Terms and Policy Informed Consent for Counseling 

Welcome to New Creations, LLC, the private practice of Erin Brindle, LPC, ATR-BC. In order to promote a trusting and productive counseling relationship, the following is provided for your understanding and consent. 

The Counseling Experience 

The goal for counseling is to assist you in making positive steps toward achieving wellness. Many people come to counseling because they want to make significant changes in their lives and are interested in the supportive, nonjudgmental assistance that counseling can provide toward achieving that change. Others seek counseling because change or other difficult circumstances have been thrust on them, and they want support in learning to cope healthily with such changes. At times, the process of counseling may be difficult. Working toward positive change often requires you to step out of your comfort zone and take some risks. As your counselor, I will be there to support your journey of healing and growth. There are likely to be times when I will suggest "homework assignments" between sessions. Such exercises are designed to make the counseling process more effective. Counseling is about you, and it is up to you to let me know what works for you, and what doesn't. 

Confidentiality 

Generally, information disclosed during counseling will be kept strictly confidential, and will not be revealed to anyone outside of my counseling practice without your written permission. The 4 exceptions to this general rules are as follows. If any of these exceptions should arise during the course of your counseling, I will make every effort to inform you of the need to break confidentiality.

1) If you threaten to harm yourself or another person, I am legally, ethically, and morally obligated to take action to protect the safety of the threatened person. Actions could include notifying the intended victim, arranging for hospitalization for you (and/or your child), notifying family or other support system, or alerting law enforcement. 

2) If abuse or neglect of a child, elderly, or disabled person is known or suspected, I am required by law to report my concern to the Department of Children and Families. 

3) If I were to receive a legally binding court order from a judge for your counseling records or for my deposition or court testimony, I would be required by law to comply. 

4) If you (or your child) are in counseling or being evaluated by order of the court or as a condition of continued employment, I may be required to provide the court or employer with reports, documents, or testimony. If you are utilizing your health insurance benefits to cover the cost of your counseling, please be aware that nearly all insurance companies require the counselor to disclose a fair amount of information in order to authorize treatment. This occurs not only after the initial session but often on an ongoing basis, in order to authorize further sessions. Many insurance plans also require that a DSM-V diagnosis be made in order for treatment to be authorized. If I am required to submit a diagnosis, the diagnostic information will be shared with you. While you are welcome to utilize email for purposes of scheduling coordination, please realize that I cannot guarantee the confidentiality of electronic communication. 

Emergencies or Crises 

I check my email and voicemail twice daily and will return your correspondence at my earliest opportunity. If you are in need of immediate assistance and cannot reach me, please call The Suicide Prevention Line, 899. If you have a life-threatening emergency, please go to a hospital emergency room or call 911. Your safety and wellbeing is of utmost importance to me. 

Client Rights 

As a client you have the right to: 1) Be treated with dignity and respect. 2) Ask questions regarding the therapeutic process and/or office procedures. 3) Terminate therapy at any time. I can provide you with other referral sources upon request. 4) Specify and negotiate therapeutic goals and be an active participant in therapy. 5) Confidentiality as stated above. 6) Be informed about fees and payment policies. 

Fees and Policies 

Counseling fees are generally $150 per 55 minute session for individuals or $160 for couples therapy. There are some discounted options available, which we may discuss, including discounted rates for pre-payment of 3 or 6 sessions. Group counseling fees will be identified per particular group. There is never a charge for a brief telephone "check-in" or scheduling coordination for up to 5 minutes. Payment is due at the end of each session and I can provide you with a receipt for payment on a monthly basis that you may use in filing insurance claims, or for personal financial records. 

Other than an emergency or serious illness,you will be billed for missed appointments unless you provide notification 24 hours in advance. If for any reason fees per session are not paid during the session, counseling sessions will cease until payment occurs.

 HIPPA Compliance 

NOTICE OF PRIVACY PRACTICES THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION.PLEASE REVIEW THIS NOTICE CAREFULLY. 

Your health record contains personal information about you and your health. This information about you that may identify you and that relates to your past, present or future physical or mental health or condition and related health care services is referred to as Protected Health Information ("PHI"). This Notice of Privacy Practices describes how I may use and disclose your PHI in accordance with applicable law, including the Health Insurance Portability and Accountability Act ("HIPAA"), regulations promulgated under HIPAA including the HIPAA Privacy and Security Rules, and the ACA Code of Ethics. It also describes your rights regarding how you may gain access to and control your PHI. I am required by law to maintain the privacy of PHI and to provide you with notice of my legal duties and privacy practices with respect to PHI. I am required to abide by the terms of this Notice of Privacy Practices. 

I reserve the right to change the terms of our Notice of Privacy Practices at any time. Any new Notice of Privacy Practices will be effective for all PHI that I maintain at that time. I will provide you with a copy of the revised Notice of Privacy Practices by sending a copy to you in the mail upon request or providing one to you at your next appointment. 

HOW I MAY USE AND DISCLOSE HEALTH INFORMATION ABOUT YOU 

For Treatment.Your PHI may be used and disclosed by those who are involved in your care for the purpose of providing, coordinating, or managing your health care treatment and related services. This includes consultation with clinical supervisors or other treatment team members. I may disclose PHI to any other consultant only with your authorization. 

For Payment. I may use and disclose PHI so that I can receive payment for the treatment services provided to you. This will only be done with your authorization. Examples of payment-related activities are: making a determination of eligibility or coverage for insurance benefits, processing claims with your insurance company, reviewing services provided to you to determine medical necessity, or undertaking utilization review activities. If it becomes necessary to use collection processes due to lack of payment for services, I will only disclose the minimum amount of PHI necessary for purposes of collection. For Health Care Operations. I may use or disclose, as needed, your PHI in order to support my business activities including, but not limited to, quality assessment activities, employee review activities, licensing, and conducting or arranging for other business activities. For example, I may share your PHI with third parties that perform various business activities (e.g., billing or typing services) provided I have a written contract with the business that requires it to safeguard the privacy of your PHI. For training or teaching purposes PHI will be disclosed only with your authorization. Required by Law. Under the law, I must disclose your PHI to you upon your request. In addition, I must make disclosures to the Secretary of the Department of Health and Human Services for the purpose of investigating or determining my compliance with the requirements of the Privacy Rule. 

Without Authorization. Following is a list of the categories of uses and disclosures permitted by HIPAA without an authorization. Applicable law and ethical standards permit me to disclose information about you without your authorization only in a limited number of situations. As a licensed professional counselor in this state, it is my practice to adhere to more stringent privacy requirements for disclosures without an authorization.The following language addresses these categories to the extent consistent with the ASA Code of Ethics and HIPAA. 

Child Abuse or Neglect. I may disclose your PHI to a state or local agency that is authorized by law to receive reports of child abuse or neglect. 

Judicial and Administrative Proceedings. I may disclose your PHI pursuant to a subpoena (with your written consent), court order, administrative order or similar process. 

Deceased Patients. I may disclose PHI regarding deceased patients as mandated by state law, or to a family member or friend that was involved in your care or payment for care prior to death, based on your prior consent. A release of information regarding deceased patients may be limited to an executor or administrator of a deceased person's estate or the person identified as next-of-kin. PHI of persons that have been deceased for more than fifty (50) years is not protected under HIPAA.

Medical Emergencies. I may use or disclose your PHI in a medical emergency situation to medical personnel only in order to prevent serious harm. I will try to provide you a copy of this notice as soon as reasonably practicable after the resolution of the emergency. Family Involvement in Care. I may disclose information to close family members or friends directly involved in your treatment based on your consent or as necessary to prevent serious harm. 

Health Oversight. If required,I may disclose PHI to a health oversight agency for activities authorized by law, such as audits, investigations, and inspections. Oversight agencies seeking this information include government agencies and organizations that provide financial assistance to the program (such as third-party payors based on your prior consent) and peer review organizations performing utilization and quality control. 

Law Enforcement. I may disclose PHI to a law enforcement official as required by law, in compliance with a subpoena (with your written consent), court order, administrative order or similar document, for the purpose of identifying a suspect, material witness or missing person, in connection with the victim of a crime, in connection with a deceased person, in connection with the reporting of a crime in an emergency, or in connection with a crime on the premises. 

Specialized Government Functions. I may review requests from U.S. military command authorities if you have served as a member of the armed forces, authorized officials for national security and intelligence reasons and to the Department of State for medical suitability determinations, and disclose your PHI based on your written consent, mandatory disclosure laws and the need to prevent serious harm. 

Public Health. If required, I may use or disclose your PHI for mandatory public health activities to a public health authority authorized by law to collect or receive such information for the purpose of preventing or controlling disease, injury, or disability, or if directed by a public health authority, to a government agency that is collaborating with that public health authority. 

Public Safety. I may disclose your PHI if necessary to prevent or lessen a serious and imminent threat to the health or safety of a person or the public. If information is disclosed to prevent or lessen a serious threat it will be disclosed to a person or persons reasonably able to prevent or lessen the threat, including the target of the threat. Research. PHI may only be disclosed after a special approval process or with your authorization. 

Verbal Permission. I may also use or disclose your information to family members that are directly involved in your treatment with your verbal permission. With Authorization. Uses and disclosures not specifically permitted by applicable law will be made only with your written authorization, which may be revoked at any time, except to the extent that I have already made a use or disclosure based upon your authorization. 

YOUR RIGHTS REGARDING YOUR PHI 

You have the following rights regarding PHI I maintain about you. 

To exercise any of these rights, please submit your request in writing to me or speak with me directly. 

Right of Access to Inspect and Copy. You have the right, which may be restricted only in exceptional circumstances, to inspect and copy PHI that is maintained in a "designated record set". A designated record set contains mental health/medical and billing records and any other records that are used to make decisions about your care. Your right to inspect and copy PHI will be restricted only in those situations where there is compelling evidence that access would cause serious harm to you or if the information is contained in separately maintained psychotherapy notes. I may charge a reasonable, cost-based fee for copies. If your records are maintained electronically, you may also request an electronic copy of your PHI. You may also request that a copy of your PHI be provided to another person. 

Right to Amend. If you feel that the PHI I have about you is incorrect or incomplete, you may ask me to amend the information although I am not required to agree to the amendment. If I deny your request for amendment, you have the right to file a statement of disagreement with me. I may prepare a rebuttal to your statement and will provide you with a copy. Please contact me if you have any questions. 

Right to an Accounting of Disclosures. You have the right to request an accounting of certain of the disclosures that I make of your PHI. I may charge you a reasonable fee if you request more than one accounting in any 12-month period. 

Right to Request Restrictions. You have the right to request a restriction or limitation on the use or disclosure of your PHI for treatment, payment, or health care operations. I am not required to agree to your request unless the request is to restrict disclosure of PHI to a health plan for purposes of carrying out payment or health care operations, and the PHI pertains to a health care item or service that you paid for out of pocket. In that case, I am required to honor your request for a restriction. 

Right to Request Confidential Communication. You have the right to request that I communicate with you about health matters in a certain way or at a certain location. I will accommodate reasonable requests. I may require information regarding how payment will be handled or specification of an alternative address or other method of contact as a condition for accommodating your request. I will not ask you for an explanation of why you are making the request. 

Breach Notification. If there is a breach of unsecured PHI concerning you, I may be required to notify you of this breach, including what happened and what you can do to protect yourself. 

Right to a Copy of this Notice. You have the right to a copy of this notice. 

COMPLAINTS If you believe I have violated your privacy rights, you have the right to file a complaint in writing with me or with the Secretary of Health and Human Services at 200 Independence Avenue, S.W. Washington, D.C. 20201 or by calling (202) 619-0257. 

I will not retaliate against you for filing a complaint. 

Consent for Counseling I have read and understood the information on this form, and voluntarily agree to participate in counseling, or consent to participation of my child in counseling.

Signature of Client or Legal Guardian  Date