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Terms and Policy

Disclosure Statement and Consent to Treat

Better Peace of Mind Counseling, AKA Black Potatoe LLC

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 judgemental, 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 adultabuse

      Physical abuse, sexual abuse, or neglect of achild

      Imminentdanger

If anyofthesesituationsare identifiedthroughoutthetherapeuticprocessyourtherapist willfileareportwiththeappropriateauthorities.Beadvised, under these circumstances,thattherapeuticrecordsmaybe subpoenaedby acourtoflaw.If thisoccurs,yourtherapistwilladviseyouand make recordsavailable.

If youparticipateinmaritalandfamilytherapy,yourtherapistwillnotdiscloseconfidential information about your treatment unless all persons involved in treatment provide their written authorizationtoreleasetheinformation.Itiscriticaltonotethatyourtherapistusesa"no-secret" policywhenconductingmarriageandfamilytherapy.Thispolicymeansthatifyouparticipatein marriage or family therapy, your therapist is allowed to use information obtained in individual sessionsyoumayhavehadwithherinordertoaidthetherapeuticprocess.

Therapist is bound by confidentiality. At times, this therapist may provide services to several familymembersorreceivereferralsfromindividualswhoknowoneanotherinpersonalspheres. Inthecaseofservicesprovidedtofamilymembers,eachclientistreatedasanindividualclient andconfidentialityisstrictlyenforcedforeachclient.

Confidentialitywillonlybebrokenifclient 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 supportandencouragementbetweensessions.Noinformationwillbesharedwithotherswithout an active Release of Information onfile.

Intheeventacurrentclientmakesareferraloffriend/acquaintancetothistherapistforservices, 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 intosession.

In the Case of Custody and Guardianship:

PleasebeadvisedthatstrictcriterionisobservedwithinthispracticeinaccordancewithArizona Revised Statutes and the Arizona Board of Behavioral Healthrequirements.

      ConsentfortherapeuticservicescanonlybeauthorizedbyacurrentlegalGuardian.

      Ifparentsareseparatedandsharemedicaldecisionmaking,thenconsentmustbegivenbybothparents.

      Fordivorcedparents,consentmaybegivenbytheparentauthorizedtomakelegalmedical decisions, although may require co-signature of the other parent if possible.

      Emailsmaybeusedtocommunicateabouttherapyissuesattheriskofthelegalguardian.Email is not a guaranteed confidential method of communication. Text messages are not secure and therapist may opt not communicate viatext.

      Youmayberequestedtoprovideacopyofyourlegaldocumentsidentifyingyouastheparent authorized to make legal medicaldecisions.

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 $150.00 for individual therapy session/ $180 for couples or family session / $200 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.

***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.


ACKNOWLEDGMENT OF RECEIPT OF 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

( Type Full Name )