Thank you for choosing Counseling Associates. The first step to beginning the counseling process is to complete this paperwork as completely as you can. We know most people don't like this part. That's why we have condensed this form as much as we can. Your counselor will read this form prior to your first session and ask for omitted information and clarify your responses. This form is critical to accurate billing and setting up your counseling goals.

Please have your insurance card ready, we will photocopy it for our records. We recommend calling the insurance company before (or during) the visit to verify copays and deductibles. Insurance company

Telehealth and Email

1. I understand that Counseling Associates has invited me to engage in a telehealth appointment to provide assessment and short-term counseling.

2. My provider has explained to me that video conferencing technology will not be the same as a direct patient provider visit due to the fact that I will not be in the same room as my provider.

3. I understand that there are potential risks associated with use of this technology such as interruptions, technical difficulties, and inability to obtain information sufficient for decision making about my problem and that all possible precautions will be taken to minimize these risks. In addition, my provider or I can discontinue the telehealth visit if it is felt that the information obtained through the telehealth connection is not adequate for decision-making or for implementing management of my issue(s In that event, we will complete the session by phone or schedule an in-person appointment at the location where adequate assessment and short term counseling can be provided, I understand that the information I provide may be shared only with other individuals at my provider's office for scheduling purposes.

4.The alternatives to a telehealth appointment/consultation have been explained to me.

Risks of using Email: Transmitting client information via email has possible risks that clients should consider. These include but are not limited to, the following: -Email can be circulated, forwarded, stored electronically and on paper, and broadcast to unintended recipients. .Email senders can easily misaddress an email. Backup copies of email may exist even after the sender of the recipient has deleted his or her copy. Employers and on-line services have a right to inspect email transmitted through their systems. -Email can be intercepted, altered, forwarded or used without authorization or detection. Email can be used to introduce viruses into computer systems.

HIPAA Policy for Counseling Associates Notice of Privacy Practices

THIS NOTICE DESCRIBES HOW YOUR MEDICAL INFORMATION MAY BE USED, DISCLOSED, AND HOW YOU CAN GAIN ACCESS TO THE INFORMATION. PLEASE REVIEW IT CAREFULLY.

Your Privacy Rights, Our Responsibilities Counseling Associates is required by law to protect the privacy of your health information and provide you with this Notice of Privacy Practices. This notice describes how we may use and share your health information and explains your privacy rights. The center will use or disclose your information only as described in this notice. We do, however, reserve the right to change our privacy practices and the terms of this notice and to make new provisions effective for all health information that we maintain. Revisions will be posted in the waiting area, and we will make a copy of revisions available to you upon your request. If at any time, you may have questions or concerns about the information in this notice or about our agency's privacy policies, procedures, or practices, you may contact Daniel Lee at 859-278-3456. Use and Disclosure of Protected Health Information That Requires Your Authorization Except as provided in this Notice of Privacy Practices, Counseling Associates will not use or disclose your health information without your written authorization. If you sign an authorization form, you may withdraw your authorization at any time, as long as your withdrawal is in writing. Your Rights Regarding Your Protected Health Information You have several rights with regard to your health information. Specifically, you have the right to: Obtain a paper copy of this notice. You may request a written copy at any time. Receive confidential communications. You have the right to request in writing that Counseling Associates only communicate to you in a certain format (e.g. in writing) and/or location (e.g. your work address We will accommodateall reasonable requests. Inspect and copy protected information. This right is subject to certain legal restrictions. For example, this right does not apply to psychotherapy notes or information compiled for judicial proceedings. You may be charged a fee for copying or postage. Request restrictions on certain uses and disclosures. You have the right to ask for restrictions on how your health information is used or to whom your information is disclosed. We are not required to agree to your requested restriction, but we will consider your request and the possibility of accommodating it. Request to amendment. You have a right to request in writing that portions of your records be corrected when you feel information is incorrect or incomplete. We may deny your request if the information was not created by this agency or if we believe the information is accurate. Complain. If you believe your health information privacy rights have been violated, you may contact the OCR Regional Manager, Office for Civil Rights, U.S. Department of Health and Human Services, Atlanta Federal Center, Suite 3B70, 61 Forsyth St., S.W., Atlanta, GA 30303-8909, (404) 562-7886. If you file a complaint, we will not take any action against you or change our treatment of you.

INFORMED CONSENT AND COUNSELING AGREEMENT

It is important that you read this carefully before our first session. We can discuss any questions you have at that time.

We accept only cash, check and credit card (including HSA) for payment. The fee for each 50-minute, in-person session is $130.00. Unless we make other arrangements, fees are the responsibility of the client and are payable at the beginning of each session. We will file your insurance claims for you, but you are ultimately responsible for the services provided.

CONFIDENTIALITY, PRIVILEGE, AND PRIVACY

Within our intake packet, we provide information about the Health Insurance Portability and Accountability Act (HIPAA) of 1996. HIPAA provides privacy protections and client rights regarding the use and disclosure of Protected Health Information (PHI PHI is used to manage your treatment, handle payments, and facilitate health care practice operations. HIPAA requires that you be provided with a Notice of Privacy Practices. Your Protected Health Information, treatment, and professional record are confidential except as otherwise noted in this document.

EXCEPTIONS TO CONFIDENTIALITY, PRIVILEGE, AND PRIVACYOver the past few decades, the courts and legislatures have set forth certain exceptions to confidentiality and we may be mandated by law to disclose certain material. For example, we are mandated to report any suspected child or elder (vulnerable adult) abuse; we must also intervene if we feel you are in imminent danger of harming yourself or others. In certain cases, when we am subpoenaed or court ordered to produce information, we may have to comply with such mandates. Unless prohibited by law, we will typically make efforts to contact you before turning over information in response to a subpoena or court order. You have the right to revoke a previously authorized release of information.

In regards to child abuse, if we have reason to suspect, on the basis of our professional judgment, that a child is or has been abused, we are required to report our suspicions to the authority or government agency authorized to conduct child abuse investigations. We are required to make such reports even if we do not see the child in our professional capacity. We are also mandated to report suspected child abuse if anyone tells us that he or she knows of any child who is currently being abused.

Also, if a client files a complaint or lawsuit against us or makes negative false statements about our practice or our clinicians, we may disclose relevant information regarding that client in order to defend ourselves. Additionally, if payments are delinquent, we may disclose needed information to a collection agency or attorney. The client is responsible for all costs associated with the collection. With your written permission, we may discuss your case (e.g., with other health care providers) or release your Protected Health Information to the individuals or entities you authorize.

ETHICS GUIDELINES We adhere to the American Counseling Association Code of Ethics.

LEGAL PROCEEDINGS We typically do not act as an expert witness in litigation and court proceedings. If you are in a lawsuit and you and your attorney decide to call one of our clinicians as a witness, we will charge for the time away from the practice in accordance with our normal hourly rate of $100.00 ($800.00 retainer is required prior to court appearance). This includes travel and preparation. If you are involved in or contemplating litigation, you may wish to consult with your attorney to determine whether your counseling communications may be protected by the professional counselor-client privilege law or whether such communications may be open to the other side in the lawsuit.

Psychotherapy and counseling is a major commitment on the part of the therapist and the client, requiring significant effort from each party. The client agrees to voluntarily attend all scheduled sessions, bring issues of concern to discuss, reflect on material between sessions, and pay for sessions in a timely manner. The therapist agrees to be present to the client, provide a safe arena for discussing issues, formulate a plan of action for addressing issues, and help the client find solutions to his or her problems. Considering the substantial commitment of time, money, and energy therapy requires, as well as its personal importance for your life, decisions about therapy deserve careful consideration.

Psychotherapy and counseling can have risks. Therapy often involves exploring unpleasant aspects of life so you may experience feelings like sadness, guilt, shame, frustration, anger and loneliness. On the other hand, psychotherapy has been shown to have many benefits. Therapy often leads to solutions for specific problems, significantly reduced distress, and improved relationships. Of course, there are no guarantees of what you will experience. Achieving good results from your therapy will depend on your full engagement in the process and on your motivation to change.

If you have questions of any kind, about your therapy or my procedures, we should discuss them whenever they arise. If our discussion does not satisfy you, we will be happy to help you set up a meeting with another mental health professional for a second opinion.

Appointments

To make appointments, clients should call 859-278-3456. In order to avoid a cancellation fee ($75.00), please give 24 hours notice of change. No fees will be charged for missing an appointment due to emergencies. Work conflicts do not qualify as emergencies.

Therapy sessions are typically 53-60 minutes long unless another arrangement is made prior to the appointment. The frequency and regularity of therapy sessions is important for the effectiveness of treatment and for practical reasons. If the frequency and/or scheduling is not working for you, it is your responsibility to alert us so that another alternative can be arranged.

Clients under the age of 18 will need the permission of a parent or guardian to receive services. The parent or guardian is responsible for all fees incurred by the minor client. The parent or guardian also has the right to request a copy of the minor client's health record. That record will include all intake information and psychotherapy session notes. While this is required by law, our clinicians believe and understand that the best form of therapy includes the expectation of privacy.

In keeping with generally accepted standards of practice, we frequently consult on a confidential basis with other mental health professionals regarding the management of cases. The purpose of consultation is to assure quality care. Every effort is made to protect the identity of clients.

CONTACTING US BY PHONE

When we are unavailable to answer telephone calls directly, you can leave a message on our work phone, 859-278-3456. No one other than myself can access these messages. Messages are checked regularly and calls returned at the first opportunity between the hours of 9am and 5pm. Please always leave your number and best time to call. If you are unable to reach us in the event of an emergency, contact your family physician or go to the nearest emergency room.

CONTACTING US BY EMAIL AND/OR TEXT

We use text and email communication only with your permission and only for administrative purposes. That means that email and text exchanges with our office should be limited to things such as setting and changing appointments, billing matters, and other related issues. Please do not email our clinicians about clinical matters.

Therapy is a professional relationship focused on the client's needs. For this reason, we limit contact with clients to matters directly related to therapy.

Treatment ends when the therapist and client agree that therapy goals have been met. The client may terminate prior to this time with a minimum of one full session's notice. If the client provides 24-hours' notice, the client will not be billed if the client decides to terminate.

Your signature below indicates that you have read the information in this document and agree to abide by its terms during our professional relationship.