Background
The HIPAA Privacy Rule gives individuals a fundamental new right to be informed of the privacy practices of their health plans and of most of their health care providers, as well as to be informed of their privacy rights with respect to their personal health information. Health plans and covered health care providers are required to develop and distribute a notice that provides a clear explanation of these rights and practices. The notice is intended to focus individuals on privacy issues and concerns, and to prompt them to have discussions with their health plans and health care providers and exercise their rights.

How the Rule Works
General Rule. The Privacy Rule provides that an individual has a right to adequate notice of how a covered entity may use and disclose protected health information about the individual, as well as his or her rights and the covered entity’s obligations with respect to that information. Most covered entities must develop and provide individuals with this notice of their privacy practices. The Privacy Rule does not require the following covered entities to develop a notice:

• Health care clearinghouses, if the only protected health information they create or receive is as a business associate of another covered entity. See 45 CFR 164.500(b)(1).
• A correctional institution that is a covered entity (e.g., that has a covered health care provider component).
• A group health plan that provides benefits only through one or more contracts of insurance with health insurance issuers or HMOs, and that does not create or receive protected health information other than summary health information or enrollment or disenrollment information. See 45 CFR 164.520(a).

Content of the Notice. Covered entities are required to provide a notice in plain language that describes:
• How the covered entity may use and disclose protected health information about an individual.
• The individual’s rights with respect to the information and how the individual may exercise these rights, including how the individual may complain to the covered entity.
• The covered entity’s legal duties with respect to the information, including a statement that the covered entity is required by law to maintain the privacy of protected health information.
• Whom individuals can contact for further information about the covered entity’s privacy policies.
The notice must include an effective date. See 45 CFR 164.520(b) for the specific requirements for developing the content of the notice. A covered entity is required to promptly revise and distribute its notice whenever it makes material changes to any of its privacy practices. See 45 CFR 164.520(b)(3), 164.520(c)(1)(i)(C) for health plans, and 164.520(c)(2)(iv) for covered health care providers with direct treatment relationships with individuals.

Providing the Notice.
• A covered entity must make its notice available to any person who asks for it.
• A covered entity must prominently post and make available its notice on any web site it maintains that provides information about its customer services or benefits.
• Health Plans must also:

Provide the notice to individuals then covered by the plan no later than April 14, 2003 (April 14, 2004, for small health plans) and to new enrollees at the time of enrollment.

Provide a revised notice to individuals then covered by the plan within 60 days of a material revision.

Notify individuals then covered by the plan of the availability of and how to obtain the notice at least once every three years.

• Covered Direct Treatment Providers must also:

Provide the notice to the individual no later than the date of first service delivery (after the April 14, 2003 compliance date of the Privacy Rule) and, except in an emergency treatment situation, make a good faith effort to obtain the individual’s written acknowledgment of receipt of the notice. If an acknowledgment cannot be obtained, the provider must document his or her efforts to obtain the acknowledgment and the reason why it was not obtained.

When first service delivery to an individual is provided over the Internet, through e-mail, or otherwise electronically, the provider must send an electronic notice automatically and contemporaneously in response to the individual’s first request for service. The provider must make a good faith effort to obtain a return receipt or other transmission from the individual in response to receiving the notice.

In an emergency treatment situation, provide the notice as soon as it is reasonably practicable to do so after the emergency situation has ended. In these situations, providers are not required to make a good faith effort to obtain a written acknowledgment from individuals.

Make the latest notice (i.e., the one that reflects any changes in privacy policies) available at the provider’s office or facility for individuals to request to take with them, and post it in a clear and prominent location at the facility.
• A covered entity may e-mail the notice to an individual if the individual agrees to receive an electronic notice. See 45 CFR 164.520(c) for the specific requirements for providing the notice.
Organizational Options.
• Any covered entity, including a hybrid entity or an affiliated covered entity, may choose to develop more than one notice, such as when an entity performs different types of covered functions (i.e., the functions that make it a health plan, a health care provider, or a health care clearinghouse) and there are variations in its privacy practices among these covered functions. Covered entities are encouraged to provide individuals with the most specific notice possible.
• Covered entities that participate in an organized health care arrangement may choose to produce a single, joint notice if certain requirements are met. For example, the joint notice must describe the covered entities and the service delivery sites to which it applies. If any one of the participating covered entities provides the joint notice to an individual, the notice distribution requirement with respect to that individual is met for all of the covered entities. See 45 CFR 164.520(d).

OCR HIPAA Privacy
December 3, 2002 Revised April 3, 2003

I’m very pleased that you have selected me to be your therapist and I am sincerely looking forward to assisting you. This document is designed to inform you about what you can expect from me regarding confidentiality, emergencies, and several other details regarding your treatment.


Although providing this document is part of an ethical obligation to my profession, more importantly, it is part of my commitment to keep you fully informed of every part of your therapeutic experience. Please know that your relationship with me is a collaborative one, and I welcome any questions, comments, or suggestions regarding your course of therapy at any time.

Background Information

The following information regarding my educational background and experience. If you have any questions please feel free to ask. I have a Master’s of Counseling Psychology from the Georgia School of Professional Psychology. I am a Licensed Professional Counselor in the state of Georgia with over 16 years of experience in the mental health field. Additionally, I have had extensive work experience and training in Dialectical Behavior Therapy, Trauma-Focused CBT, and Theraplay. I have experience in working with adults, children, adolescents, and families.
I have provided counseling services since 1998 at such facilities as Hillside, Devereux, Pathways Transition Services, and GA Parent Support Network and was part of the Governor’s internship program.


Theoretical Views & Client Participation

I utilize many models of therapy in my work with clients in an effort to obtain them their goals. I have been intensively trained in Dialectical Behavior Therapy which is focused on acceptance and change. It is my belief my clients are doing the best they can and they can make changes to make their lives happier. Sometimes that is processing previous traumas and sometimes it is accepting the things that they cannot change. Some clients need only a few sessions to achieve these goals, whereas others may require months or even years of therapy. Therapy is a collaborative effort and you get to determine the course of treatment. You can end your relationship with me at any point. I do not believe in the one size fits approach to therapy and your treatment will be individualized.

In order for therapy to be most successful, it is important for you to take an active role, both during and between sessions which may include diary cards, journaling, and/or practice assignments. Generally, the more of yourself you are willing to invest, the greater the return. By committing to being my client, you are agreeing to stay alive and not attempt suicide while in my care. I also am not open to appear in court as an expert witness.

Furthermore, it is my policy to only see clients who I believe have the capacity to resolve their own problems with my assistance. It is my intention to empower you in your growth process to the degree that you are capable of facing life’s challenges in the future without me. I also don’t believe in creating dependency or prolonging therapy if the therapeutic intervention does not seem to be helping. If this is the case, I will direct you to other resources that will be of assistance to you. Your personal development is my number one priority. I encourage you to let me know if you feel that transferring to another therapist is necessary at any time. My goal is to facilitate healing and growth, and I am very committed to helping you in whatever way seems to produce maximum benefit.

Confidentiality & Records

Your communications with me will become part of a clinical record of treatment, and it is referred to as Protected Health Information (PHI). Your PHI will be kept in a file stored securely. Additionally, I will always keep everything you say to me completely confidential, with the following exceptions: (1) you direct me to tell someone else and you sign a “Release of Information” form; (2) I determine that you are a danger to yourself or to others; (3) you report information about the abuse of a child, an elderly person, or a disabled individual who may require protection; or (4) I am ordered by a judge to disclose information. In the latter case, my license does provide me with the ability to uphold what is legally termed “privileged communication.” Privileged communication is your right as a client to have a confidential relationship with a therapist. The state of Georgia has a very good track record in respecting this legal right. If for some reason a judge were to order the disclosure of your private information, this order can be appealed. I cannot guarantee that the appeal will be sustained, but I will do everything in my power to keep what you say to me confidential.

Please note that in couple’s counseling, I do not agree to keep secrets. Information revealed in any context may be discussed with either partner.

Structure and Cost of Sessions

I agree to provide psychotherapy for the fee of $100 50-60 minute session, $150 per 90 minute session. Doing psychotherapy by telephone/Skype is available (although unsecure) and I'm available for call coaching if needed. If coaching occurs too often it may indicate the need for additional supports. If this is the case, you and I will need to explore adding sessions or developing other resources you have available to help you. This excludes call coaching or skill texting which is encouraged. I will explain more about coaching calls the initial session.

Insurance companies have many rules and requirements specific to certain plans. At this time I do not accept insurance due to my desire to put my clients' best interest at heart. I am more than willing to provide a statement so that you can submit for reimbursement.

Cancellation Policy

In the event that you are unable to keep an appointment, you must notify me beforehand preferably at least 24 hours in advance.

In Case of an Emergency

My practice is considered to be an outpatient and I am set up to accommodate individuals who are reasonably safe and resourceful. I am not available at all times and texting is usually most effecting way of communication. This includes coaching calls. Once a commitment is made to therapy you will have access to call/text coaching and are encouraged to do so when needed. If at any time this does not feel like sufficient support, please inform me, and we can discuss additional resources. Generally, I will return phone calls within 24 hours. If you have a mental health emergency, I encourage you not to wait for a call back, but to do one or more of the following:

• Call the GA Help and Crisis line at 1-800-715-4225
• Call 911.
• Go to your nearest emergency room.

Professional Relationship

Psychotherapy is a professional service I will provide to you. Because of the nature of therapy, your relationship with me has to be different from most relationships. It may differ in how long it lasts, the objectives, or the topics discussed. It must also be limited to only the relationship of therapist and client. If you and I were to interact in any other ways (e.g., social, business, etc.), we would then have a "dual relationship." Dual relationships may compromise our treatment and, therefore, are discouraged in the mental health profession. In order to offer all of my clients the best care, my judgment needs to be unselfish and purely focused on your needs. This is why your relationship with me must remain professional in nature.

Additionally, there are important differences between therapy and friendship. Friends may see your position only from their personal viewpoints and experiences. Friends may want to find quick and easy solutions to your problems so that they can feel helpful. These short-term solutions may not be in your long-term best interest. Friends do not usually follow up on their advice to see whether it was useful. They may need to have you do what they advise. A therapist offers you choices and helps you choose what is best for you. A therapist helps you learn how to solve problems better and make better decisions. A therapist's responses to your situation are based on tested theories and methods of change.

You should also know that therapists are required to keep the identity of their clients’ secret. As much as I would like to, for your confidentiality I will not address you in public unless you speak to me first. I also must decline any invitation to attend gatherings with your family or friends. To help keep your confidentiality and effective boundaries I do not participate in social media "friendships." In sum, it is my duty to always maintain a professional role. Please note that these guidelines are not meant to be discourteous in any way; they are strictly for your long-term protection and healing.
Technology Statement

In our ever-changing technological society, there are several ways we could potentially communicate and/or follow each other electronically. It is of utmost importance to me to maintain your confidentiality, respect your boundaries, and ascertain that our relationship remains therapeutic and professional. Therefore, I’ve developed the following policies:

Cell phones: It is important for you to know that cell phones may not be completely secure and confidential. If you would like for me not to use a cell phone when contacting you, please let me know.

Text Messaging and Email: Both text messaging and emailing are not secure means of communication and may compromise your confidentiality. However, I realize that many people prefer to text and/or email because it is a quick way to convey information. If you choose to utilize texting or email, please discuss this with me. You also need to know that I am required to keep a copy of all emails and texts as part of your clinical record.

Facebook, LinkedIn, Etc: It is my policy not to accept requests from any current or former client on social networking sites such as Facebook or LinkedIn because it may compromise your confidentiality. Additionally, my ethics code prevents me from soliciting endorsements from clients, and the concept of “Fanning” is considered to be bordering on such solicitation. However, it is still your prerogative to view or share any content on my professional pages.

Google: I do not search for clients on Google. I respect your privacy and make it a policy to allow you to share information about yourself to me as you feel appropriate. If there is content on the Internet that you would like to share with me for therapeutic reasons, please print this material out and bring it to your session.

In summary, technology is constantly changing, and there are implications to all of the above that I may not realize at this time. Please feel free to ask questions, and know that I’m open to any feelings or thoughts you have about these and other modalities of communication.

Statement Regarding Ethics, Client Welfare & Safety

I assure you that my services will be rendered in a professional manner consistent with the ethical standards of the American Psychological Association / American Counseling Association / National Association of Social Workers/American Association for Marriage and Family Therapists. If at any time you feel that I am not performing in an ethical or professional manner, I ask that you please let me know immediately. I will work strongly to resolve the issue. If we are unable to resolve your concern, I will provide you with information to contact the Georgia professional licensing board that governs my profession.

Due to the very nature of psychotherapy, as much as I would like to guarantee specific results regarding your therapeutic goals, I am unable to do so. However, with your participation, we will work to achieve the best possible results for you. Please also be aware that changes made in therapy may affect other people in your life. For example, an increase in your assertiveness may not always be welcomed by others. It is my intention to help you manage changes in your interpersonal relationships as they arise, but it is important for you to be aware of this possibility nonetheless.


Additionally, at times people find that they feel somewhat worse when they first start therapy before they begin to feel better. This may occur as you begin discussing certain sensitive areas of your life. However, a topic usually isn’t sensitive unless it needs attention. Therefore, discovering the discomfort is actually a success. Once you and I are able to target your specific treatment needs and the particular modalities that work the best for you, help is generally on the way.

I am sincerely looking forward to facilitating you on your journey toward healing and growth. If you have any questions about any part of this document, please ask.

Please print, date, and sign your name below indicating that you have read and understand the contents of this “Information, Authorization and Consent to Treatment” form as well as the “Health Insurance Portability and Accountability Act (HIPAA) Notice of Privacy Practices” provided to you separately. Your signature also indicates that you agree to the policies of your relationship with me as your therapist, and you are authorizing me to begin treatment with you.