Health Insurance Portability and Accountability Act (HIPAA)

NOTICE OF PRIVACY PRACTICES

I. COMMITMENT TO YOUR PRIVACY:   Life Performance Counseling, PLLC is dedicated to maintaining the privacy of your protected health information (PHI).  PHI is information that may identify you and that relates to your past, present or future physical or mental health condition and related health care services either in paper or electronic format. This Notice of Privacy Practices ("Notice") is required by law to provide you with the legal duties and the privacy practices that Katie Steinert maintains concerning your PHI.  It also describes how medical and mental health information may be used and disclosed, as well as your rights regarding your PHI.  Please read carefully and discuss any questions or concerns with your therapist.

II. LEGAL DUTY TO SAFEGUARD YOUR PHI: By federal and state law, Katie Steinert is required to ensure that your PHI is kept private.  This Notice explains when, why, and how Katie Steinert would use and/or disclose your PHI. Use of PHI means when Katie Steinert shares, applies, utilizes, examines, or analyzes information within its practice; PHI is disclosed when Katie Steinert releases, transfers, gives, or otherwise reveals it to a third party outside of the Katie Steinert. With some exceptions, Katie Steinert may not use or disclose more of your PHI than is necessary to accomplish the purpose for which the use or disclosure is made; however, Katie Steinert is always legally required to follow the privacy practices described in this Notice.

III.  CHANGES TO THIS NOTICE:    The terms of this notice apply to all records containing your PHI that are created or retained by Katie Steinert.  Please note that Katie Steinert reserves the right to revise or amend this Notice of Privacy Practices.  Any revision or amendment will be effective for all of your records that Katie Steinert has created or maintained in the past and for any of your records that Katie Steinert may create or maintain in the future.  Katie Steinert will have a copy of the current Notice in the office in a visible location at all times, and you may request a copy of the most current Notice at any time.  The date of the latest revision will always be listed at the end of Katie Steinert's Notice of Privacy Practices.

IV. HOW YOUR NAME MAY USE AND DISCLOSE YOUR PHI:  Katie Steinert will not use or disclose your PHI without your written  authorization, except as described in this Notice or as described in the  "Information, Authorization and Consent to Treatment" document.  Below you will find the different categories of possible uses and disclosures with some examples.

1. For Treatment: Katie Steinert may disclose your PHI to physicians, psychiatrists, psychologists, and other licensed health care providers who provide you with health care services or are; otherwise involved in your care. Example: If you are also seeing a psychiatrist for medication management, Katie Steinert may disclose your PHI to her/him in order to coordinate your care.   Except for in an emergency, Katie Steinert will always ask for your authorization in writing prior to any such consultation.

2. For Health Care Operations: Katie Steinert may disclose your PHI to facilitate the efficient and correct operation of its practice, improve your care, and contact you when necessary. Example:  We use health information about you to manage your treatment and services.

3. To Obtain Payment for Treatment: Katie Steinert may use and disclose your PHI to bill and collect payment for the treatment and services Katie Steinert provided to you. Example: Katie Steinert might send your PHI to your insurance company or managed health care plan in order to get payment for the health care services that have been provided to you. Katie Steinert could also provide your PHI to billing companies, claims processing companies, and others that process health care claims for Katie Steinert's office if either you or your insurance carrier are not able to stay current with your account.  In this latter instance, Katie Steinert will always do its best to reconcile this with you first prior to involving any outside agency.

4. Employees and Business Associates:  There may be instances where services are provided to Katie Steinert by an employee or through contracts with third-party "business associates."  Whenever an employee or business associate arrangement involves the use or disclosure of your PHI, Katie Steinert will have a written contract that requires the employee or business ​​associate to maintain the same high standards of safeguarding your privacy that is required of Katie Steinert. 

Note:  This state and Federal law provides additional protection for certain types of health information, including alcohol or drug abuse, mental health and AIDS/HIV, and may limit whether and how Katie Steinert may disclose information about you to others.

V. USE AND DISCLOSURE OF YOUR PHI IN CERTAIN SPECIAL CIRCUMSTANCES - YOUR NAME may use and/or disclose your PHI without your consent or authorization for the following reasons:

1. Law Enforcement: Subject to certain conditions, Katie Steinert may disclose your PHI when required by federal, state, or local law; judicial, board, or administrative proceedings; or, law enforcement. Example: Katie Steinert may make a disclosure to the appropriate officials when a law requires Katie Steinert to report information to government agencies, law enforcement personnel and/or in an administrative proceeding.   

2. Lawsuits and Disputes:  Katie Steinert may disclose information about you to respond to a court or administrative order or a search warrant.   Katie Steinert may also disclose information if an arbitrator or arbitration panel compels disclosure, when arbitration is lawfully requested by either party, pursuant to subpoena duces tectum (e.g., a subpoena for mental health records) or any other provision authorizing disclosure in a proceeding before an arbitrator or arbitration panel.  Katie Steinert will only do this if efforts have been made to tell you about the request and you have been provided an opportunity to object or to obtain an appropriate court order protecting the information requested.

3. Public Health Risks:  Katie Steinert may disclose your PHI to public health or legal authorities charged with preventing or controlling disease, injury, disability, to report births and deaths, and to notify persons who may have been exposed to a disease or at risk for getting or spreading a disease or condition.

4. Food and Drug Administration (FDA):  Katie Steinert may disclose to the FDA, or persons under the jurisdiction of the FDA, PHI relative to adverse events with respect to drugs, foods, supplements, products and product defects, or post marketing surveillance information to enable product recalls, repairs, or replacement.

5. Serious Threat to Health or Safety: Katie Steinert may disclose your PHI if you are in such mental or emotional condition as to be dangerous to yourself or the person or property of others, and if Katie Steinert determines in good faith that disclosure is necessary to prevent the threatened danger.  Under these circumstances, Katie Steinert may provide PHI to law enforcement personnel or other persons able to prevent or mitigate such a serious threat to the health or safety of a person or the public. 

6. Minors:  If you are a minor (under 18 years of age), Katie Steinert may be compelled to release certain types of information to your parents or guardian in accordance with applicable law.

7. Abuse and Neglect:  Katie Steinert may disclose PHI if mandated by Colorado child, elder, or dependent adult abuse and neglect reporting laws. Example: If Katie Steinert has a reasonable suspicion of child abuse or neglect, Katie Steinert will report this to the Colorado Department of Human Services.

8. Coroners, Medical Examiners, and Funeral Directors: Katie Steinert may release PHI about you to a coroner or medical examiner.  This may be necessary, for example, to identify a deceased person, determine the cause of death or other duties as authorized by law.  Katie Steinert may also disclose PHI to funeral directors, consistent with applicable law, to carry out their duties. 

9. Communications with Family, Friends, or Others:  Katie Steinert may release your PHI to the person you named in your Durable Power of Attorney for Health Care (if you have one), to a friend or family member who is your personal representative (i.e., empowered under state or other law to make health-related decisions for you), or any other person you identify, relevant to that person's involvement in your care or payment related to your care.  In addition, Katie Steinert may disclose your PHI to an entity assisting in disaster relief efforts so that your family can be notified about your condition.

10.  Military and Veterans:  If you are a member of the armed forces, Katie Steinert may release PHI about you as required by military command authorities.  Katie Steinert may also release PHI about foreign military personnel to the appropriate military authority.

11.  National  Security, Protective Services for the President, and Intelligence Activities: Katie Steinert may release PHI about you to authorized federal officials so they may provide protection to the President, other authorized persons, or foreign heads of state, to conduct special investigations for intelligence, counterintelligence, and other national activities authorized by law.

12.  Correctional Institutions:  If you are or become an inmate of a correctional institution, Katie Steinert may disclose PHI to the institution or its agents when necessary for your health or the health and safety of others

13.  For Research Purposes: In certain limited circumstances, Katie Steinert may use information you have provided for medical/psychological research, but only with your written authorization.  The only circumstance where written authorization would not be required would be if the information you have provided could be completely disguised in such a manner that you could not be identified, directly or through any identifiers linked to you.  The research would also need to be approved by an institutional review board that has examined the research proposal and ascertained that the established protocols have been met to ensure the privacy of your information.

14.  For Workers' Compensation Purposes: Katie Steinert may provide PHI in order to comply with Workers' Compensation or similar programs established by law.

15.  Appointment Reminders: Katie Steinert is permitted to contact you, without your prior authorization, to provide appointment reminders or information about alternative or other health-related benefits and services that you may need or that may be of interest to you. 

16.  Health Oversight Activities: Katie Steinert may disclose health information to a health oversight agency for activities such as audits, investigations, inspections, or licensure of facilities. These activities are necessary for the government to monitor the health care system, government programs and compliance with laws.  Example: When compelled by U.S. Secretary of Health and Human Services to investigate or assess Katie Steinert's compliance with HIPAA regulations.

17.  If Disclosure is Otherwise Specifically Required by Law.

18.  In the Following Cases, Katie Steinert Will Never Share Your Information Unless You Give us Written Permission: Marketing purposes, sale of your information, most sharing of psychotherapy notes, and fundraising. If we contact you for fundraising efforts, you can tell us not to contact you again.

VI. Other Uses and Disclosures Require Your Prior Written Authorization:   In any other situation not covered by this notice, Katie Steinert will ask for your written authorization before using or disclosing medical information about you.  If you chose to authorize use or disclosure, you can later revoke that authorization by notifying Katie Steinert in writing of your decision.  You understand that Katie Steinert is unable to take back any disclosures it has already made with your permission, Katie Steinert  will continue to comply with laws that require certain disclosures, and Katie Steinert  is required to retain records of the care that its therapists have provided to you.

VII. RIGHTS YOU HAVE REGARDING YOUR PHI:

1. The Right to See and Get Copies of Your PHI either in paper or electronic format:  In general, you have the right to see your PHI that is in Katie Steinert's possession, or to get copies of it; however, you must request it in writing. If Katie Steinert does not have your PHI, but knows who does, you will be advised how you can get it. You will receive a response from Katie Steinert within 30 days of receiving your written request. Under certain circumstances, Katie Steinert  may feel it must deny your request, but if it does, Katie Steinert will give you, in writing, the reasons for the denial.  Katie Steinert  will also explain your right to have its denial reviewed.  If you ask for copies of your PHI, you will be charged a reasonable fee per page and the fees associated with supplies and postage. Katie Steinert may see fit to provide you with a summary or explanation of the PHI, but only if you agree to it, as well as to the cost, in advance.

2. The Right to Request Limits on Uses and Disclosures of Your PHI: You have the right to ask that Katie Steinert limit how it uses and discloses your PHI. While Katie Steinert will consider your request, it is not legally bound to agree. If Katie Steinert does agree to your request, it will put those limits in writing and abide by them except in emergency situations. If you pay for a service or health care item out-of-pocket in full, you can ask us not to share that information for the purpose of payment or our operations with your health insurer. You do not have the right to limit the uses and disclosures that Katie Steinert is legally required or permitted to make.

3. The Right to Choose How Katie Steinert Sends Your PHI to You: It is your right to ask that your PHI be sent to you at an alternate address (for example, sending information to your work address rather than your home address) or by an alternate method (for example, via email instead of by regular mail). Katie Steinert is obliged to agree to your request providing that it can give you the PHI, in the format you requested, without undue inconvenience.

4. The Right to Get a List of the Disclosures.  You are entitled to a list of disclosures of your PHI that Katie Steinert has made. The list will not include uses or disclosures to which you have specifically authorized (i.e., those for treatment, payment, or health care operations, sent directly to you, or to your family; neither will the list include disclosures made for national security purposes, or to corrections or law enforcement personnel.  The request must be in writing and state the time period desired for the accounting, which must be less than a 6-year period and starting after April 14, 2003. 

  Katie Steinert will respond to your request for an accounting of disclosures within 60 days of receiving your request. The list will include the date of the disclosure, the recipient of the disclosure (including address, if known), a description of the information disclosed, and the reason for the disclosure. Katie Steinert will provide the list to you at no cost, unless you make more than one request in the same year, in which case it will charge you a reasonable sum based on a set fee for each additional request.

5. The Right to 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 your rights and make choices about your health information.  We will make sure the person has this authority and can act for you before we take any action.

6. The Right to Amend Your PHI: If you believe that there is some error in your PHI or that important information has been omitted, it is your right to request that Katie Steinert correct the existing information or add the missing information. Your request and the reason for the request must be made in writing. You will receive a response within 60 days of Katie Steinert's receipt of your request. Katie Steinert may deny your request, in writing, if it  finds that the PHI is: (a) correct and complete, (b) forbidden to be disclosed, (c) not part of its records, or (d) written by someone other than Katie Steinert. Denial must be in writing and must state the reasons for the denial. It must also explain your right to file a written statement objecting to the denial. If you do not file a written objection, you still have the right to ask that your request and Katie Steinert's denial will be attached to any future disclosures of your PHI. If Katie Steinert approves your request, it will make the change(s) to your PHI. Additionally, Katie Steinert will tell you that the changes have been made and will advise all others who need to know about the change(s) to your PHI.

6. The Right to Get This Notice by Email: You have the right to get this notice by email. You have the right to request a paper copy of it as well.

VIII. COMPLAINTS:  If you are concerned your privacy rights may have been violated, or if you object to a decision Katie Steinert made about access to your PHI, you are entitled to file a complaint.  You may also send a written complaint to the Secretary of the Department of Health and Human Services Office of Civil Rights.  Katie Steinert will provide you with the address. Under no circumstances will you be penalized or retaliated against for filing a complaint.

Please discuss any questions or concerns with your therapist.  Your signature on the "Information, Authorization, and Consent to Treatment" (provided to you separately) indicates that you have read and understood this document.

IX. Katie Steinert's Responsibilities: We are required by law to maintain the privacy and security of your PHI. We will let you know promptly if a breach occurs that may have compromised the privacy or security of your information. We must follow the duties and privacy practices described in this notice and give you a copy of it. We will not use or share your information other than as described here unless you tell us we can in writing.  If you tell us we can, you may change your mind at any time. Let us know in writing if you change your mind. 

Date of Last Revision: 11/14/2021

Successful therapy depends on building a relationship of trust, good faith, and openness between client(s) and therapist(s).  Often, audio or video recording can inhibit candor and introspection in therapy.  Covert recording is a direct violation of trust and good faith to all the other persons in the room.  

In addition, recordings made and taken home by clients sometimes fall into unintended hands through loss, random or targeted theft, or action by police, court or governmental agency. Such loss could compromise or nullify your legal expectation of confidentiality in the extremely sensitive personal or interpersonal matters that may have been discussed.  Courts may not give your own recordings all the legal confidentiality they give to a therapist's office notes and may find them self serving. Client recordings can more easily end up becoming an issue in conflicts such as divorce, child custody, or other legal cases or be used by agencies of government.  A client who makes a recording solely for personal use or to use against a partner may later be surprised to find the recording being used against him- or herself instead.  And once an unfavorable recording exists, its deletion can become legally punishable if a subpoena is issued for it.  Additionally, most users of recording technology lack the technological tools and knowledge required to delete a recording in a way that makes it unrecoverable and un-hackable.

Factors like these undermine the therapeutic process and the building or rebuilding of trust that takes place between partners in session and between the client(s) and therapist(s).

For these reasons and others like them, Life Performance Counseling, PLLC maintains a strict policy on recording.

Therefore, the client signing below agrees that:

1. Recording may only take place with the knowledge and explicit consent of ALL (not just one) clients, therapists, and other persons present during a session or other interaction, whether face-to-face or taking place by live textual, audio, or video link.

2. Consent for each recording must take the form of dated written signatures from all persons on a paper form available for that purpose, with a copy to each person recorded.  Additionally the recording itself must include the live consent of all persons present, with such consent stated at the start of the recording or when they join a session or interaction already in progress.

Life Performance Counseling, PLLC will only consent to recording of a session for exceptional reasons and only after the drawbacks and risks have been discussed and the benefit clearly outweighs them.  Violation of this policy by covert recording or non-conformance with this agreement will lead to termination of therapy.

I acknowledge that I have read and understood this policy, accept it, and pledge to uphold it.

INFORMATION, AUTHORIZATION, & CONSENT TO TREATMENT

I am 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 you 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 as a therapist is an ethical requirement of my profession.  If you have any questions, please feel free to ask.

I received my bachelors degree from the University of Montevallo in 2015 and my masters degree in 2017 from the University of Denver. I have been practicing psychotherapy since 2016 in a variety of settings including residential, partial hospitalization, and outpatient treatment. I am licensed in the states of Colorado (LPC.0015909), Oregon (C6383), and Alabama (LPC05382) as a Licensed Professional Counselor and I hold a South Carolina Professional Counselor Telehealth Provider license (733). 

Theoretical Views & Client Participation:

I believe that our environment, our physical health, and our mental health are intimately linked. Because of this belief, I take a whole person approach to counseling where we will address multiple aspects of your health and functioning in order to improve your mental health. I am also person-centered and practical in my approach, meaning that you determine the direction that you want to go in therapy and I work with you to find pragmatic, workable strategies to help get you there. Another important part of my approach is helping you to broaden your awareness and build insight into how your thoughts, behaviors, and emotions interact and may be keeping you stuck in unhealthy cycles. I also work with my clients on values identification to help guide us in developing practical steps to get you unstuck and moving forward in life in a meaningful way. My main treatment modalities are Cognitive Behavioral Therapy and Acceptance and Commitment Therapy.

It is my belief that as people become more aware and accepting of themselves, they are more capable of finding a sense of peace and contentment in their lives.  However, self-awareness and self-acceptance are goals that may take a long time to achieve.  Some clients need only a few sessions to achieve these goals, whereas others may require months or even years of therapy.  As a client, you are in complete control, and you may end your relationship with me at any point. 

In order for therapy to be most successful, it is important for you to take an active role.  This means working on the things you and I talk about both during and between sessions.  This also means avoiding any mind-altering substances like alcohol or non-prescription drugs for at least eight hours prior to your therapy sessions.  Generally, the more of yourself you are willing to invest, the greater the return.

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 terminating therapy or 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.  I truly hope we can talk about any of these decisions. If at any point you are unable to keep your appointments or I don't hear from you for 90 days, I will need to close your chart.  However, as long as I still have space in my schedule, reopening your chart and resuming treatment is always an option.

Confidentiality & Records and Informed Consent Regarding Legal Proceedings:

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 stored electronically with CounSol, a secure storage company who has signed a HIPAA Business Associate Agreement (BAA). The BAA ensures that they will maintain the confidentiality of your PHI in a HIPAA compatible secure format using point-to-point, Federally approved encryption. Additionally, I will always keep everything you say to me completely confidential, with the following exceptions: (1) if you direct me to tell someone else and you sign a "Release of Information" form; (2) if I determine that you are a danger to yourself or to others; (3) if you report information about the abuse of a child, an elderly person, or a disabled individual who may require protection; or (4) if 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. If for some unusual 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 confidential. 

If the client believes it necessary to subpoena the therapist, the client would be responsible for the therapist's fact witness fees in the amount of $800 for one-half (1/2) day to be paid five (5) days in advance of any court appearance or deposition. Any additional time the therapist spends over one-half (1/2) day would be billed at the rate of $150.00 per hour including travel time. Further, if the therapist is requested to have contact with the legal system on the client's behalf, the therapist will seek legal counsel for consult and the client will be responsible for any fees associated with obtaining legal counsel for the therapist.

I may seek supervision or consultation from other trained/licensed providers about your circumstances for additional guidance in order to keep in line with professional standards of practice. I will not share any identifying information and only relevant facts pertaining to your case will be discussed.

I am required to retain a client's record for a period of seven (7)  years, commencing on either the termination of professional counseling services or the date of last contact with the client, whichever is later.  An exception to this is when the client is a child, the record shall be retained for a period of seven (7) years commencing either upon the last day of treatment or when the child reaches eighteen (18) years of age, whichever comes later, but in no event shall records be kept for more than twelve (12) years.

In the event that the therapist becomes incapacitated due to illness or injury, records may be requested by contacting Dana Avey, LMFT via email (danaavey@outlook.com). Dana Avey, LMFT has entered into an agreement to manage records as outlined through a Professional Will in the event that the therapist is rendered incapable of practice.

Professional Relationship:

Our relationship 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 way, we would then have a "dual relationship," which could prove to be harmful to you in the long run and is, therefore, unethical in the mental health profession. Dual relationships can set up conflicts between the therapist's interests and the client's interests, and then the client's (your) interests might not be put first.  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.

There is another dual relationship that therapists are ethically required to avoid. This is providing therapy while also providing a legal opinion. These are considered mutually exclusive unless you hire a therapist specifically for a legal opinion, which is considered "forensic" work and not therapy. My passion is not in forensic work but in providing you with the best therapeutic care possible. Therefore, by signing this document, you acknowledge that I will be providing therapy only and not forensic services. You also understand that this means I will not participate in custody evaluations, depositions, court proceedings, or any other forensic activities.  

You should also know that therapists are required to keep the identity of their clients confidential. For your confidentiality, I will not address you in public unless you speak to me first.  I must also decline any invitation to attend gatherings with your family or friends.  Lastly, when your therapy is completed, I will not be able to be a friend to you like your other friends.  In sum, it is my ethical duty as a therapist 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.

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 Counseling Association. 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.  If we are unable to resolve your concern, I will provide you with information to contact the 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. 

For the safety of all my clients, their accompanying family members and children, and other therapists in the building I maintain a zero tolerance weapons policy.  No weapon of any kind is permitted on the premises, including guns, explosives, ammunition, knives, swords, razor blades, pepper spray, garrotes, or anything that could be harmful to yourself or others.  I reserve the right to contact law enforcement officials and/or terminate treatment with any client who violates my weapons policy.

TeleMental Health Statement:

TeleMental Health is defined as follows: "TeleMental Health means the mode of delivering services via technology-assisted media, such as but not limited to, a telephone, video, internet, a smartphone, tablet, PC desktop system or other electronic means using appropriate encryption technology for electronic health information. TeleMental Health facilitates client self-management and support for clients and includes synchronous interactions and asynchronous store and forward transfers."

Breaches of confidentiality over the past decade have made it evident that Personal Health Information (PHI) as it relates to technology needs an extra level of protection. Additionally, there are several other factors that need to be considered regarding the delivery of TeleMental Health services in order to provide you with the highest level of care. Therefore, I have completed specialized training in TeleMental Health. I have also developed several policies and protective measures to assure your PHI remains confidential.  These are discussed below.

The Different Forms of Technology-Assisted Media Explained:

The following information explains how the therapist handles and stores the client's PHI while the client is receiving counseling if the client chooses any of the following counseling modalities. Although it is not guaranteed that these methods will prevent 100% of confidentiality breaches, they are designed with the intention of supporting the confidentiality of all clinical communications:

Email:

Email is not a secure means of communication and may compromise your confidentiality.  However, I realize that many people prefer to email because it is a quick way to convey information. 

All email correspondences will be done through https://lifeperformancecounseling.secure-client-area.com. https://lifeperformancecounseling.secure-client-area.com stores our email correspondence and it is encrypted to the federal standard, HIPAA compatible, and the company has signed a HIPAA Business Associate Agreement (BAA). The BAA means that the company is willing to attest to HIPAA compliance and assume responsibility for keeping your PHI secure. I encourage you to also utilize this software for protection on your end. Otherwise, when you reply to one of my emails, everything you write in addition to what I have written to you (unless you remove it) will no longer be secure. My encrypted email service only works to send information and does not govern what happens on your end. You also need to know that I am required to keep a copy or summary of all emails as part of your clinical record that address anything related to therapy. 

I also strongly suggest that you only communicate through a device that you know is safe and technologically secure (e.g., has a firewall, anti-virus software installed, is password protected, not accessing the internet through a public wireless network, etc.).  If you are in a crisis, please do not communicate this to me via email because I may not see it in a timely matter. Instead, please see below under "Emergency Procedures."

Phone:

All phone correspondences will be done through a GoogleVoice number: 719-642-0167

I have chosen this technology because it is encrypted to the federal standard, HIPAA compatible, and the company has signed a HIPAA Business Associate Agreement (BAA). The BAA means that the company is willing to attest to HIPAA compliance and assume responsibility for keeping your PHI secure. I encourage you to also utilize this software if you do not wish for others to have access to our communications.

It is important for you to know that landline telephones and cell phones may not be completely secure and confidential.  There is a possibility that someone could overhear or even intercept your conversations with special technology. Individuals who have access to your telephone or your telephone bill may be able to determine who you have talked to, who initiated that call, how long the conversation lasted, and where each party was located when that call occurred. If you have a landline or a cell phone and you provided me with that phone number, I may contact you on this line from my from my cell phone, typically only regarding setting up an appointment if needed.  If this is not an acceptable way to contact you, please let me know. Telephone conversations (other than just setting up appointments) are billed at my hourly rate. Additionally, I keep your phone number in my cell phone, but it is listed by your initials only and my phone is password protected.  If this is a problem, please let me know, and we will discuss our options.

Text messaging is also not a secure means of communication and may compromise your confidentiality.  However, I realize that many people prefer to text because it is a quick way to convey information. Nonetheless, please know that it is my policy to utilize this means of communication strictly for appointment confirmations.  Please do not bring up any therapeutic content via text to prevent compromising your confidentiality.  You also need to know that I am required to keep a copy or summary of all texts as part of your clinical record that address anything related to therapy. I also strongly suggest that you only communicate through a device that you know is safe and technologically secure (e.g., password protected).

Video Conferencing:

All video conferencing correspondences will be done through https://lifeperformancecounseling.secure-client-area.com which is encrypted to the federal standard.

Video Conferencing is an option for us to conduct remote sessions over the internet where we not only can speak to one another, but we may also see each other on a screen. I utilize CounSol. This VC platform is encrypted to the federal standard, HIPAA compatible, and has signed a HIPAA Business Associate Agreement (BAA).  The BAA means that CounSol is willing to attest to HIPAA compliance and assumes responsibility for keeping our VC interaction secure and confidential. If we choose to utilize this technology, I will give you detailed directions regarding how to log-in securely. I also ask that you please sign on to the platform at least five minutes prior to your session time to ensure we get started promptly. The client is responsible for initiating the connection with the therapist at the time of the client's session. I strongly suggest that you only communicate through a computer or device that you know is safe (e.g., has a firewall, anti-virus software installed, is password protected, not accessing the internet through a public wireless network, etc.).

Please do not join telehealth appointments while driving your car. I will not conduct telehealth sessions while you are operating a vehicle for safety reasons. If you join your appointment and are driving and do not have the ability to pull over to a safe location to participate in your appointment, we will have to cancel the appointment and a late cancellation fee will be assessed according to my late cancellation policy. 

In-person:

All in-person sessions will be held at the therapist's office located at 2975 Broadmoor Valley Road, Suite 103B. All session notes will be maintained through https://lifeperformancecounseling.secure-client-area.com which is encrypted to the federal standard. 

It is my policy not to accept "friend" or "connection" requests from any current or former client on my personal social networking sites such as Facebook, Twitter, Instagram, Pinterest, etc. because it may compromise your confidentiality and blur the boundaries of our relationship. 

Blogs: 

I may post counseling information or therapeutic content on a professional blog.  If you have an interest in following my blog, please feel free to do so. However, please be mindful that the general public may see that you're following my blog. Once again, maintaining your confidentiality is a priority.

Website Portal:

I have a client portal that is accessible through https://lifeperformancecounseling.secure-client-area.com or through my website at www.lifeperformancecounseling.com, which is powered by CounSol. CounSol ensures this portal is encrypted to the federal standard, HIPAA compatible, and has agreed to sign a HIPAA Business Associate Agreement (BAA). The BAA means that CounSol is willing to attest to HIPAA compliance and assumes responsibility for keeping our interactions secure and your PHI confidential. If we choose to utilize this technology, I will give you detailed directions regarding how to log-in securely. I also strongly suggest that you only communicate through a device that you know is safe (e.g., has a firewall, anti-virus software installed, is password protected, not accessing the internet through a public wireless network, etc.). Additionally, through the client portal, you have the option of receiving text and/or email reminders of your appointments with me and/or billing information. 

I utilize an electronic chat forum through CounSol. I have chosen a technology company for chatting that is encrypted to the federal standard, HIPAA compatible, and has agreed to sign a HIPAA Business Associate Agreement (BAA). The BAA means that CounSol is willing to attest to HIPAA compliance and assumes responsibility for keeping our interactions secure and your PHI confidential. I also strongly suggest that you only communicate through a device that you know is safe (e.g., has a firewall, anti-virus software installed, is password protected, not accessing the internet through a public wireless network, etc.).

Recommendations to Websites or Applications (Apps): 

During the course of our treatment I may recommend that you visit certain websites for pertinent information or self-help. I may also recommend certain apps that could be of assistance to you and enhance your treatment. Please be aware that websites and apps may have tracking devices that allow automated software or other entities to know that you've visited these sites or applications. They may even utilize your information to attempt to sell you other products. Additionally, anyone who has access to the device you used to visit these sites/apps may be able to see that you have been to these sites by viewing the history on your device. Therefore, it is your responsibility to decide if you would like this information as adjunct to your treatment or if you prefer that I do not make these recommendations. Please let me know by checking (or not checking) the appropriate box at the end of this document.

Electronic Transfer of PHI for Certain Credit Card Transactions:

I utilize CardPointe as the company that processes your credit card information. This company may send the credit card-holder a text or an email receipt indicating that you used that credit card for my services, the date you used it, and the amount that was charged. This notification is usually set up two different ways - either upon your request at the time the card is run or automatically. Please know that it is your responsibility to know if you or the credit cardholder has the automatic receipt notification set up in order to maintain your confidentiality if you do not want a receipt sent via text or email. Additionally, please be aware that the transaction will also appear on your credit-card bill.

Your Responsibilities for Confidentiality & TeleMental Health:

Please communicate only through devices that you know are secure as described above. It is also your responsibility to choose a secure location to interact with technology-assisted media and to be aware that family, friends, employers, co-workers, strangers, and hackers could either overhear your communications or have access to the technology that you are interacting with. Additionally, you agree not to record any TeleMental Health sessions.

In Case of Technology Failure:

During a TeleMental Health session, we could encounter a technological failure. The most reliable backup plan is to contact one another via telephone. Please make sure you have a phone with you, and I have that phone number. If we get disconnected from a video conferencing or chat session, end and restart the session.  If we are unable to reconnect within ten minutes, please call me. If we are on a phone session and we get disconnected, please call me back or contact me to schedule another session. If the issue is due to my phone service, and we are not able to reconnect, I will not charge you for that session.

Limitations of TeleMental Health Therapy Services:

TeleMental Health services may have some limitations. Primarily, there is a risk of misunderstanding one another when communication lacks visual or auditory cues. For example, if video quality is lacking for some reason, I might not see a tear in your eye. Or, if audio quality is lacking, I might not hear the crack in your voice that I could easily pick up if you were in my office. There may also be a disruption to the service (e.g., phone gets cut off or video drops). This can be frustrating and interrupt the normal flow of personal interaction. Please know that I have the utmost respect and positive regard for you and your wellbeing. I would never do or say anything intentionally to hurt you in any way, and I strongly encourage you to let me know if something I've done or said has upset you. I invite you to keep our communication open at all times to reduce any possible harm.

Identification & Passwords for New Clients:

During our first session, I will require you to show a valid picture ID and another form of identity verification such a credit card in your name. At this time, you will also choose a password, phrase, or number which you will use to identify yourself in all future sessions. This procedure prevents another person from posing as you.

Consent to TeleMental Health Services:

By signing this form, you are authorizing me to utilize the following TeleMental Health services for your treatment or administrative purposes: Texting, Email, Video Conferencing, Website Portal, Electronic Chat Forum,  Recommendations to Websites or Apps.

Together, we will ultimately determine which modes of communication are best for you. However, you may withdraw your authorization to use any of these services at any time during the course of your treatment just by notifying me in writing. If you do not see an item discussed previously in this document listed for your authorization below, this is because it is built-in to my practice, and I will be utilizing that technology unless otherwise negotiated by you.

Feel free to ask questions, and please know that I am open to any feelings or thoughts you have about these and other modalities of communication and treatment.

Informed Consent Regarding Form Completion Requests:

If the client is requesting completion of any forms for submission to others (e.g. FMLA), the forms will be completed at the discretion of the therapist. Due to the increased administrative time, form completion requests are billed at my hourly rate for the time I spend preparing and completing all requested documentation. Please submit the form completion request well in advance of when they are needed. The therapist will attempt to complete the forms as quickly as possible, if deemed appropriate. An accompanying Release of Information must be completed for the party to whom the forms are to be released, to include the client. Payment is required prior to completion of all forms.

Communication Response Time:

My practice is considered to be an outpatient facility, and I am set up to accommodate individuals who are reasonably safe and resourceful.  I do not carry a beeper nor am I available at all times.  If at any time this does not feel like sufficient support, please inform me, and we can discuss additional resources or transfer your case to a therapist or clinic with 24-hour availability.  I will return phone calls, texts, or e-mails within 48 business hours. However, I do not return calls, texts, or e-mails on weekends or holidays. If you are having a mental health emergency and need immediate assistance, please follow the instructions below.

In Case of an Emergency:

If you have a mental health emergency, I encourage you not to wait for communication back from me, but do one or more of the following:

FOR COLORADO RESIDENTS:

Go to Diversus Health Crisis Walk- In Center at 115 S. Parkside Drive 

Go to Cedar Springs Hospital located at 2135 Southgate Road

Go to Peak View Behavioral Health located at 7353 Sisters Grove 

Call the National Suicide Prevention Lifeline at (800) 273-8255 

Call Trevor Project (LGBTQ) at (866) 488-7386

Call 911 or go to the emergency room of your choice

FOR OREGON RESIDENTS:

Call the Yamhill County Mental Health Crisis Line at (844) 842-8200

Go to the Psychiatric Crisis Center located at 1118 Oak St SE, Salem, OR 97301 or call (503) 585-4949

Call Trevor Project (LGBTQ) at (866) 488-7386

Just need to talk? Call the Recovery Outreach Community Center Warmline at (971) 239-7255

Call the National Suicide Prevention Lifeline at (800) 273-8255 

Call 911 or go to the emergency room of your choice

FOR ALABAMA RESIDENTS:

Call or go to the AltaPointe Behavioral Health Crisis Center 251-662-8000, 2401 Gordon Smith Drive, Mobile 36617, Serving: Baldwin, Clark, Conecuh, Escambia, Monroe, and Washington counties

Call or go to Carastar Crisis Center 800-408-4197, 5915 Carmichael Road, Montgomery 36117, Serving: Autauga, Bullock, Chambers, Elmore, Lee, Lowndes, Macon, Montgomery, Pike, Russell, and Tallapoosa counties

Call or go to Indian Rivers Hope Pointe Behavioral Health Crisis Care, 205-391-4000, 1401 Greensboro Ave, Tuscaloosa 35401, Serving:  Bibb, Choctaw, Dallas, Greene, Hale, Marengo, Perry, Pickens, Sumter, Wilcox, and Tuscaloosa counties

Call or go to JBS Craig Crisis Care Center, 205-263-1701, 401 Beacon Parkway W, Birmingham 35209, Serving: Blount, Calhoun, Chilton, Clay, Cleburne, Coosa, Jefferson, Randolph, St. Clair, Shelby, and Talladega counties

Call or go to WellStone Emergency Services, 256-705-6444, 4020 Memorial Parkway SW, Huntsville 35802, Serving: Cherokee, Cullman, Dekalb, Etowah, Fayette, Jackson, Lamar, Lawrence, Limestone, Madison, Marion, Marshall, Morgan, Walker, and Winston counties

All of these facilities operate 24/7. If the client goes somewhere due to a mental health emergency, the client is encouraged to sign releases of information once there and request staff to notify the therapist so the therapist may follow up as appropriate on their behalf. This therapist does not provide emergency services. 

If we decide to include TeleMental Health as part of your treatment, there are additional procedures that we need to have in place specific to TeleMental health services. These are for your safety in case of an emergency and are as follows:

You understand that if you are having suicidal or homicidal thoughts, experiencing psychotic symptoms, or in a crisis that we cannot solve remotely, I may determine that you need a higher level of care and TeleMental Health services are not appropriate. 

I require an Emergency Contact Person (ECP) who I may contact on your behalf in a life-threatening emergency only. Either you or I will verify that your ECP is willing and able to go to your location in the event of an emergency. Additionally, if either you, your ECP, or we determine necessary, the ECP agrees take you to a hospital. Your signature at the end of this document indicates that you understand we will only contact this individual in the extreme circumstances stated above. 

You agree to inform me of the address where you are at the beginning of every TeleMental Health session.

You agree to inform me of the nearest mental health hospital to your primary location that you prefer to go to in the event of a mental health emergency (usually located where you will typically be during a TeleMental Health session). Please list this hospital and contact number here:

For clients paying out of pocket for services, the cost of the sessions will be communicated clearly prior to initiation of counseling and a Self Pay Fee Agreement will be signed prior to initiating services. The rate for service will also be stated on the client's scheduled appointment on the client portal https://lifeperformancecounseling.secure-client-area.com/portal/access/login/. The client is responsible for the cost of technology at the client's location, such as a computer, phone, etc. for those scheduling teletherapy appointments. Statements are issued to the client in the portal when an appointment is scheduled. Cash and all major credit cards are acceptable for payment, and all payments are expected to be received prior to scheduled appointment. If paying by cash, the client may provide cash payment upon arrival to the appointment. Otherwise, all other payments should be made online before the session via the client portal https://lifeperformancecounseling.secure-client-area.com/portal/access/login/ 

Phone calls, texting, and emails (other than just setting up appointments) are billed at my hourly rate for the time I spend reading and responding. Your credit card will be charged before each tele mental health interaction. Again, this includes any therapeutic interaction other than setting up appointments. 

The therapist reserves the right to refuse services if payment has not been received prior to start of session. If there is financial hardship, the client will discuss with the therapist in advance to services being rendered or as soon as such arises within the treatment process. For clients with insurance or using a form of Employee Assistance Program (e.g. Modern Health) benefits for payment, by signing this document, the client is consenting to information sharing with the insurance/third-party biller (Headway/EAP) as required for the purposes of authorization and billing. The client is ultimately responsible for knowing their insurance coverage and benefits and agrees to pay in the event that insurance denies payment both during time of service and beyond termination. If a self-pay client wishes to seek reimbursement from their insurance provider who is out-of-network for this provider, the client may print a superbill (receipt) from the portal after payment is made. If opting for the superbill process, the client would then submit the superbill to the client's insurance provider for the possibility of being reimbursed by the insurance provider (if eligible). Therapist does not guarantee reimbursement. 

By not cancelling an appointment as stated in the Cancellation Policy (see next section), the client is agreeing to the price of the session as stated on https://lifeperformancecounseling.secure-client-area.com (unless the client is covered by an EAP which prohibits such). If the client is using insurance, their no-show rate will be the same as the insurance reimbursement rate. If the client makes a payment in advance, but cancels in accordance to the Cancellation Policy, the client will be credited the amount paid for a future session. Refunds are not provided.

The client portal https://lifeperformancecounseling.secure-client-area.com requires the client to have a credit card on file prior to scheduling. Unless other arrangements have been made, the client's card on file will be charged if the client has not submitted payment for the services received that day by close of business. Likewise, if the client does not cancel an appointment as outlined in the cancellation policy, the client's card will be billed by close of business the day of the scheduled session. 

Cancellation and No Show Policy:

In the event that you are unable to keep your appointment, you must notify me at least 24 hours in advance.  If such advance notice is not received, you will be financially responsible for the full fee of the session you missed.  Please note that insurance companies do not reimburse for missed sessions. 

If you are more than 10 minutes late to your appointment, the appointment will be cancelled and you will be financially responsible for the full fee of the session you missed. 

If you have 3 or more instances of being late or canceling your appointment within the 24 hour period before the appointment start time or if you have 3 or more instances where you do not show up for an appointment, the remainder of your appointments will be cancelled and you will be referred to another provider.  

Termination Policy:

In the event there is not a scheduled closing session to discuss termination of the counseling relationship and the therapist has had no contact from the client within the past 90 days, the therapist will contact the client via the secure portal once to inquire if the client wishes to continue the therapeutic relationship. This message will advise of a time-frame for scheduling to remain an active client and will explain how to reach the therapist in the future for services if needed. If no appointment is scheduled within the designated time-frame as identified or agreed upon, the client's account access to the web portal will cease, and the client's chart will be closed. This action terminates the therapeutic relationship.  Any unpaid balances on the client's account will be billed to the card on file, regardless of how termination arises.

Our Agreement to Enter into a Therapeutic Relationship:

Please 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, and you are authorizing me to begin treatment with you. Please note that this updated "Information, Authorization & Consent to Treatment" replaces any previously signed informed consents.

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.