CONFIDENTIALITY: All information disclosed within sessions and the written records pertaining to those sessions are confidential and may not be revealed to anyone without ("the client") written permission, except where disclosure is required by law. Most of the provisions explaining when the law requires disclosure were described to you in the Notice of Privacy Practices that you received with this form.

When Disclosure Is Required By Law: Some of the circumstances where disclosure is required by the law are: where there is a reasonable suspicion of child, dependent or elder abuse ore neglect; where a client presents a danger to self, to others, to property, or is gravely disabled.

When Disclosure May Be Required: Disclosure may be required pursuant to a legal proceeding. If you place your mental status at issue in litigation initiated by you, the defendant may have the right to obtain the psychotherapy records and/or testimony by the attending psychotherapist. In couple and family therapy, or when different family members are seen individually, confidentiality and privilege do not apply between the couple or among family members. The attending psychotherapist will use his/her clinical judgment when revealing such information. The attending psychotherapist will not release records to any outside party unless he is authorized to do so by all adult family members who were part of the treatment.

Emergencies: If there is an emergency during our work together, or in the future after the end of therapy where the attending psychotherapist becomes concerned about your personal safety, the possibility of you injuring someone else, or about you receiving proper psychiatric care, he/she will do whatever he/she can within the limits of the law, to prevent you from injuring yourself or others and to ensure that you receive the proper medical care. For this purpose, he/she may also contact the person whose name you have provided on the biographical form.

Health Insurance & Confidentiality of Records: Disclosure of confidential information may be required by your health insurance carrier or HMO/PPO/MCO/EAP in order to process the claims. If you instruct the attending psychotherapist only the minimum necessary information will be communicated to the carrier. The attending psychotherapist has no control or knowledge over what insurance companies do with the information he submits or who has access to this information. You must be aware that submitting a mental health invoice for reimbursement or a treatment report required by the insurance company carries a certain amount of risk to confidentiality, privacy or to future capacity to obtain health or life insurance.

Confidentiality of E-mail, Cell Phone and Faxes Communication: It is very important to be aware that e-mail and cell phone communication can be relatively easily accessed by unauthorized people and hence, the privacy and confidentiality of such communication can be compromised. E-mails, in particular, are vulnerable to such unauthorized access due to the fact that servers have unlimited and direct access to all e-mails that go through them. Faxes can easily be sent erroneously to the wrong address. Please notify the attending psychotherapist at the beginning of treatment if you decide to avoid or limit in any way the use of any or all of the above-mentioned communication devices. Please do not use e-mail or faxes for emergencies.

Litigation Limitation: Due to the nature of the therapeutic process and the fact that it often involves making a full disclosure with regard to many matters which may be of a confidential nature, it is agreed that should there be legal proceedings (such as, but not limited to divorce and custody disputes, injuries, lawsuits, etc.), neither you (client's) nor your attorney's, nor anyone else acting on your behalf will call on the attending psychotherapist to testify in court or at any other proceeding, nor will a disclosure of the psychotherapy records be requested.

Consultation: The attending psychotherapist consults with other professionals regarding his clients; however, a client's name or other identifying information is never mentioned. The client's identity remains completely anonymous, and confidentiality is fully maintained.

*Considering all of the above exclusions, if it is still appropriate, upon your request, the attending psychotherapist will release information to any agency/person you specify unless the attending psychotherapist assesses that releasing such information might be harmful in any way.

TELEPHONE & EMERGENCY PROCEDURES: If you need to contact the attending psychotherapist between sessions, please leave a message on the answering machine or voice mail, and your call will be returned as soon as possible. The attending psychotherapist checks his/her messages a few times a day, unless he/she is out of town. If an emergency situation arises, please indicate it clearly in your message. If you need to talk to someone right away, you can call 1-800-LIFENET (1-800-543-3638), the Police (911), or other Crisis Hotlines listed in the Customer Guide section of your Phone Book. Your Insurance Company may also have a 24-hour crisis line available.

PAYMENTS (Private Pay & Out-of-Network): Clients are expected to pay the standard fee of per 55-minute session at the beginning or end of each session unless other arrangements have been made. The fee schedule is as follows:
Individual - $125/55 minutes
Couples or family - $275/60 minutes, $350/90 minutes Insurance plans are accepted, as well as out-of-network

If you are unable to afford the standard fee, you may discuss other fee arrangements with the attending psychotherapist. Payment is required prior or at the time services are rendered. You can pay for services by check, cash, credit card or PayPal. Please have your PayPal payments sent or your check made out before your session to maximize our time together. All payments are to be made payable to Inspired Leadership Consulting and Therapy Services.

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Telephone conversations over 10 minutes, site visits, report writing and reading, consultation with other professionals, releasing information, reading records, longer sessions, travel time, etc. will be charged at the same standard rate (per 45 minutes), unless indicated and agreed otherwise. Please notify the attending psychotherapist if any problem arises during the course of therapy regarding your ability to make timely payments. Clients who carry insurance should remember that professional services are rendered and charged to the clients and not to the insurance company. You may arrange with the attending psychotherapist for him/her to provide you with a copy of your receipt on a weekly basis, which you can then submit to your insurance company for reimbursement if you so choose. As indicated in the section Health Insurance & Confidentiality of Records, you must be aware that submitting a mental health invoice for reimbursement carries a certain amount of risk. NOT ALL ISSUES/CONDITIONS/PROBLEMS, WHICH ARE THE FOCUS OF PSYCHOTHERAPY, ARE REIMBURSED BY INSURANCE COMPANIES. IT IS YOUR RESPONSIBILITY TO VERIFY THE SPECIFICS OF YOUR COVERAGE.

THE PROCESS OF THERAPY/EVALUATION: Participation in therapy can result in a number of benefits to you (or your child, if your child is being seen). These include improving interpersonal relationships, reduction or elimination of symptoms, and resolution of the specific concerns that led you to seek therapy. Working toward these benefits, however, requires effort on your part. Psychotherapy requires your very active involvement, honesty, and openness in order to change your thoughts, feelings and/or behavior. The attending psychotherapist will ask for your feedback and views on your therapy, its progress and other aspects of the therapy and will expect you to respond openly and honestly. Sometimes more than one approach can be helpful in dealing with a certain situation. During evaluation or therapy, remembering or talking about unpleasant events, feelings, or thoughts can result in you experiencing discomfort or strong feelings of anger, sadness, worry, fear, etc. or experiencing anxiety, depression, insomnia, etc. The attending psychotherapist may challenge some of your assumptions or perceptions or propose different ways of looking at, thinking about, or handling situations which may cause you to feel upset, angry, depressed, challenged or disappointed. Attempting to resolve issues that brought you to therapy in the first place may result in changes that were not originally intended. Disruptions in your life and emotional distress may occur. Psychotherapy may result in decisions about changing behaviors, employment, substance use, schooling, housing or relationships. Sometimes a decision that is positive for one family member is viewed quite negatively by another family member. Change will sometimes be easy and swift, but more often it will be slow and even frustrating. There is no guarantee that psychotherapy will yield positive or intended results. During the course of therapy, the attending psychotherapist is likely to draw on various psychological approaches according, in part, to the problem that is being treated and his assessment of what will best benefit you. These approaches include psychodynamic, cognitive behavioral, developmental, family/systems, play therapy (for children), transpersonal (spiritual), person-centered treatment, or psycho educational.

Discussion of Treatment Plan: Within a reasonable period of time after beginning treatment, the attending psychotherapist will discuss with you (client) his/her working understanding of the problem, treatment plan, therapeutic objectives and his/her view of the possible outcomes of treatment. If it is possible to estimate length of treatment, the attending psychotherapist will try to answer your questions in this area, but frequently it is only possible to give general, not specific, estimates of length of treatment. If you have any unanswered questions about any of the procedures used in the course of your therapy, their possible risks, the attending psychotherapist expertise in employing them, or about the treatment plan, please ask and he/she will answer them. You also have the right to ask about other treatments for your condition and their risks and benefits. If you could benefit from any treatment that the attending psychotherapist does not provide, he/she will assist you in obtaining those treatments.

Ending Therapy: After the first couple of meetings, the attending psychotherapist will assess if he/she can be of benefit to you. The attending psychotherapist does not accept clients who, in his opinion, he cannot help. In such a case, he will give you referrals that you can contact. If at any point during psychotherapy the attending psychotherapist assesses that he/she is not effective in helping you reach the therapeutic goals he will discuss it with you and, if appropriate, terminate treatment. In such a case, he would give you referrals that may be of help to you. If you request it and authorize it in writing, the attending psychotherapist will talk to the psychotherapist of your choice in order to help with the transition. If at any time you want another professional's opinion or wish to consult with another therapist, the attending psychotherapist will assist you in finding someone qualified, and if he/she has your written consent, he will provide her or him with the essential information needed. You may choose to end therapy at any time, but it is usually best to discuss this with the attending psychotherapist so he/she can assess whether it might be in your best interest to continue therapy. Whatever may be the attending psychotherapist view on this, you have the right to make your own decision. If you choose to end therapy, the attending psychotherapist will offer to provide you with names of other professionals whose services you might prefer.

TELEMENTAL HEALTH: Telemental health requires prior written consent for all clients.  Clients are required to participate in a secure location that provides confidentiality and is compliant with HIPAA regulations.  Inspired Leadership ensures that all providers will comply with HIPAA requirements and utilizes Counsol.com to ensure a secure site.  In case of emergencies, telemental health service clients will be expected to contact 911 emergency services.  For non-emergencies, telemental health clients will be able to contact the clinician at 240-696-9200 for connectivity issues or another number designated by the clinician.  

CANCELLATION: Since scheduling of an appointment involves the reservation of time specifically for you, a minimum of 24 hours (1 days) notice is required for rescheduling or canceling an appointment. Unless we reach a different agreement, the full fee will be charged for sessions missed without such notification. Most insurance companies do not reimburse for missed sessions so you will be responsible for this fee. The debit or credit card number provided at the point of intake will be charged for the full fee of the session.

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 we 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 NASW Code of Ethics. It also describes your rights regarding how you may gain access to and control your PHI.

We are required by law to maintain the privacy of PHI and to provide you with notice of our legal duties and privacy practices with respect to PHI. We are required to abide by the terms of this Notice of Privacy Practices. We 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 we maintain at that time. We will provide you with a copy of the revised Notice of Privacy Practices by posting a copy on our website, sending a copy to you in the mail upon request or providing one to you at your next appointment.

HOW WE 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. We may disclose PHI to any other consultant only with your authorization.

For Payment. We may use and disclose PHI so that we 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, we will only disclose the minimum amount of PHI necessary for purposes of collection.

For Health Care Operations. We may use or disclose, as needed, your PHI in order to support our business activities including, but not limited to, quality assessment activities, employee review activities, licensing, and conducting or arranging for other business activities. For example, we may share your PHI with third parties that perform various business activities (e.g., billing or typing services) provided we 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, we must disclose your PHI to you upon your request. In addition, we must make disclosures to the Secretary of the Department of Health and Human Services for the purpose of investigating or determining our 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 us to disclose information about you without your authorization only in a limited number of situations.

As a social worker licensed in this state and as a member of the National Association of Social Workers, it is our 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 NASW Code of Ethics and HIPAA.
Child Abuse or Neglect. We 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. We may disclose your PHI pursuant to a subpoena (with your written consent), court order, administrative order or similar process.

Deceased Patients. We 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. We may use or disclose your PHI in a medical emergency situation to medical personnel only in order to prevent serious harm. Our staff 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. We 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, we 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. We 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. We 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, we 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. We 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.

Fundraising. We may send you fundraising communications at one time or another. You have the right to opt out of such fundraising communications with each solicitation you receive.
Verbal Permission. We 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 we have already made a use or disclosure based upon your authorization. The following uses and disclosures will be made only with your written authorization: (i) most uses and disclosures of psychotherapy notes which are separated from the rest of your medical record; (ii) most uses and disclosures of PHI for marketing purposes, including subsidized treatment communications; (iii) disclosures that constitute a sale of PHI; and (iv) other uses and disclosures not described in this Notice of Privacy Practices.

YOUR RIGHTS REGARDING YOUR PHI
You have the following rights regarding PHI we maintain about you. To exercise any of these rights, please submit your request in writing to our Privacy Officer at:
Orin Howard
11720 Beltsville Drive

Suite 500-A18

Beltsville, Maryland 20705

- 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. We 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 we have about you is incorrect or incomplete, you may ask us to amend the information although we are not required to agree to the amendment. If we deny your request for amendment, you have the right to file a statement of disagreement with us. We may prepare a rebuttal to your statement and will provide you with a copy. Please contact the Privacy Officer 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 we make of your PHI. We 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. We are 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, we are required to honor your request for a restriction.

- Right to Request Confidential Communication. You have the right to request that we communicate with you about health matters in a certain way or at a certain location. We will accommodate reasonable requests. We 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. We 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, we 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 we have violated your privacy rights, you have the right to file a complaint in writing with our Privacy Officer at 1120 Crosspointe Lane Suite 4B, Webster, NY 14580, 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.
The effective date of this Notice is January 1, 2016.