Both South Carolina State law and Public Law 104-191 mandate the majority of this document. It is provided for your protection.
The information you share in psychotherapy is protected health information and is generally considered confidential by both South Carolina statute law and federal regulations. Please note, however, that your therapy file can be subpoenaed in South Carolina through a court order signed only by a judge. It is considered privileged in the federal court system.
Johannah Hornak is mandated by standards through the "Duty to Warn" statute to breach confidentiality if she discovers:
- You are threatening self-harm (suicide)
- You are threatening to harm another (homicide)
- A child has been or is being abused or neglected, and/or
- A vulnerable adult has been or is being abused or neglected. If you wish for your protected health information to be released to another party, you must sign a specific "Release of Information" intended for this purpose.
Ethics: Johannah Hornak follows the Code of Ethics of the following organizations: The South Carolina Board of Examiners for the Licensure of Professional Counselors, Marriage and Family Therapists, and Psycho-Educational Specialists
Informed Consent: You will be asked to sign the last page of this document. Your signature verifies that (1) you have read this document and the HIPAA document that follows, and (2) you consent to treatment. You also need to be aware of the following:
- Counseling is not always successful and may open unexpected emotionally sensitive
- Johannah Hornak is not a physician and cannot prescribe medications
- Johannah Hornak is not available 24 hours a day
- Placing Johannah Hornak in a situation of conflict between parents / guardians or the child / parent may cause a conflict of interest and impede my ability to provide therapy to your child.
- If Johannah Hornak is asked to confer with your attorney and/or guardian ad litem you agree to pay $100 per hour for information provided either written or verbal.
- If Johannah Hornak is required to appear in court you agree to pay $200 per hour or $1,500 per day of more than 4 hours. If you or your attorney and/or guardian ad litem request or subpoena a summary for use in court you agree to pay $100 per hour for the time it takes to review your child's record and prepare that summary written or verbal.
- If Johannah Hornak is legally required to provide a copy of your child's record you agree to pay me $100 to cover administrative costs, payment is required prior to the release of the record. By release of any record you are waiving your confidentiality and/or privilege and must sign a consent form prior to release.
- If you cannot make your appointment and do not cancel within 24 hours, you will agree to pay a late cancellation fee of $50.