Terms & Policies

Notice of Privacy Practices 

THIS NOTICE DESCRIBES HOW HEALTH INFORMATION MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY.

MY PLEDGE REGARDING HEALTH INFORMATION

I understand that health information about you and your health care is personal. I am committed to protecting health information about you. I create a record of the care and services you receive from me. I need this record to provide you with quality care and to comply with certain legal requirements. This notice applies to all of the records of your care generated by this mental health care practice. This notice will tell you about the ways in which I may use and disclose health information about you. I also describe your rights to the health information I keep about you and describe certain obligations I have regarding the use and disclosure of your health information. I am required by law to:

• Make sure that protected health information (“PHI”) that identifies you is kept private.

• Give you this notice of my legal duties and privacy practices with respect to health information.

• Follow the terms of the notice that is currently in effect.

• I can change the terms of this Notice, and such changes will apply to all information I have about you. The new Notice will be available upon request, in my office, and on my website.

II. HOW I MAY USE AND DISCLOSE HEALTH INFORMATION ABOUT YOU

The following categories describe different ways that I use and disclose health information. For each category of uses or disclosures I will explain what I mean and try to give some examples. Not every use or disclosure in a category will be listed. However, all of the ways I am permitted to use and disclose information will fall within one of the categories.

For Treatment Payment, or Health Care Operations: Federal privacy rules (regulations) allow health care providers who have direct treatment relationship with the patient/client to use or disclose the patient/client’s personal health information without the patient’s written authorization, to carry out the health care provider’s own treatment, payment or health care operations. I may also disclose your protected health information for the treatment activities of any health care provider. This too can be done without your written authorization. For example, if a clinician were to consult with another licensed health care provider about your condition, we would be permitted to use and disclose your person health information, which is otherwise confidential, in order to assist the clinician in diagnosis and treatment of your mental health condition.

Disclosures for treatment purposes are not limited to the minimum necessary standard. Because therapists and other health care providers need access to the full record and/or full and complete information in order to provide quality care. The word “treatment” includes, among other things, the coordination and management of health care providers with a third party, consultations between health care providers and referrals of a patient for health care from one health care provider to another.

Lawsuits and Disputes: If you are involved in a lawsuit, I may disclose health information in response to a court or administrative order. I may also disclose health information about your child in response to a subpoena, discovery request, or other lawful process by someone else involved in the dispute, but only if efforts have been made to tell you about the request or to obtain an order protecting the information requested.

III. CERTAIN USES AND DISCLOSURES REQUIRE YOUR AUTHORIZATION

1. Psychotherapy Notes. I do keep “psychotherapy notes” as that term is defined in 45 CFR § 164.501, and any use or disclosure of such notes requires your Authorization unless the use or disclosure is: a. For my use in treating you. b. For my use in training or supervising mental health practitioners to help them improve their skills in group, joint, family, or individual counseling or therapy. c. For my use in defending myself in legal proceedings instituted by you. d. For use by the Secretary of Health and Human Services to investigate my compliance with HIPAA. e. Required by law and the use or disclosure is limited to the requirements of such law. f. Required by law for certain health oversight activities pertaining to the originator of the psychotherapy notes. g. Required by a coroner who is performing duties authorized by law. h. Required to help avert a serious threat to the health and safety of others.

2. Marketing Purposes. As a psychotherapist, I will not use or disclose your PHI for marketing purposes.

3. Sale of PHI. As a psychotherapist, I will not sell your PHI in the regular course of my business.

IV. CERTAIN USES AND DISCLOSURES DO NOT REQUIRE YOUR AUTHORIZATION

 Subject to certain limitations in the law, I can use and disclose your PHI without your Authorization for the following reasons:

1. When disclosure is required by state or federal law, and the use or disclosure complies with and is limited to the relevant requirements of such law.

2. For public health activities, including reporting suspected child, elder, or dependent adult abuse, or preventing or reducing a serious threat to anyone’s health or safety.

3. For health oversight activities, including audits and investigations.

4. For judicial and administrative proceedings, including responding to a court or administrative order, although my preference is to obtain an Authorization from you before doing so.

5. For law enforcement purposes, including reporting crimes occurring on my premises.

6. To coroners or medical examiners, when such individuals are performing duties authorized by law.

7. For research purposes, including studying and comparing the mental health of patients who received one form of therapy versus those who received another form of therapy for the same condition.

8. Specialized government functions, including, ensuring the proper execution of military missions; protecting the President of the United States; conducting intelligence or counter-intelligence operations; or, helping to ensure the safety of those working within or housed in correctional institutions.

9. For workers’ compensation purposes. Although my preference is to obtain an Authorization from you, I may provide your PHI in order to comply with workers’ compensation laws.

10. Appointment reminders and health related benefits or services. I may use and disclose your PHI to contact you to remind you that you have an appointment with me. I may also use and disclose your PHI to tell you about treatment alternatives, or other health care services or benefits that I offer.

V. CERTAIN USES AND DISCLOSURES REQUIRE YOU TO HAVE THE OPPORTUNITY TO OBJECT

Disclosures to family, friends, or others. I may provide your PHI to a family member, friend, or other person that you indicate is involved in your care or the payment for your health care, unless you object in whole or in part. The opportunity to consent may be obtained retroactively in emergency situations.

VI. YOU HAVE THE FOLLOWING RIGHTS WITH RESPECT TO YOUR PHI:

1. The Right to Request Limits on Uses and Disclosures of Your PHI. You have the right to ask me not to use or disclose certain PHI for treatment, payment, or health care operations purposes. I am not required to agree to your request, and I may say “no” if I believe it would affect your health care.

2. The Right to Request Restrictions for Out-of-Pocket Expenses Paid for In Full. You have the right to request restrictions on disclosures of your PHI to health plans for payment or health care operations purposes if the PHI pertains solely to a health care item or a health care service that you have paid for out-of-pocket in full.

3. The Right to Choose How I Send PHI to You. You have the right to ask me to contact you in a specific way (for example, home or office phone) or to send mail to a different address, and I will agree to all reasonable requests.

4. The Right to See and Get Copies of Your PHI. Other than “psychotherapy notes,” you have the right to get an electronic or paper copy of your medical record and other information that I have about you. I will provide you with a copy of your record, or a summary of it, if you agree to receive a summary, within 30 days of receiving your written request, and I may charge a reasonable, cost based fee for doing so.

5. The Right to Get a List of the Disclosures I Have Made. You have the right to request a list of instances in which I have disclosed your PHI for purposes other than treatment, payment, or health care operations, or for which you provided me with an Authorization. I will respond to your request for an accounting of disclosures within 60 days of receiving your request. The list I will give you will include disclosures made in the last six years unless you request a shorter time. I will provide the list to you at no charge, but if you make more than one request in the same year, I will charge you a reasonable cost-based fee for each additional request.

6. The Right to Correct or Update Your PHI. If you believe that there is a mistake in your PHI, or that a piece of important information is missing from your PHI, you have the right to request that I correct the existing information or add the missing information. I may say “no” to your request, but I will tell you why in writing within 60 days of receiving your request.

7. The Right to Get a Paper or Electronic Copy of this Notice. You have the right get a paper copy of this Notice, and you have the right to get a copy of this notice by e-mail. And, even if you have agreed to receive this Notice via e-mail, you also have the right to request a paper copy of it. 

EFFECTIVE DATE OF THIS NOTICE

This notice went into effect on 01/01/2019

Acknowledgement of Receipt of Privacy Notice

Under the Health Insurance Portability and Accountability Act of 1996 (HIPAA), you have certain rights regarding the use and disclosure of your protected health information. By checking the box below, you are acknowledging that you have received a copy of HIPAA Notice of Privacy Practices.

Informed Consent for Psychotherapy

GENERAL INFORMATION

The therapeutic relationship is unique in that it is a highly personal and at the same time, a contractual agreement. Given this, it is important for us to reach a clear understanding about how our relationship will work, and what each of us can expect. This consent will provide a clear framework for our work together. Feel free to discuss any of this with me.

For Personalized Solutions LLC to consider providing services to you or your child, you must read and sign this consent form. You may withdraw this consent to treatment at any time and ask that your file be closed. You should also know that this is not an agreement by Personalized Solutions LLC to provide services to you. You may wish to talk with your provider about your consent to treatment during your intake session. They will answer your questions.

UNDERSTANDING PSYCHOTHERAPY AND/OR OTHER SERVICES PERSONALIZED SOLUTIONS LLC PROVIDES

Psychotherapy services and other services Personalized Solutions LLC provides are designed to help you change. Sometimes this kind of change is difficult because it raises feelings, thoughts, and worries that you try to keep inside. The benefits may include improved behavior, relationships, and mood. You may learn to communicate better with those around you. You should know that this is not a precise science. In many cases we are successful in helping people to change. In some cases, we are not. Personalized Solutions LLC cannot guarantee the success of any treatment.

THE THERAPEUTIC PROCESS

You have taken a very positive step by deciding to seek therapy. The outcome of your treatment depends largely on your willingness to engage in this process, which may, at times, result in considerable discomfort. Remembering unpleasant events and becoming aware of feelings attached to those events can bring on strong feelings of anger, depression, anxiety, etc. There are no miracle cures. I cannot promise that your behavior or circumstance will change. I can promise to support you and do my very best to understand you and repeating patterns, as well as to help you clarify what it is that you want for yourself.

GRIEVANCE PROCEDURE

At times clients in psychotherapy may find themselves in conflict with their therapist about some aspect of treatment. This may come from a misunderstanding between client and therapist, or a genuine disagreement in how treatment should proceed. We attempt to resolve any conflicts in a manner that is suitable to our clients, while maintaining important treatment standards. If you reach a point of conflict in your treatment, you should first attempt resolution with your therapist. If this does not solve the conflict, we may suggest seeking services elsewhere. You may also contact your insurance provider.

SECOND OPINIONS AND SERVICE REFERRAL

Clients are entitled to a second opinion. A second opinion may be helpful when you do not agree with a Personalized Solutions LLC diagnosis or treatment finding. Personalized Solutions LLC does not usually make specific recommendations about where or when to seek a second opinion. At times however, Personalized Solutions LLC may find that we do not have adequate training, experience, or services to properly address your needs. In this case we may recommend other resources that are more suitable. This is especially true for adults, who may require services that we do not offer or that we cannot easily access. Client’s may contact MCO for referrals.

CONFIDENTIALITY

All services provided are strictly confidential. We cannot release any information about your case to anyone outside Personalized Solutions LLC without your written consent.  See Notice of Privacy Practices for Protected Health Information.

Occasionally I may need to consult with other professionals in their areas of expertise in order to provide the best treatment for you. Information about you may be shared in this context without using your name.

If we see each other accidentally outside of the therapy office, I will not acknowledge you first. Your right to privacy and confidentiality is of the utmost importance to me, and I do not wish to jeopardize your privacy. However, if you acknowledge me first, I will be more than happy to speak briefly with you but feel it appropriate not to engage in any lengthy discussions in public or outside of the therapy office.

BREAKING CONFIDENTIALITY

There Are Exceptions to Confidentiality. Below Are Reasons This May Occur:

1.    Duty to Warn and Protect.  When a client discloses intentions or a plan to harm another person, the mental health professional is required to warn the intended victim and report this information to legal authorities. In cases in which the client discloses or implies a plan for suicide, the health care professional is required to notify legal authorities and make reasonable attempts to notify the family of the client.

2.    Abuse of Children and Vulnerable Adults. If a client states or suggests that he or she is abusing a child (or vulnerable adult) or has recently abused a child (or vulnerable adult), or a child (or vulnerable adult) is in danger of abuse, the mental health professional is required to report this information to the appropriate social service and/or legal authorities.

3.    Prenatal Exposure to Controlled Substances. Mental Health care professionals are required to report admitted prenatal exposure to controlled substances that are potentially harmful.

4.    Minors/Guardianship. Parents or legal guardians of non-emancipated minor clients have the right to access the clients’ records.

5.    Insurance Providers AND Billing Providers: Insurance companies and other third-party payers are given information that they request regarding services to clients. Information that may be requested includes, but is not limited to: types of service, dates/times of service, diagnosis, treatment plan, and description of impairment, progress of therapy, case notes, and summaries.

6.    Court of law subpoenas (demands to see) the records. If this happens, we will attempt to invoke privileged communication (a legal protection of your right to therapeutic confidentiality) if you or your attorney asks us to do so. However, under some circumstances, the court can override privileged communication and order us to disclose these records. Personalized Solutions LLC reserves the right to contact the police anytime danger of self or others is of concern.

CRISIS INTERVENTION 

As a therapy practice, Personalized Solutions LLC specializes in working with children, teenagers, families, adults, and couples. If you expect to need crisis intervention – or have used psychiatric crisis intervention in previous therapies – you need to be aware that Personalized Solutions LLC is limited to meet your needs. Please talk with your therapist about what is available for adult crisis management and community alternatives. After-hour emergency should be report to your local Mental Health Center, hospital, and/or call 911.

WORKING WITH YOUR PHYSICIAN:

It is often in your clinical best interest for Personalized Solutions LLC to work with your physician. This is especially true when you are being seen for medication. By signing this document, you are agreeing to have us contact your physician as necessary to coordinate treatment.

OBLIGATION 

By signing this document, you are agreeing to pay for the services you receive at Personalized Solutions LLC. Please read each of the following paragraphs to assure your understanding of our billing procedure and ask your therapist if you have any questions about these procedures.

EVERYONE MUST READ

Self-Pay: I am paying all fees in full by cash, credit card, or money order.  See Payment form for specific pricing. 

OR 

Insurance:I have provided Personalized Solutions with my insurance card / information that I intend to use for payment of services. Your insurance provider may not be accepted by Personalized Solutions LLC and MUST BE REVIEWED before services are provided.

I understand that all missed appointments and late cancellations incur a charge 100% your agreed session/program amount. A missed appointment is any appointment not cancelled. A late cancel is any appointment not cancelled with 24 hour’s notice. Fees for missed or late-cancelled appointments due to legitimate emergencies may be waived. Personalized Solutions LLC may offer reminders to clients, but failure to send a reminder does not release me from paying a no-show fee. No showing or late canceling two appointments may result in losing regular therapy appointment time and/or may be put on a call list. Termination of services may occur if 3 or more missed appointments occur.

I understand that I must pay all costs. If I am over the age of 18 and have a parent or other party (guarantor) paying my bill, I understand that I remain primarily responsible. This means that if that person does not pay outstanding charges, I remain liable for them. I also understand that if my check is returned, fees up to 25% of the face value of the check will be added to any delinquent account placed for collection.

Practice Policies 

RECORDING

Under no circumstances will any party record a session without prior written authorization or consent. If recording is requested by the Consumer both the Therapist and Executive Director will be required to sign off on the request.  Prior written authorization must be requested in writing 48 hours in advance for each occurrence.  Any breach of this agreement is subject to immediate disruption of services and the full fee will be charged for the session.  I further agree that any recording taken without the provider's express written consent is not able to be used in any litigious manner.

APPOINTMENTS AND CANCELLATIONS

Please remember to cancel or reschedule 24 hours in advance. You will be responsible for the entire fee if cancellation is less than 24 hours.  This is considered same-day cancellation. This is necessary because a time commitment is made to you and is held exclusively for you. If you are late for a session, you may lose some of that session time. If three consecutive same-day cancellations occur, you will be placed on a same-day schedule policy.  When three consecutive same-day appointments have been kept we will allow you to schedule appointments ahead of time.  This policy is at the sole-discretion of the therapist and Personalized Solutions LLC. 

The standard meeting time for psychotherapy is 55 minutes. It is up to you, however, to determine the length of time of your sessions. Requests to change the 55-minute session needs to be discussed with the therapist in order for time to be scheduled in advance.

PAYMENT

Payment is due at time of service.  If you are utilizing insurance or an Employee Assistance Program, please review with therapist before session.  Cash or Credit / Debit Cards are acceptable.  Credit/Debit Card processing incurs and additional 4% fee with a minimum service charge of $5.00, whichever is greater.  Checks are generally not accepted unless a special circumstance applies, and you have received prior approval from the Therapist or Personalized Solutions LLC business office.  A $30.00 service charge will be charged for any checks returned for any reason for special handling.

TELEPHONE ACCESSIBILITY

If you need to contact me between sessions, please leave a message on my voice mail. I am often not immediately available; however, I will attempt to return your call within 24 hours. Please note that Face- to-face sessions are highly preferable to phone sessions. However, in the event that you are out of town, sick or need additional support, phone sessions are available. If a true emergency situation arises, please call 911 or any local emergency room.

SOCIAL MEDIA AND TELECOMMUNICATION

Due to the importance of your confidentiality and the importance of minimizing dual relationships, I do not accept friend or contact requests from current or former clients on any social networking site (Facebook, LinkedIn, etc.). I believe that adding clients as friends or contacts on these sites can compromise your confidentiality and our respective privacy. It may also blur the boundaries of our therapeutic relationship. If you have questions about this, please bring them up when we meet, and we can talk more about it.

ELECTRONIC COMMUNICATION

I cannot ensure the confidentiality of any form of communication through electronic media, including text messages. If you prefer to communicate via email or text messaging for issues regarding scheduling or cancellations, I will do so. While I may try to return messages in a timely manner, I cannot guarantee immediate response and request that you do not use these methods of communication to discuss therapeutic content and/or request assistance for emergencies.

Effective therapy is often facilitated when the therapist gathers within a session or a series of sessions, a multitude of observations, information, and experiences about the client. Therapists may make clinical assessments, diagnosis, and interventions based not only on direct verbal or auditory communications, written reports, and third person consultations, but also from direct visual and olfactory observations, information, and experiences. When using information technology in therapy services, potential risks include, but are not limited to the therapist's inability to make visual and olfactory observations of clinically or therapeutically potentially relevant issues such as: your physical condition including deformities, apparent height and weight, body type, attractiveness relative to social and cultural norms or standards, gait and motor coordination, posture, work speed, any noteworthy mannerism or gestures, physical or medical conditions including bruises or injuries, basic grooming and hygiene including appropriateness of dress, eye contact (including any changes in the previously listed issues), sex, chronological and apparent age, ethnicity, facial and body language, and congruence of language and facial or bodily expression. Potential consequences thus include the therapist not being aware of what he or she would consider important information, that you may not recognize as significant to present verbally the therapist.

Email Contact. At your discretion you may contact your therapist via email for the same purpose you would initiate phone contact. However, for therapy you are advised against using unsolicited fax transmissions as they are not monitored as closely. Personalized Solutions LLC considers all contact to be therapeutic and will bill it as such. Informal contact such as email or text messaging is considered administrative and supportive contact. By initiating email contact, you are accepting this understanding and agreeing to act accordingly. You are advised that email communication is protected by federal law but should not be considered secure. It is possible that someone on the Internet might read your communication or our communication back to you. By initiating this sort of contact you are waiving this level of confidentiality unless you specify in your email a limitation of the expected response (e.g., “please don’t reply”). If you are especially concerned about this issue, please discuss it with your therapist at intake.

Text Messaging. Some therapists have found that text messaging can be a very helpful tool in keeping in touch. Please provide your text information OR advise your therapist if you DO NOT want to be contacted by text messaging. 

MINORS

If you are a minor, your parents may be legally entitled to some information about your therapy. I will discuss with you and your parents what information is appropriate for them to receive and which issues are more appropriately kept confidential.

PARENTING PROGRAM

The Parenting Program of Personalized Solutions LLC is an evidenced informed program that also is tailored to be specific to each case we serve.  By participating in Personalized Solutions LLCs parenting education program you understand that it is an evaluation/teaching process.  By signing this document, you understand that Personalized Solutions LLC will not fully have their completed evaluation until your treatment plan discussed between you and your therapist has been completed. Your full participation and consistency with appointments is needed in order to obtain an appropriate evaluation for your therapist to make their final recommendations on your completion in the program.  The outcome of the program may or may not be successful.  You agree to not take legal action against Personalized Solutions LLC if you do not agree with the final recommendations of their evaluation. Payment for said Program is required in full at the beginning and a refund is not provided if you fail to participate in the program or the recommendations in the final report are not to your satisfaction.  At any time in the program you are encouraged to discuss with your therapist if you have questions or concerns about how your treatment plan is progressing.

TERMINATION

Ending relationships can be difficult. Therefore, it is important to have a termination process in order to achieve some closure. The appropriate length of the termination depends on the length and intensity of the treatment. I may terminate treatment after appropriate discussion with you and a termination process if I determine that the psychotherapy is not being effectively used or if you are in default on payment. I will not terminate the therapeutic relationship without first discussing and exploring the reasons and purpose of terminating. If therapy is terminated for any reason or you request another therapist, I will provide you with a list of qualified psychotherapists to treat you. You may also choose someone on your own or from another referral source.

Should you fail to schedule an appointment for three consecutive weeks, unless other arrangements have been made in advance, for legal and ethical reasons, I must consider the professional relationship discontinued.