause substantial harm to such other person or to yourself, 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 content of Psychotherapy Notes vary from client to client, they can include notes regarding the contents of our conversations, my analysis of those conversations, and how they impact on your therapy. They also can 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 examine and/or 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 both sets of records, 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 it is recommended that you initially review them in my presencewith your psychiatrist, or have them forwarded to another mental health professional so you can discuss the contents. In most circumstances, I am allowed to (There may be a charge a fee for copying records). The exceptions to this policy are contained in the attached Privacy Notice formNotice. If your request for access to your records is refused, you have a right of review, which will be discussed with you upon request. In addition, your psychiatrist may also keep a set of Psychotherapy Notes. These Notes are for your psychiatrist’s use and are designed to assist in providing you with the best treatment. While the contents of Psychotherapy Notes vary from client to client, they can include the contents of your conversations with your psychiatrist, an analysis of those conversations, and how they impact on your therapy. They may also contain particularly sensitive information that you may reveal to your therapist that is not required to be included in your Clinical Record and information revealed to your therapist 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 a separate 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. CLIENT RIGHTS HIPAA provides you with several new or expanded rights with regard to your Clinical Record Records and disclosures of protected health information. These rights include requesting that I your psychiatrist amend your record; requesting restrictions on what information from your Clinical Record Records is disclosed to others; requesting an accounting of most disclosures of Protected Health Information 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 our policies and procedures recorded in your records; and the right to a paper view and copy of this Agreement, the Privacy Notice form, and my privacy policies and proceduresyour records,. I am Your psychiatrist will be happy to discuss any of these rights and/or issues with you. Patients under 18 years of age who These rights are not emancipated and their parents should be aware that explained further in 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 typically provide them only with general information about the progress of the child’s treatment, and his/her attendance at scheduled sessions. I also may provide parents with a summary of their child’s treatment when it is complete. Most 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 information, I will discuss the matter with the child, if possible, and do my best to handle any objections he/she may havePrivacy Notice.

PROFESSIONAL RECORDS. You should be aware that, according to the rules The standards of HIPAA, my profession require that I keep Protected Health Information about you in two sets of professional records. One set constitutes your Clinical Record. It includes Except in unusual circumstances that involve danger to yourself and 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 about your reasons for seeking therapyhas been supplied to me confidentially by others, 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. 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 content of Psychotherapy Notes vary from client to client, they can include notes regarding the contents of our conversations, my analysis of those conversations, and how they impact on your therapy. They also can 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 examine and/or 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 both sets of records, 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 circumstancessituations, I am allowed to charge a copying fee of $.50 cents per page (and for copying certain other expenses like postage). 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. The exceptions to this policy are contained in the Privacy Notice form. HIPAA HIPPA 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 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 Privacy attached Notice form, and my privacy policies and procedures. I am happy to discuss any of these rights and/or issues with you. Patients under 18 years of age who You are not emancipated and their parents should be aware that expected to pay for the law may allow parents to examine their child’s treatment records. Because privacy in psychotherapy session when the service 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 recordsprovided. If they agreeyou have insurance I take, during treatmentthe insurance company may pay for part of this fee. If I take your insurance, I will typically provide file the insurance for you, but you are responsible for assuring that the insurance company pays their part of your bill. I am paid different rates by different insurance companies. If you have questions about any charges or fees, please feel free to discuss these with me. The parts of my fee not covered by insurance (the co-pay and/or coinsurance and deductible) are your responsibility, and I will expect you to pay them only with general information about at the progress time of the child’s treatmentsession. You are required to know how much your part of the fee will be, and his/her attendance to be sure that your sessions are authorized ahead of time by the insurance company or the managed care company administering the benefits for the insurance company. This is usually done by calling the number for mental health services on your insurance card. Please remember that when a managed care company authorizes sessions, the paperwork contains a disclaimer that even though they are authorizing the service, they cannot guarantee payment. This is the responsibility of you and your insurance company. In the event you do not know your co-pay or co-insurance, you will be responsible for the full amount at the time of service and can request reimbursement from your insurance company. If I do not accept your insurance, you may request a bill which you may submit to your insurance company. Some insurance companies will reimburse you with the “out of network” benefit. It is your responsibility to find out if your insurance will pay for an out of network therapist. This is usually accomplished by calling the number for mental health services or behavioral health services on the back of your insurance card. Your therapy appointment time is reserved only for you. This is different from other medical offices, where more than one person may be scheduled sessionsat the same time. If you run late to an appointment, it will still end at the scheduled time, because someone has a scheduled appointment right after yours. If you miss an appointment for any reason, you will be charged the full fee of $125 for the session if you do not call at least 24 hours in advance of your appointment to cancel the appointment. Your insurance will not reimburse you for a missed appointment fee. If you need to cancel an appointment, call my number and leave a voice mail. I accept cash, checks and money orders as payment for your session. Credit cards are not accepted. In the event that you have a check returned to me for non-payment of funds, you will be expected to pay for the associated costs I have. These charges will include a returned check charge and any bank charges that I incur. I may also may provide parents ask you to pay by cash or money order in the future. I schedule appointments Monday through Friday, with later appointments available on Monday, Wednesday and Thursday evenings. My cell phone number is available to you and if I do not answer, I encourage you to leave a summary of their child’s treatment when it is completemessage. Most other communication I check my messages daily and will require the child’s Authorization, unless I feel that the child is in danger or is a danger to someone else, in which casereturn calls as soon as possible. If you call after 6:00pm, I will notify return your call if necessary but will most likely call the parents following day. If you call on the weekend, your call will be returned on Monday. If you have an emergency, and I do not return your call within a few minutes, please contact the emergency room of my concernthe hospital covered by your insurance company or call 911. Before giving parents Both federal and state laws establish strict requirements for most programs regarding the disclosure of confidential information, and I will discuss the matter must comply with the childthose laws. For situations where stricter disclosure requirements do not apply, if possiblethis Notice of Privacy Practices describes how I may use and disclose your protected health information for treatment, payment, health care operations and for certain other purposes. This notice also describes your rights to access and control your protected health information, and do my best provides information about your right to handle make a complaint if you believe I have improperly used or disclosed your "protected health information." Protected health information is information that may personally identify you and relates to your past, present or future physical or mental health or condition and related health care services. I am required to abide by the terms of this Notice of Privacy Practices, and may change the terms of this notice, at any objections he/she may havetime. A new notice will be effective for all protected health information that I maintain at the time of issuance. Any changes in this notice will made available to you.

PROFESSIONAL RECORDS. You should be aware that, according pursuant to the rules of 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 involve danger to yourself and others (for which I will provide you with an accurate and representative summary of your 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. In most circumstances, I am allowed to charge a copying fee of $.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 sometimes 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 content contents of Psychotherapy Notes vary from client to client, they can include notes regarding the contents of our conversations, my analysis of those conversations, and how they impact on your therapy. They also can 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 both sets of records, if you request it in writing. Because these are professional records, they can your Psychotherapy Notes unless I determine that such disclosure would be misinterpreted and/or upsetting injurious 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 fee for copying records. The exceptions to this policy are contained in the Privacy Notice formyou. 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 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 Privacy attached Notice form, and my privacy policies and procedures. I am happy to discuss any of these rights and/or issues with you. Patients under 18 years Should you wish to utilize any of age who are not emancipated these rights, please request them in writing 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 typically can provide them only with general information about the progress of the child’s treatment, and his/her attendance at scheduled sessions. I also may provide parents with a summary of their child’s treatment when it is complete. Most 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 information, I will discuss the matter you with the child, if possible, and do my best to handle any objections he/she may haveproper form or procedure.

PROFESSIONAL RECORDS. You should be aware that, according pursuant to the rules of HIPAA, I may keep Protected Health Information about you in two sets of professional records. One set constitutes your Clinical Record. It includes information about your reasons for seeking therapy, 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. Although any past treatment records that I receive from other providers are included in the Clinical Record, they cannot be released to anyone and must be requested of the person or agency that initially generated them. You may examine and/or receive a copy of your Clinical Record 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 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 your 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 my patients with the best treatment, . While the content contents of Psychotherapy Notes vary from client to client, they can include notes regarding the contents of our conversations, my analysis of those conversations, and how they impact on your therapy. They may also can 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 Authorizationauthorization. Insurance companies cannot require your Authorization authorization as a condition of coverage nor penalize you in any way for your refusal. You may examine and/or receive a copy of both sets of recordsyour Psychotherapy Notes unless I determine that it would adversely affect your well-being, if in which case you request it in writing. Because these are professional records, they can be misinterpreted and/or upsetting have a right to untrained readers. For this reason, I recommend that you initially review them in my presence, or a summary and to have them forwarded your record sent to another mental health professional so you can discuss the contents. In most circumstances, I am allowed to charge a fee for copying records. The exceptions to this policy are contained in the Privacy Notice formprovider or your attorney. 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 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 Privacy HIPAA Notice form, and my privacy policies and procedures. I am happy to discuss any of these rights and/or issues with you. Patients under 18 years of age who are not emancipated and their parents should be aware that the law may allow allows parents to examine their child’s treatment records, unless I believe this review would be harmful to the patient and his/her treatment. Because privacy in psychotherapy is often crucial to successful progress, particularly with teenagers, it is sometimes my policy to request an agreement from that parents that they consent to give up their access to their child’s records. If they agree, agree (by signing this Agreement) then during treatment, I will typically provide them only with general information about the progress of the child’s treatment, and his/her attendance at scheduled sessions. I also may provide parents with a summary of their child’s treatment when it is complete. Most 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, 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. 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 from Blue Cross Blue Shield, which requires another arrangement since I am a contracted provider for them. In circumstances of unusual financial hardship, I may be willing to negotiate a fee adjustment or payment installation plan. If your account has not been paid for more than 30 days, I will discuss your unpaid bill in our session and discuss plans for payment. 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. In order for us to set realistic 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 may provide some coverage for mental health treatment. If my services are covered by your insurance policy, I will 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. If you have questions about the coverage, please contact your plan administrator. 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 a lot 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 most insurance companies require you to authorize me to provide them with a clinical diagnosis. Sometimes I have to provide additional clinical information such as treatment plans or summaries, or copies of the entire record (in rare cases). 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. By signing this Agreement, you agree that I can provide requested information to your insurance carrier if you will be seeking reimbursement from your insurance company for our sessions.

PROFESSIONAL RECORDS. You should be aware that, according pursuant to the rules of HIPAA, I keep the Practice keeps 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 you and your psychologist set for treatment, your progress towards those goals, your medical and social history, your treatment history, any past treatment records that I we receive from other providers, reports of any professional consultations, your billing records, and any reports that have been sent to anyone, including reports to your insurance carrier. Except in unusual circumstances that involve danger to yourself and others, you may examine and/or receive a copy of your Clinical Record if you request it in writing. You should be aware that pursuant to Texas law, psychological test data are not part of a patient’s record. Because these are professional records, they can be misinterpreted to untrained readers. For this reason, we recommend that you initially review them in our 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 we refuse your request for access to your Clinical Record, you have a right of review, which we will discuss with you upon your request. In addition, I we also keep a set of Psychotherapy Notes. These Notes are for my our own use and are designed to assist me us in providing you with the best treatment, . While the content contents of Psychotherapy Notes vary from client to client, they can include notes regarding the contents of our conversations, my analysis our interpretation of those conversations, and how they impact on your therapy. They also can contain particularly sensitive information that you may reveal to me us 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 both sets of recordsyour Psychotherapy Process Notes unless we determine that release would be harmful to your physical, 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 presencemental, or have them forwarded to another mental health professional so you can discuss the contents. In most circumstances, I am allowed to charge a fee for copying records. The exceptions to this policy are contained in the Privacy Notice form. 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 Privacy Notice form, and my privacy policies and procedures. I am happy to discuss any of these rights and/or issues with you. 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 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 typically provide them only with general information about the progress of the child’s treatment, and his/her attendance at scheduled sessions. I also may provide parents with a summary of their child’s treatment when it is complete. Most 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 information, I will discuss the matter with the child, if possible, and do my best to handle any objections he/she may haveemotional health.

PROFESSIONAL RECORDS. You should be aware that, according pursuant to the rules of HIPAA, I we keep Protected Health Information about you in two sets of professional records. One set constitutes your Clinical Record. It includes information about your reasons for seeking therapy, a description of the ways in which your problem impacts on your life, your diagnosis, the goals that we set for treatment, your progress towards those goals, your medical and social history, your treatment history, any past treatment records that I we receive from other providers, reports of any professional consultations, your billing records, and any reports that have been sent to anyone, including reports to your insurance carrier. In additionExcept in unusual circumstances that involve danger to yourself and/or others or the record makes reference to another person (unless such other person is a health care provider) and we believe that access is reasonably likely to cause substantial harm to such other person, 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 content of Psychotherapy Notes vary from client to client, they can include notes regarding the contents of our conversations, my analysis of those conversations, and how they impact on your therapy. They also can 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 examine and/or 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 both sets of records, 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 we recommend that you initially review them in my our presence, or have them forwarded to another mental health professional so you can discuss the contents. We are sometimes willing to conduct this review meeting without charge. In most circumstances, I am we are allowed to charge a copying fee of $0.50 per page (and for copying certain other expenses). If we refuse your request for access to your records, you have a right of review, which we will discuss with you upon request. The exceptions In addition, we also keep a set of Psychotherapy Notes. These Notes are for our own use and are designed to this policy are contained assist us in the Privacy Notice form. HIPAA provides providing you with several new or expanded rights with regard the best treatment. While the contents of Psychotherapy Notes vary from client to client, they can include the contents of our conversations, our analysis of those conversations, and how they impact on your therapy. They also contain particularly sensitive information that you may reveal to your counselor that is not required to be included in your Clinical Record and disclosures of protected health informationinformation revealed confidentially by others. These rights include requesting that I amend your record; requesting restrictions on what information Psychotherapy Notes are kept separate 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 Privacy Notice form, and my privacy policies and proceduresRecord. I am happy to discuss any of these rights and/or issues with you. Patients under 18 years of age who Your Psychotherapy Notes are not emancipated available to you and their parents should cannot be aware that the law may allow parents sent 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 typically provide them only with general information about the progress of the child’s treatment, and his/her attendance at scheduled sessions. I also may provide parents with a summary of their child’s treatment when it is complete. Most other communication will require the child’s Authorization, unless I feel that the child is in danger or is a danger to someone 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 which case, I will notify the parents of my concern. Before giving parents information, I will discuss the matter with the child, if possible, and do my best any way for your refusal to handle any objections he/she may haveprovide it.

PROFESSIONAL RECORDS. You should be aware that, according Pursuant to the rules of HIPAA, I keep your clinical file contains two types of information, PHI and a Designated Record Set. The Designated Record Set refers to information in your health record/file that can identify you. The Protected Health Information about you in two sets of professional records. One set constitutes is your Clinical Record. It clinical record which 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 treatmentyour treatment goals, your progress towards toward those goals, your medical medical, social and social psychological history, your treatment history, any past history and 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, anyone including reports to your insurance carriercarriers. In addition, I also keep The therapist keeps a set of Psychotherapy Notespsychotherapy notes/progress notes. These Notes notes are for my own the therapist’s use and are designed to assist me in tracking your treatment and providing you with the best treatment, . While the content of Psychotherapy Notes progress notes vary from client to client, they can include notes regarding the contents of our conversations, my analysis of those conversations, conversations and how they their impact on your therapy. They also can 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 RecordPHI with your written authorization, they cannot receive a copy of your Psychotherapy Notes progress 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 refusalauthorization. You may examine and/or receive a copy of both sets your progress notes unless I determine that such access to the notes will cause you psychological harm. In those instances I request to review the notes with you and provide you with a treatment summary. You will be charged for the cost of records, photocopying your notes at a rate of $0.10 per page or $15 per hour. You will also be charged $150 per hour if you request it in writing. Because these are professional records, they can be misinterpreted and/or upsetting the therapist 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 write a fee for copying records. The exceptions to this policy are contained in the Privacy Notice form. 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 Privacy Notice form, and my privacy policies and procedures. I am happy to discuss any of these rights and/or issues with youtreatment summary. 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 most often crucial to successful progress, particularly with teenagers, it is sometimes my the therapist’s policy to request an agreement from parents that they consent to give up their access to their childchildren’s records. If they agree, during treatment, I the therapist will typically provide them only the parents with general information about the progress of the child’s treatment, progress and his/her attendance at scheduled sessions. I also may provide parents Most often the therapist will work towards the child sharing information with a summary of their child’s treatment when it is completehis/her parents. Most Any other communication will require the child’s Authorizationauthorization, unless I feel it is the therapist’s opinion that the child is in danger or is a danger to someone else, in which case, I case the therapist will notify the parents of my concernparents. Before giving parents sensitive information, I the therapist will discuss the matter with the child, if possible, and do my best seek to handle any objections he/she may have. You are expected to pay for each session at the time of service.

PROFESSIONAL RECORDS. The laws and standards of my profession require that I keep Protected Health Information about you in your Clinical Record. You should be aware that, according pursuant to the rules of HIPAA, I keep Protected Health Information about you in two sets of professional records. One set constitutes your Clinical Record. It includes things such as 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 you and I 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. 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 content of Psychotherapy Notes vary from client to client, they can include notes regarding the contents of our conversations, my analysis of those conversations, and how they impact on You or your therapy. They also can contain particularly sensitive information that you legal representative 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 examine and/or 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 both sets of records, if you request it in writing, except in unusual circumstances that involve danger to yourself or others or if the record contains a 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 your psychotherapist confidentially by others]. 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, with me or have them forwarded to another mental health professional so you can discuss the contents. In most circumstances, these situations I am allowed to will charge a copying fee (and fees for copying recordscertain other related expenses). The exceptions In addition to this policy the Clinical Record I keep a set of Psychotherapy Notes. These Notes are contained for my own use and are designed to assist me in the Privacy Notice form. HIPAA provides providing you with several new or expanded rights with regard the best treatment. While the contents of Psychotherapy Notes vary from client to client, they can include the contents of conversations, 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 disclosures of protected health informationinformation supplied to me confidentially by others]. These rights include requesting that I amend your record; requesting restrictions on what information Psychotherapy Notes are kept separate 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 Privacy Notice form, and my privacy policies and proceduresRecord. I am happy to discuss any of these rights and/or issues with you. Patients under 18 years of age who Your Psychotherapy Notes are not emancipated available to you and their parents should cannot be aware that the law may allow parents sent 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 typically provide them only with general information about the progress of the child’s treatment, and his/her attendance at scheduled sessions. I also may provide parents with a summary of their child’s treatment when it is complete. Most other communication will require the child’s Authorization, unless I feel that the child is in danger or is a danger to someone 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 which case, I will notify the parents of my concern. Before giving parents information, I will discuss the matter with the child, if possible, and do my best any way for your refusal to handle any objections he/she may haveprovide it.

PROFESSIONAL RECORDS. You should be aware that, according to the rules Laws and standards of HIPAA, I our profession require that we 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. 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 content of Psychotherapy Notes vary from client to client, they can include notes regarding the contents of our conversations, my analysis of those conversations, and how they impact on your therapy. They also can 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 Except in unusual circumstances where disclosure would endanger you and/or others, you may examine and/or 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 both sets of records, 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 we recommend that you initially review them in my presence, our 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 clients will be charged an appropriate fee for copying any time spent preparing information requests. If we refuse your request for access to your records, you have a right of review, which we will discuss with you upon request. The exceptions In addition to this being able to review your notes, you may also add information to them if you believe they contain inaccurate or incomplete information. Also, please note that in some cases our files may include information from other treatment providers that clients have given us written permission to obtain. If you have given permission to obtain such records, we cannot provide the records of other professionals to you if you ask to review your files. Instead, we would ask for you to contact the provider who created the records and obtain copies directly from her or him. It is our office policy are contained in to retain clients’ records for seven years after the Privacy Notice formend of our therapy. HIPAA provides you with several new or expanded rights with regard to your Clinical Record Records and disclosures of protected health informationPHI. These rights include requesting that I we amend your record; requesting restrictions on what information from your Clinical Record Records is disclosed to others; requesting an accounting of most disclosures of Protected Health Information PHI that you have neither consented to nor authorized; determining the location to which protected information PHI disclosures are sent; having any complaints you make about my our policies and procedures recorded in your records; the right to restrict certain disclosures of PHI to a health plan when you pay out-of-pocket in full for services at Health Psych Maine; the right to Be Notified if There is a Breach of Your Unsecured PHI and the right to a paper copy of this Agreement, the Privacy attached Notice form, and my our privacy policies and procedures. I am We are happy to discuss any of these rights and/or issues with to you. Patients under 18 years Maine has two conflicting sections of age law regarding access to records when the patient or client is a minor. Therefore, if the patient is a minor, we will probably want to have a discussion with the parent(s) to establish some sort of agreement about who are will have access to what information. One section of Maine law allows minor children to independently consent to and receive mental health treatment without parental consent; in that situation, information about that treatment possibly may not emancipated and their parents should be aware that disclosed to anyone without the law may allow parents to examine their minor child’s treatment recordsagreement. Because While privacy in psychotherapy is often crucial to successful progressvery important, particularly with teenagers, parental involvement is also usually important for successful treatment, particularly with younger children. Therefore, it is sometimes my our general policy not to request provide treatment to a child unless there is agreement about what information may be shared. What generally works well is to have an agreement from between the patient and his/her parents that they consent allowing us to give up their access to their child’s records. If they agree, during treatment, I will typically provide them only with share general information about the progress of the their child’s treatment, and his/her attendance at of scheduled sessions. I also may provide parents with a summary of their child’s treatment when it is complete. Most Any other communication will require the child’s Authorization, unless I we feel that the child is in danger or is a danger to someone else, in which case, I we will notify the parents of my our concern. Before giving parents any information, I we will discuss the matter with the child, if possible, and do my our best to handle any objections he/she may have. This should be discussed further, preferably at the first session.

PROFESSIONAL RECORDS. You should be aware that, according to the rules The laws and standards of HIPAA, I our profession require that we keep Protected Health Information about you in two sets of professional records. One set constitutes your Clinical Client 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. 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 content of Psychotherapy Notes vary from client to client, they can include notes regarding the contents of our conversations, my analysis of those conversations, and how they impact on your therapy. They also can 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 both sets of recordsyour Clinical Record, if you request it in writing, with the following unusual exceptions. The exceptions would involve danger to yourself or others. An example would include reference to another person when we believe that your accessing your Clinical Record is reasonably likely to cause substantial harm to that other person. Another example would be when information has been supplied to RCC confidentially by others. Because these are professional records, they can be misinterpreted and/or upsetting to untrained readers. For this reason, I we recommend that you initially review them your treatment records in my your provider’s presence, or have them forwarded to another mental health professional so you can discuss the contents. If we need to refuse your request for access to your records, you have a right of review (except for information provided to us confidentially by others), which we will discuss with you upon request. In most circumstancesaddition, I am allowed your therapist may also keep a set of Psychotherapy Notes on your case. These notes are for your therapist’s own use and are designed to charge assist him/her in providing you with the best psychotherapy and counseling. While the contents of Psychotherapy Notes vary from client to client, they generally consist of notes to ourselves about our work that would not be very meaningful to others. They may also contain particularly sensitive information that you or others reveal to us that is not required to be included in your Client Record. These Psychotherapy Notes are kept separate from your Client Record. Psychotherapy Notes regarding you are not available to you and cannot be sent to anyone else, with the possible exception of a fee court order. We are not typically asked to release copies of Psychotherapy Notes, and in virtually all cases, would refuse to do so unless mandated by law, so this information remains highly protected and confidential. Insurance companies cannot require you to authorize us to release Psychotherapy Notes as a condition of coverage nor penalize you in any way for copying records. The exceptions your refusal to this policy are contained in the Privacy Notice formprovide it. HIPAA provides you with several new or expanded rights with regard to your Clinical Client Record and disclosures of protected health information. These rights include requesting that I your provider 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 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 our policies and procedures recorded in your records; and the right to a paper copy of this Agreement, the Privacy attached Notice form, and my RCC privacy policies and procedures. I am happy We are willing to discuss any of these rights and/or issues with you. Patients Clients under 18 years of age who are not emancipated (and their parents parents) should be aware that the law may allow allows parents to examine their child’s treatment recordsrecords unless the provider believes that doing so would endanger the child or we agree otherwise. Because privacy in psychotherapy therapy, specifically, is often crucial to successful progress, particularly with teenagers, it is sometimes my our policy to request an agreement from parents that they consent to give up their access to their child’s records. If they agree, during treatment, I the therapist will typically provide them only with general information about the progress of the child’s treatment, and his/her attendance at scheduled sessions. I also may provide parents with a summary of their child’s treatment when it is complete. Most Any other communication will require the child’s Authorization, unless I feel the therapist feels that the child is in danger or is a danger to someone else, in which case, I we will notify the parents of my the concern. Before giving parents any information, I the therapist will discuss the matter with the child, if possible, and do my his/her best to handle any objections he/she may have. For clients under the age of 18 seeking psychiatric services, it is imperative that the Legal Guardian is available (preferably in person, but at minimum by phone) during the appointment time in order to provide consent for beginning new medications if any are prescribed. You will be expected to pay for each appointment 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. We request that all individuals maintain a credit card on file in the event of an unforeseen balance developing. Because we never wish to take our clients to small claims court or turn their accounts over to collections agencies, we work to prevent balances by requiring a credit card on file. In the event of a missed appointment (late cancelation or no-show), or a balance accruing because of insurance deductibles or changes to copays, your card will be charged at the time of the new balance. Disputing valid charges to a credit card on file may be grounds for termination from services and you will continue to be responsible for the balance due even while the disputed charges are under review by your bank. It is our policy that any patient balances must be paid at the time of services or you will be required to reschedule your appointment when the balance has been paid, barring a clinical crisis. This may mean not being seen at the time of your appointment if you have not made your payment and will result in a late cancelation fee since your provider has set aside that appointment time only for you. True emergency situations will be evaluated on a case-by-case basis, as we do understand that emergencies can arise. We charge the full session fee if you miss an appointment without giving notice. This is the amount that is billed to insurance if you are using your insurance. In the event of missed appointments, insurance cannot be billed. In the case of therapists, this amount is $135. For our RD, this fee is $100. For our Psychiatric Nurse Practitioner, this would be $330 for an hour; $165 for 30 minutes; and $110 for 20 minutes. If you cancel your appointment with less than 24 hours notice, then we charge half of the session fee that you would have been paying or that would have been billed to your insurance. In the event that we must utilize a collections agency or law firm to obtain the balance owed to us, you will be responsible for all collections and attorney’s fees. If you are a Medicaid beneficiary, we are prevented as participating providers from billing for a missed appointment. However, we retain the right to terminate our patient relationship with you for one no show and three, or more, late-canceled appointments.

PROFESSIONAL RECORDS. You should be aware that, according to the rules The standards of HIPAA, my profession require that I keep Protected Health Information about you in two sets of professional records. One set constitutes your Clinical Record. It includes Except in unusual circumstances that involve danger to yourself and 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 about your reasons for seeking therapyhas been supplied to me confidentially by others, 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. 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 content of Psychotherapy Notes vary from client to client, they can include notes regarding the contents of our conversations, my analysis of those conversations, and how they impact on your therapy. They also can 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 examine and/or 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 both sets of records, 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 circumstancessituations, I am allowed to charge a copying fee of $.50 cents per page (and for copying certain other expenses like postage). 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. The exceptions to this policy are contained in the Privacy Notice form. HIPAA HIPPA 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 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 Privacy attached Notice form, and my privacy policies and procedures. I am happy to discuss any of these rights and/or issues with you. Patients under 18 years of age who You are not emancipated and their parents should be aware that expected to pay for the law may allow parents to examine their child’s treatment records. Because privacy in psychotherapy session when the service 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 recordsprovided. If they agreeyou have insurance I take, during treatmentthe insurance company may pay for part of this fee. If I take your insurance, I will typically provide file the insurance for you, but you are responsible for assuring that the insurance company pays their part of your bill. I am paid different rates by different insurance companies. If you have questions about any charges or fees, please feel free to discuss these with me. The parts of my fee not covered by insurance (the co-pay and/or coinsurance and deductible) are your responsibility, and I will expect you to pay them only with general information about at the progress time of the child’s treatmentsession. You are required to know how much your part of the fee will be, and his/her attendance to be sure that your sessions are authorized ahead of time by the insurance company or the managed care company administering the benefits for the insurance company. This is usually done by calling the number for mental health services on your insurance card. Please remember that when a managed care company authorizes sessions, the paperwork contains a disclaimer that even though they are authorizing the service, they cannot guarantee payment. This is the responsibility of you and your insurance company. If I do not accept your insurance, you may request a bill which you may submit to your insurance company. Some insurance companies will reimburse you with the “out of network” benefit. It is your responsibility to find out if your insurance will pay for an out of network therapist. This is usually accomplished by calling the number for mental health services or behavioral health services on the back of your insurance card. Your therapy appointment time is reserved only for you. This is different from other medical offices, where more than one person may be scheduled at the same time. If you run late to an appointment, it will still end at the scheduled sessionstime, because someone has a scheduled appointment right after yours. If you miss an appointment for any reason, you will be charged the full fee for the session if you not call at least 24 hours in advance of your appointment to cancel the appointment. Your insurance will not reimburse you for a missed appointment fee. If you need to cancel an appointment, call my number and leave a voice mail. I accept cash, checks and money orders as payment for your session. Credit cards are not accepted. In the event that you have a check returned to me for non-payment of funds, you will be expected to pay for the associated costs I have. These charges will include a returned check charge and any bank charges that I incur. I may also may provide parents ask you to pay by cash or money order in the future. I schedule appointments Tuesday through Saturday, with later appointments available on Tuesday and Thursday evenings. My cell phone number is available to you and if I do not answer, I encourage you to leave a summary of their child’s treatment when it is completemessage. Most other communication I check my messages daily and will require the child’s Authorization, unless I feel that the child is in danger or is a danger to someone else, in which casereturn calls as soon as possible. If you have called after 6:00pm, I will notify return your call if necessary but will most likely call the parents following day. If you call on the weekend, your call will be returned on Tuesday. If you have an emergency, and I do not return your call within a few minutes, please contact the emergency room of my concernthe hospital covered by your insurance company or call 911. Before giving parents Both federal and state laws establish strict requirements for most programs regarding the disclosure of confidential information, and I will discuss the matter must comply with the childthose laws. For situations where stricter disclosure requirements do not apply, if possiblethis Notice of Privacy Practices describes how I may use and disclose your protected health information for treatment, payment, health care operations and for certain other purposes. This notice also describes your rights to access and control your protected health information, and do my best provides information about your right to handle make a complaint if you believe I have improperly used or disclosed your "protected health information." Protected health information is information that may personally identify you and relates to your past, present or future physical or mental health or condition and related health care services. I am required to abide by the terms of this Notice of Privacy Practices, and may change the terms of this notice, at any objections he/she may havetime. A new notice will be effective for all protected health information that I maintain at the time of issuance. Any changes in this notice will made available to you.

PROFESSIONAL RECORDS. You should be aware that, according to the rules The laws and standards of HIPAA, I our profession require that we keep Protected Health Information about you in two sets of professional records. One set constitutes your Clinical Record. It includes information about your reasons for seeking therapyservices, 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 we receive from other providers, reports of any professional consultations, your billing records, and any reports that have been sent to anyone, including reports to your insurance carrier. In additionExcept in unusual circumstances that involve danger to yourself and/or others or where information has been supplied to us confidentially by others, 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 content of Psychotherapy Notes vary from client to client, they can include notes regarding the contents of our conversations, my analysis of those conversations, and how they impact on your therapy. They also can 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 both sets of records, your Clinical Record if you request it in writing. This accessibility does not extend to testing protocols, because of test security issues. Because these are professional records, they can be misinterpreted and/or upsetting to untrained readers. For this reason, I we recommend that you initially review them in my our presence, or have them forwarded to another mental health professional so you can discuss the contents. In most circumstancessituations, I am we are allowed to charge a fee for copying recordscopying, postage, and administrative fee. The exceptions to this policy are contained in the Privacy Notice form. HIPAA Health Insurance Portability and Accountability Act (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 we 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 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 our policies and procedures recorded in your records; and the right to a paper copy of this Agreement, the Privacy attached Notice form, and my our privacy policies and procedures. I am We are happy to discuss any of these rights and/or issues with you. Patients under 18 years of age (minors) who are not emancipated and from their parents should be aware that the law may allow parents to examine their child’s treatment records. Because privacy in psychotherapy is often crucial to successful progress, particularly with teenagers, it is sometimes my our policy to request an agreement from parents that they consent to give up their access to their child’s 's records. If they agree, during treatment, I we will typically provide them only with general information about the progress of the child’s 's treatment, and his/her attendance at scheduled sessions. I We will also may provide parents with a summary of their child’s 's treatment when it is complete. Most Any other communication will require the child’s 's Authorization, unless I we feel that the child is in danger or is a danger to someone else, ; in which case, I we will notify the parents of my our concern. Before giving parents any information, I we will discuss the matter with the child, child if possible, and do my our best to handle any objections he/she may have. BILLING AND PAYMENTS (initial) 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, we have the option of using legal means to secure the payment. This may involve hiring a collection agency or going through small claims court which will require us to disclose otherwise confidential information. In most collection situations, the only information we release regarding a patient's treatment is his/her name, the nature of services provided, and the amount due. If such legal action is necessary, all costs will be included in the claim and be the responsibility of the patient. This is a fee for service practice. We do not accept insurance. If you wish to submit a claim to your insurance company, we will provide you with a diagnosis code, if one is available and CPT codes. All insurance companies claim to keep such information confidential; we have no control over the use of the information once it has been submitted to the insurance company by our clients.. Please specify your preferred form of contact: Telephone: Type: Email: Mail: Our standard practice is to provide patients with appointment reminders via telephone or email contact. These reminders include: the patient’s name, the name of our practice (Beljan Psychological Services) and/or the name of the professional with whom you have an appointment, the date and time of your appointment, and our telephone number. We will not disclose PHI in voicemail messages left on your cellular, home, or office phones unless you specifically authorize us to do so. If you would like us to leave appointment reminders via voicemail, please specify the telephone number at which appointment reminders may be left. By signing this agreement you give us the permission to treat you or your child in accordance with the information stated in this document. This treatment includes but is not limited to neuropsychological assessment, psychoeducational/intellectual assessment, psychotherapy, and other treatments previously discussed and agreed upon with the patient and/or guardian.

PROFESSIONAL RECORDS. You should be aware thatClient medical records are stored electronically using subscription based HIPPA compliant Electronic Medical Records software and are accessible only to authorized personnel. Before the initial paper intake forms are converted to Electronic Medical Records, according they are maintained in a secured office accessible only to the rules appropriate Cathexis staff. Paper records are promptly shredded after being uploaded to our Electronic Medical Records software and back up drive. The laws and standards of HIPAA, I keep our profession require that Cathexis keeps Protected Health Information about you or your child in two sets of professional records. One set constitutes your the Clinical Record. It includes Except in unusual circumstances that involve danger to yourself and/or others or where information about your reasons for seeking therapyhas been supplied to Cathexis confidentially by others, 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. 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 content of Psychotherapy Notes vary from client to client, they can include notes regarding the contents of our conversations, my analysis of those conversations, and how they impact on your therapy. They also can 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 both sets of records, yours or your child’s Clinical Record if you request it in writing. Because these are professional records, they can be misinterpreted and/or upsetting to untrained readers; therefore, Cathexis clinicians reserve the right to redact information as determined necessary. For this reason, I we recommend that you only request these records in extenuating circumstances and that you initially review them in my presence, your counselor’s presence or have them forwarded to another mental health professional so you can discuss the contents. In most circumstancessituations, I am allowed to Cathexis can charge a copying fee of $.07 per page, and a minimum of 72-hour notice is required to fulfill such requests. In addition, your counselor also keeps a set of Progress Notes. These notes are for copying recordsthe therapist’s use and are designed to assist him/her in providing you with the best treatment. While information in the Progress Notes vary from client to client, the content typically consists of the conversations during session, the counselor’s assessment of the session, the status of your Treatment Plan goals or impact on your therapy. The exceptions to this policy are contained in the Privacy Notice form. HIPAA provides you with several new or expanded rights with regard to Progress Notes may include sensitive information that is not part of your Clinical Record and disclosures may also be redacted at the clinician’s discretion. Progress Notes are not released to other parties (i.e. doctors, disability insurance companies) without explicit written consent and direction from you. You may examine and/or receive a copy of protected health informationyour Progress Notes unless Cathexis determines that such access is clinically contraindicated. 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 Cathexis clinician always reserve the right to a paper copy of this Agreementredact any information they feel is contraindicated to the client’s clinical wellbeing. Please be advised that in order to maintain ethical and therapeutic boundaries, the Privacy Notice formCathexis is unable to provide expert witness in custody, disability, or other court hearings. The clinician’s role is to provide therapeutic support to their individual client, and my privacy policies therefore becoming involved in a client’s legal proceedings significantly affects your therapist’s ability to focus solely upon your emotional and proceduresmental growth. I am happy to discuss any Release of these rights and/or issues with yourecords to you in no way commits Cathexis to any level of participation in legal hearings. Patients under 18 years More information regarding the use of age who your medical information for purposes of scheduling, billing, audit compliance and other administrative functions are not emancipated and their parents should be aware that the law may allow parents to examine their child’s treatment records. Because privacy described 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 typically provide them only with general information about the progress of the child’s treatment, and his/her attendance at scheduled sessions. I also may provide parents with a summary of their child’s treatment when it is complete. Most 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 information, I will discuss the matter with the child, if possible, and do my best to handle any objections he/she may haveSection 3 – HIPAA Privacy Statement.

PROFESSIONAL RECORDS. You should be aware thatClient medical records are stored electronically using subscription based HIPPA compliant Electronic Medical Records software and are accessible only to authorized personnel. Before the initial paper intake forms are converted to Electronic Medical Records, according they are maintained in a secured office accessible only to the rules appropriate Cathexis staff. Paper records are promptly shredded after being uploaded to our Electronic Medical Records software. The laws and standards of HIPAA, I keep our profession require that Cathexis keeps Protected Health Information about you in two sets of professional records. One set constitutes or 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. 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 content of Psychotherapy Notes vary from client to client, they can include notes regarding the contents of our conversations, my analysis of those conversations, and how they impact on your therapy. They also can contain particularly sensitive information that you may reveal to me that is not required to be included child 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 RecordExcept in unusual circumstances that involve danger to yourself and/or others or where information has been supplied to me confidentially by others, 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 both sets of records, 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, Cathexis clinicians reserve the right to redact information as determined necessary. For this reason, I we recommend that you only request these records in extenuating circumstances and that you initially review them in my presence, your counselor’s presence or have them forwarded to another mental health professional so you can discuss the contents. In most circumstancessituations, I am allowed to Cathexis can charge a copying fee of $.07 per page. In addition, your counselor also keeps a set of Progress Notes. These notes are for copying recordsthe therapist’s use and are designed to assist him/her in providing you with the best treatment. While the contents of Progress Notes vary from client to client, the content typically consists of the conversations during session, the counselor’s assessment of the session and the plan or impact on your therapy. The exceptions to this policy are contained in the Privacy Notice form. HIPAA provides you with several new or expanded rights with regard to Progress Notes may include sensitive information that is not part of your Clinical Record and disclosures of protected health informationmay also be redacted at the clinician’s discretion. These rights include requesting that I amend your record; requesting restrictions on what information Progress Notes are not released to other parties (i.e. doctors, insurance companies) without explicit written consent and direction 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 you. You may examine and/or receive a paper copy of this Agreementyour Progress Notes unless Cathexis determines that such access is clinically contraindicated. Please be advised that in order to maintain ethical and therapeutic boundaries, the Privacy Notice formXxxxxxxx is unable to provide expert witness in custody, disability, or other court hearings. The clinician’s role is to provide therapeutic support to their individual client, and my privacy policies therefore becoming involved in a client’s legal proceedings significantly affects your therapist’s ability to focus solely upon your emotional and proceduresmental growth. Release of these records to you in no way commits Cathexis to any level of participation in legal hearings. I am happy allow Cathexis to discuss any release my medical records as needed for the purpose of these rights and/or issues Coordination of Care with you. 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 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 typically provide them only with general information about the progress of the child’s treatment, and his/her attendance at scheduled sessions. I also may provide parents with a summary of their child’s treatment when it is complete. Most other communication will require the child’s Authorization, unless I feel that the child is in danger or is a danger to someone elsefollowing organizations, in which case, I am enrolled. This approval will notify the parents of remain in force during my concern. Before giving parents information, active care with Cathexis until I will discuss the matter am either no longer enrolled with the childlisted agencies, or I terminate services with Cathexis Coordination of Care Agency (if possible, and do my best to handle any objections heapplicable) Other Organization/she may have.Person in which I approve the release of client’s medical records:

PROFESSIONAL RECORDS. You should be aware that, according to the rules The laws and standards of HIPAA, my profession require that 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. 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 content of Psychotherapy Notes vary from client to client, they can include notes regarding the contents of our conversations, my analysis of those conversations, and how they impact on your therapy. They also can contain particularly sensitive information that you may reveal to me that is not required to be included in your Clinical Recordclinical record. These Psychotherapy Notes You are kept separate from your Clinical Record. While insurance companies can request and entitled to 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 both sets of records, if or I can prepare a summary for you request it in writinginstead. Because these are professional records, they can be misinterpreted and/or upsetting to untrained readers. For this reasonIf you wish to see your records, I recommend that you initially review them in my presence, or have them forwarded to another mental health professional presence so you that we can discuss the contents. In most circumstances, I am sometimes willing to conduct a review meeting without charge. You are entitled to a free copy of your record; however I am allowed to charge a copying fee of $1 per page (and for copying records. The exceptions to this policy are contained in the Privacy Notice formcertain other expenses) for any subsequent copies. HIPAA provides you with several new or expanded rights with regard to your Clinical Record 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 clinical record is disclosed to others; , requesting an accounting of most disclosures of Protected Health Information protected heath 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 Privacy Notice form, agreement and my privacy policies and procedures. I am happy to discuss any of these rights and/or issues with you. Patients I will provide treatment/evaluation to children only with custodial consent to do so. Clients under 18 17 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 therapy is often crucial to successful progress, particularly with teenagers, it is sometimes my policy to request an agreement from parents that they consent regarding how children’s privacy can be honored. Information given to give up their access me by your child which involves risk to their life, incidences of abuse or neglect, or other unlawful activity will be shared with you as soon as reasonably possible, and, if necessary, appropriate actions taken to aid in the protection of your child and any other potential victim. I will use my clinical judgment to advise you of your child’s records. If they agree, during treatment, I will typically provide them only with general information about the progress of the child’s treatment, and his/her attendance at scheduled sessions. I also may provide parents with a summary of their child’s treatment when it is complete. Most 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 information, I will discuss the matter with the child, if possible, and do my best to handle any objections he/she may havestatements regarding issues outside those stated areas.

PROFESSIONAL RECORDS. You should be aware that, according pursuant to the rules of HIPAA, I we keep Protected Health Information about you in two sets of professional records. One set constitutes your Clinical Record. It includes information about your reasons for seeking therapy, a description of the ways in which your problem impacts on your life, your diagnosis, the goals that we set for treatment, your progress towards those goals, your medical and social history, your treatment history, any past treatment records that I we receive from other providers, reports of any professional consultations, your billing records, and any reports that have been sent to anyone, including reports to your insurance carrier. In additionExcept in unusual circumstances where disclosure would physically endanger you and/or others or 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, 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 content of Psychotherapy Notes vary from client to client, they can include notes regarding the contents of our conversations, my analysis of those conversations, and how they impact on your therapy. They also can 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 both sets of records, 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 we recommend that you initially review them in my presencethe presence of your therapist, or have them forwarded to another mental health professional so you can discuss the contents. In most circumstances, I am we are allowed to charge a copying fee for copying recordsof $1 per page. The exceptions to this policy are contained in the Privacy Notice formattached Notice. If we refuse your request for access to your Clinical Records, you have a right of review (except for information supplied to us confidentially by others), which we will discuss with you upon request. In addition, we also keep Psychotherapy Notes. These Notes are for our own use and are designed to assist us in providing you with the best treatment. While the contents of Psychotherapy Notes vary from client to client, they can include the contents of your conversations with your therapist, our analysis of those conversations, and how they impact your therapy. They also contain particularly sensitive information that you may reveal 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. HIPAA provides you with several new or expanded rights with regard to your Clinical Record Records and disclosures of protected health information. These rights include requesting that I we amend your record; requesting restrictions on what information from your Clinical Record Records is disclosed to others; requesting an accounting of most disclosures of Protected Health Information 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 our policies and procedures recorded in your records; and the right to a paper copy of this Agreement, the Privacy Notice formattached Notice, and my our privacy policies and procedures. I am We are happy to discuss any of these rights and/or issues with you. 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 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 typically provide them only with general information about the progress of the child’s treatment, and his/her attendance at scheduled sessions. I also may provide parents with a summary of their child’s treatment when it is complete. Most 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 information, I will discuss the matter with the child, if possible, and do my best to handle any objections he/she may have.

PROFESSIONAL RECORDS. You should be aware that, according pursuant to the rules of HIPAA, I may keep Protected Health Information about you in two sets of professional records. One set constitutes your Clinical Record. It includes information about your reasons for seeking therapy, 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. In addition, I also keep a set of Psychotherapy Notes. These Notes are for my own use Except in unusual circumstances that involve danger to yourself and are designed to assist me in providing you with the best treatment, While the content of Psychotherapy Notes vary from client to client, they can include notes regarding the contents of our conversations, my analysis of those conversations, and how they impact on your therapy. They also can contain particularly sensitive others or where information that you may reveal has been supplied to me by others confidentially, or the record makes reference to another person (unless such other person is a health care provider) and I believe that access is not required reasonably likely 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 Recordcause substantial harm to such other person, 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 both sets of records, 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 am sometimes willing to conduct this review meeting without charge.) In most circumstances, I am allowed to charge a copying fee and for copying recordscertain other expenses. The exceptions to this policy are contained in the Privacy attached Notice formForm. HIPAA provides 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. In addition, I also keep a set of Clinical Therapy Notes. These Notes are for my own use and are designed to assist me in providing you with several new or expanded rights with regard the best treatment. While the contents of Clinical Therapy 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 disclosures of protected health informationRecord. These rights include requesting that I amend your record; requesting restrictions on what information Clinical Therapy Notes are kept separate 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 Privacy Notice form, and my privacy policies and proceduresRecord. I am happy to discuss any of these rights and/or issues with you. Patients under 18 years of age who Your Clinical Therapy Notes are not emancipated available to you and their parents should cannot be aware that the law may allow parents sent 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 typically provide them only with general information about the progress of the child’s treatment, and his/her attendance at scheduled sessions. I also may provide parents with a summary of their child’s treatment when it is complete. Most other communication will require the child’s Authorization, unless I feel that the child is in danger or is a danger to someone 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 which case, I will notify the parents of my concern. Before giving parents information, I will discuss the matter with the child, if possible, and do my best any way for your refusal to handle any objections he/she may haveprovide it.

PROFESSIONAL RECORDS. You should be aware that, according Pursuant to the rules of HIPAA, I keep your clinical file contains two types of information, PHI and a Designated Record Set. The Designated Record Set refers to information in your health record/file that can identify you. The Protected Health Information about you in two sets of professional records. One set constitutes is your Clinical Record. It clinical record which 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 treatmentyour treatment goals, your progress towards toward those goals, your medical medical, social and social psychological history, your treatment history, any past history and 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, anyone including reports to your insurance carriercarriers. In addition, I also keep The therapist keeps a set of Psychotherapy Notespsychotherapy notes/progress notes. These Notes notes are for my own the therapist’s use and are designed to assist me in tracking your treatment and providing you with the best treatment, . While the content of Psychotherapy Notes progress notes vary from client to client, they can include notes regarding the contents of our conversations, my analysis of those conversations, conversations and how they their impact on your therapy. They also can 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 RecordPHI with your written authorization, they cannot receive a copy of your Psychotherapy Notes progress 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 refusalauthorization. You may examine and/or receive a copy of both sets your progress notes unless I determine that such access to the notes will cause you psychological harm. In those instances I request to review the notes with you and provide you with a treatment summary. You will be charged for the cost of records, photocopying your notes at a rate of $0.10 per page or $15 per hour. You will also be charged $150 per hour if you request it in writing. Because these are professional records, they can be misinterpreted and/or upsetting the therapist 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 write a fee for copying records. The exceptions to this policy are contained in the Privacy Notice form. 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 Privacy Notice form, and my privacy policies and procedures. I am happy to discuss any of these rights and/or issues with youtreatment summary. 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 most often crucial to successful progress, particularly with teenagers, it is sometimes my the therapist’s policy to request an agreement from parents that they consent to give up their access to their childchildren’s records. If they agree, during treatment, I the therapist will typically provide them only the parents with general information about the progress of the child’s treatment, progress and his/her attendance at scheduled sessions. I also may provide parents Most often the therapist will work towards the child sharing information with a summary of their child’s treatment when it is completehis/her parents. Most Any other communication will require the child’s Authorizationauthorization, unless I feel it is the therapist’s opinion that the child is in danger or is a danger to someone else, in which case, I case the therapist will notify the parents of my concernparents. Before giving parents sensitive information, I the therapist will discuss the matter with the child, if possible, and do my best seek to handle any objections he/she may have. You are expected to pay for each session at the time of service. You may be asked to sign a separate Financial Policies form. Xx. XxXxxxx utilizes third-party billing software to generate invoices and to allow clients to make credit card payments online or in person.

PROFESSIONAL RECORDS. You should Please be aware that, according pursuant to the rules of HIPAA, I keep Protected Health Information about you in two 2 sets of professional records. One set constitutes is 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 toward those goals, your medical and social history, your our 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. Except in unusual circumstances that involve danger to you/others or where information has been supplied to us by others confidentially, including reports to your insurance carrier. 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 content of Psychotherapy Notes vary from client to client, they can include notes regarding the contents of our conversations, my analysis of those conversations, and how they impact on your therapy. They also can 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 examine and/or receive a copy of your Clinical Record, they cannot receive with 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 both sets of records, 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, presence or have them forwarded to another mental health professional so you can discuss the contents. In most circumstancessituations, I am allowed to charge a copying fee of $.20 per page. If the copying of requested records exceeds 5 minutes, there is an additional charge of $3 for copying every 5 minutes of time it takes to copy the records. The exceptions If I refuse your request for access to this policy your records you have a right of review which I will discuss with you upon request. In addition, I keep a set of Psychotherapy Notes. These Notes are contained for our own use and are designed to assist in providing you with the Privacy Notice formbest treatment. While the contents of Psychotherapy Notes vary from client to client, they can include the contents/analysis of our conversations and how they impact 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. While insurance companies can request a copy of your Clinical Record, they cannot receive a copy of your Psychotherapy Notes 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. You may examine and/or receive your Psychotherapy Notes unless I determine that such access is clinically contraindicated. In the event of my death or incapacitation, I have appointed a professional colleague to act on my behalf to notify you and to make decisions about storing, releasing and/or disposing of my professional records: Xxxxxx Xxxxxx-Xxxxx, LMFT, 00000 X. Xxxxxxxxxx Xx. #155, Scottsdale, AZ 85254; 000-000-0000 HIPAA provides you with several new or expanded rights with regard to your Clinical Record and disclosures of protected health informationPHI. These rights include requesting that I we amend your record; record (must be made in writing), requesting restrictions on of what information from your Clinical Record is disclosed to others; , requesting an accounting of most disclosures of Protected Health Information PHI 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 Privacy Notice form, and my privacy policies and proceduresagreement. I am will be happy to discuss any of these rights and/or issues with you. Patients Clients under 18 years of age (who are not emancipated emancipated) and their parents should be aware that the law may allow parents to examine their child’s treatment records. Because privacy in psychotherapy therapy 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 typically provide them only with general information about the progress of the child’s treatment, and his/her attendance at scheduled sessions. I also may provide parents with a summary of their child’s treatment when it is complete. Most 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 information, I will discuss the matter with the child, if possible, and do my best to handle any objections he/she may have.from

PROFESSIONAL RECORDS. You should be aware that, according to the rules The standards of HIPAA, my profession require that I keep Protected Health Information about you in two sets of professional records. One set constitutes your Clinical Record. It includes Except in unusual circumstances that involve danger to yourself and 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 about your reasons for seeking therapyhas been supplied to me confidentially by others, 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. 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 content of Psychotherapy Notes vary from client to client, they can include notes regarding the contents of our conversations, my analysis of those conversations, and how they impact on your therapy. They also can 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 examine and/or 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 both sets of records, 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 circumstancessituations, I am allowed to charge a copying fee of $.50 cents per page (and for copying certain other expenses like postage). 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. The exceptions to this policy are contained in the Privacy Notice form. HIPAA HIPPA 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 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 Privacy attached Notice form, and my privacy policies and procedures. I am happy to discuss any of these rights and/or issues with you. Patients under 18 years of age who You are not emancipated and their parents should be aware that expected to pay for the law may allow parents to examine their child’s treatment records. Because privacy in psychotherapy session when the service 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 recordsprovided. If they agreeyou have insurance I take, during treatmentthe insurance company may pay for part of this fee. If I take your insurance, I will typically provide file the insurance for you, but you are responsible for assuring that the insurance company pays their part of your bill. I am paid different rates by different insurance companies. If you have questions about any charges or fees, please feel free to discuss these with me. The parts of my fee not covered by insurance (the co-pay and/or coinsurance and deductible) are your responsibility, and I will expect you to pay them only with general information about at the progress time of the child’s treatmentsession. You are required to know how much your part of the fee will be, and his/her attendance to be sure that your sessions are authorized ahead of time by the insurance company or the managed care company administering the benefits for the insurance company. This is usually done by calling the number for mental health services on your insurance card. Please remember that when a managed care company authorizes sessions, the paperwork contains a disclaimer that even though they are authorizing the service, they cannot guarantee payment. This is the responsibility of you and your insurance company. If I do not accept your insurance, you may request a bill which you may submit to your insurance company. Some insurance companies will reimburse you with the “out of network” benefit. It is your responsibility to find out if your insurance will pay for an out of network therapist. This is usually accomplished by calling the number for mental health services or behavioral health services on the back of your insurance card. Your therapy appointment time is reserved only for you. This is different from other medical offices, where more than one person may be scheduled at the same time. If you run late to an appointment, it will still end at the scheduled sessionstime, because someone has a scheduled appointment right after yours. If you miss an appointment for any reason, you will be charged for the session if you not call at least 24 hours in advance of your appointment to cancel the appointment. Your insurance will not reimburse you for a missed appointment fee. If you need to cancel an appointment, call my number and leave a voice mail. I accept cash, checks and money orders as payment for your session. Credit cards are not accepted. In the event that you have a check returned to me for non-payment of funds, you will be expected to pay for the associated costs I have. These charges will include a returned check charge and any bank charges that I incur. I may also may provide parents with ask you to pay by cash or money order in the future. I schedule appointments Monday through Friday. My cell phone number is available to you and if I do not answer, I encourage you to leave a summary of their child’s treatment when it is completemessage. Most other communication I check my messages daily and will require the child’s Authorization, unless I feel that the child is in danger or is a danger to someone else, in which casereturn calls as soon as possible. If you have called after 6:00pm, I will notify return your call if necessary but will most likely call the parents following day. If you call on the weekend, your call will be returned on Monday. If you have an emergency, and I do not return your call within a few minutes, please contact the emergency room of my concernthe hospital covered by your insurance company or call 911. Before giving parents Both federal and state laws establish strict requirements for most programs regarding the disclosure of confidential information, and I will discuss the matter must comply with the childthose laws. For situations where stricter disclosure requirements do not apply, if possiblethis Notice of Privacy Practices describes how I may use and disclose your protected health information for treatment, payment, health care operations and for certain other purposes. This notice also describes your rights to access and control your protected health information, and do my best provides information about your right to handle make a complaint if you believe I have improperly used or disclosed your "protected health information." Protected health information is information that may personally identify you and relates to your past, present or future physical or mental health or condition and related health care services. I am required to abide by the terms of this Notice of Privacy Practices, and may change the terms of this notice, at any objections he/she may havetime. A new notice will be effective for all protected health information that I maintain at the time of issuance. Any changes in this notice will made available to you.

PROFESSIONAL RECORDS. You should be aware that, according to The laws and standards of psychology and counseling professions require that the rules of HIPAA, I clinician 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. 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 content of Psychotherapy Notes vary from client to client, they can include notes regarding the contents of our conversations, my analysis of those conversations, and how they impact on your therapy. They also can 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 Except in unusual circumstances that involve danger to yourself and/or others, you may examine and/or 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 both sets of records, if you request it in writingwriting and the request is signed by you and dated not more that 60 days from the date submitted. Because these are professional records, they can be misinterpreted and/or upsetting to the untrained readers. For this reason, I recommend it is recommended that you initially review them in my presence, the presence of the clinician or have them forwarded to another mental health professional so you can discuss the contents. In most circumstances, I am allowed the law allows clinicians 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 copying recordsrecords search plus postage. The exceptions If your request for access to this policy are contained in your records is refused, you have the Privacy Notice formright of review, which will be discussed with you upon request. HIPAA HIPPA provides you with several new or expanded guidelines and policies regarding your rights with regard to your Clinical Record and disclosures of protected health information. These rights include requesting that I the clinician 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 protected health information that you have neither consented to nor authorized; determining the location to which protected information disclosures are sent; having any complaints complaint you make about my policies and procedures recorded in your records; and the right to a paper copy of this Agreement, the Privacy Notice form, and my privacy policies and procedures. I am happy to discuss any of these rights and/or issues with you. Patients Clients who are under 18 14 years of age and who are not emancipated and emancipated, along with their parents parents, should be aware that the law may allow allows parents to examine their child’s treatment recordsrecords unless the clinician decides that such access would injure the child, or parties have agreed otherwise. Because Children between the ages of 14 and 18 years of age may independently consent to and receive up to 6 sessions of psychotherapy/counseling services provided it is within a 30 day period. No information about those sessions can be disclosed to anyone without the child’s agreement. While privacy in psychotherapy psychotherapy/counseling is often crucial to successful progress, particularly with teenagers, parental involvement is also essential to successful treatment. For children 14 and over, it is sometimes my policy to request an agreement from between the client and his/her parents that they consent allowing the clinician to give up their access to their child’s records. If they agree, during treatment, I will typically provide them only with share general information about the progress of the child’s treatment, treatment and his/her attendance at scheduled sessions. I The clinician will also may provide parents with a summary of their child’s treatment when it is complete. Most Any other communication will require the child’s Authorization, unless I feel the clinician feels that the child is in danger danger, or is a danger to someone else, or a threat to property, in which case, I the clinician will notify the parents of my the concern. Before giving parents any information, I the clinician will discuss the matter with the child, if possible, and will do my his/her best to handle any objections he/she the child may have.

PROFESSIONAL RECORDS. You should be aware that, according to The laws and standards of the rules of HIPAA, mental health profession require that I keep Protected Health Information about you in two sets of professional records. One set constitutes your Clinical Record. It includes Except in circumstances that involve danger to yourself and/or others, where 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 has been sent to anyone, including reports to your insurance carrier. 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 content of Psychotherapy Notes vary from client to client, they can include notes regarding the contents of our conversations, my analysis of those conversations, and how they impact on your therapy. They also can contain particularly sensitive information that you may reveal supplied to me that is not required to be included confidentially by others, or if the information has been gathered in your Clinical Record. These Psychotherapy Notes are kept separate from your Clinical Record. While insurance companies can request and receive a copy reasonable anticipation of your Clinical Recordor specifically for use in litigation, 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 both sets of records, your Clinical Record if you request it in writing. Because these are professional records, they can be misinterpreted and/or upsetting distressing to untrained readers. For this reason, I recommend that you initially review them in my presencewith me, 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 $1.00 per page (and for copying certain other expenses). If I determine that obtaining your record may cause harm, I have the right to refuse your request for access to you records. The exceptions You have the right of review in some instances, which I will discuss with you upon request. In some instances, there is no right to this policy are contained have a review of the decision to refuse your request to inspect and/or copy the protected health information in your record. You should be advised that in the Privacy Notice formevent of my untimely death or catastrophic illness, I have made provision for a licensed colleague to maintain my records for the time required by law and to destroy them in accordance with HIPAA and my licensing body. In my absence my licensed proxy will use his/her best clinical judgment with regard to any request for records. HIPAA provides you with several new or expanded rights with regard to your Clinical Record 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 protected health information that you have neither consented to nor authorized; determining the location to which protected information disclosures disclosure are sent; having any complaints you make about my practice policies and procedures recorded in your records; and the right to a paper copy of this Agreement, Agreement and/or the Notice of Policies and Practices to Protect the Privacy Notice form, and my privacy policies and proceduresof your Health Information. I am will be happy to discuss any of these rights and/or issues with you. Patients 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 a agreement from parents that they consent to give up their access to their child’s records. If they agree, during treatment, I will typically provide them only with general information about the progress of the child’s treatment, and his/her attendance at scheduled sessions. I also may will also, at your request and with your child’s knowledge provide parents with a summary of their your child’s treatment when it is complete. Most Any other communication will require the child’s Authorization, unless I feel have reason to believe that the child is in danger or is a danger to someone else, in which case, 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. I reserve the right to refuse to provide services to a child if a parent will not agree to accept these conditions. You will be expected to pay for each session at the beginning of the scheduled appointment time. I have agreed otherwise or unless another arrangement has been made regarding insurance coverage. Insurance is only accepted by licensed counselors/psychotherapists and coverage will only be accepted when agreed upon by the individual treatment provider and the client. Payment schedules for other professional services will be agreed to when they are requested. By signing this document, you are stating that you understand that you are responsible for any and all fees for services provided by this therapist to which you have consented, and that failing to pay such fees may result in termination of any further services available to you. 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 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 her/his name, the nature of services provided, and the amount due. If such legal action is necessary, its cost will be included in the claim.

PROFESSIONAL RECORDS. You should be aware that, according to The laws and standards of psychology and counseling professions require that the rules of HIPAA, I clinician 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. 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 content of Psychotherapy Notes vary from client to client, they can include notes regarding the contents of our conversations, my analysis of those conversations, and how they impact on your therapy. They also can 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 Except in unusual circumstances that involve danger to yourself and/or others, you may examine and/or 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 both sets of records, if you request it in writingwriting and the request is signed by you and dated not more than 60 days from the date submitted. Because these are professional records, they can be misinterpreted and/or upsetting to untrained readers. For this reason, I recommend it is recommended that you initially review them in my presence, the presence of the clinician or have them forwarded to another mental health professional so you can discuss the contents. In most circumstances, I am allowed the law allows clinicians 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 copying recordsrecords search, plus postage. The exceptions If you request for access to this policy are contained in your records is refused, you have the Privacy Notice formright of review, which will be discussed with you upon request. HIPAA HIPPA provides you with several new or expanded guidelines and policies regarding your rights with regard to your Clinical Record and disclosures of protected health information. These rights include requesting that I the clinician 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 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 Privacy Notice form, and my privacy policies and procedures. I am happy to discuss any of these rights and/or issues with you. Patients Clients who are under 18 14 years of age and who are not emancipated and emancipated, along with their parents parents, should be aware that the law may allow allows parents to examine their child’s treatment recordsrecords unless the clinician decides that such access would injure the child, or parties have agreed otherwise. Because Children between the ages of 14 and 18 years of age may independently consent to and receive up to 6 sessions of psychotherapy/counseling services provided it is within a 30 day period. No information about those sessions can be disclosed to anyone without the child’s agreement. While privacy in psychotherapy psychotherapy/counseling is often crucial to successful progress, particularly with teenagers, parental involvement is also essential to successful treatment. For children 14 and over, it is sometimes my policy to request an agreement from between the client and his/her parents that they consent allowing the clinician to give up their access to their child’s records. If they agree, during treatment, I will typically provide them only with share general information about the progress of the child’s treatment, treatment and his/her attendance at scheduled sessions. I The clinician will also may provide parents with a summary of their child’s treatment when it is complete. Most Any other communication will require the child’s Authorization, unless I feel the clinician feels that the child is in danger danger, or is a danger to someone else, or a threat to property, in which case, I the clinician will notify the parents of my the concern. Before giving parents any information, I the clinician will discuss the matter with the child, if possible, and will do my his/her best to handle any objections he/she that the child may have.

PROFESSIONAL RECORDS. You should be aware that, according ▪ Pursuant to HIPAA and the rules laws and standards of HIPAAmy profession, I keep Protected Health Information about you in two sets of professional records. One set constitutes your a Clinical Record. It includes Record for everyone, including information about your reasons for seeking therapy, a description of the ways in which how your problem impacts on your life, your a diagnosis, the goals that we set for treatmenttreatment goals, your progress towards those goals, your medical and social historya complete medical, your social, 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. In addition▪ You may examine and/or receive a copy of your Clinical Record, if you request it in writing, except in unusual circumstances (e.g., danger to yourself and others or when another individual (other than another health care provider) is referenced and disclosing that information puts the other person at risk of substantial harm). As these are professional records that can be misinterpreted and/or upsetting to untrained readers, I request that you initially review them in my presence or have them forwarded to another mental health professional so you can discuss the contents. I am allowed to charge a copying fee of $1.00 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. ▪ I may also keep a set of Psychotherapy NotesNotes for those situations described in the previous section that involve harm to the patient or to another person. These Notes are for my own use and are designed to assist me in providing you with the best treatment, While the content of . Psychotherapy Notes vary from client to client, they notes can include notes regarding the contents of our conversations, my analysis of those conversations, and how they impact on your therapy. They may also can contain particularly sensitive information that you may reveal to me that is not required to be included in your Clinical Record, as well as information from others provided to me confidentially. These Psychotherapy Notes are kept separate from your Clinical Record. While Record and are not available to you and cannot be sent to anyone else, including insurance companies can request and receive a copy of your Clinical Record, they cannot receive a copy of your Psychotherapy Notes without your signedwritten, written signed Authorization. Insurance companies cannot require your Authorization authorization as a condition of coverage nor penalize you in any way for your refusalrefusal to provide it. You may examine and/or receive a copy of both sets of records, 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 fee for copying records. The exceptions to this policy are contained in the Privacy Notice form. ⮚ PATIENT RIGHTS: ▪ HIPAA provides you with several new or expanded rights with regard to regarding your Clinical Record Records and disclosures of protected health information. These rights include requesting that I amend , including: • Requesting amendments your record; requesting , restrictions on what information from your Clinical Record Records is disclosed to others; requesting an accounting of most disclosures of Protected Health Information protected health information that you have neither consented to nor authorized; determining . • Information about the location to which protected information disclosures are sent; having . • Having any complaints complaints, you make about my policies and procedures recorded in your records; and the . • The right to a paper copy of this Agreement, the Privacy attached Notice form, and my privacy policies and procedures. I am happy to discuss any of these rights and/or issues with you. 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 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 typically provide them only with general information about the progress of the child’s treatment, and his/her attendance at scheduled sessions. I also may provide parents with a summary of their child’s treatment when it is complete. Most 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 information, I will discuss the matter with the child, if possible, and do my best to handle any objections he/she may have.

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 be potentially harmful to 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 misinterpreted and/or upsetting to untrained readers. For this reason, I recommend that you initially review them in my presence. In most situations, I am allowed to charge a copying fee of $1.00 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, according pursuant to the rules of HIPAA, I may keep Protected Health Information about you in two sets of professional records. One set constitutes your Clinical Record. It includes information about your reasons for seeking therapy, 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. . The exceptions to this policy are contained in the attached Notice Form. 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 content contents of Psychotherapy Notes vary from client to client, they can include notes regarding the contents of our conversations, my analysis of those conversations, and how they impact on your therapy. They also can contain particularly sensitive information that you may reveal to me that is not required to be included in your Clinical Recordrecord. 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 both sets of recordsyour Psychotherapy Notes unless I determine that it would adversely affect your well-being, if in which case you request it in writing. Because these are professional records, they can be misinterpreted and/or upsetting have a right to untrained readers. For this reason, I recommend that you initially review them in my presence, or a summary and to have them forwarded your record sent to another mental health professional so you can discuss the contents. In most circumstances, I am allowed to charge a fee for copying records. The exceptions to this policy are contained in the Privacy Notice formprovider or your attorney. 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 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 Privacy attached Notice form, and my privacy policies and procedures. I am happy to discuss any of these rights and/or issues with you. Patients under 18 years of age who are not emancipated and their parents should be aware that the law may allow allows parents to examine their child’s treatment records, unless I believe this review would be harmful to the patient and his/her treatment. 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 typically provide them only with general information about the progress of the child’s treatment, and his/her attendance at scheduled sessions. I will also may provide parents with a summary of their child’s treatment when it is complete. Most 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 immediately of my concernconcerns. 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 RECORDS. You should be aware that, according to The laws and standards of psychology and counseling professions require that the rules of HIPAA, I clinician 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. 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 content of Psychotherapy Notes vary from client to client, they can include notes regarding the contents of our conversations, my analysis of those conversations, and how they impact on your therapy. They also can 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 Except in unusual circumstances that involve danger to yourself and/or others, you may examine and/or 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 both sets of records, if you request it in writingwriting and the request is signed by you and dated not more than 60 days from the date submitted. Because these are professional records, they can be misinterpreted and/or upsetting to untrained readers. For this reason, I recommend it is recommended that you initially review them in my presence, the presence of the clinician or have them forwarded to another mental health professional so you can discuss the contents. In most circumstances, I am allowed the law allows clinicians to charge a copying fee of $3.07 per page for copying recordsthe first ten pages, 64 cents per page for pages 11 through 50, and 26 cents per page for pages in excess of fifty, plus postage, as of 2015. The exceptions If you request for access to this policy are contained in your records is refused, you have the Privacy Notice formright of review, which will be discussed with you upon request and we will provide them to a psychologist or licensed mental health professional designated by you. HIPAA provides you with several new or expanded guidelines and policies regarding your rights with regard to your Clinical Record and disclosures of protected health information. These rights include requesting that I the clinician 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 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 Privacy Notice form, and my privacy policies and procedures. I am happy to discuss any Please consult the Notice form for more complete information of these rights and/or issues with yourights. Patients Clients who are under 18 years of age and who are not emancipated and emancipated, along with their parents parents, should be aware that the law may allow allows parents to examine their child’s treatment recordsrecords absent a court order blocking a parent’s access. Because Also, children between the ages of 14 and 18 years of age may independently consent to and receive up to 6 sessions of psychotherapy/counseling services provided it is within a 30 day period and no information will be disclosed to the parent/guardian unless there is a compelling need for disclosure based on a substantial probability of harm to the minor or other persons and the minor is told of the intent of the mental health professional to inform the minor’s parent or guardian. No information about those sessions can be disclosed to anyone without the child’s agreement. Under this option only the minor child is responsible for payment. While the privacy in psychotherapy psychotherapy/counseling is often crucial to successful progress, particularly with teenagers, parental involvement can also be essential to successful treatment. For children 14 and over, it is sometimes my policy to request an agreement from between the client and his/her parents that they consent allowing the clinician to give up their access to their child’s records. If they agree, during treatment, I will typically provide them only with share general information about the progress of the child’s treatment, treatment and his/her attendance at scheduled sessions. I The clinician will also may provide parents with a summary of their child’s treatment when it is complete. Most Any other communication will require the child’s Authorization, unless I feel the clinician feels that the child is in danger danger, or is a danger to someone else, or a threat to property, in which case, I the clinician will notify the parents of my the concern. Before giving parents any information, I the clinician will discuss the matter with the child, if possible, and will do my his/her best to handle any objections he/she that the child may have. However, the parent(s) signing such an agreement may revoke their consent to this agreement, so although it may provide some protection involving the release of information, we cannot guarantee that it will always be effective. Both parents must recognize that if a minor child or children are the only client(s), that typically both parents hold the privilege on all communication involving the child while in therapy and that anything that either of them says in a session is available to the other parent, unless blocked by a court order.

PROFESSIONAL RECORDS. You should be aware that, according to the rules The laws and standards of HIPAA, my profession require that I keep Protected Health Information about you in two sets of professional records. One set constitutes your Clinical Record. It Your clinical record includes information about your reasons for seeking therapy, a description of the ways in which your problem impacts on your life, your diagnosis, the goals that we set for treatment, your progress towards those goals, your medical and social history, your treatment history, any past treatment records that 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 that disclosure is reasonably likely to endanger you or others, you may examine and/or receive a copy of your Clinical Record, if you request it in writing. There is a reasonable charge for copying these records and the time involved. 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. 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, 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.) In addition, I also may keep a set of Psychotherapy NotesNotes [which include Personal Notes as permitted by Maine law]. These Notes are for my own use and are designed to assist me in providing you with the best treatment, . While the content contents of Psychotherapy Notes vary from client to client, they can include notes regarding the contents of our conversations, my analysis of those conversations, and how they impact on your therapy. They also can 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. [Personal Notes contain information that is not directly relevant to your treatment.] 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 both sets of recordsyour Psychotherapy Notes unless I determine that disclosure would be detrimental to your health. If I so decide, if you request it in writing. Because have a right to require that I forward 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 presencenotes, or have them forwarded a narrative thereof, to another mental health professional so you can discuss the contentsyour authorized representative. In most circumstances, [I am allowed not required to charge a fee for copying records. The exceptions disclose my Personal Notes to this policy are contained in the Privacy Notice form. either you or your authorized representative.] HIPAA provides you with several new or expanded rights with regard to your Clinical Record Records and disclosures of protected health information. These rights include requesting that I amend your record; requesting restrictions on what information from your Clinical Record Records is disclosed to others; requesting an accounting of most disclosures of Protected Health Information 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 Privacy attached Notice form, and my privacy policies and procedures. I am happy to discuss any of these rights and/or issues with you. Patients under 18 years of age who are not emancipated Clients 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 law may allow parents to examine their minor child’s treatment recordsagreement. Because While privacy in psychotherapy is often crucial to successful progressvery important, particularly with teenagers, parental involvement is also essential to successful treatment, particularly with younger children. Therefore, it is sometimes my policy not to provide treatment to a child under 10 unless he/she agrees that I can share whatever information I consider necessary with his/her parents. For children 10 and over, I request an agreement from between my client and his/her parents that they consent allowing me to give up their access to their child’s records. If they agree, during treatment, I will typically provide them only with share general information about the progress of the their child’s treatment, and his/her attendance at scheduled sessions. I also may provide parents with a summary of their child’s treatment when it is complete. Most 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. 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. I accept cash, check and credit card. Credit card payments are taken via Ivy Pay. Ivy Pay is a HIPAA-secure, PCI (Payment Card Industry)-protected card on- file payment service. The app keeps your therapy service and your credit card information confidential and secure. By signing this form, you are agreeing to the terms and use of Ivy pay for payment if needed. 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 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.] 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. If it is necessary to clear confusion, I will be willing to call the company on your behalf. It is sometimes difficult to determine exactly how much mental health coverage is available. Many “Managed Health Care” plans such as HMOs and PPOs often require authorization before they provide reimbursement for mental health services. 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 clients 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 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. In order for your therapy to be covered by the insurance company, I am required to provide a clinical diagnosis. This diagnosis will become part your medical record with your insurance company. If you have any questions about your diagnosis, YOUR SIGNATURE BELOW INDICATES:

PROFESSIONAL RECORDS. You should be aware that, according Pursuant to the rules of HIPAA, I am allowed to keep Protected Health Information PHI about you in two sets of professional records. One The major set constitutes your Clinical Record. It includes information about your reasons for treatment. In most circumstances I will only keep a single 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 toward 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. 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 content of Psychotherapy Notes vary from client to client, they can include notes regarding the contents of our conversations, my analysis of those conversations, and how they impact on your therapy. They also can contain particularly sensitive information that you 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 examine and/or 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 both sets of records, if you request it in writing, except in unusual circumstances which I judge could involve significant physical danger to yourself or others. Should that be the case, I will provide you with an accurate and representative summary of your Clinical Record if you request it in writing. If our therapy has involved more than one person as a client, either person is allowed to request access to or authorize release of the Clinical Record, even though the record will contain information about other(s). 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. Generally, I keep your Clinical Record for seven years after your treatment ends, as required by law, or up to 10 years. I have a designated colleague on record with the State Board of Psychologist Examiners who would take over and properly dispose of my professional records should something happen to me. In most circumstances, legally I am allowed to charge a base fee of $30 for 10 or fewer pages and a copying recordsfee of $.50 per page up to 50 pages, then $.25 per page thereafter. The exceptions to this policy are contained in law may change these parameters, and if so, I will follow the Privacy Notice formchanges made by law. HIPAA provides you with several new or expanded rights with regard If I refuse your request for access 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 Record, you have neither consented to nor authorized; determining the location to a right of review, 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 Privacy Notice form, and my privacy policies and procedures. I am happy to discuss any of these rights and/or issues with you. 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 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 typically provide them only with general information about the progress of the child’s treatment, and his/her attendance at scheduled sessions. I also may provide parents with a summary of their child’s treatment when it is complete. Most 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 information, I will discuss the matter with you upon request. In addition, I am permitted by law to 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 childbest treatment. While the contents of Psychotherapy Notes vary from client to client, if possiblethey can include the contents of our conversations, my analysis of those conversations, and how they influence our work together. They may also contain some particularly sensitive information that you may reveal to me that is not required to be included in 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. If I have made them, you may request to examine and/or receive a copy of your Psychotherapy Notes unless I determine that such disclosure could be injurious to you. PLEASE NOTE, however, that in most cases I do my best to handle any objections he/she may havenot keep a separate set of Psychotherapy Notes but include all written information, required and otherwise, in your main Clinical Record.

PROFESSIONAL RECORDS. You should be aware that, according to The laws and standards of psychology and counseling professions require that the rules of HIPAA, I clinician 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. 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 content of Psychotherapy Notes vary from client to client, they can include notes regarding the contents of our conversations, my analysis of those conversations, and how they impact on your therapy. They also can 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 Except in unusual circumstances that involve danger to yourself and/or others, you may examine and/or 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 both sets of records, if you request it in writingwriting and the request is signed by you and dated not more than 60 days from the date submitted. Because these are professional records, they can be misinterpreted and/or upsetting to untrained readers. For this reason, I recommend it is recommended that you initially review them in my presence, the presence of the clinician or have them forwarded to another mental health professional so you can discuss the contents. In most circumstances, I am allowed the law allows clinicians to charge a copying fee of $3.07 per page for copying recordsthe first ten pages, 64 cents per page for pages 11 through 50, and 26 cents per page for pages in excess of fifty, plus postage, as of 2015. The exceptions If you request for access to this policy are contained in your records is refused, you have the Privacy Notice formright of review, which will be discussed with you upon request and we will provide them to a psychologist or licensed mental health professional designated by you. HIPAA HIPPA provides you with several new or expanded guidelines and policies regarding your rights with regard to your Clinical Record and disclosures of protected health information. These rights include requesting that I the clinician 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 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 Privacy Notice form, and my privacy policies and procedures. I am happy to discuss any Please consult the Notice form for more complete information of these rights and/or issues with yourights. Patients Clients who are under 18 years of age and who are not emancipated and emancipated, along with their parents parents, should be aware that the law may allow allows parents to examine their child’s treatment recordsrecords absent a court order blocking a parent’s access. Because Also, children between the ages of 14 and 18 years of age may independently consent to and receive up to 6 sessions of psychotherapy/counseling services provided it is within a 30 day period and no information will be disclosed to the parent/guardian unless there is a compelling need for disclosure based on a substantial probability of harm to the minor or other persons and the minor is told of the intent of the mental health professional to inform the minor’s parent or guardian. No information about those sessions can be disclosed to anyone without the child’s agreement. Under this option only the minor child is responsible for payment. While the privacy in psychotherapy psychotherapy/counseling is often crucial to successful progress, particularly with teenagers, parental involvement can also be essential to successful treatment. For children 14 and over, it is sometimes my policy to request an agreement from between the client and his/her parents that they consent allowing the clinician to give up their access to their child’s records. If they agree, during treatment, I will typically provide them only with share general information about the progress of the child’s treatment, treatment and his/her attendance at scheduled sessions. I The clinician will also may provide parents with a summary of their child’s treatment when it is complete. Most Any other communication will require the child’s Authorization, unless I feel the clinician feels that the child is in danger danger, or is a danger to someone else, or a threat to property, in which case, I the clinician will notify the parents of my the concern. Before giving parents any information, I the clinician will discuss the matter with the child, if possible, and will do my his/her best to handle any objections he/she that the child may have. However, the parent(s) signing such an agreement may revoke their consent to this agreement, so although it may provide some protection involving the release of information, we cannot guarantee that it will always be effective. Both parents must recognize that if a minor child or children are the only client(s), that typically both parents hold the privilege on all communication involving the child while in therapy and that anything that either of them says in a session is available to the other parent, unless blocked by a court order.

PROFESSIONAL RECORDS. The laws and standards of the therapeutic profession require that we keep Protected Health Information (PHI) about you in your clinical record. Except for unusual circumstances that can involve danger to yourself and/or others, or where information has been supplied to us 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 easily misinterpreted and possibly confusing to an untrained reader. For this reason, we recommend that you initially review them with your therapist, or have them forwarded to another mental health professional so you can discuss the contents. We are allowed to charge a reasonable fee for expenses incurred. If we refuse your request for access to your records, for reasons stated above, you have a right of review, which we will discuss with you upon request. You should be aware that, according pursuant to the rules of HIPAA, I we keep Protected Health Information about you in two sets of professional records. One set constitutes your Clinical Recordclinical record. It includes information about your reasons for seeking therapy, a description of the ways in which your problem impacts on problems impact your life, your diagnosis, the goals that we are set for treatment, your progress towards those goals, your medical and social history, your treatment history, any past treatment records that I we receive from other providers, reports of any professional consultations, your billing records, and any reports that have been sent to anyone, including reports to your insurance carrier. In addition, I also your therapist may keep a set of Psychotherapy Notes. These Notes are for my own use and are notes designed to assist me them in providing you with the best treatment, care. While the content contents of Psychotherapy Notes counseling notes vary from client to client, they can include notes regarding the contents of our your conversations, my your therapist’s analysis of those conversations, and how they impact on your therapy. They also can contain particularly sensitive information that you may reveal to me your therapist that is not required to be included in your Clinical Recordclinical record. They also include information from others provided to your therapist confidentially. These Psychotherapy Notes counseling notes are kept separate from your Clinical Record. While insurance companies can request clinical record and receive a copy of your Clinical Record, they are not available to you and cannot receive a copy of your Psychotherapy Notes without your signedbe sent to anyone else, written Authorizationincluding insurance companies. Insurance companies cannot require your Authorization authorization for these notes as a condition of coverage nor penalize you in any way for your refusal. You may examine and/or receive a copy of both sets of records, if you request it in writing. Because these are professional records, they can be misinterpreted and/or upsetting refusal 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 fee for copying records. The exceptions to this policy are contained in the Privacy Notice form. 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 Privacy Notice form, and my privacy policies and procedures. I am happy to discuss any of these rights and/or issues with you. 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 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 typically provide them only with general information about the progress of the child’s treatment, and his/her attendance at scheduled sessions. I also may provide parents with a summary of their child’s treatment when it is complete. Most 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 information, I will discuss the matter with the child, if possible, and do my best to handle any objections he/she may havethem.

PROFESSIONAL RECORDS. You should be aware thatUnder HIPAA regulations, according to the rules of HIPAA, I keep your AGAPE therapist may store 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 are set for treatment, your progress towards those goals, your medical and social history, your treatment history, any past treatment records that I receive were received from other providers, reports of any professional consultations, your billing records, and any reports that have been sent to anyone, including reports to your insurance carrier. Generally, you may review and/or receive a copy of your Clinical Record if you request it in writing. However, because these are professional records, they can be easily misinterpreted and/or be potentially upsetting to untrained readers. For this reason, XXXXX recommends that you initially review them in the presence of your therapist, or have them forwarded to another qualified mental health professional with whom you can discuss the contents. As allowed by law, XXXXX charges a retrieval/copying fee of 15¢ for the first five pages of a record and 25¢ per page thereafter. In additioncircumstances where XXXXX feels that your review or receipt of your Clinical Record may result in a danger to yourself or another or when disclosure of your record compromises the privacy of another person, I XXXXX may deny your request. If your request for access to your Clinical Record is refused, you have a right of review, which your therapist or the Clinical Director will discuss with you upon request. The exceptions to this policy are contained in the Notice form. In addition to your Clinical Record, your therapist may also keep a set of Psychotherapy Notes. These Notes are for my his/her own use and are designed to assist me him/her in providing you with the best treatment, While the . These may include more detailed content of Psychotherapy Notes vary from client to clientyour conversations with the therapist, they can include notes regarding the contents of our conversations, my his/her analysis of those conversations, and how they impact on your therapy. They also can contain particularly sensitive information that you may reveal to me the therapist that is not required to be included in your Clinical Record. These Also included may be information from others provided to the therapist confidentially. Psychotherapy Notes are kept separate from your Clinical Record. While insurance companies can request Your Psychotherapy Notes are not available to you and receive a copy of your Clinical Record, they cannot receive a copy of your Psychotherapy Notes be sent to anyone else, including insurance companies, without your signed, written signed Authorization. Insurance companies cannot require you to authorize release of your Authorization Psychotherapy Notes as a condition of coverage nor penalize you in any way for your refusal. You may examine and/or receive a copy of both sets of records, if you request it in writing. Because these are professional records, they can be misinterpreted and/or upsetting refusal 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 fee for copying records. The exceptions to this policy are contained in the Privacy Notice form. 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 Privacy Notice form, and my privacy policies and procedures. I am happy to discuss any of these rights and/or issues with you. 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 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 typically provide them only with general information about the progress of the child’s treatment, and his/her attendance at scheduled sessions. I also may provide parents with a summary of their child’s treatment when it is complete. Most 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 information, I will discuss the matter with the child, if possible, and do my best to handle any objections he/she may haveit.

PROFESSIONAL RECORDS. You should be aware that, according to the rules of HIPAA, I Mental health clinicians may keep Protected Health Information about you (PHI) in two sets of professional records. One set constitutes your Medical/Clinical Record. It includes If kept, the second set contains your Psychotherapy Notes. Current CHPA providers rarely maintain separate psychotherapy notes. Please ask your clinician if you have any questions. Medical records include information about your reasons for seeking therapyevaluation/medication/therapy or other services, a description of the ways in which your problem impacts on your life, your diagnosis, the goals that we were set for treatment, your progress towards those goals, your medical and social history, your treatment history, any past treatment records that I we receive from other providers, reports of any professional consultations, your billing records, and any reports that have been sent to anyone, including reports to your insurance carrier. In additionThe laws and standards of our professional providers require that we keep PHI about you in your Medical Record. Typical use of these records includes documentation of the treatment process, I also keep assistance for the provider in treatment planning and overview, or communication with a set collaborating provider within CHPA. Furthermore, typical disclosure of Psychotherapy Notes. These Notes are for my own use and are designed to assist me in providing you treatment records occur with the best treatment, client’s written consent in order to communicate with a Primary Care Provider or another mental health professional outside CHPA. While the content contents of Psychotherapy Notes vary from client to client, they can include notes regarding the contents of our conversations, my analysis of those conversations, conversations and how they impact on your therapy. They also can contain particularly sensitive information that you may reveal to me a provider that is not required to be included in your Clinical RecordRecord and information revealed confidentially by others such as your primary care physician. These Psychotherapy Notes are kept separate from your Clinical Record. While insurance companies can request , and receive a higher level of confidentiality protection. HIPAA provides you with several new or expanded rights with regard to your Medical Records and disclosures of PHI. These rights include requesting that we amend your record; requesting restrictions on what information from your Medical Records 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; being informed of a breach of unsecured PHI, having the right to restrict certain disclosures of PHI to a health plan if the client pays out of pocket in full for the health care service, having any complaints you make about policies and procedures recorded in your records; and the right to a paper copy of your Clinical Recordthis Agreement, they cannot receive a copy and the attached Notice form. We are happy to discuss any of your Psychotherapy Notes without your signedthese rights with you. Except in unusual circumstances that involve danger to yourself and/or others who may be named in the record, 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 both sets of records, if you your Medical Record. We require that the request it be made in writing. Because these are professional records, they can be misinterpreted and/or upsetting to untrained readers. For this reason, I recommend and it is our policy that you initially review them in my presencethe presence of your provider, or have them forwarded to another mental health professional so you can discuss the contents. In most circumstances, I am allowed These are professional records meant to facilitate your treatment rather than to represent a comprehensive summary of all issues you reviewed; they can be misunderstood by untrained readers. The clinician will charge a pro­rated fee for copying his or her time supervising the record review. If this is done as part of your treatment it may be covered by your insurance. If we refuse your request for access to your records, you have a “right of review” which your clinician will discuss with you upon request. The exceptions to this policy are contained in the Privacy attached Notice Form. Patients may also request a copy of their record in electronic form, with the associated fee not exceeding the labor costs. 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 rules also require 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 we notify patients that you they 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 opt out of receiving fundraising and/or marketing solicitations and that we will not sell a paper copy of this Agreement, the Privacy Notice form, and my privacy policies and procedures. I am happy to discuss any of these rights and/or issues with you. 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 childpatient’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 typically provide them only with general health information about the progress of the child’s treatment, and without his/her attendance at scheduled sessions. I also may provide parents with a summary of their child’s treatment when it is complete. Most other communication will require the child’s Authorizationexpress consent – however, unless I feel that the child is in danger CHPA does not send out such marketing requests or is a danger seek to someone else, in which case, I will notify the parents of my concern. Before giving parents sell recorded information, I will discuss the matter with the child, if possible, and do my best to handle any objections he/she may have.