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Terms and Policy

Notice of Privacy Practices
Apricity Behavioral Health, LLC

Notice of Privacy Practices 

Effective: November 17, 2017

THIS NOTICE DESCRIBES HOW MENTAL, BEHAVIORAL, MEDICAL AND OTHER HEALTH CARE INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY.

Apricity Behavioral Health,LLC (herein referred to as "Apricity") provides outpatient behavioral health and other counseling related services in a virtual environment with a headquarters mailing address of 752 Steeplechase Rd., Landisville, PA 17538. 

PURPOSE. We are required by law to maintain the privacy of your health information. This Notice describes our legal duties and privacy practices. This Notice tells you how we may use and disclose your health information. This Notice also describes your rights and how you may exercise your rights. Apricity agrees to abide by the terms of this Notice.

Your Protected Health Information. We refer to your mental, behavioral, medical and other health care information as "protected health information" or "PHI". "PHI" is health information we have collected in our records from you or received from other health care providers, health plans, or the county. It may include information about your past, present or future physical or mental health or condition. For example, PHI in your records could include your diagnosis, treatment plan, or evaluations. PHI also includes information about payment for services.


Confidentiality of Your PHI. Your PHI is confidential. We are required to maintain the confidentiality of your PHI by the following federal and Pennsylvania laws.The Health Insurance Portability and Accountability Act of 1996. The Department of Health and Human Services issued the following regulations: "Standards for Privacy of Individually Identifiable Health Information". We call these regulations the "HIPAA Privacy Regulations". We may not use or disclose your PHI except as required or permitted by the HIPAA Privacy Regulations. The HIPAA Privacy Regulations require us to comply with Pennsylvania laws that are more stringent and provide greater protection for your PHI.

Pennsylvania Mental Health Confidentiality Laws. For individuals who receive treatment and services in our mental health programs, Pennsylvania laws may provide greater protection for your PHI than the HIPAA Privacy Regulations. For example, we are not permitted to disclose or release PHI in response to a Pennsylvania subpoena. Also, any information acquired by a licensed social worker in the course of your treatment is privileged under Pennsylvania law and may not be released without your authorization or court order. Finally, if mental health records include information relating to drug or alcohol abuse or dependency, we are required to comply with the Pennsylvania Drug and Alcohol Abuse Control Act. We will comply with the Pennsylvania laws that are more stringent than the HIPAA Privacy Regulations and provide greater protection for your PHI.

Confidentiality of Drug and Alcohol Treatment Records. For individuals who receive treatment and services for drug or alcohol use, federal and Pennsylvania laws may provide more protection for your PHI than the HIPAA Privacy Regulations. We will comply with the federal and Pennsylvania laws that are more stringent than the HIPAA Privacy Regulations and provide greater protection for your PHI.

Confidentiality of HIV-Related Information. Pennsylvania laws may provide greater protection for PHI related to HIV as provided for in 35 P.S. 7601 ET. Seq. We will comply with Pennsylvania laws that are more stringent than the HIPAA Privacy Regulations and provide greater protection for your PHI.

Why this Notice is Important. The HIPAA Privacy Regulations require that we provide you with this Notice. The effective date of this Notice is November 17, 2017. We will post a current copy of the Notice on our website. We reserve the right to change the terms of this Notice at any time. The revised Notice will be posted on our website, and available to you upon request. The new Notice will be effective for all PHI that we maintain at that time and for information we receive in the future.


AUTHORIZATION TO DISCLOSE YOUR PHI

Except as described in this Notice, it is our practice to obtain your authorization before we disclose your PHI to another person or party. If you are receiving services in our mental health program, Pennsylvania law states that you are entitled to inspect the PHI before it is released. You may revoke an authorization, at any time, in writing. If you revoke an authorization, we will no longer use or disclose your PHI. However, we cannot undo any disclosures we have already made.

HOW WE MAY USE OR DISCLOSE YOUR PHI WITHOUT YOUR AUTHORIZATION

Uses and Disclosures for Treatment, Payment and Health Care Operations. Unless prohibited by more stringent Pennsylvania mental health, mental retardation, substance abuse or other laws, the HIPAA Privacy Regulations permit us to use and disclose your PHI for the following purposes in order to provide your treatment.

For Treatment. It is necessary for us to use your PHI to care for you. In order to help you, our clinicians and other staff need to use your PHI. For example, we may need to share your PHI with a case manager who is responsible for coordinating your care. We may disclose your PHI to another health care provider (e.g. primary care physician) for your treatment. When you are referred to another provider we are permitted to provide your PHI if it is necessary for the continuity of your care and treatment.

For Payment. We will use and disclose your PHI to obtain payment for our services. Before you receive services, we may disclose PHI to your insurance company, health plan, county, or other third party payer to permit them to: make a determination of eligibility or coverage; review the medical necessity of your services; review your coverage; or review the appropriateness of care or our charges. We will also use your PHI for billing, claims management, collection activities, and data processing. For example, a bill may be sent to you or whoever pays for your services. The bill may include PHI that identifies you as well as your diagnosis, procedures, and supplies used in the course of your treatment. We may also disclose PHI to another provider for payment activities of the provider that receives the PHI.

For Health Care Operations. We may use and disclose your PHI within the company in order to carry out our health care operations. For example, your PHI is used for: business management and general administrative duties; quality assessment and improvement activities; medical, legal, and accounting reviews; business planning and development; licensing and training. Our quality assurance team may use PHI in your record to assess the care and outcomes in your case and others like it. This information will then be used in an effort to improve the quality and effectiveness of the services we provide. In addition, we sometimes hire business associates to help in our operations. We are permitted to share your PHI with a "business associate" that performs or assists in various activities involving PHI (e.g., billing, transcription services, and auditors) for us. Whenever we engage a business associate we will have a written contract that contains terms that will protect the privacy of your PHI.

Other Uses and Disclosures. We may contact you to provide appointment reminders, or information about treatment alternatives or other health related benefits that may be of interest to you.

USES AND DISCLOSURES THAT MAY BE MADE WITHOUT YOUR AUTHORIZATION, BUT SUBJECT TO YOUR OPPORTUNITY TO AGREE OR OBJECT

Your Opportunity to Agree or Object to Certain Uses and Disclosures. It is our practice to obtain your written authorization prior to disclosing PHI to another person or party. However, as described in this section, it may be necessary to disclose your PHI without your written authorization (exception: no disclosure for Drug/Alcohol treatment). Under these circumstances, the HIPAA Privacy Regulations permit us to use or disclose PHI when you are present and have the capacity to make health care decisions if, prior to the use or disclosure, we obtain your agreement, provide you with an opportunity to object (and you do not express an objection), or we can reasonably inter from the circumstances, based upon our professional experience, that you do not object. If you are not present or the opportunity to obtain your agreement or objection cannot practicably be obtained due to your incapacity or an emergency, then we may in the exercise of professional judgment determine whether the disclosure is in your best interests and, if so, disclose only PHI that is directly relevant to that person's involvement in your case.

Family Members and Others Involved in Your Healthcare. Subject to your opportunity to agree or object, we may share your PHI with a family member, other relative, close personal friend, or any other person you identify (your "personal representative"). The PHI shared with your personal representative will be directly relevant to your personal representative's involvement with your care or payment for services. For example, your personal representative may act on your behalf by picking up forms or medical supplies for you.

Notification. Subject to your opportunity to agree or object, we may use or disclose PHI to notify, or assist in the notification of (including identifying or locating), a personal representative of your location, general condition, or death.

Disaster Relief. Subject to your opportunity to agree or object, we may use or disclose your PHI to a public or private entity (e.g. the American Red Cross) authorized by law or by its charter to assist in disaster relief efforts. The purpose of such use or disclosure of your PHI is to coordinate with a disaster relief agency and/or your personal representative your location, general condition, or death. Only specific information pertinent to the relief effort and the emergency may be released without your authorization.

Residential Facility Directories. If you are receiving services in one of our residential facilities, you may be entitled to receive telephone messages and visitors. We maintain a limited directory of persons living at each residential facility. Unless otherwise directed by you, with regard to messages or visitors, we will indicate that you live at and may be contacted at the facility.

OTHER PERMITTED AND REQUIRED USES AND DISCLOSURES THAT MAY BE MADE WITHOUT YOUR AUTHORIZATION

Introduction. Unless prohibited by more stringent Pennsylvania mental health, mental retardation, substance abuse laws or other laws, the HIPAA Privacy Regulations permit us to use or disclose your PHI without your authorization or agreement under the following circumstances.

As Required By Law. We will disclose PHI about you when required to do so by federal or Pennsylvania law. Any use or disclosure must comply with and be limited to the relevant requirements of the law. For example, we are required to report or disclose PHI related to child or elder abuse or neglect and commitment proceedings authorized by the Pennsylvania Mental Health Procedure Act of 1966.

Emergencies. We may use or disclose your PHI in an emergency treatment situation when use and disclosure of the PHI is necessary to prevent serious risk of bodily harm or death to you.

Public Health Activities. If required by federal or Pennsylvania law, we will disclose your PHI for public health activities in order to: prevent disease, injury or disability; report births and deaths; report child abuse or neglect; report reactions to medications; notify a person who may be at risk for contracting or spreading a disease or condition; or, notify appropriate government authorities if we believe a patient has been the victim of abuse, neglect or domestic violence, when required to do so by law or with your agreement. Only specific information required by law may be disclosed without your authorization.

Health Oversight Activities. If required by law, we may use or disclose PHI about you to a health oversight agency. A Health Oversight agency includes government agencies such as Medicare, Medicaid or county programs. Oversight activities include audits, accreditation, investigations, inspections, utilization review, and licensure of Pennsylvania Counseling Services, Inc.

To Avert a Serious Threat to Health or Safety. The HIPAA Privacy Regulations permit us to use and disclose PHI about you when necessary to prevent a serious and imminent threat to your health or safety or to the health or safety of the public or another person. Under these circumstances, we will only disclose health information to someone who is able to help prevent or lessen the threat. However, if you are receiving mental health services, more stringent Pennsylvania laws require our mental health professionals to exercise reasonable care to warn another person if you communicate a specific and immediate threat of serious bodily injury against a specific person or readily identifiable person. 

Disclosures in Legal Proceedings. We are not permitted by Pennsylvania law to disclose PHI regarding mental health or drug and alcohol services in response to a Pennsylvania subpoena, unless a court or administrative agency issues us an order to release your PHI. If you are receiving services in our mental health program, Pennsylvania law requires us to make a good faith effort to notify you by certified mail at your last known address that we disclosed your PHI pursuant a court order.

Law Enforcement Activities. We are not permitted by Pennsylvania laws to disclose PHI regarding mental health or drug and alcohol services to Law Enforcement agencies or officials except pursuant to a court order or in special circumstances required by law. For example, we may disclose the minimum necessary PHI to report a death or criminal conduct on our premises.

Special Situations. We are not permitted by Pennsylvania laws to disclose PHI regarding mental health or drug and alcohol services except pursuant to your authorization, a court order or in special circumstances required by federal and state laws. Subject to these more stringent federal or Pennsylvania laws, the HIPAA Privacy Regulations permit us to disclose PHI related to: Military and Veterans agencies; National Security and Protective Services for the President and others; inmates or if you are under the custody of a law enforcement official; a coroner or medical examiner to identify a deceased person or determine the cause of death; or to a funeral director as necessary to carry out their duties.

YOUR RIGHTS REGARDING YOUR PHI

Right to Request Restrictions. You have the right to request a limitation or a restriction on our use or disclosure of your PHI for treatment, payment or healthcare operations. You may also request that we limit the PHI we disclose to family members, friends or a personal representative who may be involved in your care. However, we are not required to agree to a restriction. If we agree to the requested restriction, we may not use or disclose your PHI in violation of that restriction unless it is needed to provide emergency treatment. You may request a restriction by making your request in writing, including: (a) what PHI you want to limit; (b) whether you want us to limit our use, disclosure or both; and (c) to whom you want the limits to apply.

Right to Request Confidential Communication. You have the right to request that confidential communications from us be sent to you in a certain way or at an alternative location. For example, you can ask that we only contact you at your home or by mail. We will accommodate reasonable requests. We may also condition this accommodation by asking you for specific information. We will not request an explanation from you as to the basis for the request. Please make this request in writing specifying how or where you wish to be contacted.

Right to Inspect and Copy. You have the right to inspect and obtain a copy of your PHI that is contained in our records. However, you may not inspect or copy the following records: psychotherapy notes; or information compiled in reasonable anticipation of, or use in, a civil, criminal, or administrative action or proceeding. In addition you may be denied access to your PHI if it was obtained from a person under a promise of confidentiality; or disclosure is likely to endanger the life and physical safety of you or another person. A decision to deny access may be reviewed. To inspect and copy PHI, submit your request in writing to our Privacy / Compliance Officer. If you request a copy of the information, we may charge a fee for the costs of copying, mailing, or other related costs.

Right to Amend. If you believe the PHI that we have collected about you is incorrect, you have certain rights. If you are receiving mental health services, you have the right to submit a written statement qualifying or rebutting information in our records that you believe is erroneous or misleading. This statement will accompany any disclosure of your records. You also have the right under the HIPAA Privacy Regulations to request an amendment of the PHI maintained in our records. We may deny your request for an amendment if it is not in writing or does not include a reason to support the request. In addition, we may deny your request if you ask us to amend PHI that: was not created by us (unless the person or entity that created the information is no longer available to make the amendment); the information is not part of the record kept by us; the PHI is not subject to inspection or copying; or the record is accurate and complete. If we deny your request for amendment, you have the right to appeal our decision and file a statement of disagreement with us. We may prepare a rebuttal to your statement and will provide you with a copy of any such rebuttal. Please contact our Privacy / Compliance Officer if you have questions about submitting a written statement or to request an amendment of your records.

Right to Receive an Accounting of Disclosures. You have the right to request an "accounting of disclosures". This is a list of the disclosures we have made of PHI about you. We are not required to account for disclosures related to: treatment, payment, or our health care operations; authorizations signed by you; or disclosures to you, to family members or your personal representative involved in your care, or for notification purposes. You have the right to receive specific information regarding these disclosures that occurred after November 17, 2017.

Right to a Paper Copy of this Notice. You have the right to receive a paper copy of this Notice upon request. To obtain a paper copy, contact Apricity at (717) 742-0501. You may also obtain an electronic copy of this Notice at our website: 
http://www.apricitybehavioralhealth.com.

GRIEVANCE PROCEDURES; RIGHT TO FILE A COMPLAINT

If you are not pleased with your care or feel your PHI was not kept confidential you may officially file a grievance with us. Under the PCS grievance procedure, we will work with you to address your questions, concerns and complaints. The HIPAA Privacy Regulations also entitle you to file a complaint with the U.S. Secretary of Health and Human Services. To file a complaint with us or learn more about the grievance process, you may contact Apricity by phone at (717) 742-0501, or by mail at 752 Steeplechase Rd. Landisville, PA 17538. A complaint problem form will be provided to assist you. We will not retaliate against you for filing a complaint.

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Telehealth Policies, Consent and Agreement Form

This form is in addition to the regular Therapy, Policies, Agreement and Consent Form and Notice of Privacy Practices for Protected Health Informationcommonly known as HIPAA.  You must sign both in order to participate in Technology Assisted Counseling (TAC) sessions.  TAC incorporates email, phone and video counseling.  Prior to engage in TAC an assessment/consultation will be done to assure that TAC is an appropriate form of counseling. This is to inform you about what you can expect regarding your participation in TAC counseling.   

Benefits:

The benefits to TAC counseling are:

1.     The ability to expand your choice of service provider. 

2.     More convenient counseling options including location, time, no driving, etc. 

3.     Reduces the overall cost and time of therapy due to not having to drive to and from and office. 

4.     Ability to have real time monitoring and reduces the wait time for scheduling office appointments. 

5.     Increased availability of services to homebound clients. clients with limited mobility, and clients without convenient transportation options.  

Limitations: 

It is important to note that there are limitations to TAC counseling that can affect the quality of the session(s). These limitations include but are not limited to the following:

1.     I cannot see you, your body language, or your non-verbal reactions to what we are discussing. 

2.     Due to technology limitations I may not hear all of what you are saying and may need to ask you to repeat things.

3.     Technology might fail before or during the TAC counseling session. 

4.     Although every effort is made to reduce confidentiality breaches, breaches may occur for various reasons.  

5.     To reduce the effect of these limitations, I may ask you to describe how you are feeling, thinking, and/or acting in more detail than I would during a face-to-face session. You may also feel that you need to describe your feelings, thoughts, and/or actions in more detail than you would during a face-to-face session.

Logistics: 

When I provide phone/video-counseling sessions, I will call you at our scheduled time or send you a link for our secure and HIPAA compliant video session.  I expect that you are available at our scheduled time and are prepared, focused and engaged in the session.  I am calling you from a private location where I am the only person in the room.  You also need to be in a private location where you can speak openly without being overheard or interrupted by others to protect your own confidentiality.  If you choose to be a in a place where there are people or others can hear you, I cannot be responsible for protecting your confidentiality.  Every effort MUST be made on your part to protect your own confidentiality.  I suggest you wear a headset to increase confidentiality and also increase sound quality of our sessions.  Please know that I cannot guarantee the privacy or confidentiality of conversations held via phone, as phone conversations can be intercepted either accidentally or intentionally.  Please assure you reduce all possibilities of interruptions for the duration of our scheduled appointment.  

Please know that per best practices and ethical guidelines I can only practice in the state(s) I am licensed in.  That means wherever you reside I must be licensed.  You agree to inform me if your therapy location has changed or if you have relocated your domicile to a different jurisdiction.

Connection Loss:

During Phone Sessions: If we lose our phone connection during our session, I will call you back immediately.  Please also attempt to call me at +1 (717) 742-0501 if I cannot reach you. If we are unable to reach each other due to technological issues, I will attempt to call you three times.  If I cannot reach you, I will remain available to you during the entire course of our scheduled session.  Should you contact me back and there is time left in your session we will continue.  If the reason for a connection loss i.e. technology, your phone battery dying, bad reception, etc. occurs on your part, you will still be charged for the entire session.  If the loss for connection is a result of something on my end, I will call you from an alternate number.  The number may show up as restricted or blocked please be sure to pick it up.  

During Video Sessions: If we lose our connection during a video session and cannot establish an immediate re-connection, I will call you to troubleshoot the reason we lost connection.  If I cannot reach you, I will remain available to you during the entire course of our scheduled session.  Should you contact me back and there is time left in your session we will continue.  If the reason for a connection loss i.e. technology, battery dying, bad reception, etc. occurs on your part, you will still be charged for the entire session. If the loss for connection is a result of something on my end, we can either complete our session via. phone or plan an alternate time to complete the remaining minutes of our session. 

Recording of Sessions:

Please note that recording, screenshots, etc of any kind of any session is not be permitted and are grounds for termination of the client-therapist relationship. 

Payment for Services: 

Payments for services must be made prior to each session.  We reserve the right to charge the credit card on file for any outstanding balances.

Cancellation Policy: 

If you must cancel or reschedule an appointment, 24-hour advanced notice is required, otherwise you will be held financially responsible. Should you cancel or miss an appointment with notification less than 24 hours this will result in being charged the full fee for your missed appointment.  If clients have more than 2 cancellations during the course of treatment/therapy the therapist and client will address the need for ongoing therapy.  Should a client express and wish and/or desire to continue, a client may be asked to pre-pay for sessions when they are scheduled. If the client cancels or misses the session with less than 24 hours notice and the session is pre-paid, this follows the cancelation guidelines and the payment will not be reimbursed for the missed or canceled session less than 24 hours.  If you are late getting on the phone, are unable to talk at our scheduled time, your battery has died and you are unable to access another confidential place to talk, or any other variable that would have you not be able to attend our session please know that you will be charged for the session.  Please make the necessary arrangements you need to be available and present for your session. 


Legal Stuff

In the event that you choose to pursue legal action against Apricity Behavioral Health and/or any of its personnel, you understand and hereby agrees that all matters are to be litigated in the country and state where the personnel in question is licensed. In addition, and as a condition of treatment, I hereby agree that Apricity Behavioral Health is not responsible for and does not abide by the client's local legislation, and releases them of any matters which require local litigation.


Consent to Participate in TAC Sessions:

By signing below you agree that you have read and understand all of the above sections of TAC informed consent. You agree that you also understand the limitations associated with participating in TAC counseling sessions and consent to attend sessions under the terms described in this document.

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Social Media Policy

This document outlines my policies related to use of Social Media. Please read it to understand how I conduct myself on the Internet as a mental health professional and how you can expect me to respond to various interactions that may occur between us on the Internet.

If you have any questions about anything within this document, I encourage you to bring them up when we meet. As new technology develops and the Internet changes, there may be times when I need to update this policy. If I do so, I will notify you in writing of any policy changes and make sure you have a copy of the updated policy.

Friending

I do not accept friend or contact requests from current or former clients on any social networking site (Facebook, LinkedIn, etc). I believe that adding clients as friends or contacts on these sites can compromise your confidentiality and our respective privacy. It may also blur the boundaries of our therapeutic relationship. You may, however, follow my business page on Facebook. If you have questions about this, please bring them up when we meet and we can talk more about it.

Following

I publish a blog on my website and frequently update my Facebook business page. I have no expectation that you as a client will want to follow my blog or Facebook page. 

Interacting

Once our therapeutic relationship begins, please do not use Social Networking sites such as Facebook or LinkedIn to contact me. These sites are not secure and I may not read these messages in a timely fashion. Do not use Wall postings or other means of engaging with me in public online if we have an already established client/therapist relationship. Engaging with me this way could compromise your confidentiality. It may also create the possibility that these exchanges become a part of your legal medical record and will need to be documented and archived in your chart.

If you need to contact me between sessions, the best way to do so is by phone or emailing me through the secure client portal or the Signal App. Direct email at shannon@apricitybehavioralhealth.com is second best for quick, administrative issues such as changing appointment times. See the email section below for more information regarding email interactions.

Use of Search Engines

It is NOT a regular part of my practice to search for clients on Google or Facebook or other search engines. Extremely rare exceptions may be made during times of crisis. If I have a reason to suspect that you are in danger and you have not been in touch with me via our usual means (coming to appointments, phone, or email) there might be an instance in which using a search engine (to find you, find someone close to you, or to check on your recent status updates) becomes necessary as part of ensuring your welfare. These are unusual situations and if I ever resort to such means, I will fully document it and discuss it with you when we next meet.

Google Reader

I do not follow current or former clients on Google Reader and I do not use Google Reader to share articles. If there are things you want to share with me that you feel are relevant to your treatment whether they are news items or things you have created, I encourage you to bring these items of interest into our sessions.

Business Review Sites

You may find my therapy practice on sites such as Yelp, Healthgrades, Yahoo Local, Bing, or other places which list businesses. Some of these sites include forums in which users rate their providers and add reviews. Many of these sites comb search engines for business listings and automatically add listings regardless of whether the business has added itself to the site. If you should find my listing on any of these sites, please know that my listing is NOT a request for a testimonial, rating, or endorsement from you as my client.

The American Psychological Association's Ethics Code states under Principle 5.05 that it is unethical for psychologists to solicit testimonials: "Psychologists do not solicit testimonials from current therapy clients/patients or other persons who because of their particular circumstances are vulnerable to undue influence."

Of course, you have a right to express yourself on any site you wish. But due to confidentiality, I cannot respond to any review on any of these sites whether it is positive or negative. I urge you to take your own privacy as seriously as I take my commitment of confidentiality to you. You should also be aware that if you are using these sites to communicate indirectly with me about your feelings about our work, there is a good possibility that I may never see it.

If we are working together, I hope that you will bring your feelings and reactions to our work directly into the therapy process. This can be an important part of therapy, even if you decide we are not a good fit. None of this is meant to keep you from sharing that you are in therapy with me wherever and with whomever you like. Confidentiality means that I cannot tell people that you are my client and my Ethics Code prohibits me from requesting testimonials. But you are more than welcome to tell anyone you wish that I'm your therapist or how you feel about the treatment I provided to you, in any forum of your choosing.

If you do choose to write something on a business review site, I hope you will keep in mind that you may be sharing personally revealing information in a public forum. I urge you to create a pseudonym that is not linked to your regular email address or friend networks for your own privacy and protection.

Email

I prefer using email only to arrange or modify appointments. If you wish to discuss content related to your therapy sessions, please use the client portal messaging function or through the Signal App as both are secure . If you choose to communicate with me by email, be aware that all emails are retained in the logs of your and my Internet service providers. While it is unlikely that someone will be looking at these logs, they are, in theory, available to be read by the system administrator(s) of the Internet service provider. You should also know that any emails I receive from you and any responses that I send to you become a part of your legal record.

Conclusion

Thank you for taking the time to review my Social Media Policy. If you have questions or concerns about any of these policies and procedures or regarding our potential interactions on the Internet, do bring them to my attention so that we can discuss them.

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No Show and Cancellation Policy

No Show & Late Cancellation Policy

Missed and cancelled sessions pose some issues for both of us. First, the work of psychotherapy is sometimes challenging and when we hit a difficult place together, it can feel easier to want to avoid coming in for treatment. I would prefer we speak about this intentionally rather than you canceling sessions. Also, I hold your scheduled appointment time specifically for you and you alone. I also see a limited number of patients so that I can give you the focus and attention you deserve. It is extremely difficult for me to fill your last minute cancelled session on a short notice. Therefore, I charge for appointments cancelled with less than 24 hours notice unless we can find another time that week that works for us both. If we are able to, before the weekend, I will allow you to reschedule at no extra fee.

If you are running late for your appointment, please phone or email me as soon as you can to let me know you will be late. If I do not hear from you by 20 minutes into your session, I will call to check on you and may assume you do not plan to attend your session.

If you are late for your session, we will still end at our regular time so that I have time to prepare for my next appointments and I can be on time for them.

Fee Schedule

First time clients must pre-pay for their first session. Thereafter, full payment is expected at the time of service unless otherwise agreed upon. Apricity Behavioral  Health reserves the right to charge your credit card for the full balance owed at the end of 30 days and to withhold services until all balances are paid in full.

Balances: I do not permit clients to carry a balance of more than two sessions. Our office clears balances on accounts on the 15th and last day of every month by charging the credit card you have on file. If you are unable to pay this balance, we will discuss whether it makes sense to pause your care or develop another strategy so that you can avoid incurring additional debt. Please let me know if any problem arises during the course of therapy regarding your ability to make timely payments.


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Consent to Treatment - Adult


SOCIAL WORKER-CLIENT SERVICE AGREEMENT 

Welcome to my practice. This document contains important information about my professional services and business policies. It also contains summary information about the Health Insurance Portability and Accountability Act (HIPAA), a federal law that provides privacy protections and patient rights about the use and disclosure of your Protected Health Information (PHI) for the purposes of treatment, payment, and health care operations. Although these documents are long and sometimes complex, it is very important that you understand them. When you sign this document, it will also represent an agreement between us. We can discuss any questions you have when you sign them or at any time in the future.

MENTAL HEALTH SERVICES
Therapy is a relationship between people that works in part because of clearly defined rights and responsibilities held by each person. As a client in psychotherapy, you have certain rights and responsibilities that are important for you to understand. There are also legal limitations to those rights that you should be aware of. I, as your therapist, have corresponding responsibilities to you. These rights and responsibilities are described in the following sections.

Psychotherapy has both benefits and risks. Risks may include experiencing uncomfortable feelings, such as sadness, guilt, anxiety, anger, frustration, loneliness, and helplessness because the process of psychotherapy often requires discussing the unpleasant aspects of your life.  However, psychotherapy has been shown to have benefits for individuals who undertake it.  Therapy often leads to a significant reduction in feelings of distress, increased satisfaction in interpersonal relationships, greater personal awareness, and insight, and increased skills for managing stress and resolutions to specific problems.  But, there are no guarantees about what will happen.  Psychotherapy requires a very active effort on your part. In order to be most successful, you will have to work on things we discuss outside of sessions.

The first 2-4 sessions will involve a comprehensive evaluation of your needs. By the end of the evaluation, I will be able to offer you some initial impressions of what our work might include. At that point, we will discuss your treatment goals and create an initial treatment plan. You should evaluate this information and make your own assessment about whether you feel comfortable working with me. If you have questions about my procedures, we should discuss them whenever they arise. 

APPOINTMENTS
Appointments will ordinarily be 45-50 minutes in duration, once per week at a time, we agree on, although some sessions may be more or less frequent as needed. The time scheduled for your appointment is assigned to you and you alone. If you need to cancel or reschedule a session, I ask that you provide me with 24 hours' notice. If you miss a session without canceling or cancel with less than 24-hour notice, my policy is to collect the amount of your co-payment [unless we both agree that you were unable to attend due to circumstances beyond your control]. It is important to note that insurance companies do not provide reimbursement for canceled sessions; thus, you will be responsible for the portion of the fee as described above. If it is possible, I will try to find another time to reschedule the appointment. In addition, you are responsible for coming to your session on time; if you are late, your appointment will still need to end on time.

PROFESSIONAL FEES
The standard fee for the initial intake is $100.00 and each subsequent session is $100.00.  You are responsible for paying at the time of your session. Payment must be via the client portal using a credit or debit card. 

In addition to weekly appointments, it is my practice to charge this amount on a prorated basis (I will break down the hourly cost) for other professional services that you may require such as report writing, telephone conversations that last longer than 15 minutes, attendance at meetings or consultations which you have requested, or the time required to perform any other service which you may request of me. If you anticipate becoming involved in a court case, I recommend that we discuss this fully before you waive your right to confidentiality. If your case requires my participation, you will be expected to pay for the professional time required even if another party compels me to testify.

INSURANCE
At this time, I do not participate in any insurance plans.  You are required to pay for all services upfront.

PROFESSIONAL RECORDS
I am required to keep appropriate records of the mental services that I provide. Your records are maintained in a HIPPA-compliant virtual cloud provided through Counsol.com. I keep brief records noting that you were here, your reasons for seeking therapy, the goals and progress we set for treatment, your diagnosis, topics we discussed, your medical, social, and treatment history, records I receive from other providers, copies of records I send to others, and your billing records. Except in unusual circumstances that involve danger to yourself, you have the right to a copy of your file. Because these are professional records, they may be misinterpreted and/or upsetting to untrained readers.  For this reason, I recommend that you initially review them with me, or have them forwarded to another mental health professional to discuss the contents. If I refuse your request for access to your records, you have a right to have my decision reviewed by another mental health professional, which I will discuss with you upon your request. You also have the right to request that a copy of your file be made available to any other health care provider at your written request.

CONFIDENTIALITY
My policies about confidentiality, as well as other information about your privacy rights, are fully described in a separate document entitled Notice of Privacy Practices.  You have been provided with a copy of that document and we have discussed those issues. Please remember that you may reopen the conversation at any time during our work together.

PARENTS & MINORS
While privacy in therapy is crucial to successful progress, parental involvement can also be essential. It is my policy not to provide treatment to a child under age 13 unless s/he agrees that I can share whatever information I consider necessary with a parent. For children 14 and older, I request an agreement between the client and the parents allowing me to share general information about treatment progress and attendance, as well as a treatment summary upon completion of therapy. All other communication will require the child's agreement unless I feel there is a safety concern (see also above section on Confidentiality for exceptions), in which case I will make every effort to notify the child of my intention to disclose information ahead of time and make every effort to handle any objections that are raised.  

CONTACTING ME

I am often not immediately available by telephone. I do not answer my phone when I am with clients or otherwise unavailable. At these times, you may leave a message on my confidential voice mail and your call will be returned as soon as possible, but it may take a day or two for non-urgent matters. If for any number of unseen reasons, you do not hear from me or I am unable to reach you, and you feel you cannot wait for a return call or if you feel unable to keep yourself safe, call 911 and ask to speak to the mental health worker on call. I will make every attempt to inform you in advance of planned absences and provide you with the name and phone number of the mental health professional covering my practice.

OTHER RIGHTS
If you are unhappy with what is happening in therapy, I hope you will talk with me so that I can respond to your concerns. Such comments will be taken seriously and handled with care and respect. You may also request that I refer you to another therapist and are free to end therapy at any time. You have the right to considerate, safe, and respectful care, without discrimination as to race, ethnicity, color, gender, sexual orientation, age, religion, national origin, or source of payment. You have the right to ask questions about any aspects of therapy and about my specific training and experience. You have the right to expect that I will not have social or sexual relationships with clients or with former clients.

CONSENT TO THERAPY
Your signature below indicates that you have read this Agreement and the Notice of Privacy Practices and agree to their terms.

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Privacy of Information Shared in Therapy:
Your Rights and My Policies 


What to expect: 

The purpose of meeting with a counselor or therapist is to get help with problems in your life that are bothering you or that are keeping you from being successful in important areas of your life. You may be here because you wanted to talk to a counselor or therapist about these problems. Or, you may be here because your parent, guardian, doctor or teacher had concerns about you. When we meet, we will discuss these problems. I will ask questions, listen to you and suggest a plan for improving these problems. It is important that you feel comfortable talking to me about the issues that are bothering you. Sometimes these issues will include things you don't want your parents or guardians to know about. For most people, knowing that what they say will be kept private helps them feel more comfortable and have more trust in their counselor or therapist. Privacy, also called confidentiality, is an important and necessary part of good counseling.

As a general rule, I will keep the information you share with me in our sessions confidential, unless I have your written consent to disclose certain information. There are, however, important exceptions to this rule that are important for you to understand before you share personal information with me in a therapy session. In some situations, I am required by law or by the guidelines of my profession to disclose information whether or not I have your permission. I have listed some of these situations below.

Confidentiality cannot be maintained when:

>You tell me you plan to cause serious harm or death to yourself, and I believe you have the intent and ability to carry out this threat in the very near future. I must take steps to inform a parent or guardian of what you have told me and how serious I believe this threat to be. I must make sure that you are protected from harming yourself.

> You tell me you plan to cause serious harm or death to someone else who can be identified, and I believe you have the intent and ability to carry out this threat in the very near future. In this situation, I must inform your parent or guardian, and I must inform the person who you intend to harm.

>You are doing things that could cause serious harm to you or someone else, even if you do notintend to harm yourself or another person. In these situations, I will need to use my professional judgment to decide whether a parent or guardian should be informed.

>You tell me you are being abused-physically, sexually or emotionally-or that you have been abused in the past. In this situation, I am required by law to report the abuse to the Virginia Department of Social Services.

>You are involved in a court case and a request is made for information about your counseling or therapy. If this happens, I will not disclose information without your written agreement unless the court requires me to. I will do all I can within the law to protect your confidentiality, and if I am required to disclose information to the court, I will inform you that this is happening.

Communicating with your parent(s) or guardian(s): 

Except for situations such as those mentioned above, I will not tell your parent or guardian specific things you share with me in our private therapy sessions. This includes activities and behavior that your parent/guardian would not approve of - or would be upset by - but that do not put you at risk of serious and immediate harm. However, if your risk-taking behavior becomes more serious, then I will need to use my professional judgment to decide whether you are in serious and immediate danger of being harmed. If I feel that you are in such danger, I will communicate this information to your parent or guardian.

Example: If you tell me that you have tried alcohol at a few parties, I would keep this information confidential. If you tell me that you are drinking and driving or that you are a passenger in a car with a driver who is drunk, I would not keep this information confidential from your parent/guardian. If you tell me, or if I believe based on things you've told me, that you are addicted to alcohol, I would not keep this information confidential.

Example: If you tell me that you are having protected sex with a boyfriend or girlfriend, I would keep this information confidential. If you tell me that, on several occasions, you have engaged in unprotected sex with people you do not know or in unsafe situations, I will not keep this information confidential. You can always ask me questions about the types of information I would disclose. You can ask in the form of "hypothetical situations," in other words: "If someone told you that they were doing ________, would you tell their parents?"

Even if I have agreed to keep information confidential - to not tell your parent or guardian - I may believe that it is important for them to know what is going on in your life. In these situations, I will encourage you to tell your parent/guardian and will help you find the best way to tell them. Also, when meeting with your parents, I may sometimes describe problems in general terms, without using specifics, in order to help them know how to be more helpful to you.

[You should also know that, by law in Virginia, your parent/guardian has the right to see any written records I keep about our sessions. It is extremely rare that a parent/guardian would ever request to look at these records.]

Communicating with other adults:

School: I will not share any information with your school unless I have your permission and permission from your parent or guardian. Sometimes I may request to speak to someone at your school to find out how things are going for you. Also, it may be helpful in some situations for me to give suggestions to your teacher or counselor at school. If I want to contact your school, or if someone at your school wants to contact me, I will discuss it with you and ask for your written permission. A very unlikely situation might come up in which I do not have your permission but both I and your parent or guardian believe that it is very important for me to be able to share certain information with someone at your school. In this situation, I will use my professional judgment to decide whether to share any information.

Doctors: Sometimes your doctor and I may need to work together; for example, if you need to take medication in addition to seeing a counselor or therapist. I will get your written permission and permission from your parent/guardian in advance to share information with your doctor. The only time I will share information with your doctor even if I don't have your permission is if you are doing something that puts you at risk for serious and immediate physical/medical harm.

Signing below indicates that you have reviewed the policies described above and understand the limits to confidentiality. If you have any questions as we progress with therapy, you can ask your therapist at any time.



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