DISCLOSURE STATEMENT AND CONSENT TO TREAT
The purpose of this document is to allow you, the client
and/or Parent or Guardian, to make an informed
decision about your treatment. For clarification about any part
of this document, feel free to ask questions.
Information about your therapist:
The individual therapist who operates this practice is:
Amy Elizabeth "Beth" Williams, LCSW-15806, Licensed Clinical
Social Worker
Your therapist will verbally discuss her professional
background with you and provide you with information related to
her experience, education, special areas of practice, and
professional orientation. This agency is committed to your
treatment and believes in a collaborative relationship between
the therapist and the client(s).
Therapeutic Services:
Psychotherapy varies per client and their individually
identified treatment goals. The therapist's role is to evaluate
all information provided and offer therapeutic recommendations
that will best address identified problems and result in
progress toward desired goals. As a client, you have the right
to refuse treatment, ask for clarification of and/or challenge
procedures, understand the goals of therapy, seek a second
opinion or terminate treatment at any time.
The preference is to see new patients weekly for four to six
sessions to build safety and rapport. After this time period,
the frequency of sessions will be re-evaluated. Session length
is 50-60 minutes per session. If you require more frequent
sessions, such as twice per week, the therapist and the paid
billing service representatives can assist in determining if
insurance will cover more frequent sessions. If not, private
pay is an option.
Psychotherapy involves both risks and benefits. Each person
responds differently to treatment and there are no guarantees
about outcomes.
Risks Involved:
Talking about highly emotional life experiences such as trauma
can elicit strong emotional reactions that can vary and may
include sadness, anxiety, guilt and anger. If these reactions
become disruptive to your daily life, it is highly recommended
you contact your therapist and schedule an emergency session so
a safety assessment can be conducted to determine next steps in
safety planning.
Benefits Involved:
Individuals participating in psychotherapy often benefit from
the act of sharing and processing life experiences with another
objective, non-judgmental, skillful and empathetic person.
Psychotherapy often elicits a feeling of relief resulting in
improved quality of life, acquisition of new coping skills and
perspectives and improved self-awareness and self-confidence.
Confidentiality:
You have the right to privacy and all information identifying
you will remain confidential as required by the legal and
ethical standards set forth by The Arizona Board of Behavioral
Health. All communication that occurs with your therapist will
be maintained in strict confidence unless you provide written
permission to release information about your treatment.
Asamandatedreporter,yourtherapistisrequiredtobreakconfidentialityinthefollowing
instances:
Danger to self
Danger to others
Elder or vulnerable adult
abuse
Physical abuse, sexual
abuse, or neglect of a child
Imminent danger
If any of these situations are identified throughout the
therapeutic process your therapist will file a report with the
appropriate authorities. Be advised, under these circumstances,
that therapeutic records maybe subpoenaed by a court of law. If
this occurs, yourt herapist will advise you and make
records available.
If you participate in marital and family therapy, your
therapist will not disclose confidential information about
your treatment unless all persons
involved in treatment provide their written
authorization to release the information. It is critical to
note that your therapist uses a "no-secret" policy when
conducting marriage and family therapy. This policy means that
if you participate in marriage or family therapy, your
therapist is allowed to use information obtained in individual
sessions you may have had with her in order to aid the
therapeutic process.
Therapist is bound by confidentiality. At
times, this therapist may provide services to several
family members or receive referrals from individuals who know
one another in personal spheres. In the case of services
provided to family members, each client is treated as an
individual client and confidentiality is strictly enforced for
each client.
Confidentiality will only be broken if client is determined
to be a danger to self or others. Parents
of minor children will only be provided
therapeutic updates regarding homework or interventions
learned in order to be a
source of support and encouragement between sessions.
No information will be shared with others without an active
Release of Information on file.
In the event a current client makes a referral of
friend/acquaintance to this therapist for services, the
therapist will strictly observe confidentiality for each party
and will not discuss or acknowledge the outside
relationship. This practice will strive to
schedule referred clients at different times. In the
event overlap occurs, this therapist will preserve
confidentiality and will promptly
transfer client into session.
In the Case of Custody and Guardianship:
Please be advised that strict criterion is observed within this
practice in accordance with Arizona Revised Statutes and the
Arizona Board of Behavioral Health requirements.
Consent for therapeutic
services can only be authorized by a current legal Guardian.
If parents are separated
and share medical decision making, then consent must be given
by both parents.
For divorced parents,
consent may be given by the parent authorized to make legal
medical decisions, although may require co-signature of the
other parent if possible.
Emails may be used to
communicate about therapy issues at the risk of the legal
guardian. Email is not a guaranteed confidential method of
communication. Text messages are not
secure and therapist may opt not communicate via
text.
You may be requested to
provide a copy of your legal documents identifying you as the
parent authorized to make legal medical decisions.
Request for Records:
You have a right to your records or a summary of your records
as deemed appropriate by your therapist. Requests must be made
in writing and it may take up to 30 days to obtain your
records, depending on the amount of information requested.
There is a fee for requested documents. Each page costs 25
cents to copy. Records will be mailed at cost of shipping to
client.
Please be advised that therapist has the legal right to omit or
redact any information that may be deemed harmful to the
client. Progress notes are protected documents per HIPPA and
are not legally required to be included in a medical records
request. Therapist has discretion in the release of records and
may require a court order or subpoena which will be the
financial responsibility of the client.
Confidentiality Specific to Child and Adolescent Therapeutic
Process:
Sometimes child therapy involves disagreement among parents
and/or disagreement between parents and therapist regarding the
best interests of the child. If such disagreements occur,
therapist will strive to listen carefully so that she can
understand your perspectives and fully explain therapeutic
perspective. At times disagreements can be resolved or both
parties "can agree to disagree", as long as this enables your
child's therapeutic progress. Ultimately, you, as the parent,
or guardian, will decide whether therapy will continue. If
either of you decides that therapy should end, that decision
will be honored, however therapist asks that you allow her the
option of having a few closing sessions to appropriately end
the treatment relationship.
Therapy is most effective when a trusting relationship exists
between the therapist and the client. Privacy is especially
important in securing and maintaining that trust. One goal of
treatment is to promote a stronger and better relationship
between children and their parents. However, it is often
necessary for children to develop a "zone of privacy" whereby
they feel free to discuss personal matters with greater
freedom. This is particularly true for adolescents who are
naturally developing a greater sense of independence and
autonomy. By signing this agreement, you will be waiving your
right of access to your child's treatment records.
It is this practice's policy to provide you with general
information about treatment status. Therapist will raise issues
that may impact your child either inside or outside the home.
If it is necessary to refer your child to another mental health
professional with more specialized skills, therapist will share
that information with you. Therapist will not share with you
what your child has disclosed without your child's consent.
Therapist will tell you if your child does not attend sessions.
At the end of your child's treatment, therapist may provide you
with a treatment summary that will describe what issues were
discussed, what progress was made, and what areas are likely to
require intervention in the future.
If your child is an adolescent, it is possible that he/she will
reveal sensitive information regarding sexual contact, alcohol
and drug use, or other potentially problematic behaviors.
Sometimes these behaviors are within the range of normal
adolescent experimentation, but at other times they may require
parental intervention. It is important that direct discussion
occur about your feelings and opinions regarding acceptable
behavior. If therapist believes that your child is at serious
risk of harming him/herself or another, therapist will inform
you immediately.
Although therapist's responsibility to your child may require
involvement in conflicts between the parents, it is critical
that both parents agree that therapist involvement will be
strictly limited to that which will benefit your child. This
means, among other things, that you will treat anything that is
said in session with therapist as confidential. Neither parent
will attempt to gain advantage in any legal proceeding between
the two of you from therapist involvement with your
child/children. Therapist asks your agreement that in any such
proceedings, neither party will ask therapist to testify in
court, whether in person, or by affidavit. You also agree to
instruct your attorneys not to subpoena therapist or to refer
in any court filing to anything therapist has said or done in
the confines of the therapeutic relationship.
Note that such agreement may not prevent a judge from requiring
therapist's testimony, even though therapist will work to
prevent such an event. If therapist is required to testify,
therapist is ethically bound not to give an opinion about
either parent's custody or visitation suitability. If the court
appoints a custody evaluator, guardian ad litem, or parenting
coordinator, therapist will provide information as needed (if
appropriate releases are signed or a subpoena is provided), but
therapist will not make any recommendation about the final
decision.
Furthermore, if therapist is required to appear as a witness,
the party responsible for therapist participation agrees to
reimburse at the following rates which are non-negotiable:
Telephone Consultation (per
15 minute segments)
$100.00
Appearance / Court
Testimony (per hour)
$450.00
Record review, subpoena
response, report writing (per hour)
$450.00
Client/attorney or attorney
staff consultation (per hour)
$450.00
Deposition lasting between
one and four hours (per hour)
$650.00
Deposition rate for each
additional hour after first four hours (per hour)
$450.00
Conciliation consultation
(parenting advisors, etc.)
not available
Therapeutic visitation (4
hours paid in advance)
not available
(Any part of an hour-no
reimbursement if session is stopped)
Travel time reimbursement
rate, rounded up to next hour (per hour)
$200.00
Mileage (per mile)
$2.00
Payment:
This practice is a fee for service private pay out of network
provider at a rate of $175.00 for individual therapy
session/ $200 for couples or family session / $250 for intake
or initial session per hour. This practice accepts some
insurances. Any payment such as co-payments, late cancellation,
no call/no show, or deductibles is required at the time of
service. Payment methods accepted include cash, funds transfer
and credit/debit cards. A super bill can be created for you to
submit to your HSA or out of network health insurance provider.
This will be provided to you at your next scheduled appointment
if requested.
This practice offers a private pay sliding fee program based on
family income and family size and/or post-secondary student
status. You can apply for the program if you need assistance to
help you pay for your care. To apply for the sliding fee
program you will need to provide your most recent pay stubs for
the last 30 days and current personal income tax return or an
unemployment benefit statement. For students, in addition to
any of the previous documents, you will need to provide your
most recent valid course schedule and post-secondary school
registration. This practice can accommodate no more than three
sliding fee scale clients per month and fees range from $80 -
$150 depending on eligibility.
***PLEASE NOTE***If you need to cancel an appointment, you
are expected to contact your therapist at least 24 hours prior
to your scheduled appointment. If you do not provide at least
24-hour notification in advance, you will be responsible
for the full private pay rate fee of the missed
session and the credit card on file will be charged the
full price session cost that day. If your credit card on file
is declined, it will result in cancellation of future
appointments until balance is paid in full. Should you fail to
pay any outstanding balances, your account may be sent to a
collections agency and additional costs will be incurred by the
client.
If you fail to attend your appointment it will be identified
as a "no show." Greater than 15 minutes late to your
appointment is also considered a "no show" and the remainder of
the appointment may be cancelled at your therapist's
discretion. You will be responsible for the full fee private
pay rate of the session at appointment regardless of length of
session. Should you have two or more "no shows" your therapist
reserves the right to terminate you as a client with the
practice.
If a missed appointment is related to a genuine emergency,
therapist reserves the right to waive all outstanding fees and
may request proof of emergency from client.
Therapist may confirm your appointment via email or text
message which is not a secure form of communication. If you
choose not to receive appointment confirmation via email or
text message, please inform therapist. You will also receive
reminders from the practice via secure client portal, CounSol.
Therapist does not prefer to communicate about clinical issues
via text messages as they are not secure and confidentiality
cannot be ensured.
Therapist Availability and Emergencies:
In the event of a medical emergency please contact 911.
If you are experiencing a mental health crisis please contact
602-222-9444.
You may leave a message for your therapist at any time on
voicemail. If you wish to receive a return call, please be sure
to leave a message including your name, contact phone number,
best time to return the call, and nature of the matter. Your
therapist will return your call within 24-48 hours.
A temporary break in treatment may be necessary when your
therapist is ill, on vacation, or has a personal emergency.
Please know that advance notice of appointment cancellations or
rescheduling will be offered as far in advance as is possible.
NOTICE OF PRIVACY PRACTICES
THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE
USED AND DISCLOSED AND HOW YOU CAN ACCESS THIS INFORMATION.
PLEASE REVIEW IT CAREFULLY.
THERAPIST HAS A LEGAL DUTY TO SAFEGUARD YOUR
PROTECTED HEALTH INFORMATION (PHI)
This practice is legally required to protect the privacy of
your PHI, which includes information that can be used to
identify you. This information can be obtained from documents
you have provided to this practice, documentation that has been
created in accordance with legal and ethical standards,
documentation received from other sources, or written
information about your past, present or future health
conditions, the provision of health care to you, or the payment
of this health care. Therapist must provide you with this
Notice about my privacy practices, and such notice must explain
how, when, and why practice will 'use' and 'disclose' your PHI.
A 'use' of PHI occurs when practice shares, examines, utilizes,
applies, or analyzes such information within this practice; PHI
is 'disclosed' when it is released, transferred, has been given
to, or is otherwise divulged to a third party outside of my
practice.
With some exceptions, therapist may not use or disclose any
more of your PHI than is necessary to accomplish the purpose
for which the use or disclosure is made. And,
therapist is legally required to follow the privacy practices
described in this notice. However, therapist reserves the right
to change the terms of this notice and privacy policies at any
time. Any changes will apply to PHI on file with practice
already. Before therapist makes any important changes to
policies, practice will promptly change this notice and post a
new copy of it in my office and on client portal (if
applicable). You can also request a copy of this notice from
me, or you can view a copy of it in office or on portal (if
applicable).
HOW THERAPIST MAY USE AND DISCLOSE YOUR PHI
Therapist will use and disclose your PHI for many different
reasons. For some of these uses or disclosures, therapist will
need your prior written authorization; for others, however,
therapist does not. Listed below are the categories of uses and
disclosures along with some examples of each category:
1. Uses and Disclosures Relating
to Treatment, Payment, or Health Care Operations do not require
your prior written consent. Therapist and 3rd Party Biller,
Cuub Med Management, can use and disclose your PHI without your
consent for the following reasons:
a. For Treatment and Coordination
of Care. Therapist can use your PHI within practice to provide
you with mental health treatment and whole health education,
including discussing or sharing your PHI with billers.
Therapist can disclose your PHI to physicians, psychiatrists,
psychologists, and other licensed health care providers who
provide you with healthcare services or are involved in your
care. For example, if a psychiatrist is treating you, therapist
can disclose your PHI to your psychiatrist to coordinate your
care.
b. To Obtain Payment for
Treatment. Therapist can use and disclose your PHI to bill and
collect payment for the treatment and services provided by
therapist to you. For example, therapist might send your PHI to
your insurance company or health plan to get paid for the
health care services provided to you. Therapist may also
provide your PHI to business associates, such as billing
companies, claims processing companies, and others that process
this practice's health care claims.
c. For Health Care Operations.
Therapist can use and disclose your PHI to operate practice.
For example, therapist might use your PHI to evaluate the
quality of health care services you received or to evaluate the
performance of the health care professionals who provided such
services to you. Therapist may also provide
your PHI to her attorney, accountant, consultants, or others to
further this practice's health care operations.
d. Patient Incapacitation or
Emergency. Therapist may also disclose your PHI to others
without your consent if you are incapacitated or if an
emergency exists. For example, your consent is not required if
you need emergency treatment, as long as therapist tries to get
your consent after treatment is rendered, or if therapist tries
to get your consent but you are unable to communicate (for
example you are unconscious or in severe pain) and therapist
thinks you would consent to treatment if you were able to do
so.
2. Certain Other Uses and
Disclosures also do not require your consent or authorization.
Therapist can use and disclose your PHI without your consent of
authorization for the following reasons:
a. When federal, state, or local
laws require disclosure. For example, therapist may have to
make a disclosure to applicable governmental officials when
a law requires mandated report information to government
agencies and law enforcement personnel about victims of abuse
or neglect.
b. When judicial proceedings
require disclosure. For example, if you are involved in a
lawsuit or a claim for workers' compensation benefits,
therapist may have to use or disclose your PHI in response to a
subpoena.
c. When law enforcement requires
disclosure. For example, therapist may use or disclose your PHI
in response to a search warrant.
d. When public health activities
require disclosure. For example, therapist may have to use or
disclose your PHI to report to a government official an adverse
reaction to a medication.
e. When health oversight
activities require disclosure. For example, therapist may have
to provide information to assist the government in
investigating or inspection of a healthcare provider or
organization.
f. To avert a serious threat
to health or safety. For example, therapist may have to use or
disclose your PHI to avert a serious threat to the health or
safety of others. However, any such disclosures will only be
made to someone able to prevent the threatened harm from
occurring.
g. For specialized government
functions. If you are in the military, therapist may have to
disclose your PHI for national security purposes, including
protecting the President of the United States or conducting
intelligence operations.
h. To remind you about
appointments and to inform you of health-related benefits or
services. For example, therapist may have to use or disclose
your PHI to remind you of your appointments, or give you
information about treatment alternatives, other health care
services, or other healthcare benefits that I offer that may be
of interest to you.
3. Certain Uses and Disclosures
require you to have the opportunity to object.
a. Disclosures to Family, Friends,
or Others. Therapist may provide your PHI to a family member,
friend, or other person that you indicate is involved in your
care or the payment for your health care, unless you object in
whole or in part. The opportunity to consent may be obtained
retroactively in emergency situations.
Other Uses and Disclosures Require Your Prior Written
Authorization. In any other situation not described above,
therapist will need your written authorization before using or
disclosing any of your PHI. If you choose to sign an
authorization to disclose your PHI, you can later revoke such
authorization in writing to stop any future uses and
disclosures (to the extent that therapist has not taken any
action in reliance on such authorization) or your PHI by
therapist.
WHAT RIGHTS YOU HAVE REGARDING YOUR PHI
You have the following rights with respect to your PHI:
1. The Right to Request
Restrictions on Practice Uses and Disclosures: You have the
right to request restrictions or limitations on uses or
disclosures of your PHI to carry out treatment, payment, or
health care operations. You also have the right to request that
therapist restrict or limit disclosures of your PHI to family
members or others involved in your care or who are financially
responsible for your care. Please submit such requests to
practice in writing. Therapist will consider your requests but
is not legally required to accept them. If therapist does not
accept your requests, therapist will put them in writing and
will abide by the law, except in emergency situations. However,
be advised, that you may not limit the uses and disclosures
that therapist is legally required to make.
2. The Right to Choose How
Therapist Sends PHI to you: You have the right to request that
therapist send confidential information to you at an
alternative address (for example sending it to your work
address rather than your home address) or by alternative means
(for example, email or text instead of regular mail). Therapist
must agree to your request so long as it is reasonable and you
specify how or where you wish to be contacted and, when
appropriate, you provide therapist with information as to how
payment for such alternative communications will be handled.
Therapist may not require an explanation from you as to the
basis of your request as a condition of providing
communications on a confidential basis.
3. The Right to Inspect and
Receive a Copy of your PHI: In most cases, you have the right
to inspect and receive a copy of the PHI that therapist has,
but you must make the request to inspect and receive a copy of
such information in writing. If therapist doesn't have your PHI
but therapist knows who does, therapist will tell you how to
get it. Therapist will respond to your request within 30 days
of receiving your written request. In certain situations,
therapist may deny your request. If request is denied,
therapist will tell you, in writing, the reasons for the denial
and explain your right to have the denial reviewed. If you
request copies of your PHI, therapist will charge you no more
than 25 cents for each page. Instead of providing you the PHI
you requested, therapist may provide you with a summary or
explanation of the PHI as long as you agree to that and the
cost in advance.
4. The Right to Receive a List of
the Disclosures Therapist Has Made: You have the right to
receive a list of instances, i.e. an Accounting of Disclosure,
in which therapist has disclosed your PHI. The list will not
include disclosures made for treatment, payment, or health care
operations; disclosures made by you; disclosures you
authorized; disclosure permitted to or required by federal
privacy rule; disclosures made for national security or
intelligence; or disclosures made by correctional institutions
or law enforcement personnel. Therapist will respond to your
request for an Accounting of disclosures within 60 days of such
request. The list therapist provides will include disclosures
made in the last six years unless you request a shorter time.
The list will include the date the disclosure was made, to whom
the PHI was disclosed (including address if known), a
description of the information disclosed, and the reason for
the disclosure. Therapist will provide the list at no charge,
but if you make more than one request in the same year,
therapist may charge you a reasonable cost based fee for each
additional request.
5. The Right to Amend Your PHI: If
you believe there is a mistake in your PHI or that a piece of
important information is missing, you have the right to request
therapist to correct the existing information or add the
missing information. You must provide your request or the
reason for your request in writing if the PHI is (i) correct
and complete, (ii) not created by therapist, (iii) not allowed
to be disclosed, or (iv) the information is not part of
therapists' original records. My written denial will state the
reasons for the denial and explain your right to file a written
statement of disagreement with the denial. If you don't file
one, you have the right to request that your request and
therapists' denial be attached to all full disclosures of your
PHI. If therapist approves your request, therapist will make
the change to your PHI, tell you that she has done so, and tell
others that need to know about the change to your PHI.
6. The Right to Receive a Paper
Copy of this Notice: You have a right to receive a paper copy
of this notice and/or receive it via email.
HOW TO COMPLAIN ABOUT OUR PRIVACY PRACTICES
If you believe therapist may have violated your privacy rights,
or you disagree with a decision therapist made with regard to
accessing your PHI, you may file a formal complaint with the
Secretary of the Department of Health and Human Services at 200
Independence Ave S.W., Washington, D.C., 20201. This practice
will take no retaliatory against you if you file a complaint
regarding privacy practices.
By signing this form, you acknowledge receipt of the Notice of
Privacy Practices provided in this document. Please feel free to
copy this document after signing and retain for your records.This
Notice of Privacy Practices provides you information about how
this practice/therapist may use and disclose your protected
health information. Please read it in its entirety as it is
updated yearly to be in accordance with current
legalrequirements.
This Notice of Privacy Practices is subject to change. If a
change is implemented, you may obtain a copy of the revised
notice for your personal records. At that time, you will be asked
to sign a new acknowledgment of receipt to keep in your personal
file.
This signature is an acknowledgment of the receipt of the Privacy
Practices for Better Peace of Mind Counseling AKA Black Potatoe,
LLC.
____________________________________________ ______________________
Client Date
____________________________________________ _______________________
Parent/Guardian Date