Notice of Privacy Practices

I. OUR PLEDGE REGARDING HEALTH INFORMATION:

We understand that health information about you and your health care is personal. We are committed to protecting health information about you. We create a record of the care and services you receive from us. We need this record to provide you with quality care and to comply with certain legal requirements. This notice applies to all of the records of your care generated by this mental health care practice. This notice will tell you about the ways in which we may use and disclose health information about you. We also describe your rights to the health information kept about you and describe certain obligations we have regarding the use and disclosure of your health information. We are required by law to:

• Make sure that protected health information (“PHI”) that identifies you is kept private.
• Give you this notice of my legal duties and privacy practices with respect to health information.
• Follow the terms of the notice that is currently in effect.
• W can change the terms of this Notice, and such changes will apply to all information we have about you. The new Notice will be available upon request, in our office, and on our website.

II. HOW WE MAY USE AND DISCLOSE HEALTH INFORMATION ABOUT YOU:
The following categories describe different ways that we use and disclose health information. Not every use or disclosure in a category will be listed. However, all of the ways we are permitted to use and disclose information will fall within one of the categories.

For Treatment Payment, or Health Care Operations: Federal privacy rules (regulations) allow health care providers who have direct treatment relationship with the patient/client to use or disclose the patient/client’s personal health information without the patient’s written authorization, to carry out the health care provider’s own treatment, payment or health care operations. We may also disclose your protected health information for the treatment activities of any health care provider. This too can be done without your written authorization. For example, if a clinician were to consult with another licensed health care provider about your condition, we would be permitted to use and disclose your person health information, which is otherwise confidential, in order to assist the clinician in diagnosis and treatment of your mental health condition.

Disclosures for treatment purposes are not limited to the minimum necessary standard. Because therapists and other health care providers need access to the full record and/or full and complete information in order to provide quality care. The word “treatment” includes, among other things, the coordination and management of health care providers with a third party, consultations between health care providers and referrals of a patient for health care from one health care provider to another.

Lawsuits and Disputes: If you are involved in a lawsuit, we may disclose health information in response to a court or administrative order. We may also disclose health information about your child in response to a subpoena, discovery request, or other lawful process by someone else involved in the dispute, but only if efforts have been made to tell you about the request or to obtain an order protecting the information requested.

III. CERTAIN USES AND DISCLOSURES REQUIRE YOUR AUTHORIZATION:

Psychotherapy Notes. I do keep “psychotherapy notes” as that term is defined in 45 CFR § 164.501, and any use or disclosure of such notes requires your Authorization unless the use or disclosure is:
a. For our use in treating you.
b. For our use in training or supervising mental health practitioners to help them improve their skills in group, joint, family, or individual counseling or therapy.
c. For our use in defending myself in legal proceedings instituted by you.
d. For use by the Secretary of Health and Human Services to investigate our compliance with HIPAA.
e. Required by law and the use or disclosure is limited to the requirements of such law.
f. Required by law for certain health oversight activities pertaining to the originator of the psychotherapy notes.
g. Required by a coroner who is performing duties authorized by law.
h. Required to help avert a serious threat to the health and safety of others.

Marketing Purposes. As psychotherapist, we will not use or disclose your PHI for marketing purposes.

Sale of PHI. As psychotherapists, we will not sell your PHI in the regular course of our business.

IV. CERTAIN USES AND DISCLOSURES DO NOT REQUIRE YOUR AUTHORIZATION.

Subject to certain limitations in the law, we can use and disclose your PHI without your Authorization for the following reasons:

When disclosure is required by state or federal law, and the use or disclosure complies with and is limited to the relevant requirements of such law.

For public health activities, including reporting suspected child, elder, or dependent adult abuse, or preventing or reducing a serious threat to anyone’s health or safety.

For health oversight activities, including audits and investigations.

For judicial and administrative proceedings, including responding to a court or administrative order, although my preference is to obtain an Authorization from you before doing so.

For law enforcement purposes, including reporting crimes occurring on my premises.

To coroners or medical examiners, when such individuals are performing duties authorized by law.

For research purposes, including studying and comparing the mental health of patients who received one form of therapy versus those who received another form of therapy for the same condition.

Specialized government functions, including, ensuring the proper execution of military missions; protecting the President of the United States; conducting intelligence or counter-intelligence operations; or, helping to ensure the safety of those working within or housed in correctional institutions.

For workers’ compensation purposes. Although my preference is to obtain an Authorization from you, we may provide your PHI in order to comply with workers’ compensation laws.

Appointment reminders and health related benefits or services. We may use and disclose your PHI to contact you to remind you that you have an appointment with a therapist here. We may also use and disclose your PHI to tell you about treatment alternatives, or other health care services or benefits that we offer.

V. CERTAIN USES AND DISCLOSURES REQUIRE YOU TO HAVE THE OPPORTUNITY TO OBJECT.

Disclosures to family, friends, or others. We 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.
VI. YOU HAVE THE FOLLOWING RIGHTS WITH RESPECT TO YOUR PHI:

The Right to Request Limits on Uses and Disclosures of Your PHI. You have the right to ask us not to use or disclose certain PHI for treatment, payment, or health care operations purposes We are not required to agree to your request, and we may say “no” if we believe it would affect your health care.

The Right to Request Restrictions for Out-of-Pocket Expenses Paid for In Full. You have the right to request restrictions on disclosures of your PHI to health plans for payment or health care operations purposes if the PHI pertains solely to a health care item or a health care service that you have paid for out-of-pocket in full.

The Right to Choose How We Send PHI to You. You have the right to ask us to contact you in a specific way (for example, home or office phone) or to send mail to a different address, and we will agree to all reasonable requests.

The Right to See and Get Copies of Your PHI. Other than “psychotherapy notes,” you have the right to get an electronic or paper copy of your medical record and other information that I have about you. We will provide you with a copy of your record, or a summary of it, if you agree to receive a summary, free of charge for the first request within 30 days of receiving your written request, and we may charge a reasonable, cost-based fee for any subsequent copies for doing so.

The Right to Get a List of the Disclosures We Have Made. You have the right to request a list of instances in which we have disclosed your PHI for purposes other than treatment, payment, or health care operations, or for which you provided me with an Authorization. We will respond to your request for an accounting of disclosures within 60 days of receiving your request. The list we will give you will include disclosures made in the last six years unless you request a shorter time. We will provide the list to you at no charge, but if you make more than one request in the same year, we will charge you a reasonable cost-based fee for each additional request.

The Right to Correct or Update Your PHI. If you believe that there is a mistake in your PHI, or that a piece of important information is missing from your PHI, you have the right to request that we correct the existing information or add the missing information. We may say “no” to your request, but we will tell you why in writing within 60 days of receiving your request.

The Right to Get a Paper or Electronic Copy of this Notice. You have the right get a paper copy of this Notice, and you have the right to get a copy of this notice by e-mail. And, even if you have agreed to receive this Notice via e-mail, you also have the right to request a paper copy of it.

EFFECTIVE DATE OF THIS NOTICE

This notice went into effect on September 20, 2013 and was updated on September 30, 2022.

Acknowledgement of Receipt of Privacy Notice

Under the Health Insurance Portability and Accountability Act of 1996 (HIPAA), you have certain rights regarding the use and disclosure of your protected health information. By checking the box below, you are acknowledging that you have received a copy of HIPAA Notice of Privacy Practices.

Informed Consent for Psychotherapy

General Information
The therapeutic relationship is unique in that it is a highly personal and at the same time, a contractual agreement. Given this, it is important for us to reach a clear understanding about how our relationship will work, and what each of us can expect. This consent will provide a clear framework for our work together. Feel free to discuss any of this with me. Please read and indicate that you have reviewed this information and agree to it by filling in the checkbox at the end of this document.

The Therapeutic Process
You have taken a very positive step by deciding to seek therapy. The outcome of your treatment depends largely on your willingness to engage in this process, which may, at times, result in considerable discomfort. Remembering unpleasant events and becoming aware of feelings attached to those events can bring on strong feelings of anger, depression, anxiety, etc. There are no miracle cures. We cannot promise that your behavior or circumstance will change. We can promise to support you and do our very best to understand you and repeating patterns, as well as to help you clarify what it is that you want for yourself.

Confidentiality
1. The session content and all relevant materials to the client’s treatment will be held confidential unless the client requests in writing to have all or portions of such content released to a specifically named person/persons. Limitations of such client held privilege of confidentiality exist and are itemized below:

2. If a client threatens or attempts to commit suicide or otherwise conducts him/herself in a manner in which there is a substantial risk of incurring serious bodily harm.

3. If a client threatens grave bodily harm or death to another person.

4. If the therapist has a reasonable suspicion that a client or other named victim is the perpetrator, observer of, or actual victim of physical, emotional or sexual abuse of children under the age of 18 years.

5. Suspicions as stated above in the case of an elderly person who may be subjected to these abuses.

6. Suspected neglect of the parties named in items #3 and # 4.

7. If a court of law issues a legitimate subpoena for information stated on the subpoena.

8. If a client is in therapy or being treated by order of a court of law, or if information is obtained for the purpose of rendering an expert’s report to an attorney.

Occasionally we may need to consult with other professionals in their areas of expertise in order to provide the best treatment for you. Information about you may be shared in this context without using your name.

If we see each other accidentally outside of the therapy office, we will not acknowledge you first. Your right to privacy and confidentiality is of the utmost importance to us, and we do not wish to jeopardize your privacy. However, if you acknowledge us first, we will be more than happy to speak briefly with you, but feel it appropriate not to engage in any lengthy discussions in public or outside of the therapy office.

Drugs and Alcohol

Please refrain from being under the influence of mind-altering drugs or alcohol immediately prior or during sessions as they impair judgment and, therefore, interfere with the counseling process and therapeutic relationship. We reserve the right to end a session if it becomes evident that you are under the influence. In this case the full fee will be charged for the terminated session.

Court Fees

Clients are discouraged from having their therapist subpoenaed. Even though you are responsible for the testimony fee, it does not mean that our testimony will be solely in your favor. We can only testify to the facts of the case and to our professional opinion.

Preparation time (including submission of records): $350/hr (pro-rated by the quarter hour)

Phone calls: $350/hr (pro-rated by the quarter hour)

Depositions: $500/hour (pro-rated by the quarter hour)

Time required in giving testimony: $500/hour (pro-rated by the quarter hour)

Mileage: $0.625/mile (subject to annual mileage reimbursement rate and adjustment due to rising cost of fuel)

Time away from office due to depositions or testimony: $350/hour (pro-rated by the quarter hour)

All attorney fees and costs incurred by the therapist as a result of the legal action.

Filing a document with the court: $200

The minimum charge for a court appearance: $2500

A retainer of $2500 is due in advance. All court-related payments are to be by cashier’s check only. If a subpoena or notice to meet attorney(s) is received without a minimum of 48-hour notice, there will be an additional $500 “express” charge. Also, if the case is reset with less than 72 business hours’ notice, then the client will be charged $500 (in addition to the retainer of $2500).

Finally, all fees are doubled if counselor has verifiably pre-scheduled plans to be away from the office.

PRACTICE POLICIES

APPOINTMENTS AND CANCELLATIONS
Please remember to cancel or reschedule 24 hours in advance. You may be responsible for the entire fee if cancellation is less than 24 hours.

The standard meeting time for psychotherapy is 50 minutes. It is up to you, however, to determine the length of time of your sessions. Requests to change the 50-minute session needs to be discussed with the therapist in order for time to be scheduled in advance.

A $30.00 service charge will be charged for any checks returned for any reason for special handling.

Cancellations and re-scheduled sessions will be subject to a full charge if NOT RECEIVED AT LEAST 24 HOURS IN ADVANCE. This is necessary because a time commitment is made to you and is held exclusively for you. If you are late for a session, you may lose some of that session time.

—More than 24-hours notice = No Charge
—Fewer than 24-hours notice = Automatic $50 charge
—Fewer than 6-hours = Automatic $75 charge
—No Show-no attempt to cancel = Automatic $100 charge

If you are an Oregon Health Plan member, please be aware that although a fee will not be assessed for late cancels or no shows, we reserve the right to remove you from our active client list if you have more than 3 late cancellations or no-shows within a 6-month period. Should that occur, you would be placed on our waitlist, behind anyone else who might already be waiting.

TELEPHONE ACCESSIBILITY If you need to contact us between sessions, please leave a message on our voice mail. We are often not immediately available; however, we will attempt to return your call within 48 hours. Please note that face-to-face sessions are highly preferable to phone sessions. However, in the event that you are out of town, sick or need additional support, phone sessions are available. We do not have clinicians on call therefore, if a true emergency situation arises, call Multnomah County Crisis Line (503-988-4888), Clackamas County Crisis Line (503-655-8585), Washington County Crisis Line (503-291-9111), 988, or go to the hospital depending on the severity of the crisis.

SOCIAL MEDIA AND TELECOMMUNICATION Due to the importance of your confidentiality and the importance of minimizing dual relationships, we do not accept friend or contact requests from current or former clients on any social networking site (Facebook, Instagram, LinkedIn, etc.). We 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. If you have questions about this, please bring them up when we meet and we can talk more about it.

ELECTRONIC COMMUNICATION
We cannot ensure the confidentiality of any form of communication through electronic media, including text messages. If you prefer to communicate via email for issues regarding scheduling or cancellations, we will do so. While we may try to return messages in a timely manner, we cannot guarantee immediate response and request that you do not use these methods of communication to discuss therapeutic content and/or request assistance for emergencies.

Services by electronic means, including but not limited to telephone communication, the Internet, facsimile machines, and e-mail is considered telemedicine by the State of Oregon. Under the OR Revised Statutes Sec.442.015 telemedicine is broadly defined as the use of information technology to deliver medical services and information from one location to another. If you and your therapist chose to use information technology for some or all of your treatment, you need to understand that:
(1) You retain the option to withhold or withdraw consent at any time without affecting the right to future care or treatment or risking the loss or withdrawal of any program benefits to which you would otherwise be entitled.
(2) All existing confidentiality protections are equally applicable.
(3) Your access to all medical information transmitted during a telemedicine consultation is guaranteed, and copies of this information are available for a reasonable fee.
(4) Dissemination of any of your identifiable images or information from the telemedicine interaction to researchers or other entities shall not occur without your consent.
(5) There are potential risks, consequences, and benefits of telemedicine. Potential benefits include, but are not limited to improved communication capabilities, providing convenient access to up-to-date information, consultations, support, reduced costs, improved quality, change in the conditions of practice, improved access to therapy, better continuity of care, and reduction of lost work time and travel costs. Effective therapy is often facilitated when the therapist gathers within a session or a series of sessions, a multitude of observations, information, and experiences about the client. Therapists may make clinical assessments, diagnosis, and interventions based not only on direct verbal or auditory communications, written reports, and third person consultations, but also from direct visual and olfactory observations, information, and experiences. When using information technology in therapy services, potential risks include, but are not limited to the therapist’s inability to make visual and olfactory observations of clinically or therapeutically potentially relevant issues such as: your physical condition including deformities, apparent height and weight, body type, attractiveness relative to social and cultural norms or standards, gait and motor coordination, posture, work speed, any noteworthy mannerism or gestures, physical or medical conditions including bruises or injuries, basic grooming and hygiene including appropriateness of dress, eye contact (including any changes in the previously listed issues), sex, chronological and apparent age, ethnicity, facial and body language, and congruence of language and facial or bodily expression. Potential consequences thus include the therapist not being aware of what he or she would consider important information, that you may not recognize as significant to present verbally the therapist.

MINORS
If you are a minor, your parents may be legally entitled to some information about your therapy. We will discuss with you and your parents’ what information is appropriate for them to receive and which issues are more appropriately kept confidential.

TERMINATION
Ending relationships can be difficult. Therefore, it is important to have a termination process in order to achieve some closure. The appropriate length of the termination depends on the length and intensity of the treatment. We may terminate treatment after appropriate discussion with you and a termination process if we determine that the psychotherapy is not being effectively used or if you are in default on payment. We will not terminate the therapeutic relationship without first discussing and exploring the reasons and purpose of terminating. If therapy is terminated for any reason or you request another therapist, we will provide you with a list of qualified psychotherapists to treat you. You may also choose someone on your own or from another referral source.

Should you fail to schedule or attend (including late cancellations, which is considered canceling within 24 hours) an appointment for three consecutive weeks, unless other arrangements have been made in advance, for legal and ethical reasons, we must consider the professional relationship discontinued.

Limits of the Therapy Relationship: What Clients Should Know

Psychotherapy is a professional service we are able to provide to you. However, because of the nature of therapy, our relationship has to be different from most other relationships. It may differ in how long it lasts, in the topics we discuss, or in its goals. It must also be limited to the relationship of therapist and client only. If we were to interact in any other ways, we would then have a “dual relationship,” which might be harmful and may not be legal. The different therapy professions all have rules against such relationships to protect us both. Let us explain why having a dual relationship is not a good idea.

Dual relationships can set up conflicts between your best interests and our best interests. What is best for you might not be what is best for us, and we must put your interests before our own, because you are our client. So, we must have only one relationship. Because of this, dual relationships like these are improper:

None of us can be your supervisor, teacher, or evaluator for custody, disability, or similar issues.

None of us can serve as your advocate or take your side in any legal matter or court action.

None of us can be a therapist to our relatives, friends (or the relatives of friends), people we know or knew socially, or business contacts.

None of us can have any other kind of business relationship with you besides for therapy. For example, we cannot employ you, lend to or borrow from you, trade or barter your services (such as for tutoring, repairing, child care, etc.) for ours, or trade goods for therapy.

None of us can give legal, medical, financial, or any other type of professional advice.

None of us can have any kind of romantic or sexual relationship with a current or former client, or with any other people close to a client.

We should not exchange gifts.

We will not “friend” clients on social media or accept clients’ “friend” requests.

There are important differences between therapy and friendship. While we expect friendly and respectful sessions, as your therapist we cannot be a typical friend. Friendships are two-way exchanges, but in therapy we will offer very little about ourselves and our feelings, because our focus is on you and your needs and development. Friends usually see you only from their personal viewpoints and experiences, and we will try to be more objective and nonjudgmental. Friends may want to find quick and simple solutions to your problems so that they can feel helpful, but these responses may not be in your long-term best interest, which is our goal. Therapists can focus on issues and motives that are not apparent and that require persistent exploration for change to occur. Friends do not usually follow up on their advice to see whether it was useful; therapists do follow up to be more helpful. Friends may feel a need to have you do what they advise; a therapist offers you options and helps you choose what is best for you. A therapist’s responses to your situation are based on tested theories and proven methods of change, not just personal experiences. To preserve your confidentiality, therapists are required to keep the identity of their clients private. Therefore, we will let you take the lead on whether to acknowledge or recognize me if we meet in a public place, and we will decline to attend your family’s gatherings if you invite us. Lastly, when our therapy is completed, we will not be able to be a friend to you like your other friends.

In sum, our duty as therapists is to care for you and all of our clients, but only in the professional role of therapist.

Telemental Health Services Informed Consent

Overview

• You will need access to the certain technological services and tools to engage in telemental health-based services with your provider

• Telemental health has both benefits and risks, which you and your provider will be monitoring as you proceed with your work

• It is possible that receiving services by telemental health will turn out to be inappropriate for you, and that you and your provider may have to cease work by telemental health

• You can stop work by telemental health at any time without prejudice

• You will need to participate in creating an appropriate space for your telemental health sessions

• You will need to participate in creating an appropriate space for your telemental health sessions

• You will need to participate in making a plan for managing technology failures, mental health crises, and medical emergencies

• Your provider follows security best practices and legal standards in order to protect your health care information, but you will also need to participate in maintaining your own security and privacy

What is Telemental Health?

“Telemental health” means, in short, provision of mental health services with the provider and recipient of services being in separate locations, and the services being delivered over electronic media.

Services delivered via telemental health rely on a number of electronic, often Internet-based, technology tools. These tools can include videoconferencing software, email, text messaging, virtual environments, specialized mobile health (“mHealth”) apps, and others.

Your provider typically provides telemental health services using the following tools:

Telemental Health platform within the SimplePractice Electronic Health Record.

• You will need access to Internet service and technological tools needed to use the above-listed tools in order to engage in telemental health work with your provider.

• If you have any questions or concerns about the above tools, please address them directly to your provider so you can discuss their risks, benefits, and specific application to your treatment.

Benefits and Risks of Telemental Health

Receiving services via telemental health allows you to:

• Receive services at times or in places where the service may not otherwise be available.

• Receive services in a fashion that may be more convenient and less prone to delays than in-person meetings.

• Receive services when you are unable to travel to the service provider’s office.

The unique characteristics of telemental health media may also help some people make improved progress on health goals that may not have been otherwise achievable without telemental health.

Receiving services via telemental health has the following risks:

• Telemental health services can be impacted by technical failures, may introduce risks to your privacy, and may reduce your service provider’s ability to directly intervene in crises or emergencies. Here is a non-exhaustive list of examples:

• Internet connections and cloud services could cease working or become too unstable to use

• Cloud-based service personnel, IT assistants, and malicious actors (“hackers”) may have the ability to access your private information that is transmitted or stored in the process of telemental health-based service delivery.

• Computer or smartphone hardware can have sudden failures or run out of power, or local power services can go out.

• Interruptions may disrupt services at important moments, and your provider may be unable to reach you quickly or using the most effective tools. Your provider may also be unable to help you in-person.

• There may be additional benefits and risks to telemental health services that arise from the lack of in-person contact or presence, the distance between you and your provider at the time of service, and the technological tools used to deliver services. Your provider will assess these potential benefits and risks, sometimes in collaboration with you, as your relationship progresses.

Assessing Telemental Health’s Fit For You

Although it is well validated by research, service delivery via telemental health is not a good fit for every person. Your provider will continuously assess if working via telemental health is appropriate for your case. If it is not appropriate, your provider will help you find in-person providers with whom to continue services.

Please talk to your provider if you find the telemental health media so difficult to use that it distracts from the services being provided, if the medium causes trouble focusing on your services, or if there are any other reasons why the telemental health medium seems to be causing problems in receiving services. Raising your questions or concerns will not, by itself, result in termination of services. Bringing your concerns to your provider is often a part of the process.

You also have a right to stop receiving services by telemental health at any time without prejudice. If your provider also provides services in-person and you are reasonably able to access the provider’s in-person services, you will not be prevented from accessing those services if you choose to stop using telemental health.

Your Telemental Health Environment

You will be responsible for creating a safe and confidential space during sessions. You should use a space that is free of other people. It should also be difficult or impossible for people outside the space to see or hear your interactions with your provider during the session. If you are unsure of how to do this, please ask your provider for assistance.

Our Communication Plan

At our first session, we will develop a plan for backup communications in case of technology failures and a plan for responding to emergencies and mental health crises. In addition to those plans, your provider has the following policies regarding communications:

The best way to contact your provider between sessions is to call at 503-659-3480.

Your provider will make the best effort to respond to your messages within 24 business hours. Please note that your provider may not respond at all on weekends or holidays. Your provider may also respond sooner than stated in this policy. That does not mean they will always respond that quickly.

Our work is done primarily during our appointed sessions, which will generally occur during regular business hours. Contact between sessions should be limited to:

1. Confirming or changing appointment times
2. Billing questions or issues

Your provider is located in the Pacific time zone.

Please note that all textual messages you exchange with your provider, e.g. emails and text messages, will become a part of your health record.

Your provider may coordinate care with one or more of your other providers. Your provider will use reasonable care to ensure that those communications are secure and that they safeguard your privacy.

Our Safety and Emergency Plan

As a recipient of telemental health-based services, you will need to participate in ensuring your safety during mental health crises, medical emergencies, and sessions that you have with your provider.

Your provider will require you to designate an emergency contact. You will need to provide permission for your provider to communicate with this person about your care during emergencies.

Your provider will also develop with you a plan for what to do during mental health crises and emergencies, and a plan for how to keep your space safe during sessions. It is important that you engage with your provider in the creation of these plans and that you follow them when you need to.

Your Security and Privacy

Except where otherwise noted, your provider employs software and hardware tools that adhere to security best practices and applicable legal standards for the purposes of protecting your privacy and ensuring that records of your health care services are not lost or damaged.

As with all things in telemental health, however, you also have a role to play in maintaining your security. Please use reasonable security protocols to protect the privacy of your own health care information. For example: when communicating with your provider, use devices and service accounts that are protected by unique passwords that only you know. Also, use the secure tools that your provider has supplied for communications.

Recordings

Please do not record video or audio sessions without your provider’s consent. Making recordings can quickly and easily compromise your privacy and should be done so with great care. Your provider will not record video or audio sessions.