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

I. Treatment, Payment, and Health Care Operations

Each time that you visit a mental health practitioner, that provider makes a record of your visit which documents your care and is required by law. Typically, this record contains your health history, current symptoms, medical information, test results, diagnosis, and treatment plan. This is typically referred to as your medical record. Information within your record that could identify you is referred to as protected health information (PHI). HIPAA (Health Information Portability and Accountability Act) and Tennessee state law provide privacy protections about your PHI and how that information is used by my office. This is a summary of my Privacy Practices. Specifically, I am allowed to disclose PHI for the purposes of treatment, payment, and health care operations with your consent. By signing the Acknowledgement section at the end of this document, you have offered your general consent to care (treatment) and authorization for me to conduct payment and health care operations.
-An example of treatment would be if I consult with another health care provider, such as your primary care physician, about treatment progress or medication changes.
-An example of payment would be if I disclosed your PHI to your health insurer to obtain reimbursement for your care.
-An example of health care operations is if I use your confidential information to remind you of an appointment (by phone or mail) or provide you with information about treatment options or other health-related services.

II. Uses and Disclosures Requiring Your Authorization

I am allowed to disclose your PHI for reasons other than treatment, payment, or health care operations when I obtain your authorization (consent). This authorization will be in written form and will permit specific disclosures for a specified amount of time. A copy of that authorization will be given to you for your records. For example, if you ask me to send a copy of your child's psychoeducational testing results to your child's school, I would require this additional authorization from you before I could complete this task.

Another situation in which I would require your written consent is the release of my Psychotherapy Notes, notes that I make about our conversations together that are kept separate from your medical record. These notes have a higher degree of protection than PHI due to the degree to which they are more private and contain more personal information about you.

You may revoke all authorizations to release PHI at any time in writing. You cannot revoke an authorization for an activity already done or if the authorization was obtained as a condition for obtaining insurance payment.

III. Business Associates

At times, I enter into an agreement with outside sources for ancillary administrative services (e.g. a company who provides shredding services). In those circumstances, HIPAA requires that I monitor the conduct of those sources (Business Associates) and enter into a signed agreement with these Business Associates that clearly spells out the importance of protecting your PHI as a condition for employment. I will monitor their compliance with my privacy standards and correct any errors if they should occur.

IV. Uses and Disclosures with Neither Consent nor Authorization

I am allowed to disclose your PHI without your consent or authorization in the following circumstances:
-Child Abuse or suspected child abuse including, but not limited to, any wound, injury, or disability or physical or mental condition of such a nature as to reasonably indicate that it has been caused by brutality, abuse, or neglect. This includes sexual abuse as well.
-Adult and Domestic Abuse (e.g. disabled adult is being abused)
-Health oversight (e.g. a complaint is filed with the Tennessee Board of Examiners in Psychology)
-Judicial or Administrative proceedings (e.g. ordered by a judge to release PHI)
-Serious threat to self or others (e.g. immediate threat of bodily harm and likely to carry out such threat)
-Workers compensation claim (e.g. if you file a claim to have your counseling reimbursed under workers compensation, your employer and insurer automatically has access to your PHI)
-To communicate with law enforcement if required by law
-To communicate with federal officials involved in securities activities or disaster situations
V. Patient's Rights and My Duties

-You have the right to request restrictions on certain uses or disclosures of your PHI which I may or may not agree to
-You have the right to receive confidential communications by alternative means and at alternative locations. An example may be having your bills sent to an alternative location so that your family does not know you are seeing a counselor.
-You have the right to inspect and copy your record which includes both mental health and billing records. I will discuss the process of inspecting your record once you make the request. You do not have the right to view psychotherapy notes without my permission.
-You have the right to amend the record which I may or may not allow. I may refuse your request if I did not make the entry, if the information is not part of your medical record that I keep, if I believe that the record is accurate and complete.
-You have the right to obtain an accounting of nonauthorized uses and disclosures of your PHI for the past 6 years.
-You have the right to revoke an authorization to disclose PHI except to the extent to which I have taken action in reliance on the consent or authorization.

My duties include maintaining the privacy of your PHI and implementing reasonable and appropriate physical, administrative, and technical safeguards to protect your information. I can provide you with a paper copy of this notice at any time per your request. My duties include developing a sanction policy to discipline any who breech privacy or confidentiality policies and to mitigate (lessen the harm of) any breach that should occur. I reserve the right to change my practices and to make the new provisions effective for all individually identifiable health information that I maintain. If I change my information practices, I will provide you with a revised notice of my information practices.

VI. Complaints

I act as the HIPAA Privacy and Security Officer for my practice per HIPAA regulations. If you have any concerns of any sort that your rights have been compromised please come to me immediately about the matter. You may also send a written complaint, of which I can provide you a copy, to the Secretary of the U.S. Department of Health and Human Services. Remember that you have specific rights under the HIPAA Privacy Rule and my duty is to protect those rights. I will not retaliate against you for exercising your rights or if you should have a complaint.

This notice is in effect on September 19, 2015

ACKNOWLEDGMENT OF HIPAA NOTICE
I acknowledge that I have reviewed the Notice of Information Practices which provides a detailed description of the uses and disclosures of my protected health information. I understand that I have the right to review this document before signing this acknowledgment form.

Over the years of being a counselor, I have become more and more aware of the honor that my clients give to me when they share their stories with me and allow me to witness their lives. I am grateful you have chosen me to serve as your counselor and to be a part of this journey with you. I first recognized my desire to be a counselor while in college at Lipscomb University where I graduated with a bachelor's in Psychology in 1998. I went on to complete my masters at Middle Tennessee State University in 2003 where I majored in Clinical Psychology with an emphasis on children, adolescents, and families. While there, I discovered an additional passion for testing and assessment due to the answers and insights that it allowed me to provide my clients. Since then, I have been offering counseling and testing services to children, adolescents, adults, and families. I work with my clients on a variety of issues including (but not limited to) grief and loss, anxiety, depression, developmental delays, autism spectrum disorders, adoption issues, behavioral issues, and trauma. I use an eclectic approach to therapy with a spiritual foundation to best serve my clients.
The following policy statements have been developed for your information. I value you as a client and want you to be informed.

NATURE OF COUNSELING
Often, the process of counseling can provide positive benefits for those involved. My goal in working with you is to provide a safe space in which healing and growth can happen. While it is my goal to assist you in effecting change, I cannot guarantee a specific outcome nor a specific amount of time in which change will happen. We are all ultimately responsible for our own growth.

FEE POLICY
I am committed to offering the highest quality of professional counseling services. My fee for all types of counseling services is $140 per clinical hour (50 minutes). I take cash, check or credit cards. I do not take insurance at this time, but can provide you with a receipt for billing that you may file with your insurance company upon request. There is a $35 fee for all returned checks. I take payment at the beginning of each appointment. If you do not have your payment at the beginning of the session, we will have to reschedule for another time when you can make the payment. You will owe for that session as well as the session being rescheduled. A session is typically based on a 50-minute hour; however, when working with couples or families, the session may exceed this time. Unless this time is excessive, the rate will still be based on the regular hourly fee. Cancellations need to be made 24 hours in advance; otherwise, you will be billed for the full session fee, unless the cancellation is due to an emergency. I do not testify unless required by a court order. Court appearances or related calls, documentation, travel time, etc... are $250 per hour.

CONFIDENTIALITY
Professional ethics and Tennessee State law indicate that confidential information is controlled by the client. This means (as a general rule) information shared in sessions with a counselor will be held in confidence. There are exceptions to this general rule but two of particular note. First, in the case of an emergency where the counselor believes the client is at risk of hurting himself/herself or another person, the counselor may breach the requirement of confidentiality. Secondly, Tennessee law requires that child abuse in any form be reported to the Department of Human Services or other authority such as a Juvenile Judge.
When working with minors, I will not share the content of sessions with parents or guardians unless the content must be shared for safety reasons or if my judgment warrants sharing content for the welfare and health of my client. I will discuss progress and treatment plans in general terms with parents or guardians. Parents are encouraged to take an active role in the counseling process; be prepared to be in session with your child at times and to have "homework assignments" for your family.
If you are referred by a physician or other health care professional, it a professional courtesy to maintain contact (as necessary) with that referral source. I will provide you with a release of information document granting me permission to communicate with other health care professionals or referral sources unless you request otherwise.

COUNSELING RELATIONSHIP
During the course of your treatment, we will meet regularly for 50-minute therapy sessions. We have a professional relationship that needs to be respected on both ends. There may be circumstances in which we see one another in a social context such as the grocery store or a social event. To protect you and your privacy, I will not initiate communication with you, but you are welcome to approach me as is comfortable for you. My goal is to maintain a professional relationship and meet your needs to the best of my ability.

PROFESSIONAL SERVICES
I am available for counseling appointments on Mondays, Tuesdays, and Fridays. You can contact me at 615.337.7575 to schedule or change a session or log-on to your private client portal. If you need immediate help for an emergency situation, you may obtain assistance by calling the Crisis Help Line at 615-244-7444, the YW Domestic Violence Center at 615-242-1199, or by going to your local hospital emergency room. For a crisis with minors, you can call the mobile crisis line at 866-791-9222. I am not a crisis counselor and may be unable to respond to voicemails and emails in a timely manner. Therefore do not call or email me when you are in a crisis and feeling suicidal, overwhelmed, or unsafe. Please call the crisis line or go to your nearest emergency room in these instances.

CREDENTIALS
I have a Master's Degree in Clinical Psychology and am licensed by the State of Tennessee as a Licensed Senior Psychological Examiner with the Health Service Provider designation (LSPE-HSP, license no. PE11799).

REFERRALS
I am able to meet the needs of most clients who come to my office. If I am unable to help you, I will provide you with the appropriate referral for your needs.

If you have any questions, feel free to ask me. Once you have read and understood this document, please sign and date below.

Definition of Telehealth

Telehealth involved the use of electronic communications to enable mental health professionals to connect with individuals using interactive video and audio communications.  Telehealth includes the practice of psychological health care delivery, diagnosis, consultation, treatment, education, referral to resources, and transfer of medical and clinical data.

Rights with respect to telehealth

I understand that I have the following rights with respect to telehealth:

(1) The laws that protect confidentiality of my personal information apply to telehealth. I understand that the information disclosed by me during the course of my sessions is generally confidential. However, there are both mandatory and permissive exceptions to confidentiality, including, but not limited to, reporting child, elder, and dependent adult abuse; expressed threats of violence toward an ascertainable victim; threats of suicidal intent; and where I make my mental or emotional state an issue in a legal proceeding. I also understand that the dissemination of any personally identifiable images or information from the telehealth interaction to other entities shall not occur without my written consent.

(2) I have the right to withhold or withdraw my consent to the use of telehealth in the course of my care At ANY TIME without affecting my right to future care or treatment.

(3) I understand that there are risks and consequences from telehealth, including, but not limited to, the possibility, despite reasonable efforts on the part of my counselor, that: the transmission of my personal information could be disrupted or distorted by technical failures, the transmission of my personal information could be interrupted by unauthorized persons, and/or the electronic storage of my personal information could be unintentionally lost or accessed by unauthorized persons. Anesis Counseling uses secure, HIPAA compliant audio/video transmission software to deliver telehealth.

(4) I understand that telehealth services may not be as complete as face-to-face services. I understand that if my counselor believes that I would be better served by another form of psychotherapeutic services (e.g. face-to-face), I will be referred to a psychotherapist who can provide such services on my area.

I understand that if I am having suicidal or homicidal thoughts, actively experiencing psychotic symptoms, or experiencing a mental health crisis that cannot be resolved remotely, it may be determined that telehealth services are not appropriate and higher level of care is required.

I understand that there are potential risks and benefits associated with any form of psychotherapy, and that despite my efforts and the efforts of my counselor, my condition may not improve and in some cases may even get worse. I may benefit from telehealth, but results cannot be guaranteed or assured.  

(5) I accept that telehealth services do not provide emergency services. If I am experiencing an emergency situation, I understand that I can call 911 or go to the nearest hospital emergency room. If I am having suicidal thoughts, I can call the National Suicide Prevention Lifeline at 1-800-273-TALK (8255) or the TN Statewide Crisis line at 855-CRISIS-1 (855-274-7471).

(6) I understand that there is risk of being heard by anyone near me if I am not in a private room while participating in telehealth services. I am responsible for providing the necessary telecommunications equipment and internet access for my telehealth services. I am also responsible for arranging a location with sufficient lighting and privacy that is free from distractions and intrusions for my telehealth sessions. It is the job of the counselor to do the same on her end.

(7) I understand that during a telehealth session, we could encounter technical difficulties resulting in service interruptions. If this occurs, end and restart the session. If we are unable to reconnect, please call me at 615-337-7575.

(8) I understand that different states have different laws governing the use of telehealth. In Tennessee, Anesis Counseling may not provide me services if I am outside the state of Tennessee.

Patient consent to the use of telehealth services

I have read and understand the information provided above regarding telehealth services and my questions have been answered to my satisfaction. I hereby give my informed consent to participate in the use of telehealth services for treatment under the terms described herein.

By my signature below, I hereby state that I have read, understood, and agree to the terms of this document.