AGREEMENT FOR PSYCHOTHERAPY SERVICES CONDUCTED BY KRISTEL SCORESBY

THERAPEUTIC PROCESS
Participation in therapy can result in several benefits, including resolution of the concerns that led you to seek therapy. Working towards these benefits requires your honesty, openness and active involvement. As therapy progresses, we will discuss it’s effectiveness for you. It is expected that you will provide honest feedback about your progress and your views of therapy. Discussing the issues that brought you into therapy can result in discomfort (fear, sadness, anger, anxiety, etc). I may challenge some of your perceptions and suggest different ways of looking at or handling situations. This also may cause you to feel discomfort (disappointment, anger, etc). Sometimes, as you are working towards resolution of your personal issues, it may feel that the issues “get worse” before “getting better.” This is a normal part of the therapeutic process. During the course of therapy, I will utilize various psychological approaches, depending on the problems being treated and my assessment of what will benefit you. These approaches include but are not limited to cognitive-behavioral, emotional focused, solution focused, developmental, attachment, crisis intervention or psycho-educational techniques.

PRIVACY & CONFIDENTIALITY
All information that you disclose within sessions and the written records pertaining to those sessions are confidential and may not be revealed to anyone without your written permission, except where disclosure is required by law. The notice of Privacy Practices, which you received with this Informed Consent has more details of when disclosure is required by law. Disclosure is required where there is a reasonable suspicion of child, dependent or elder, abuse or neglect; and where a client presents a danger to self, to others, or to property. If there is a situation in which I become concerned about your personal safety, or the possibility of you injuring someone else, I will contact the police, hospital or an emergency contact whose name you have provided. In addition to these limitations of confidentiality, disclosure may be required in a legal proceeding.

Electronic Communication
I use a HIPAA compliant Electronic Health Record “cloud” system. This system has a “Client Portal” in which you will complete forms, schedule appointments, make payments, and otherwise communicate with me. All of these records are secure and encrypted within this system. Please be aware that if you email me from your personal email account, not within the client portal system, that communication is not secure.

Dual Relationships
I will never acknowledge working therapeutically with anyone without his/her written permission. Even with permission, I will preserve the integrity of our working relationship. For this reason, I will not accept any invitations via social networking sites such as Facebook, Twitter, Linkedin or Pinterest, nor will I respond to blogs written by clients or accept comments on my blog from clients.

Litigation Limitation
As the therapeutic process is of a confidential nature, it is agreed that should there be legal proceedings (such as divorce, custody disputes, personal injuries, etc), neither you nor your attorney will call on me to testify in court or at any other proceeding, nor will a disclosure of the psychotherapy records be requested.

Consultation and Peer Supervision
I regularly consult with other professionals regarding my clients as a way to maintain objectivity and to utilize best practices. During this consultation, a client’s name or other identifying information is not shared. As the client’s identify remains anonymous, confidentially is maintained.

FEE FOR SERVICE & CANCELLATION POLICY
Fees are due before or at the time of your appointment. I participate on the Blue Cross Blue Shield Insurance panel as a preferred provider. For other insurance panels, I can at your request, participate as an out-of-network provider. This means that you pay the full session fee and submit an invoice to your insurance provider. They may or may not choose to reimburse you for a portion of the session fees. Also, I can accept payment from your Ecclesiastical Leader, if the Ecclesiastical Leader agreement form has been completed and signed.

Session payments via credit or debit card can be processed through the Electronic Health Record system that I use.

As scheduling an appointment reserves a time specifically for you, 24 hour notice is required for re-scheduling or canceling an appointment. Unless we reach a different agreement, half of the session fee will be charged for sessions missed without such notification.

By signing below, I am stating that I agree to the terms listed above.

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.

I. 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 AURTHORIZATION. 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.

1. 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 July 31, 2014

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 HIPPA Notice of Privacy Practices.