Notice of Privacy Practices

This notice describes how health information about you (as a client of this practice) may be used and disclosed, and how you can get access to your health information. This is required by the Privacy Regulations created as a result of the Health Information Portability and Accountability Act of 1996 (HIPAA).

My commitment to your privacy

My practice is dedicated to maintaining the privacy of your personal information. I am required by law to maintain the confidentiality of your health and personal information. I realize that these laws are complicated but I must provide you with important information:

• How I may use and disclose your personal information
• Your privacy rights
  
• My obligations concerning the use and disclosure of your health information.

I may use and disclose your health information in the following ways:

1. Treatment. Health care providers and staff may use or disclose your health information in order to treat or assist you or assist others in your treatment. Additionally, I may disclose your health information to others who may assist in your care, such as your spouse, children or parents.
   
2. Payment. My practice may use your health information to bill and collect payment for the services you receive from us. We may provide your insurer with details regarding your treatment to determine if your insurer will cover, or pay for, your treatment. We may also disclose this information to obtain payment from third parties that may be responsible for such costs, such as family members. Also, I may use your health information to bill you directly for services and items.
   
3. Health Care Operation. I may need to sue and disclose your health information to be able to run my practice at the highest clinical standards and effectively as possible. This could be used to evaluate my performance and determine if my treatment plans are effective, or determine if there are other services I should be offering. I may also compare my clinical data with other practices, review it with technicians, consultants, and others for teaching and learning purposes. I will strive to remove information that identifies you from this medical information.
   
4. Disclosures required by law. My practice will use and disclose your health information when I am required to do so by federal, state, or local law.
   
5. Appointment Reminders and Sign-In Sheets. We may want to call you by phone for appointment reminder purposes. Please advise us if you do not want us to call and leave appointment reminder messages at your home. We may also use a “sign-in” sheet at the front desk, for purposes of logging our clients as they arrive.

Use and disclosure of your health information in certain special circumstances:

1. To public health authorities and health oversight agencies that are authorized by law to collect information.
   
2. Lawsuits and similar proceedings in response to a court administrative order.
   
3. If asked to do so by a law enforcement official.
   
4. When necessary to reduce or prevent a serious threat to your health and safety of another individual or the public. We will only make disclosure to person or organization able to help prevent the threat.
   
5. To federal officials for intelligence and national security activities authorized by law.
   
6. To correctional institutions or law enforcement officials if you are an inmate or under custody of a law enforcement official.
   
7. For Workers Compensation and similar programs.

Your rights regarding your health information:

1. Communications. You can request that my practice communicates with you about your health related issues in a particular manner or at a certain location. For instance, you may ask that we contact you at home, rather than work. I will accommodate reasonable requests.
   
2. You can request a restriction in my use or disclosure of your health information for treatment, payment, or health care operations.l Additionally, you have the right to request that we restrict our disclosures of your health information to only certain individuals involved in your care, such as family members and friends. I am not required to agree to your request; however, if I do agree, I am bound by our agreement except when otherwise required by law, in emergencies, or when the information is necessary to treat you.
   
3. You have the right to inspect and obtain a copy of the health information that may be used to make decisions about you, including client records and billing records, but not including psychotherapy notes. You must submit your request in writing to me.
   
4. You may ask me to amend your health information if you believe it is incorrect or incomplete, as long as the information is kept by or for my practice. To request an amendment, your request must be made in writing and submitted to me.
   
5. Right to a copy of this notice. You are entitled to receive a copy of this notice of privacy practices. You may ask me to give you a copy of this notice at any time.
   
6. Right to file a complaint with me or with the Board of Behavioral Health Examiners 3443 North Central Avenue #1700, Phoenix, AZ 85012, phone (602)542-1882 or www.bbhe.state.az.us. All complaints must be submitted in writing and you will not be penalized for submitting a complaint.
   
7. Right to provide an authorization for other uses and disclosures. My practice will obtain written permission from you to disclose information in ways that have not been identified in this notice, or are not permitted by these laws.
   

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Terms & Conditions

Consent for Treatment, Rights & Responsibilities

Welcome to my practice! The following document is information for you to best understand the therapeutic relationship and the conditions which you will need to be successful. The therapist-client relationship differs from any other relationship you have ever experienced. Please read the following document carefully and jot down any questions you might have so we can discuss them. When you sign this document, it will represent a contractual agreement between us.

Purpose of Treatment

The purpose of treatment is to meet your therapeutic goals which will be specifically outlined in your treatment plan. We will determine your treatment plan together once we have established what has brought you to treatment, what you would like to work on and what you want to accomplish. Treatment plans are reviewed once every three months or whenever necessary to address your treatment needs.

Psychotherapeutic Services

Psychotherapy is not easily defined in general statements. It varies depending upon the personalities of the therapist and client and particular problems you bring forward. There are many different methods and modalities I may use to deal with the problems you hope to address.

Some of the benefits you may feel from therapy are enhanced awareness, emotional understanding of yourself, improvement in your relationships with others, reduction in “problems” or “issues” that brought you to therapy in the first place, greater ability to think about things clearly and cope with dysfunctional patterns, better overall functioning, greater ability to deal with stress and work through difficulties, improvement in job or school performance, strengthened sense of self and overall sense of well-being.

However, there are also risks in therapy. You may experience no change. You will most likely feel worse before you feel better; have an increase in feelings such as anger, grief, sadness, and hopelessness and feeling as if you are having increase conflicts with others as you do things differently. Therapy is not about visiting your therapist and having them “fix” you, or waving a magic wand to change everything immediately. Therapy is hard work and takes your participation and your commitment to change. Your success is directly dependant upon how much work you put into it and is also dependant upon your understanding of the limitations, benefits and risks of therapy. Since therapy often involves discussing unpleasant aspects of your life, you may experience uncomfortable feelings. You have the right to question and/or refuse any therapeutic interventions, suggestions or directives at any time.

Our first few sessions will involve an evaluation of your needs. By the end of the evaluation, I will be able to offer you some first impressions of what our work will include and we will develop a treatment plan together. You should evaluate this information and decide whether you are comfortable working with me. Therapy involves a large commitment of time, money, and energy, so you should be very careful about the therapist you select. If you have any questions about any of my procedures or interventions, you have the right to discuss them whenever they arise. If your doubts persist, I would be happy to help you set up a meeting with another mental health professional for a second opinion.

Confidentiality

I understand that you are entering into a relationship and perhaps divulging information that you have never talked about before. The information you give me during a session is strictly confidential. It will not be divulged to anyone unless you have given me written permission. However, there are a number of exceptions to your confidentiality that I am required by law to divulge when necessary. Please review the following exceptions carefully:

• My services were sought or obtained to enable or aid anyone to commit or plan to commit a crime.
• I have reasonable cause to believe that you are a danger to yourself or others. The disclosure of this information is to prevent harm to yourself or others.
• I suspect or have evidence that a minor child (under 18) is currently the victim of abuse. Child abuse means physical injury, other than accidental, inflicted on a child by an adult or other person, sexual assault, cruel punishment or neglect.
• I am ordered by the court of law to disclose information.
  

In order to provide you with the best possible treatment experience, I participate in consultation and trainings with other professionals. Unless I obtain written authorization from you, identification is not by name but by circumstance.

If a third party such as an insurance company is paying for part of your bill, I am normally required to give a diagnosis to that third party in order to be paid. Diagnoses are technical terms that describe the nature of your problems and something about whether they are short-term or long-term problems. If I do use a diagnosis, I will discuss it with you. All of the diagnoses come from a book titled the DSM-IV-TR; I have a copy in my office and will be glad to let you borrow it and learn more about what it says about your diagnosis.

Please respect the confidentiality of others seen or met in the counseling office or sessions.

Insurance

If your therapy is being paid for in full or in part by a managed care firm, there are usually further limitations to your rights as a client imposed by the contract of the managed care firm. These may include their decision to limit the number of sessions available to you, to decide the time period within which you must complete your therapy with me. They may also decide that you must see another therapist in their network rather than me, if I am not on their list. Such firms also usually require some sort of detailed reports of your progress in therapy, and on occasion, copies of your case file, on a regular basis. I do not have control over any aspect of their rules. However, I will do all that I can to maximize the benefits you receive by filing necessary forms and gaining required authorizations for treatment, and assist you in advocating with the company as needed.

Complaints

If you're unhappy with what's happening in therapy, I hope you'll talk about it with me so that I can respond to your concerns. I will take such criticism seriously, and with care and respect. If you believe that I've been unwilling to listen and respond, or that I have behaved unethically, you can complain about my behavior to the Board of Behavioral Health Examiners 3443 North Central Avenue #1700, Phoenix, AZ 85012, phone (602)542-1882 or www.bbhe.state.az.us.

Client Records

You have the right to obtain your records at any time by requesting them in writing and allowing time for copies to be made. If you are a minor, please be aware that your parents and/or legal guardian(s) have the right to examine your treatment records. Also see the above confidentiality exceptions.

Appointments

I normally conduct an assessment/evaluation that will last from 1 to 2 sessions. During this time, we can both decide whether I am the best person to provide the services you need in order to meet your treatment goals. I will usually schedule 45-50 minute sessions following your assessment/evaluation but occasionally you may require or request additional time. We will need to discuss this prior to authorizing an extended session.

Professional Fees, Billing & Payments

• $135 Intake Assessment/Evaluation
  
• $125 45/50 minute Individual Therapy
  
• $135 Family Therapy
  
• $25 Group Therapy

Standard fees are pro-rated for telephone consults, written reports and travel. Missed appointments without 24 hour notice may be charged; messages can be left at 733-2524 and forwarded to my answering service.

Other services include report writing, telephone conversations lasting longer than 15 minutes, attendance at meetings with other professionals you have authorized, preparation of records or treatment summaries, and the time spent performing any other service you may request of me. If you become involved in legal proceedings that require my participation you will be expected to pay for my professional time even if I am called to testify by another party.

You will be expected to pay each session at the time it is held, unless we agree otherwise or unless you have insurance coverage that requires another arrangement.

Termination

You have the right to discontinue treatment and terminate at any time. If you stop coming to sessions your treatment will automatically expire one year after the last therapy session attended. Termination is an important part of the treatment process, regardless of how many sessions you have had. You have the right to close in the most effective manner, so please inform me of your intent to leave therapy instead of just not returning.

Contacting Me

I am often not immediately available by telephone. While I am generally in my office between 9am to 5pm, I will probably not answer the phone when I am with a client. When I am unavailable, my telephone is answered by a receptionist or answering machine (during business hours) and answering service (after business hours). The answering machine is monitored regularly and the receptionist and answering service know where to reach me. I will make every effort to return your call on the same day you make it. If you are difficult to reach please inform me of times when you are available. In the case of an emergency and I am unavailable, please contact Help On-Call 24 hour crisis line at 323-9373 or SAMHC 24 hour crisis line at 622-6000.

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