Your psychotherapist is Kila Hillman-Sena, MA, LPCC, a Professional Clinical Mental Health Counselor, NM License #CCMH0185581, and independent contractor with Santa Fe Psychology. She provides both in person sessions in Santa Fe and Teletherapy throughout New Mexico. She has her own private office and contact information: 

Business Cell (text/calls): 505-919-8037  Email: kila@kilahillman.net

Office Address (for in person sessions): 17 Scenic Mesa Rd, Santa Fe, NM 87508

Teletherapy Link: a Zoom link will be automatically generated in your confirmation emails 

Website:  www.kilahillman.net

The confidential information gathered in this form is to help Kila gather important information about you, provide you with information about her practice, as well as, sign the necessary forms. Some common answers are pre-selected, for the purpose of expedience, which you may change if they do not apply to you. Kila looks forward to her first session with you.

 

NOTICE OF POLICIES AND PRACTICES TO PROTECT YOUR HEALTH INFORMATION

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

I. Uses and Disclosures for Treatment, Payment, and Health Care Operations

Your clinician may use or disclose your protected health information (PHI), for treatment, payment, and health care operations purposes with your consent. To help clarify these terms, here are some definitions:

• “PHI” refers to information in your health record that could identify you.
• “Treatment, Payment and Health Care Operations”
  • Treatment is when your clinician provides, coordinates or manages your health care and other services related to your health care. An example of treatment would be when he/she consults with another health care provider, such as your family physician or another psychologist.
  • Payment is when your clinician obtains reimbursement for your healthcare. Examples of payment are when he/she discloses your PHI to your health insurer to obtain reimbursement for your health care or to determine eligibility or coverage.
  • Health Care Operations are activities that relate to the performance and operation of your clinician’s practice. Examples of health care operations are quality assessment and improvement activities, business-related matters such as audits and administrative services, and case management and care coordination.
• “Use” applies only to activities within your clinician’s office such as sharing, employing, applying, utilizing, examining, and analyzing information that identifies you.
• “Disclosure” applies to activities outside of your clinician’s office, such as releasing, transferring, or providing access to information about you to other parties.

II. Uses and Disclosures Requiring Authorization
Your clinician may use or disclose PHI for purposes outside of treatment, payment, and health care operations when your appropriate authorization is obtained. An “authorization” is written permission above and beyond the general consent that permits only specific disclosures. In those instances when yourclinician is asked for information for purposes outside of treatment, payment and health care operations, he/she will obtain an authorization from you before releasing this information. Your clinician will also need to obtain an authorization before releasing your psychotherapy notes. “Psychotherapy notes” are notes he/she has made about your conversation during a private, group, joint, or family counseling session, which have been kept separate from the rest of your psychological record. These notes are given a greater degree of protection than PHI.

You may revoke all such authorizations (of PHI or psychotherapy notes) at any time, provided each revocation is in writing. You may not revoke an authorization to the extent that (1) your clinician has relied on that authorization; or (2) if the authorization was obtained as a condition of obtaining insurance coverage, and the law provides the insurer the right to contest the claim under the policy.

III. Uses and Disclosures with Neither Consent nor Authorization
Your clinician may use or disclose PHI without your consent or authorization in the following circumstances:

• Child Abuse: In certain circumstances, he/she is required to report child abuse in a variety of forms, including neglect, to (1) a local law enforcement agency; (2) the office of the Department of Child, Youth and Family Services in the county where the child resides; or (3) tribal law enforcement or social services agencies for any Indian child residing in Indian country.
• Adult and Domestic Abuse: If he/she has reasonable cause to believe that an incapacitated adult is being abused, neglected or exploited, they must immediately report that information to the Department of Child, Youth and Family Services.
• Health Oversight: If the New Mexico Board of Psychology is conducting an investigation, he/she is required to disclose your mental health records upon receipt of a subpoena from the Board.
• Judicial or Administrative Proceedings: If you are involved in a court proceeding and a request is made for information about your diagnosis and treatment and the records thereof, such information is privileged under state law, and he/she may not release information without written authorization from you or your personal or legally-appointed representative, or a court order. The privilege does not apply when you are being evaluated for a third party or where the evaluation is court-ordered. You will be informed in advance if this is the case.
• Serious Threat to Health or Safety: When he/she judges that a disclosure of confidential information is necessary to protect against a substantial and imminent risk that you will inflict serious harm on yourself or another person, he/she has a duty to report this information to the appropriate people who would address such a risk (i.e. the police or the potential victim).
• Worker’s Compensation: When a claim is filed, he/she is required by law to release those records that are directly related to any injuries or disabilities claimed by you (for which you are receiving benefits from your employer) to you, your employer, your employer’s insurer, a peer review organization or the health care selection board.

IV. Patient's Rights and Therapist's Duties Patient’s Rights:
• Right to Request Restrictions -- You have the right to request restrictions on certain uses and disclosures of protected health information about you. However, your clinician is not required to agree to a restriction you request.
• Right to Receive Confidential Communications by Alternative Means and at Alternative Locations – You have the right to request and receive confidential communications of PHI by alternative means and at alternative locations. (For example, you may not want a family member to know that you are being seen by your clinician. Upon your request, he/she will send your bills to another address.)
• Right to Inspect and Copy – You have the right to inspect or obtain a copy (or both) of PHI in your clinician's mental health and billing records used to make decisions about you for as long as the PHI is maintained in the record. He/she may deny your access to PHI under certain circumstances, but in some cases, you may have this decision reviewed. On your request, he/she will discuss with you the details of the request and denial process.
• Right to Amend – You have the right to request an amendment of PHI for as long as the PHI is maintained in the record. Your clinician may deny your request. On your request, he/she will discuss with you the details of the amendment process.
• Right to an Accounting – You generally have the right to receive an accounting of disclosures of PHI for which you have neither provided consent nor authorization (as described in Section III of this Notice). On your request, your clinician will discuss with you the details of the accounting process.
• Right to a Paper Copy – You have the right to obtain a paper copy of the Notice from your clinician upon, request, even if you have agreed to receive the notice electronically

V. Therapist’s Duties
• Your clinician is required by law to maintain the privacy of PHI and to provide you with a notice of him/her legal duties and privacy practices with respect to PHI.
• Your clinician reserves the right to change the privacy policies and practices described in this notice. Unless he/she notifies you of such changes, however, he/she is required to abide by the terms currently in effect.
• If your clinician revises their policies and procedures, he/she will mail you a revised notice. A copy will also be posted in the office.

VI. Complaints
If you are concerned that your clinician has violated your privacy rights, or you disagree with a decision made about access to your records, you may contact them at 505-795-5566. You may also send a written complaint to the Secretary of the U.S. Department of Health and Human Services. Your clinician can provide you with the appropriate address upon request.

VII. Effective Date, Restrictions and Changes to Privacy Policy
This notice will go into effect on January, 2012. Your clinician reserves the right to change the terms of this notice and to make the new notice provisions effective for all PHI that he/she maintains. Your clinician will provide you with a revised notice by mail.

Your signature below indicates that you have received and read the New Mexico Notice of Policies and Practices Concerning the Protection of your Heath Information and have all of your questions answered.

This agreement contains important information about your clinician's professional services. It also contains summary information about the Health Insurance Portability and Accountability Act (HIPAA), a federal law that provides privacy protections and patient rights with regard to the use and disclosure of your Protected Health Information (PHI). HIPAA requires that your clinician provide, you with a Notice of Privacy. The Notice, which is attached to this Intake Form explains HIPAA practices (the Notice) for use and disclosure of PHI for treatment, payment, health insurance and its application to your personal health information in greater detail. The law requires that your clinician obtain your signature acknowledging that you have been provided this information.

PSYCHOLOGICAL SERVICES
Psychotherapy is not easily described in general statements. It varies depending on the personalities of the clinician and patient, and the particular problems you are experiencing. There are many different methods your clinician may use to deal with the problems that you hope to address. Psychotherapy is not like a medical doctor visit. It calls for a very active effort on your part. Psychotherapy can have benefits and risks. Since therapy often involves discussing difficult aspects of your life, you may experience uncomfortable feelings. On the other hand, psychotherapy is shown to have many benefits. Therapy often leads to better relationships, solutions to specific problems, and significant reductions in feelings of distress. But there are no guarantees of what you will experience.

The first few sessions together will involve diagnosis and an evaluation of your needs. By the end of the evaluation, your clinician, Kila Hillman-Sena MA, LPCC will be able to offer you some first impressions of what the work and treatment will include, if you decide to continue with therapy. You should evaluate this information along with your own opinions of whether you feel comfortable working with her. If you have questions you should discuss them with her whenever they arise. If your doubts persist, she will help you set up a meeting with another mental health professional for a second opinion, if you wish.

MEETINGS
Your clinician normally conducts an assessment that will last from 2 to 6 sessions. During this time, you and Kila can both decide if she is the best person to provide the services you need in order to meet your treatment needs. If psychotherapy is begun, individual therapy will generally be one 53 minute session per week and family and couples sessions will generally be one 45 minute session per week, although sessions may vary in length or they may more frequent if needed. 

PROFESSIONAL FEES
The private pay fee for professional services with Kila is $120.00 per session, including counseling appointments, report writing, telephone conversations, telehealth sessions, consulting with other professionals, with your permission, preparation of records or treatment summaries, and the time spent performing any other service you may request. Kila does not provide court services, as it is out of the scope of her practice. If she involuntarily sapoenaed by a judge, and required to participate in court on your behalf you will be expected to pay for that professional time, including preparation and transportation time. Your clinician charges $300.00 per hour for attendance at any legal proceedings. Once an appointment is scheduled, you will be expected to pay for it unless you provide 24 hours advance notice of cancellation. Insurance companies do not provide reimbursement for cancelled sessions.

CONTACTING YOUR CLINCIAN
Kila's business phone is 505-919-8037 where she can receive text and phone calls.  Her email is kila@kilahillman.net. Due to her work schedule, your clinician may not be immediately available by telephone. She will make every effort to return your call on the same day you make it, with the exception of weekends and holidays. If you are difficult to reach, please inform her of some times when you will be available. If you are unable to reach her and feel that you can’t wait for a return call, contact the Santa Fe Crisis line at 505-820-6333, call your family physician, call 911 or go to the nearest emergency room and ask for the clincian on call. If your clinician is unavailable for an extended time, she may provide you with the name of a colleague to contact, if necessary.

LIMITS ON CONFIDENTIALITY
The law protects the privacy of all communications between a patient and a mental health professional. In most situations, your clinician can only release information about your treatment to others if you sign an authorization form that meets certain legal requirements. There are other situations that require only that you provide written, advance consent. Your signature on this agreement provides consent for those activities, as follows:
• Your clinician may occasionally find it helpful to consult other health and mental health professionals. During a consultation, she will make every effort to avoid revealing the identity of her patients. The other professionals are also legally bound to keep the information confidential. If you don’t object, she will not tell you about these consultations unless they feel that it is important to your work together. Your clinician will note all consultations in your chart.
• You should be aware that your clinician practices with other mental health professionals, employees and administrative staff. In most cases, she may need to share protected information with these individuals for clinical or administrative purposes, such as scheduling, billing and quality assurance. All of the mental health professionals are bound by the same rules of confidentiality. All staff members have received special training on how to protect your privacy and have sworn not to release any information outside of the practice without the permission of a professional staff member.
• Your clinician may also have contracts with business associates, such as bookkeepers and accountants. As required by HIPAA, she has formal business associate contracts with these businesses in which they promise to maintain the confidentiality of this data except as specifically allowed in the contract or otherwise required by law. If you wish, he/she can provide you with the names of these organizations and/or a blank copy of this contract.
• Disclosures required by health insurers or to collect overdue fees are discussed elsewhere in this Agreement. There are some situations in which your clinician is permitted or required to disclose information without either your consent or authorization.
• If you are involved in a court proceeding and a request is made for information concerning your diagnosis and treatment, such information is protected by the therapist-patient privilege law. Your clinician cannot provide any information without your (or your personal or legally-appointed representative’s) written authorization, or a court order by a judge. If you are involved in or contemplating litigation, you should consult with your attorney to determine whether a judge would be likely to order her to disclose information.
• If a government agency is requesting the information for health oversight activities, your clinician may be required to provide it for them.
• If a patient files a complaint or lawsuit against your clinician may disclose relevant information regarding that patient in order to defend herself. There are some situations in which your clinician is legally obligated to take action. When she determines it is necessary to attempt to protect a patient or others from harm, she may have to reveal some information about a patient’s treatment. These situations are uncommon in your clinician's practice.
• If your clinician knows or has reasonable cause to believe that a child under 18 is an abused or a neglected child, the law requires that she immediately report the matter to an appropriate governmental agency, usually the Child, Youth and Family Department in the county where the child resides. Once such a report is filed, she may be required to provide additional information.
• If your clinician has reasonable cause to believe that an incapacitated adult is being abused, neglected or exploited, she must immediately report that information to Adult Protective Services. Once such a report is filed, she may be required to provide additional information.
• If your clinician believes that a patient presents a substantial and imminent risk of serious harm to another, she may be required to take protective actions. These actions may include notifying the potential victim, contacting the police, or seeking hospitalization for the patient.
• If a patient threatens a substantial risk or serious harm to himself, your clinician may be obligated to seek hospitalization for them, or to contact family members or others who can help provide protection if such a situation arises, your clinician will make every effort to fully discuss it with you before taking any action and she will limit their disclosure to what is necessary. While this written summary of exceptions to confidentiality should prove helpful in informing you about potential problems, it is important that you discuss any questions or concerns that you may have now or in the future with your clinician. The laws governing confidentiality can be complex, and we are not attorneys. In situations where specific advice is required, formal legal advice may be needed.

PROFESSIONAL RECORDS
The laws and standards of our profession require that your clinician keep Protected Health Information (PHI) about you in your Clinical Record. Except in unusual circumstances that involve danger to yourself and/or others or where information has been supplied to him/her confidentially by others, you may examine and/or receive a copy of your Clinical Record, if you request it in writing. Because these are professional records, they can be misinterpreted and/or upsetting to untrained readers. For this reason, your clinician recommends that you initially review them in the her presence, or have them forwarded to another mental health professional so you can discuss the contents. In most circumstances, your clinician charges a copying fee of $.25 per page (and for certain other expenses). If your clinician refuses your request for access to your records, you have a right of review, which she will discuss with you upon request.

PATIENT RIGHTS
HIPAA provides you with several rights with regard to your Clinical Records and disclosures of protected health information. These rights include requesting that your  clinician amend your record; requesting restrictions on what information from your Clinical Record is disclosed to others; requesting an accounting of most disclosures of protected health information that you have neither consented to nor authorized; determining the location to which protected information disclosures are sent; having any complaints you make about policies and procedures recorded in your records; and the right to a paper copy of this Agreement, the attached Notice form, and your clinician’s privacy policies and procedures. Your clinician will be happy to discuss any of these rights with you.

BILLING AND PAYMENTS
You will be expected to pay for each session at the time it is held, unless your clinician agrees otherwise or unless you have insurance coverage that requires another arrangement. Payment schedules for other professional services will be agreed to when they are requested. In circumstances of unusual financial hardship, your clinician may be willing to negotiate a fee adjustment or payment installment plan. For returned checks a $4.00 insufficient charge will be billed. If your account has not been paid for more than 120 days and arrangements for payment have not been agreed upon, your clinician has the option of using legal means to secure the payment. This may involve hiring a collection agency or going through small claims court which will require the disclosure of otherwise confidential information. In most collection situations, the only information your clinician releases regarding a patient’s treatment is his/her name, the nature of services provided, and the amount due. If such legal action is necessary, its costs will be included in the claim.

MISSED APPOINTMENTS AND LATE CANCELLATION POLICY
• I understand that if I miss a scheduled appointment, or cancel less than 24 hours before the appointment, I am responsible for paying the cost of the appointment.
• I understand that if I miss an appointment, or do not cancel with 24 hour notice, which involves another party with whom I am sharing the cost, I am responsible for the total cost of the appointment.
• I understand that Kila is not able to bill my insurance for missed appointments and that I may be charged for the cost of that appointment.
• The standard fee for a missed session is $120 per session unless otherwise agreed upon by your clinician.

INSURANCE REIMBURSEMENT

In order for us to set realistic treatment goals and priorities, it is important to evaluate what resources you have available to pay for your treatment. If you have a health insurance policy, it will usually provide some coverage for mental health treatment. Your clinician will fill out forms and provide you with whatever assistance we can in helping you receive the benefits to which you are entitled; however, you (not your insurance company) are responsible for full payment of fees. It is very important that you find out exactly what mental health services your insurance policy covers. You should carefully read the section in your insurance coverage booklet that describes mental health services. If you have questions about the coverage, call your plan administrator. Your clinician will provide you with whatever information she can based on her experience and will be happy to help you in understanding the information you receive from your insurance company. If it is necessary to clear confusion, your clinician is willing to call the company on your behalf. Due to the rising costs of health care, insurance benefits have increasingly become more complex. It is sometimes difficult to determine exactly how much mental health coverage is available. “Managed Health Care” plans such as HMOs and PPOs often require authorization before they provide reimbursement for mental health services. These plans are often limited to short-term treatment approaches designed to work out specific problems that interfere with a person’s usual level of functioning. It may be necessary to seek approval for more therapy after a certain number of sessions. While much can be accomplished in shortterm therapy, some patients feel they need more services after insurance benefits end. You and your clinician may discuss the options you have under such circumstances. Once your clinician has all of the information about your insurance coverage, she will discuss what we can expect to accomplish with the benefits that are available and what will happen if they run out before you feel ready to end your therapy. It is important to remember that you always have the right to pay for services yourself to avoid the problems described above unless prohibited by contract.

You should also be aware that your contract with your health insurance company requires that your clinician provide it with information relevant to the services that are provided to you. Your clinician is required to provide a clinical diagnosis. Sometimes your clinician is required to provide additional clinical information such as treatment plans or summaries, or copies of your entire Clinical Record. In such situations, your clinician will make every effort to release only the minimum information about you that is necessary for the purpose requested. This information will become part of the insurance company files and will probably be stored in a computer. Though all insurance companies claim to keep such information confidential, your clinician has no control over what they do with it once it is in their hands. Your clinician will provide you with a copy of any report she submits, if you request it. 

By signing this Clinician-Patient Services Agreement, you agree that your clinician can provide requested information to your insurance carrier, "I hereby authorize the release of medical information to my insurance company". If insurance claims are filed through this office, "I hereby authorize medical benefits for those services to be paid to this office.” Furthermore, it will also represent an agreement between us concerning the clinician-patient services agreements as outlined in this document, that your questions have been answered, and that you understand the written information provided above. 

Definition of Telehealth 

Telehealth means the use of electronic information, imaging, and communication technologies, including interactive audio, video, data communications, store-and-forward technologies, to provide and support health care delivery, diagnosis, consultation, treatment, transfer of medical data, and education.

While we strive to use Health Insurance Portability and Accountability Act (HIPPA, a US law designed to provide privacy standards to protect patients' medical records and other health information provided to health plans, doctors, hospitals and other health care providers) platforms to provide care (offering the highest level of confidentiality and protection of information) we are currently using other non-HIPPA compliant platforms, such as FaceTime, Google Duo, Zoom, and phone calls among others. We will strive to use the HIPPA compliant platform when possible, but to continue therapy we will use other means when necessary. These other platforms are not HIPPA compliant and do not have the same level of security/confidentiality and carry more risks of being intercepted. We are offering these alternative services because we are taking into account the benefit of continued care versus the risk of information being intercepted. We believe that continuing to offer care outweighs the risks of interception, although you are able to decline care if you are uncomfortable using a non-HIPPA compliant platform.

How to Use Telehealth Technology

Your therapist, Kila, will give you instructions on how to access teletherapy sessions directly. 

What to do if an Urgent Situation Arises between Telehealth Sessions

If you experience an urgent/emergent situation in between your telehealth sessions, please call your therapist, Kila, other work cell at 505-919-8037. If  she does not answer, please leave a message and she will contact you back as soon as she is able. At that time, you and Kila will determine the best course of action, which may include setting up a more timely session. If there is a medical  emergency, such as suicidal or homicidal thoughts, call the Santa Fe Crisis number at 1-855-662-7474 or 911 immediately.

Consent for Teletherapy Treatment

I agree to participate in a telehealth psychotherapy sessions. By signing this agreement, I authorize the electronic transmission of my medical information and/or videoconference session so that it can be viewed by my therapist and other persons involved in my medical or mental health care (Note: The likelihood of this transmission being intercepted by persons other than those at Santa
Fe Psychology is small). Reasonable and appropriate efforts have been made to eliminate any confidentiality risks associated with telehealth session, and all existing confidentiality protections under federal and New Mexico state law apply to information disclosed during your telehealth sessions.

I understand that I can withdraw my permission at any time and that I do not have to answer any questions that I consider to be inappropriate or am unwilling to have heard by other persons. I understand that if I do not choose to participate in a telehealth session, no action will be taken against me that will cause a delay in my care and that I may still pursue face-to-face sessions when my therapist returns to the office. I understand that as with any technology, telehealth does have its limitations.  All existing laws regarding your access to medical information and copies of your medical records apply to your telehealth sessions. Please note, that your telecommunications are not recorded or stored. I understand that medical records of telehealth services will be kept electronically on Santa Fe Psychology’s Electronic Medical Record system, Carepaths, and Jotforms, both of which are Hippa compliant. You have been advised of all the potential risks, consequences and benefits of telehealth. Your therapist has discussed with you the information provided above. You had the opportunity to ask questions about the information presented on this form and the telehealth session. All of your questions have been answered, and you understand the written information provided above. There will be an opportunity at the end of this Intake Form to print a copy for your records.  Your therapist will keep the original copy and we can provide you a copy if needed.

YOU HAVE THE OPTION of releasing and exchanging your confidential behavioral health and medical information between Kila Hillman-Sena, MA, LPCC/Santa Fe Psychology, your primary care physician, and/or other healthcare practitioner's to promote the continuity and coordination of your behavioral health care and general medical care. This consent is automatically renewable each year and the confidential information that is exchanged will be kept by the recipient until such time as state law allows destruction of my patient record. This authorization may be revoked, in writing, at any time, except to the extent that any action has been taken in reliance thereon, and you legal representative is entitled to a copy of this form. 

CONSENT FOR BEHAVIORAL CARE AND PRIMARY CARE PHYSICIAN (PCP) COORDINATION OF CARE FORM (optional)