This document includes the following:

●  Your rights to confidentiality as a minor, parent or guardian

●  Ethics in Confidentiality when Providing Psychotherapy Services to Minors:

●  How protected health information (“PHI”) may be used and disclosed

●  HIPPA Privacy Policy

●  How to get access to this information

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. You may view this policy at www.pabcounseling.com.

Confidentiality: The therapeutic relationship is based off of trust and confidentiality. and carries on even if we are not in session. Please note that if we see each other outside of the therapy office, I am unable to acknowledge you first. This is not a means of disrespect or ignoring you. Your right to privacy and confidentiality is of the utmost importance to me, and I do not wish to jeopardize your privacy. However, if you acknowledge me first, I will be more than happy to speak briefly with you, but it is appropriate for me to engage in any lengthy discussions in public or outside of the therapy office.

Minors: If you are a minor, your parents or guardians may be legally entitled to some information about your therapy. I will discuss with you and your parents what information is appropriate for them to receive and which issues are more appropriately kept confidential. Please review this entire document so that you know your rights to privacy as a client receiving counseling services. If you have any questions, please feel free to ask your therapist at anytime.

Parents and Guardians of Minor Clients: When working with minors, confidentiality can be a tricky situation. We adhere to the American Counseling Association Code of Ethics and Standards of Practice which require counselors to protect the confidentiality of their communications with our clients of all ages. Michigan state licensure laws also protect client confidentiality.

We have an ethical responsibility to protect the confidentiality of our clients and the primary responsibility to respect their dignity and promote your child's welfare. We may have a custodial agreement that grants access to both parents. However, our client’s needs come first. If one or both of the parents accessing the file could harm your child, we can limit that access. However, we will want to discuss with your child the risks and benefits of limiting access and work to prepare the client that access may be granted legally.

Research has shown that the therapeutic relationship contributes to 30 percent of client outcome. Therefore, it is vital to develop and maintain a positive and trusting therapeutic relationship with your child. A large piece of relationship building begins in the informed consent process. We will help you understand the limitations and expectations of confidentiality that we are establishing to benefit the your child. Although a minor cannot grant consent, he or she can assent. In most cases we will encourage your child to communicate with you topics that would be beneficial to their treatment. We may even recommend family therapy. Obtaining agreement from our client for the process of counseling is an essential factor in successful treatment.

Ethics in Confidentiality when Providing Psychotherapy Services to Minors:

There are a number of ethical standards within the 2014 ACA Code of Ethics to consider, including:

●  A.1.a. (Primary Responsibility)

●  A.2.a. (Informed Consent)

●  A.2.d. (Inability to Give Consent)

●  B.1.b. (Respect for Privacy)

●  B.1.c. (Respect for Confidentiality)

●  B.2.d. (Court-Ordered Disclosure: when dealing with legal concerns such as custody

agreements)

●  B.2.e. (Minimal Disclosure)

●  B.5. (Clients Lacking Capacity to Give Informed Consent)

●  B.6.e. (Client Access)

●  Standard B.5. covers the counselor’s responsibility to the client as well as to the parent or legal guardian:

●  B.5.a. (Responsibility to Clients): “When counseling minor clients or adult clients who lack the capacity to give voluntary, informed consent, counselors protect the confidentiality of information received — in any medium — in the counseling relationship as specified by federal and state laws, written policies and applicable ethical standards.”

●  B.5.b. (Responsibility to Parents and Legal Guardians): “Counselors inform parents and legal guardians about the role of counselors and the confidential nature of the counseling relationship, consistent with current legal and custodial arrangements. Counselors are sensitive to the cultural diversity of families and respect the inherent rights and responsibilities of parents/guardians regarding the welfare of their children/ charges according to law. Counselors work to establish, as appropriate, collaborative relationships with parents/ guardians to best serve clients.”

●  Standard B.6.e. discusses client access to records and states that counselors can limit access to the client record if there is a concern that harm could come to the client from such access. The counselor would need to document the rationale for the limited access in such cases.

For more information, please review the 2014 American Counseling Association Code of Ethics and Standards of Practice or you can review "Confidentiality Concerns with Minors" - You may view these on our website at www.pabcounseling.com.

Limitations to Confidentiality: 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:

• If a client threatens or attempts to commit suicide or otherwise conducts him/her self in a manner in which there is a substantial risk of incurring serious bodily harm.
• If a client threatens grave bodily harm or death to another person.
• 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.
• Suspicions as stated above in the case of an elderly person who may be subjected to the above abuses.
• Suspected neglect of the parties named in items #3 and # 4.
• If a court of law issues a legitimate subpoena for information stated on the subpoena.
• 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.

In the situation that I 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.

Electronic Communication: I cannot ensure the confidentiality of any form of communication through electronic media, including text messages. If you prefer to communicate via email or text messaging for issues regarding scheduling or cancellations, I will do so. While I may try to return messages in a timely manner, I 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.

**MY PLEDGE REGARDING HEALTH INFORMATION:**

I understand that health information about you and your health care is personal. I am committed to protecting health information about you. I create a record of the care and services you receive from me. I 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 I may use and disclose health information about you. I also describe your rights to the health information I keep about you, and describe certain obligations I have regarding the use and disclosure of your health information. I am 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 healthinformation.

●  Follow the terms of the notice that is currently in effect.

●  I can change the terms of this Notice, and such changes will apply to all information I haveabout you.

●  New notices or updated policies will be available upon request and at www.pabcounseling.com

HOW I MAY USE AND DISCLOSE HEALTH INFORMATION ABOUT YOU: The following categories describe different ways that I use and disclose health information. For each category of uses or disclosures I will explain what I mean and try to give some examples. Not every use or disclosure in a category will be listed. However, all of the ways I am 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. I 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, I may disclose health information in response to a court or administrative order. I 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.

Certain Uses and Disclosures that 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:

1. For my use in treating you.
2. For my use in training or supervising mental health practitioners to help them
3. improve their skills in group, joint, family, or individual counseling or therapy.
4. For my use in defending myself in legal proceedings instituted by you.
5. For use by the Secretary of Health and Human Services to investigate my compliance
6. with HIPAA.
7. Required by law and the use or disclosure is limited to the requirements of such law.
8. Required by law for certain health oversight activities pertaining to the originator of
9. the psychotherapy notes.
10. Required by a coroner who is performing duties authorized by law.
11. Required to help avert a serious threat to the health and safety of others.

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

Sale of PHI. As a psychotherapist, I will not sell your PHI in the regular course of my business.

Certain Uses and Disclosures that DO NOT REQUIRE YOUR AUTHORIZATION:

Subject to certain limitations in the law, I am legally and ethically required to 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, I may provide your PHI in order to comply with workers' compensation laws.

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

Certain Uses and Disclosures that REQUIRE YOU TO HAVE THE OPPORTUNITY TO OBJECT: You are able to object disclosures to family, friends, or others. I 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.

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 me not to use or disclose certain PHI for treatment, payment, or health care operations purposes. I am not required to agree to your request, and I may say “no” if I 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 I Send PHI to You. You have the right to ask me to contact you in a specific way (for example, home or office phone) or to send mail to a different address, and I 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. I will provide you with a copy of your record, or a summary of it, if you agree to receive a summary, within 30 days of receiving your written request, and I may charge a reasonable, cost based fee for doing so.

The Right to Get a List of the Disclosures I Have Made. You have the right to request a list of instances in which I have disclosed your PHI for purposes other than treatment, payment, or health care operations, or for which you provided me with an Authorization. I will respond to your request for an accounting of disclosures within 60 days of receiving your request. The list I will give you will include disclosures made in the last six years unless you request a shorter time. I will provide the list to you at no charge, but if you make more than one request in the same year, I 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 I correct the existing information or add the missing information. I may say “no” to your request, but I 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.

HIPPA Notice of Privacy Practices Acknowledgement: Please read HIPPA privacy practices. You may ask questions about this policy at any time. You may download a copy of these policies at our website or request a paper copy for your records at anytime.

Consent and Agreement to Terms:

●  By signing this Privacy Policy, I acknowledge that I have both read, understand, and agree to the above conditions and policies contained herein.

●  If the client is under the age of 18 or unable to consent to treatment, I attest that I have legal and medical custody of this individual and am authorized to initiate and consent for treatment and/or legally authorized to initiate and consent to treatment on behalf of this individual.

●  My signature states that I have been informed either on this document, verbally, or on Pediatric and Adult Behavioral’s website of the HIPPA Privacy Practices and that I may request a copy and ask questions about these policies at anytime. I may view and download a copy of this consent and HIPPA Privacy Policies at www.pabcounseling.com

●  If client is under the age of 18, I agree to respect the privacy of the therapeutic relationship and I hereby waive my rights to all clinical documentation except crisis and safety plan, treatment plan, treatment plan review, and discharge summary.

● If this policy should change at any time, you will be provided with updates by our office or your clinician. Your signature will be required for proof of acknowledgement.