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Counseling Connection Privacy of Information Policies
This form describes the confidentiality of your medical records, how the information is used, your rights, and how you may obtain this information. Our Legal Duties State and Federal laws require that we keep your records private. Such laws require that we provide you with this notice informing you of our privacy of information policies, your rights, and our duties. We are required to abide by these policies until replaced or revised. We have the right to revise our privacy policies for all medical records, including records kept before policy changes were made. Any changes in this notice will be made available upon request before changes take place. The contents of material disclosed to us in an evaluation, intake, or counseling session are covered by the law as private information. We respect the privacy of the information you provide us and we abide by ethical and legal requirements of confidentiality and privacy of records. Use of Information Information about you may be used by Louann Hillesland for diagnosis, treatment planning, treatment, and continuity of care. She may disclose it to health care providers who provide you with treatment, such as doctors, nurses, mental health professionals, or business affiliates such as insurance providers, billing, or audits. Both verbal information and written records about a client cannot be shared with another party without the written consent of the client or the client’s legal guardian or personal representative. It is the policy of this clinic not to release any information about a client without a signed release of information except in certain emergency situations or exceptions in which client information can be disclosed to others without written consent. Some of these situations are noted below, and there may be other provisions provided by legal requirements. Duty to Warn and Protect When a client discloses intentions or a plan to harm another person or persons, the health care professional is required to warn the intended victim and report this information to legal authorities. In cases in which the client discloses or implies a plan for suicide, the health care professional is required to notify legal authorities and make reasonable attempts to notify the family of the client. Public Safety Health records may be released for the public interest and safety for public health activities, judicial and administrative proceedings, law enforcement purposes, serious threats to public safety, essential government functions, military, and when complying with worker’s compensation laws. Abuse If a client states or suggests that he or she is abusing a child or vulnerable adult, or has recently abused a child or vulnerable adult, or a child (or vulnerable adult) is in danger of abuse, the health care professional is required to report this information to the appropriate social service and/or legal authorities. If a client is the victim of abuse, neglect, violence, or a crime victim, and their safety appears to be at risk, we may share this information with law enforcement officials to help prevent future occurrences and capture the perpetrator. Prenatal Exposure to Controlled Substances Health care professionals are required to report admitted prenatal exposure to controlled substances that are potentially harmful. In the Event of a Client’s Death In the event of a client’s death, the spouse or parents of a deceased client have a right to access their child’s or spouse’s records. Professional Misconduct Professional misconduct by a health care professional must be reported by other health care professionals. In cases in which a professional or legal disciplinary meeting is being held regarding the health care professional’s actions, related records may be released in order to substantiate disciplinary concerns. Judicial or Administrative Proceedings Health care professionals are required to release records of clients when a court order has been placed. Minors/Guardianship Parents or legal guardians of non-emancipated minor clients have the right to access the client’s records. Other Provisions When payment for services are the responsibility of the client, or a person who has agreed to providing payment, and payment has not been made in a timely manner, collection agencies may be utilized in collecting unpaid debts. The specific content of the services (e.g., diagnosis, treatment plan, progress notes, testing) is not disclosed. If a debt remains unpaid it may be reported to credit agencies, and the client’s credit report may state the amount owed, the time-frame, and the name of the clinic or collection source. Insurance companies, managed care, and other third-party payers are given information that they request regarding services to the client. Information which may be requested includes type of services, dates/times of services, diagnosis, treatment plan, description of impairment, progress of therapy, and summaries. Information about clients may be disclosed in consultations with other professionals in order to provide the best possible treatment. In such cases the name of the client, or any identifying information, is not disclosed. Clinical information about the client is discussed. Some progress notes and reports are dictated/typed within the clinic or by outside sources specializing in (and held accountable for) such procedures. In the event in which the clinic or mental health professional must telephone the client for purposes such as appointment cancellations or reminders, or to give/receive other information, efforts are made to preserve confidentiality. Please notify us in writing where we may reach you by phone and how you would like us to identify ourselves. For example, you might request that when we phone you at home or work, we do not say the name of the clinic or the nature of the call, but rather the mental health professional’s first name only. If this information is not provided to us (below), we will adhere to the following procedure when making phone calls: First we will ask to speak to the client (or guardian) without identifying the name of the clinic. If the person answering the phone asks for more identifying information we will say that it is a personal call. We will not identify the clinic (to protect confidentiality). If we reach an answering machine or voice mail we will follow the same guidelines. Your Rights You have the right to request to review or receive your medical files. The procedures for obtaining a copy of your medical information is as follows. You may request a copy of your records in writing with an original (not photocopied) signature. If your request is denied, you will receive a written explanation of the denial. Records for non-emancipated minors must be requested by their custodial parents or legal guardians. You have the right to cancel a release of information by providing us a written notice. If you desire to have your information sent to a location different than our address on file, you must provide this information in writing. You have the right to restrict which information might be disclosed to others. However, if we do not agree with these restrictions, we are not bound to abide by them. You have the right to request that information about you be communicated by other means or to another location. This request must be made to us in writing. Your have the right to disagree with the medical records in our files. You may request that this information be changed. Although we might deny changing the record, you have the right to make a statement of disagreement, which will be placed in your file. You have the right to know what information in your record has been provided to whom. Request this in writing. If you desire a written copy of this notice you may obtain it by requesting it from the Clinic Director at this location. Complaints If you have any complaints or questions regarding these procedures, please contact the clinic. We will get back to you in a timely manner. You may also submit a complaint to the U.S. Dept. of Health and Human Services and/or the Colorado Department of Regulatory Agencies, State Grievance Board, 1560 Broadway, Suite 1340, Denver, Colorado, 80802. If you file a complaint we will not retaliate in any way. Direct all correspondence to: Louann Hillesland I understand the limits of confidentiality, privacy policies, my rights, and their meanings and ramifications. Client’s name (please print): Signature: Date: _____/_____/_____
Signed by: __client __guardian __personal representative
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General Information About My Psychotherapist Louann Hillesland, MA, LPC, EMDR I am a Licensed Professional Counselor in the State of Colorado and hold a Masters level degree in Counseling from Western New Mexico University in Silver City, New Mexico. In addition to private practice I am currently teaching healthy relationship classes at several local agencies. I have counseled individuals at both an outpatient mental health center for adults, a local middle school, and a grade school in New Mexico. I have a Bachelors of Science degree in education from the University of Northern Colorado. As an educator, I taught grade school, middle school and adult individuals, during a 26 year teaching career. I specialize in Cognitive Behavioral Therapy, Eye Movement Desensitization and Reprocessing, (EMDR), and biofeedback and have experience working with people of all ages. About Client Rights The Colorado Department of Regulatory Agencies has the general responsibility of regulating the practice for licensed psychologists, licensed social workers, licensed professional counselors, licensed marriage and family therapists, certified school psychologists, and unlicensed individuals who practice psychotherapy. The agency within the Department that has responsibility specifically for licensed and unlicensed psychotherapists is the State Grievance Board, 1560 Broadway, Suite 1340, Denver, Colorado, 80802, (303)894-7766. Client Rights and Important Information: You are entitled to receive information from me about my methods of therapy, the techniques I use, the duration of therapy (if I can determine it), and my fee structure. Please ask if you would like to receive this information. You can seek a second opinion from another therapist or terminate therapy at any time. In a professional relationship, such as ours, sexual intimacy between a therapist and a client is never appropriate. If sexual intimacy occurs, it should be reported to the State Grievance Board. Generally speaking, the information provided by and to a client during therapy sessions is legally confidential if the therapist is a certified school psychologist, a licensed clinical social worker, a licensed marriage and family therapist, a licensed professional counselor, or an unlicensed psychotherapist practicing under the supervision of a licensed psychotherapist. If the information is legally confidential, the therapist cannot be forced to disclose the information without the client’s consent. Information disclosed to a certified school psychologist, a licensed clinical social worker, a licensed marriage and family therapist, a licensed professional counselor, or an unlicensed psychotherapist practicing under the supervision of a licensed psychotherapist, is privileged communication and cannot be disclosed in any court of competent jurisdiction in the State of Colorado without the consent of the person to whom the testimony sought relates. There are legal exceptions to the general rule of legal confidentiality. These exceptions are listed in the Colorado Statutes (see section 12-43-218, C.R.S., in particular) There are legal exceptions to the general rule of legal confidentiality. The exceptions include: intent to harm others or yourself; abuse or suspected abuse of children, and possibly the abuse of the elderly or others unable to care for themselves; neglect or suspected neglect of children; subpoenaed testimony in criminal court cases, and orders to violate privilege by judges in child-custody, divorce and other court cases. Also, be aware that, except in the case of information given to a licensed psychologist, legal confidentiality does not apply in a criminal or delinquency proceeding. There are other exceptions that I will identify to you as the situations arise during therapy. I agree to pay $80 for each psychotherapy appointment. Psychotherapy is provided in a 50 minute clinical hour instead of a 60 minute clock hour. I agree to pay $35 for a group appointment. Maximum group size is 8 individuals. Group sessions are 90 minutes. As A Psychotherapy Client I Understand That I understand that Louann Hillesland will not (at the request of the client) testify in court as an expert witness, including divorce, child custody, or criminal cases. I understand that Louann Hillesland will not release information to or communicate with another therapist, (holding any scholastic degree), a child advocate an attorney or any other professional requiring confidential therapy information. This applies even if the client authorizes, with a written or verbal request, the release of Louann Hillesland’s confidential client files. I understand that my personal client file belongs to my therapist. If my therapist is subpoenaed by the Court, I understand that court testimony on my behalf is charged at $100.00 per hour including: testimony related matter like case research, report writing, travel depositions, actual testimony, and cross examination time and courtroom waiting time. Signing this disclosure statement gives permission for me to release confidential information in courtroom testimony and written reports to the Court if legally requested. I consent to evaluation and mental health treatment for myself, my minor child or ward. I am aware that care and treatment is not an exact science and acknowledge that no guarantees have been made to me as to the result of treatment. I understand that Louann Hillesland is not a ‘crisis’ therapist. If I have a life threatening emergency, I will call the Suicide and Crisis Hotline (303)860-1200, the police (911) or go to an emergency room. I understand that if my therapist thinks I need more intensive services I will be referred to a therapist or organization that has the ability to provide treatment to meet those needs. I understand that my psychotherapist provides non-emergency psychotherapeutic service by scheduled appointment. If my psychotherapist believes my psychotherapeutic issues are above and beyond her level of competence, or outside of her scope of practice, she is legally required to refer, terminate or consult. I understand that there may be times when my psychotherapist may need to consult with a colleague or another professional, like an attorney, about issues raised by me in therapy. My confidentiality is still protected during consultation by my psychotherapist and the professional consulted. Signing this disclosure statement gives my psychotherapist permission to consult as needed, to provide professional services to me as a client. I understand that in marriage and family counseling, my psychotherapist holds a ‘no secrets’ policy. All members of the couple or family system are treated equally and ‘secrets’ are not kept by the psychotherapist that require differential or discriminatory treatment of family members. I understand that any information shared in individual therapy MUST be also shared in couple or family therapy to insure this ‘no secrets’ policy. Signing this disclosure statement affirms permission to share this confidential information among family members. I understand that if I have any questions or would like additional information, I may ask during the initial session and any time during the psychotherapy process. By signing this disclosure statement I also give permission for the inclusion of my partners, spouses, significant others, parents, legal guardians, or other family members in psychotherapy when deemed necessary, by myself or my therapist. I understand that I am legally responsible for payment for my psychotherapy services. I understand that if I do not give 24 hours prior notice of cancellation to my psychotherapist, I will be charged the full fee for not showing up for the scheduled psychotherapy appointment. I understand that, like any other professional service, I must pay for all psychotherapy services (psychotherapy in the office, telephone therapy, report writing, consultation, parental consultation, etc.) I receive as a client. If I do not pay for services received I understand that the bill will be turned over to a collection agency to recover payment for my therapist. I also understand I must repay the full amount and any bank fees or other relevant costs to my therapist, for bounced checks. Client Signature, Acknowledgement, Agreement, and Consent I have read the preceding information and understand my rights as a client. By signing below I acknowledge my understanding and agree to all the terms discussed in this disclosure statement. By signing this disclosure statement, I also agree to permit supervision and consultation with other psychotherapists, or professionals as the need arises. I also affirm, by signing this form that I am the legal guardian and/or custodial parent with legal right to consent to treatment for any minor child or children that I am requesting psychotherapy services for, from Louann Hillesland. If you have any questions or would like additional information please feel free to ask. I have read the preceding information and understand my rights as a client/patient. ___________________________________ _______________________ Client/patient signature date ___________________________________ _______________________ Client/patient signature date ___________________________________ _______________________ Therapist signature date 7200 E. Dry Creek Road, B102, Centennial, CO 80112 www.counselingconnection-llc.com 303-721-0005 Louann Hillesland MA, LPC, EMDR |
Consent
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