Privacy Policy

Confidentiality & Privacy Policy

The law protects the relationship between a client and a psychotherapist, and information cannot be disclosed without written permission.

Exceptions include:

  • Suspected child abuse or dependant adult or elder abuse, for which I am required by law to report this to the appropriate authorities immediately.
  • If a client is threatening serious bodily harm to another person/s, I must notify the police and inform the intended victim.
  • If a client intends to harm himself or herself, I will make every effort to enlist their cooperation in ensuring their safety. If they do not cooperate, I will take further measures without their permission that are provided to me by law in order to ensure their safety.

Notice Of Privacy Practices

This notice describes how medical information about you may be used and disclosed and how you can get access to this information.  Please review it carefully. This is a summary of your rights and our responsibilities regarding your medical information and its privacy. For full and complete detail of this policy, please see our office director. If you have questions regarding this policy, please make an appointment with your therapist and he/she will answer any questions.

Our Pledge regarding medical information: We are committed to the privacy of medical information about you.

[PHI] Protected Health Information: refers to information in your health care record that could identify you.  It is individually identifiable information about your past, present, or future health or condition, the provision of health care to you, or payment for the health care.

How We May Use and Disclose Your Protected Health Information: In accordance with the Health Insurance Portability and Accountability Act of 1996, (HIPAA)  Privacy Rule (Rule), we are permitted to use and/or disclose your PHI for the purposes of treatment, the payment of services you receive, for health care operations, appointment reminders, treatment alternatives, health-related benefits and services, individuals involved in your care, worker's compensation, public health risks, as required by law, and to avert a serious threat to the health or safety.  For most other uses and/or disclosure of your PHI, you will be asked to grant your permission via a SIGNED Authorization to Release Information.

Your Rights Regarding Your Protected Health Information:

  • Right to inspect and copy: your medical information.
  • Right to Request an Amendment: of information you consider incorrect or incomplete.
  • Right to an Accounting of Disclosures: that we have made of medical information about you.
  • Right to Request Restrictions: or limitations on the information we use or disclose about you for treatment, payment or health care.
  • Right To Receive Confidential Communications: as specified by you and also by alternate means or locations.
  • Right to a Paper Copy of this Notice.

Changes to the Notice: We reserve the right to change this Notice and will post a dated copy of this Notice in the office.
If you believe your privacy rights have been violated, you may file a complaint with the office director or with the Department of Health and Human Services in your local area. You will not be penalized for filing a complaint.


I, ____________________________________, have received a copy of the Notice of Privacy Practice (above), or am aware of my right to have a copy and have declined.

Patient Signature _____________________________________________________ Date _______________________________________

Witness Signature ____________________________________________________ Date _______________________________________

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