1. Purpose of Therapy:

I understand that I am voluntarily seeking therapy for the purpose of improving my emotional, mental, and/or behavioral well-being. Therapy involves discussing personal life experiences and feelings, and there may be times when the process can lead to emotional discomfort. I understand that therapy may not have guaranteed outcomes, but it can offer significant benefits, such as personal growth, improved relationships, and coping strategies.

2. ConfidentialityI understand that all communications with my therapist are confidential, meaning my personal information will not be shared without my written consent, except in the following situations:

If there is a risk of harm to myself or others.
If child abuse, elder abuse, or dependent adult abuse is suspected.
If mandated by a court of law or other legal proceedings.
In cases where disclosure is required by law.
3. HIPAA ComplianceI acknowledge that this practice adheres to the guidelines of the Health Insurance Portability and Accountability Act (HIPAA) to ensure that my personal health information is protected. My health records will be stored securely, and only authorized personnel will have access to them.

4. Rights and Responsibilities:

I understand that I have the right to ask questions about any aspect of my treatment.
I have the right to terminate therapy at any time, although I am encouraged to discuss this decision with my therapist before discontinuing treatment.
I am responsible for attending scheduled sessions and providing 24-hour notice if I need to cancel or reschedule an appointment. Repeated cancellations or no-shows may result in termination of services.
5. Fees and PaymentI understand that I am responsible for all fees related to my therapy sessions unless agreed otherwise. I know that payment is expected within 7 days of the therapist's request for funds, following insurance payment. I am also responsible for verifying my insurance benefits and ensuring that sessions are covered, if applicable.

6. Risks and Benefits:

Therapy may involve discussing emotionally challenging topics, which can result in temporary discomfort, but it can also lead to significant personal growth, improved emotional well-being, and healthier relationships. I understand that therapy is a collaborative process, and I am encouraged to actively participate to achieve the best possible outcomes.

7. Telehealth Services:

If I engage in telehealth services, I understand that these sessions are conducted through secure, HIPAA-compliant platforms. I agree to take responsibility for ensuring that I have a private and secure space for participating in telehealth sessions to maintain confidentiality.

8. Cultural Competence: 

I understand that my therapist is committed to providing culturally competent care that respects my unique identity, including my gender identity, sexual orientation, race, ethnicity, spirituality, and other cultural factors. I am encouraged to share any specific needs or concerns related to my identity so that therapy can be adapted to suit my background.

Introduction

At Montana Queer Alliance, we are committed to protecting the privacy and confidentiality of your personal health information in compliance with the Health Insurance Portability and Accountability Act (HIPAA) and other applicable laws.

1. Use and Disclosure of Health Information:

Your health information will be used and disclosed only for the following purposes:

• Treatment: To provide, coordinate, or manage your health care services.
• Payment: To obtain payment for your health care services.
• Healthcare Operations: For activities necessary to support the operations of the practice, such as quality assessment and improvement activities.

2. Your Rights:

• Right to Access: You have the right to inspect and obtain a copy of your health records.
• Right to Amend: You may request corrections to your health information if you believe it is incorrect or incomplete.
• Right to an Accounting of Disclosures: You can request a list of disclosures we have made of your health information.
• Right to Request Restrictions: You may ask us to limit the use or disclosure of your health information.
• Right to Confidential Communications: You can request that we communicate with you through alternative means or at alternative locations.
• Right to a Copy of this Agreement: You are entitled to a paper copy of this agreement upon request.

3. Our Responsibilities:

• We are required by law to maintain the privacy of your health information.
• We will notify you in the event of a breach of unsecured health information.
• We must follow the duties and privacy practices described in this agreement.

4. Limits of Confidentiality:

Your health information may be disclosed without your consent in certain situations, including but not limited to:

• If there is a threat of serious harm to yourself or others.
• Suspected abuse or neglect of a child, elderly person, or dependent adult.
• Compliance with a valid court order or other legal processes.

5. Complaints:

If you believe your privacy rights have been violated, you may file a complaint with:

• Our Office: Ace Reba-Jones, ace@montanaqueeralliance.org
• Office for Civil Rights, U.S. Department of Health and Human Services

You will not be retaliated against for filing a complaint.

6. Contact Information:

If you have questions about this agreement or wish to exercise your rights, please contact:

Ace Reba-Jones
406-475-0070
ace@montanaqueeralliance.org

1. Purpose of Consent:

I understand that in order for my therapist and this practice to bill and receive payment from my insurance provider, it may be necessary to share certain personal health information, including diagnosis, treatment plans, and session notes, with my insurance company.

2. Information Shared:

I give my consent for the release of the following information to my insurance provider, as required for billing purposes:

• Personal identification information (name, date of birth, address)
• Diagnosis codes
• Treatment dates and types of services provided
• Any other information required by my insurance company for claims processing and payment

I understand that only the minimum necessary information will be shared with the insurance provider to process claims and manage coverage of services.

3. Revoking Consent:

I understand that I may revoke this consent at any time, but that doing so may result in my insurance provider declining to cover future services. If I choose to revoke this consent, I will notify my therapist in writing.