Practice Policies & HIPAA Compliance
Welcome to Good Mental Health, LLC.  We are a mental health counseling and wellness coaching practice based in St. Johns, Florida. My name is Diana Brummer and it is my pleasure to provide you with professional counseling and coaching services. It is my goal to assist individuals and their families by providing genuine support and to teach coping skills in a caring and confidential manner designed to help you handle life’s challenges. Please read and respond to the following disclosure statements and please note: this digital form has been created and and is stored within Google Workspace for Good Mental Health LLC, a HIPAA compliant and secure platform.

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Client Name: *
Client Date of Birth: *
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The following Disclosure Statement provides a detailed explanation of my practice. It is important that you read it as this outlines my responsibilities to you as your therapist: *
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Credentials: I, Diana Brummer, am a Licensed Clinical Social Worker in the State of Florida which means I completed a Masters Degree Program and met the necessary requirements to receive clinical licensure in the State of Florida. I received a Bachelor’s Degree in Psychology from Florida State University in 1997. Shortly after, I entered the field and have been working in mental and behavioral health, social work, and mind-body wellness for over 20 years. I returned to Florida State University in 2004, and again in 2014, receiving my Masters in Social Work in 2016. I successfully completed the mandatory requirements for clinical licensure in July 2019. It is my most sincere desire to help you by teaching you, and/or your child, strategies to change thought and behavior patterns related to the things that cause you pain as well as learn to let go of things that you cannot control but may cause you stress. I can also help you have better relationships and be a better communicator, partner, parent, or employee. For more information regarding my specialties and/or experience, please refer to my website https://goodmentalhealthllc.com. *
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Confidentiality: With the exception of certain specific circumstances, you have the absolute right to the confidentiality of your therapy. I cannot and will not tell anyone what you have told me or that you are/not in therapy with me without your prior permission in writing. I will always act to protect your privacy even if you release me in writing to share information about you. You may direct me to share information with whomever you choose and you can change your mind and revoke that permission at any time. *
You are also protected under the provisions of the Federal Health Insurance Portability and Accountability act (HIPAA) and Federal and Florida Law 42 C.F. Part 2 and 2.22. This law ensures the confidentiality of all written and electronic transmissions of information about you. Whenever I transmit information about you electronically it will be done with special safeguards to ensure confidentiality. *
 If you elect to communicate with me by email or text, please be aware that it is not completely confidential. All emails are retained in logs of your or my internet provider. While under normal circumstances no one looks at these logs they are, in theory, available to be read by the system administrator of the internet service provider. Any email I receive from you, as well as any responses that I send you will be archived and kept as part of your electronic medical record. In order to provide you with confidential electronic communication in the form of video chat or text messaging, clients will be invited to my private, HIPPA compliant online office space. *
 There are certain legal exceptions to confidentiality of which you should be aware. I will tell you if I am required to take action in response to one of these exceptions. If I have good reason to believe that you are abusing or neglecting a child or vulnerable adult, or if you give me information about someone who is doing this, I must inform Child Protective Services or  Adult Protective Services as required under F.S. 39.201.  If I believe you are in imminent danger of harming yourself or someone else, I may legally break confidentiality and contact local authorities to provide you additional assistance as may be needed or required. *
     If you have a life-threatening or potentially disabling medical emergency in my presence, I am required to release to medical personnel the minimum information necessary to assist you medically. *
A court of law can request and obtain information without your consent. Or, if you have been court-ordered to treatment, the judge may set aside your right to privileged communication. I will not automatically release information that has been requested by a court unless it is deemed necessary and compliant with the law. *
Legal Proceedings & Testimony: Please note that legal work and expert testimony are NOT services offered through this practice. If you are involved in legal proceedings such as criminal, civil, drug, dependency, juvenile, or family law court, which may require professional feedback as to your progress in treatment or expert testimony of any kind, these are not areas in which I practice. Since this is not my area of practice, I will be glad to refer you to another clinician who specializes in these areas. Should I receive a subpoena related to a legal proceeding in which you are involved, requiring my appearance, testimony, or written documentation, please be aware that my rate for any type of court work is $1,250 dollars per hour with a five-hour minimum and payment is due seven days prior to any judicial proceeding. This fee applies to the time in which I must appear in court as well as any preparation and travel time leading up to and following that court date. These fees will be invoiced and are required to be paid in full before work is performed or appearance is made. These fees are non-refundable even if your court hearing is canceled, postponed, or reaches a settlement. *
I am required by law to keep a record of our sessions, and you have the right to request a copy of your records at any time. You also have the right to request that I make a copy of your records available to any other health care provider at your request. You have the right to ask that I correct any errors in your records. All records are maintained as required under state and federal law. All requests for file copies must be in writing. *
Diagnosis:  Diagnoses are technical terms used to describe the nature and scope of your presenting issue. If I do use a diagnosis, I will discuss it with you. All of the diagnoses come from a book titled the DSM-5; I have a copy in my office and will be glad to discuss your diagnosis with you. Insurance companies usually require a diagnostic code called an ICD-10 code (as of October 2015) in order to process your insurance claim. A diagnosis is determined after assessing your present and past level of functioning. *
Managed Mental Health Care:  If you have mental health benefits as part of your health insurance coverage, you must call for your benefit information prior to our first appointment if you would like to receive any reimbursement for my fee. You need to find out if you have a copay or % that you are responsible for as well as any deductible. Since I do not accept private insurance at this time, I cannot bill your insurance provider for you but I am happy to provide you with an invoice for my services which you may submit to pursue reimbursement.   *
Good Faith Estimate: Progress in psychotherapy is assessed on an individual basis however, a typical progression through the therapeutic process may entail weekly sessions, followed by bi-weekly sessions, followed by monthly sessions. The estimated cost of the initial assessment followed by continuing psychotherapy sessions are provided on a per session basis at the costs identified in your consent for treatment. Additional sessions and services are provided, and those associated charges are included in your consent to treatment. *
Complaints:  If you are unhappy with what is happening in therapy, I strongly encourage you to speak about it with me so that I can respond to your concerns. I will take your concern seriously and respond with care and respect. If you believe that I have behaved unethically, you can complain to the Medical Quality Assurance Board of the State of Florida at www.myflorida.com or file a written complaint to the Department of Health/Consumer Services Unit, 4052  Bald Cypress Way, Bin C75, Tallahassee, FL 32399-3275. *
My Approach to Counseling:  I practice an evidence-based counseling modality called Cognitive-Behavioral Therapy. The premise of this theory is that we are influenced by our thoughts as we experience things and this effects how we react, or behave, relative to those experiences. My work is heavily informed by Family Systems and Attachment theories, which describe how our past and current interpersonal relationships effect our relationships later in life. If you have any further questions about my practice style, I am happy to answer any questions you may have. Some techniques I use are shifting negative thought patterns through identifying thoughts of lack and shifting them to more affirmative thoughts. I teach healthy interpersonal boundaries and communication tools. I may suggest that you participate in a support group or see a medical doctor for a medical evaluation. This is typically done by a psychiatrist who prescribes medicine specifically for mental health disorders. I cannot prescribe medication. You can refuse any suggestions I make. I must limit social relationships with current or former clients because it is unethical. If we see each other in a public setting, out of respect for your confidentiality, I will not acknowledge you unless you approach me first. *
There are certain emotional risks associated with the counseling process. Approaching feelings or thoughts that you have tried not to think about may be painful. Making changes to your beliefs or behaviors can be frightening and sometimes disruptive to the relationships you already have. It is important that you consider carefully whether these risks are worth the benefits to you of changing. Most people who take these risks find that therapy is helpful. Therapy will end when you decide it is time for it to end unless another arrangement is made, such as a contracted number of sessions or I refer you to another professional. You may bring whomever you wish into your therapy. I may terminate you if you exhibit any behavior deemed threatening. *
If you have questions or concerns about any of the above-listed disclosure statements, I will be glad to discuss them with you during your first appointment. I am happy to answer any questions you may have. *
By entering your name in the box below, you are effectively providing your signature, indicating that you have read the disclosure statement provided and that the information on this form is true and accurate. *
For identity verification purposes, please provide the last 4 digits of your social security number: *
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Thank you for your submission. Follow this link to schedule an appointment online: https://bit.ly/GMHappt *
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