Welcome to Choosing Change Counseling! This document contains important information about our 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) for the purposes of treatment, payment, and health care operations. When you sign this document, it will represent an agreement between us. We can discuss any questions you have when you sign these forms or at any time in the future.

Therapy is a relationship between people that works, in part, because of clearly defined rights and responsibilities held by each person. As a client in therapy, you have certain rights and responsibilities that are important for you to understand. There are also legal limitations to those rights that you should be aware of. I, as your therapist, have corresponding responsibilities to you. These rights and responsibilities are described in the following sections.

Client confidentiality is of the utmost importance. As your therapist, I am required by law to obey various legal and ethical requirements, such as HIPAA and HITECH. All communications between a client and a therapist are strictly confidential, except under the following circumstances:

1- Any child (regardless if that child is a client or not) is being abused, harmed or neglected in any way;

2- A client is being harmed or abused;

3- A client demonstrates or expresses a serious threat of harming themselves or others; or

4- A client provides written consent to disclose confidential communication toa particular person or agency (such as a medical provider

Under circumstances 1 through 3 above, I am required to take all steps necessary to provide for the safety of my client, or the child being harmed, and may be required to take the following steps

1. Reporting the abuse to Childline;

2. Contacting the police;

3. Seeking hospitalization;

4. Contacting family members;

5. Notifying potential victims; or

6. Filing a report as required by any governmental or supervisory agency.

If a client's safety is at issue, I will include the client in safety planning, if possible and appropriate.

Prior to the release of any confidential information, the client will be notified and such release shall only be made upon the client's prior written consent, unless directed by law.

Choosing Change Counseling does not provide 24/7 crisis services. If you require immediate assistance, please contact emergency services or the 988 crisis hotline.

Choosing Change Counseling and its therapists are not liable for any decisions or actions taken by the client outside of therapy sessions. Therapy is not a substitute for legal, medical, or emergency services. The client assumes full responsibility for their own well-being outside of scheduled sessions.  

All sessions are 50 minutes in length from the scheduled start time. If you are running late for session, your therapist will wait 15 minutes past the session start time for you to arrive. If you have not arrived by that 15 minute mark, your session will be canceled and need to be rescheduled for a later date, and you will be charged your full session fee. For the courtesy of other clients, late arrivals do not extend the session to end at a later time. If a client needs to cancel or reschedule a session, a minimum of 48 hours is required. If a session is cancelled or rescheduled with less than 48 hours notice, the client is responsible to pay the full session fee.

All sessions are to be paid at the beginning of the session. A receipt will be provided.

It is our practice policy to increase the therapy session fee that matches a therapist’s experience and tenure in the field. Should your therapist have a fee rate increase, you will be sent an email with at least 60 days notice before that fee increase takes place. If you are unable to afford the new fee, we will do our best to provide referrals to more affordable options. 

Additionally, we value the opportunity to collaborate with our client's treatment team. However, when we are asked to do any of the following and it surpasses 15 minutes of your therapist's time outside of session, the time will result in a charge that reflects your session fee:

1. Collaboration with outside treatment team professionals such as psychiatrist, school officials, primary care doctor, etc.

2. Writing letters for outside professionals such as school officials, court officials, ET see.

3. Providing the client with a treatment summary or other treatment documentation.

I am often not immediately available by telephone. I do not answer my phone when I am with clients or otherwise unavailable. At these times, you may leave a message on my voice mail or send me an email. Your call or email will be returned as soon as possible, but it may take a day or two for non-urgent matters. Other than scheduling/cancelling sessions, communications should be reserved for your scheduled session time. If, for any number of unseen reasons, you do not hear from me or I am unable to reach you, and you feel you cannot wait for a return call or if you feel unable to keep yourself safe, 1) go to your local Hospital Emergency Room, 2) call 988 (national suicide hotline), or 3) call 911 and ask to speak to the mental health worker on call. I will make every attempt to inform you in advance of planned absences, and provide you with the name and phone number of the mental health professional covering my practice.

From time to time, therapists may consult with other therapists/mental health professionals to seek guidance, collaboration on shared cases, a second opinion, or for the purposes of professional supervision as may be required for training. Our practice participates in case collaboration weekly for the purpose of continuity of care. 

Additionally, therapists may occasionally prepare presentations, write articles or teach classes/seminars. In any of these scenarios, no identifying information regarding a client will be disclosed and, additional efforts may be made to alter any additional information (such as changing names). 

By initialing below, I am consenting that my parent(s) be aware of and a part of the payment and scheduling process.

Under the laws of the Commonwealth of Pennsylvania, a client under 14 years of age that is seeking therapy must provide written consent from both parents. Parents must provide any court orders regarding the physical and legal custody of the child/client.

In the case of an absent parent and where there is no court order, I will make every effort to contact the absent parent to obtain consent and will document all actions taken in that regard.

Need initials of both parents/guardians.

Type N/A if not applicable.

By initialing above and signing this form on the lines below, you are hereby indicating that you understand and agree to all the terms and conditions set forth herein.

INFORMED CONSENT FOR TELETHERAPY

As a client, I hereby consent to engage in teletherapy with Choosing Change Counseling. I understand that "teletherapy" includes consultation, treatment, transfer of medical data, emails, telephone conversations and education using interactive audio, video, data and telecommunications. I understand that teletherapy also involves the communication of my medical/mental information, both orally and visually. I understand that I have the following rights with respect to teletherapy:

1) I have the right to withhold or withdraw consent at any time without affecting my right to future care or treatment.

2) I understand that our teletherapy sessions are governed by the state laws of Pennsylvania. The laws that protect the confidentiality of my medical information also apply to teletherapy. As such, I understand that the information disclosed by me during the course of my therapy or consultation is generally confidential. However, there are both mandatory and permissive exceptions to confidentiality, which are regulated by federal HIPPA, the PA Mental Health Procedures Act and other health record provisions.

3) The teletherapy sessions shall not be recorded in any way. Choosing Change Counseling will maintain a record of our session in the same way as in-person sessions, in accordance with the appropriate laws/regulations.

4) I understand that there are risks and consequences with teletherapy, including, but not limited to, the possibility, despite reasonable efforts on the part of Choosing Change Counseling, or its staff, the transmission of my information could be disrupted or distorted by technical failures; the transmission of my information could be interrupted by unauthorized persons; and/or the electronic storage of my medical information could be accessed by unauthorized persons.

5) I understand that there are potential risks and benefits associated with any form of teletherapy, and that despite my efforts and the efforts of my therapist, I may not improve and my results cannot be guaranteed or assured.

6) I understand that there is a risk of being overheard by anyone near me if I don't place myself in a secure and private area. Using a headset device is recommended. I also agree to participate fully and without interruption while in a teletherapy session.

7) I accept that teletherapy does not provide emergency services. If I am experiencing an emergency situation, I understand that I should call 911 or proceed to the nearest hospital emergency room for help. If I am having suicidal thoughts or making plans to harm myself, I can call the National Suicide Prevention Lifeline at 1-800-273-TALK (8255) for free 24-hour hotline support. I agree that calling Choosing Changing Counseling, its staff or members and leaving a message on voice mail or email is not the emergency protocol and have been discouraged to do so.

8) I understand that I am responsible for (1) providing the necessary computer, telecommunications equipment and internet access for my teletherapy sessions, (2) the information security on my computer, and (3) arranging a location with sufficient lighting and privacy that is free from distractions or intrusions for my teletherapy session.

(Note: Email is not considered a confidential medium of communication)

I understand that this person will only be contacted in the event of a true emergency, where I am not able to keep myself safe or may be placing others or myself in harm.

CONSENT FOR MINOR UNDER 14 YEARS OLD

Need signature of both parents/guardians. Please provide court documentation via email to Miriah@choosingchangecounseling.com if two parent signatures do not apply. 

Type N/A if not applicable.

THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED, AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY.

I am legally required to protect the privacy of your PHI, which includes information that can be used to identify you which I have created or received about your past, present, or future

health or condition, the provision of health care to you, or the payment of the health care.I must provide you with this Notice about my privacy practices and such Notice must explain how, when, and why I will use and disclose your PHI. A use of PHI occurs when I share, examine, give, or otherwise divulge to a third party outside of my practice. With some exceptions, I may not use or disclose any more of your PHI than is necessary to accomplish the purpose for which the use or disclosure is made. I am legally required to follow the privacy practices described in this Notice. I reserve the right to change the terms of my privacy policies at any time. Any changes will apply to PHI on file with me already. Before I make any important changes to my policies, I will promptly change this Notice and provide you with a new copy.

I will use and disclose your PHI for many different reasons. I will need your prior written authorization for some of these uses or disclosures; however, for others, I do not. Listed below are the different categories of my uses and disclosures along with some examples of each category.

a) Uses and Disclosures Relating to Treatment, Patient Emergency, or Health Care Operations Do Not Require Your Prior Written Consent. I can use and disclose your PHI without your consent for the following reasons:

i. For Treatment. I can use your PHI within my practice to provide you with mental health treatment including discussing or sharing your PHI with my trainees and interns. I can disclose your PHI to physicians, psychiatrists, psychologists, and other licensed health care providers who provide you with health care services or are involved in your case. For example, if a psychiatrist is treating you, I can disclose your PHI to your psychiatrist to coordinate your care.

ii. For Patient Emergency. I may also disclose your PHI to others without your consent if an emergency exists. For example, your consent is not required if you need emergency treatment, or hospitalization or, if I try to get your consent but you are unable to communicate with me (for example, you are unconscious) iii. For Health Care Operations. I can use and disclose your PHI to operate my practice. For example, I might provide your PHI to my accountant, attorney, consultants, or others to further my health care operations.

iv. To Obtain Payment for Treatment. I can use your PHI to collect payment for the treatment and services provided by me to you. For example, I may provide your PHI to my business associates, such as billing companies and others that process payments.

b) Certain Other Uses and Disclosures Also Do Not Require Your Consent or Authorization. I can use and disclose your PHI without your consent or authorization for the following reasons:

i. When federal, state, or local laws require disclosure. For example, I may have to make a disclosure to applicable governmental officials when a law requires me to report information to governmental agencies and law enforcement personnel about victims of abuse or neglect.

ii. When judicial or administrative proceedings require disclosure. For example, I may have to use or disclose your PHI in response to a court or administrative order if you are involved in a lawsuit. I may also have to use or disclose your PHI in response to a subpoena.

iii. To avert a serious threat to health or safety. For example, I may have to use or disclose your PHI to avert a serious threat to the health or safety of you or others. Any such disclosures will only be made to someone to try to prevent the impending harm from occurring (such as threats of serious self- harm).

c) Certain Uses and Disclosures Require You to Have the Opportunity 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 an emergency situation.

d) Other Uses and Disclosures Require Your Prior Written Authorization. In any situation not described above, I will need your written authorization before using or disclosing any of your PHI. If you choose to sign an authorization to disclose your PHI, you can later revoke such authorization in writing to stop any future uses and disclosures (to the extent that I have not taken any action in reliance on such authorization) of your PHI by me.

3) YOUR RIGHTS REGARDING YOUR PHI

You have the following rights related to your Protected Health Information:

a) To inspect and request a copy of your Protected Health Information. In most cases, you have the right to inspect and receive a copy of the PHI that I have on you, but you must make the request to inspect and receive a copy of such information in writing. I will respond to your request within 30 days of receiving your written request. In certain situations, I may deny your request. If I do, I will tell you, in writing, my reasons for the denial and explain your right to have my denial reviewed.

b) To request restriction on the use or disclosure of your Protected Health Information. You have the right to request restrictions or limitations on my uses or disclosures of your PHI to carry out my treatment, payment or health care operations. You also have the right to request that I restrict or limit disclosures of your PHI to family members, friends, or others involved in your care or who are financially responsible for your care. Please submit such requests to me in writing. I will consider your requests but am not legally required to accept them. If I do accept your requests, I will put them in writing and will abide by them except in emergency situations. Be advised that you may not limit the uses and disclosures that I am legally required to make.

c) To request that we correct your Protected Health Information. If you think that there is a mistake or that important information is missing, you may request in writing for me to correct the file. I may deny your request if I find that the file is correct and complete, not created by me, or not allowed to be disclosed. If I deny your request, I will explain the reason(s) for the denial and your rights to have the request and denial and your written response added to your file. If I approve your request, I will change the file, report that change to you, and tell others that need to know about the change in your file.

d) To request confidential communication methods. You may ask that I contact you at a certain address or in a certain way. (for example, sending information to your work address rather than your home address) or by alternate means (for example, e-mail instead of regular mail I must agree to your request as long as it is reasonably easy for me to do so.

e) To find out what disclosures have been made. You may get a list describing when, to whom, why, and what of your Protected Health Information has been disclosed during the past six years. I must respond to your request within sixty (60) days of receiving it. The list will not include disclosures made for my treatment, payment, or health care operations; disclosures made to you; disclosures you authorized; disclosures permitted or required by the federal privacy rule; disclosures made for national security or intelligence; The list I will give you will include disclosures made in the last six years unless you request a shorter time. The list will include the date the disclosure was made, to whom the PHI was disclosed (including their address, if known), a description of the information disclosed, and the reason for the disclosure. I will provide the list to you at no charge, but if you make more than one request in the same year, I may charge you a reasonable, cost-based fee for each additional request.

f) To receive notice if your records have been breached. You will be notified if there has been an acquisition, access, use or disclosure of your Protected Health Information in a manner not allowed under the law and which I am required by law to report to you. I will review any suspected breach to determine the appropriate response under the circumstances.

g) To obtain a paper copy of this Notice. Upon your request, I will give you a paper copy of this Notice.

How to Complain about Privacy Practices

If you think I may have violated your privacy rights, or if you disagree with a decisionI made about your Protected Health Information, you may file a complaint by notifying me in writing. You may also file a written complaint with the Secretary of the U.S. Department of Health and Human Services, 200 Independence Avenue SW, Washington, D.C. 20201. will take no action against you if you make a complaint.

How to Receive More Information About our Privacy Practices

If you have questions about this Notice or about our privacy practices, please contact our Privacy Officer, Miriah Rutledge, Choosing Change Counseling, 485 Devon Park Drive, Suite 100, Wayne, Pa 19087.

Effective Date: February 23, 2021

I have read and understand Choosing Change Counseling's Notice of Privacy Practices outlined above.

As a client of Choosing Change Counseling, you may be discharged for one or more of the following reasons:

1. Client has successfully completed their treatment goals.
2. Client requires a different level or type of care.
3. Client has not attended therapy within the past 6 months.
*Note if the client desires to come back to therapy after being discharged for one of the above circumstances, they are able to contact Choosing Change Counseling to reopen their file after completing required paperwork.

4. Client has been harassing the staff or disruptive to the treatment of other
5. Therapist is managing life-changing circumstances (i.e.- death, illness, relocation, retirement, etc.)
6. Client is unable to pay for session. If so, Choosing Change will administratively discharge client and refer them to a lower fee provider.

My signature below represents that I understand and accept the above.

I authorize Choosing Change LLC to charge my credit card for therapy sessions provided by my therapist at the predetermined rate per 50 minute session. If I decide, that I need a session to be longer than 50 minutes, the charge to my credit card will reflect the additional time. In addition, I consent for Choosing Change LLC to charge my credit card the same rate for cancellations less than 48 hours from the scheduled session time, per the practice's cancellation policy, as well as any missed sessions.

 My signature on this form confirms the following:

• I authorize to leave this credit card on file and be automatically ran for payment.
• I will not dispute or charge back any charges on this account for services I received or did not cancel within 48 hours.
• I will renew this credit card upon expiration and keep an active credit card on file at all times.
• I testify that this credit card is rightfully owned by me and I have the rightful charging abilities to this credit card. Any fraud or dispute associated with this credit card is not the responsibility of this agency nor of any of its employees or service providers.
• I understand that this agency may change their pricing model at any time with only a 30 day written notice and I understand if I choose to leave my credit card on file for those pricing changes that I extend this authorization for those price changes.

Additionally, we value the opportunity to collaborate with our client's treatment team. However, when we are asked to do any of the following and it surpasses 15 minutes of your therapist's time outside of session, the time will result in a charge that reflects your session fee:

1. Collaboration with outside treatment team professionals such as psychiatrist, school officials, primary care doctor, etc.

2. Writing letters for outside professionals such as school officials, court officials, etc.

I understand that my therapist will notify me of these charges when they are made. I guarantee payment for any services rendered made with my credit card, including renewed cards.

Important: You must bring your card to the first session, to be stored on file.