Please read this Policy Statement carefully and sign the Policy Acknowledgement at the end.

Welcome to Golden Sky Counseling! This document (the Agreement) contains important information about my professional services and business policies. It also contains summary information about the Health Insurance Portability and Accountability Act (HIPAA), a federal law that provides privacy protections and patient rights about the use and disclosure of your Protected Health Information (PHI) used for the purpose of treatment, payment, and health care operations. HIPAA requires that I provide you with a Notice of Privacy Practices (the Notice) for use and disclosure of PHI for treatment, payment, and health care operations. The Notice explains HIPAA and its application to your personal health information in greater detail. The law requires that I obtain your signature acknowledging that I have provided you with this information.

Although these documents are long and sometimes complex, it is very important that you read them carefully. We can discuss any questions you have about the procedures. When you sign this document, it will also represent an agreement between us. You may revoke this Agreement in writing at any time. That revocation will be binding on us unless we have already acted in reliance on the agreement between us.

Patient Rights

HIPPA provides you with expanded rights about your PHI and disclosures of protected health information. These rights include requesting that your therapist amend your PHI due to factual inaccuracies, requesting restrictions on what information from your PHI is disclosed to others; requesting an accounting of most disclosures of protected health information that you have neither consented to nor authorized; determining the location to which protected information disclosures are sent; having any complaints you make about my practice policies and procedures recorded in your records; and the right to a paper copy of the Notice form. Your therapist is not obligated to amend clinical interpretations or diagnostic impressions.

Requests for edited versions of evaluation and testing reports, letters, treatment summaries, requests for accommodations, etc. will be provided only at the sole discretion of your therapist and will incur an additional fee. Your therapist reserves the right to decline such requests.

Minors and Parents

Patients under 18 years of age who are not emancipated, and their parents, should be aware that the law may allow parents to examine their child’s PHI. Children between 13 and 17 may independently consent to (and control access to the records of) diagnosis and treatment in a crisis. I encourage parents/guardians to inform me of important occurrences and concerns in your child’s life.

This agreement provides that during treatment, I will provide parents only with general information about the patient’s attendance at scheduled sessions, his/her level of participation and the progress of the treatment. Because privacy in psychotherapy is often crucial to successful progress (particularly with teenagers) and parent’s involvement is also essential, it is usually our policy to discuss with minors (over 13 years) and their parents about access to information. Before giving parents any information, I will discuss the matter with the child, if possible, and do my best to handle any objections that they may have. Any other communications will require the child’s authorization, unless I feel that the child is in danger or is a danger to someone else, in which case, I will notify the parents of his/her concerns.

Telephone Accessibility

If you need to contact me between sessions, please leave a message on my voice mail or send me a text. I will do my best to return your message within 24 hours. If a true emergency arises, please call 911 or any local emergency room.

Electronic Communications

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.

Social Media

Due to the importance of your confidentiality and the importance of minimizing dual relationships, I do not accept a friend or contact requests from current or former clients on any social networking site (Facebook, LinkedIn, etc.) I 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.