If you're a first-time client, please review and complete the following forms, and bring them to your first session.
- Client Intake Form
- Limits of Confidentiality/Cancellation Policy Form
- Professional Disclosure Form
- Policy Information Form
- Anxiety Questionnaire
- Depression Questionnaire
- Adverse Childhood Experience Questionnaire
|Client Intake Form||Please complete this form and bring it to your first session.|
|Confidentiality and Cancellation||Please sign this form and bring it to your first session.|
|Professional Disclosure and Fee Agreement||Please complete and sign this form and bring it to your first session|
Policy Information and HIPAA Receipt
Please sign this form and bring it to your first session
|Anxiety Questionnaire||Please complete this and bring it to your first session|
|Depression Questionnaire||Please complete this and bring it to your first session|
|Adverse Childhood Experience Questionnaire||
If you would like me to coordinate care with another provider (for example, your psychiatrist, endocrinologist, etc.), complete this form:
- Consent to Release Information Form
|Release of Information|
Please read the HIPAA Privacy notice below and then sign the receipt form in the Policy Information packet above:
HIPAA Privacy and Security Notice.
PLEASE REVIEW THIS NOTICE CAREFULLY.
The following is an example of your right to privacy under the Health Information Portability and Accountability Act. You are not required to sign such an agree to receive care. You provider is required to document that you were informed and had access to a copy of their HIPAA agreement,
Your Information. Your Rights. Provider Responsibilities.
- This notice describes how medical information you provide may be used and disclosed and how you can get access to this information.
Patients have the right to:
- Get a copy of their paper or electronic medical record
- Correct their paper or electronic medical record
- Request confidential communication
- Ask your provider to limit the information your provider shares
- Get a list of those with whom providers have shared their information.
- Get a copy of this privacy notice. Choose someone to act for you.
- File a complaint if you believe their privacy rights have been violated
You have choices in the ways that your provider can use and share your information:
- Tell family and friends about their condition
- Provide disaster relief
- Include you in a hospital directory
- Provide mental health care
- Market provider services and sell their information
- Raise funds
Your Provider Uses and Disclosures
Your provider may use and share their information as your provider to:
- Treat you
- Run their organization
- Bill for their services
- Help with public health and safety issues
- Do research
- Comply with the law
- Respond to organ and tissue donation requests
- Work with a medical examiner or funeral director
- Address workers’ compensation, law enforcement, and other government requests
- Respond to lawsuits and legal actions
- When it comes to their health information, you have certain rights. This next section explains their rights and some of our responsibilities to help you.
Get an electronic or paper copy of their medical record
- You can ask to see or get an electronic or paper copy of their medical record and other health information your provider have about you. Ask your provider how to do this.
- Your provider will provide a copy or a summary of their health information, usually within 30 days of their request. Your provider may charge a reasonable, cost-based fee.
Ask your provider to correct their medical record
- You can ask your provider to correct health information about you that you think is incorrect or incomplete. Ask your provider how to do this.
- Your provider may say “no” to their request, but we’ll tell you why in writing within 60 days.
Request confidential communications
- You can ask your provider to contact you in a specific way (for example, home or office phone) or to send mail to a different address.
- Your provider will say “yes” to all reasonable requests.
Ask your provider to limit what your provider use or share
- Your provider can ask your provider not to use or share certain health information for treatment, payment, or our operations. Your provider are not required to agree to their request, and your provider may say “no” if it would affect their care.
- If you pay for a service or health care item out-of-pocket in full, you can ask your provider not to share that information for the purpose of payment or our operations with their health insurer. Your provider will say “yes” unless a law requires your provider to share that information.
Get a list of those with whom we’ve shared information
- You can ask for a list (accounting) of the times we’ve shared your health information for six years prior to the date you ask, who your provider shared it with, and why.
- Your provider will include all the disclosures except for those about treatment, payment, and health care operations, and certain other disclosures (such as any you asked your provider to make). Provide provide one accounting a year for free but may charge a reasonable, cost-based fee if you ask for another one within 12 months.
Get a copy of this privacy notice
- You can ask for a paper copy of your providers specific HIPPA notice at any time, even if you have agreed to receive the notice electronically. Your provider will provide you with a paper copy as soon as reasonably possible.
Choose someone to act for you
- If you have given someone medical power of attorney or if someone is your legal guardian, that person can exercise their rights and make choices about your health information.
- Your provider will make sure the person has this authority and can act for you before your provider takes any action.
File a complaint if you feel their rights are violated
- You can complain if you feel your provider has violated their rights by contacting your provider.
- You can file a complaint with the U.S. Department of Health and Human Services Office for Civil Rights by sending a letter to 200 Independence Avenue, S.W., Washington, D.C. 20201, calling 877-696-6775, or visiting www.hhs.gov/ocr/privacy/hipaa/complaints/.
- Your provider should not retaliate against you for filing a complaint.
- For certain health information, you can tell your provider your choices about what your provider can share. If you have a clear preference for how your provider share your information in the situations described below, talk to your provider. Tell your provider what you want your provider to do, and your provider will follow their instructions.
- In these cases, you have both the right and choice to tell your provider to:
- Share information with their family, close friends, or others involved in their care.
- Share information in a disaster relief situation.
- Include their information in a hospital directory.
If you are not able to tell your provider your preference, for example if you are unconscious, your provider may go ahead and share your information if your provider believe it is in your best interest. Your provider may also share your information when needed to lessen a serious and imminent threat to health or safety.
In these cases your provider will never share your information unless you give your provider written permission:
- Marketing purposes
- Sale of their information
- Most sharing of psychotherapy notes
In the case of fundraising:
- Your provider may contact you for fundraising efforts, but you can tell your provider not to contact you again.
Your provider typically use or share your health information in the following ways:
- Treat you.
- Your provider can use your health information and share it with other professionals who are treating you.
(Example: A doctor treating you for an injury asks another doctor about your overall health condition.)
Run the provider’s organization
- Your provider can use and share their health information to run our practice, improve their care, and contact you when necessary
- Example: Your provider use health information about you to manage their treatment and services
Bill for their services
- Your provider can use and share their health information to bill and get payment from health plans or other entities.
- Example: Your provider give information about you to your health insurance plan so it will pay for their services.
How else can your provider use or share their health information?
- Your provider is are allowed or required to share your information in other ways – usually in ways that contribute to the public good, such as public health and research. Your provider has to meet many conditions in the law before your provider can share their information for these purposes. For more information see: www.hhs.gov/ocr/privacy/hipaa/understanding/consumers/index.html.
Help with public health and safety issues
- Your provider can share health information about you for certain situations such as:
- Preventing disease
- Helping with product recalls
- Reporting adverse reactions to medications
- Reporting suspected abuse, neglect, or domestic violence
- Preventing or reducing a serious threat to anyone’s health or safety
- Your provider can use or share their information for health research.
Comply with the law
- Your provider will share information about you if state or federal laws require it, including with the Department of Health and Human Services if it wants to see that your complying with federal privacy law.
Respond to organ and tissue donation requests
- Your provider can share health information about you with organ procurement organizations.
Work with a medical examiner or funeral director
- Your provider can share health information with a coroner, medical examiner, or funeral director when an individual dies
- Workers’ compensation, law enforcement, and other government requests
Your provider can use or share health information about you:
- For workers’ compensation claims
- For law enforcement purposes or with a law enforcement official
- With health oversight agencies for activities authorized by law
- For special government functions such as military, national security, and presidential protective services
Respond to lawsuits and legal actions
- Your provider can share health information about you in response to a court or administrative order, or in response to a subpoena.
- Providers are required by law to maintain the privacy and security of their protected health information.
- Providers should let you know promptly if a breach occurs that may have compromised the privacy or security of their information.
- Provider should follow the duties and privacy practices described in this notice and give you a copy of it.
- Providers should not use or share their information other than as described here unless you tell your provider they can in writing. If you tell your provider they can, you may change their mind at any time. Let your provider know in writing if you change their mind.
For more information see:
Changes to the Terms of this Notice
- Your provider can change the terms of this notice, and the changes will apply to all information your provider have about you. The new notice will be available upon request, in their office, and on their web site.