Due to the often sensitive nature of servicing families that are affected by a custody agreement, such as families of divorce or separation, families in which legal guardians are appointed, and foster families, your Silver Linings Counseling therapist requires additional consent regarding providing treatment to minors from such families. A minor is a child who is under the age of 18.

The term “legal guardians” will be used to refer to those family members or persons with legal responsibility for the minor client.

 

• Legal guardians agree to provide a copy of the divorce decree and/or custodial arrangement documents prior to the first appointment/start of treatment, if asked.
• Legal guardians must provide written consent via the Shared Custody Consent Form as well as SLC’s Client Contract and Consent to Treatment in order for the minor client to receive treatment, unless the divorce decree/custody agreement states otherwise.
• Legal guardians understand that the focus of therapy is to improve the welfare of the child and support healthy family functioning. 
• Legal guardians understand that therapy is not to be used as a punishment for the child or family members.
• Legal guardians understand that therapy is not to be used as leverage in the court system.
• Legal guardians understand that the therapist’s role is to support the child and the family through the changes in family dynamics, through the challenges posed by the child living in multiple households, as well as to support the child with any issues he/she faces individually and personally.
• Legal guardians are expected to behave respectfully in the presence of their children in the therapy setting and understand therapy is not for attacking, undermining or disparaging other parents or guardians.
• Legal guardians agree to be responsible for communicating about and coordinating appointments. The therapist is not responsible for informing legal guardians who are not present at counseling appointments about future appointments.
• Legal guardians agree to participate in group contact with therapist so that legal guardians are equally informed of treatment progress, goals and concerns. Therapist does not agree to withhold information from legal guardians or to collude with one or another parent. Rule of thumb: If you cannot say it to the other parent, do not say it to the therapist.
• Legal guardians agree that communication with therapist be informative and insightful into what is occurring with the child and legal guardians should avoid discussion of other guardians.
• Legal guardians agree to be responsible for the costs of counseling as dictated by the divorce decree and/or custodial documents and/or subscriber’s insurance. Should there be a dispute about payments and payments are not made, the client’s and family’s treatment will be suspended until payment arrangements are resolved.
• Any therapy services provided to legal guardians will be billed to the same payer as the client.
• Legal guardians understand and agree that should they need to communicate with therapist outside of the client's scheduled appointment time, there may be charges equal to $1/minute for time spent by phone or by e-mail beyond 10 minutes.
• Legal guardians agree to pay no show or late cancellation fees up to $125 should an appointment be missed without at least 24 hours notice
• Legal guardians understand that therapists are not investigators. Should you believe your child is being abused or neglected, even if by another legal guardian, it is the responsibility of said parent/guardian to contact Children’s Protective Services or the police.
• Legal guardians understand that therapists are mandated reporters of child abuse and required by law to report any “suspected child abuse”. Therapists have the right to report this information anonymously.
• Legal guardians understand that therapists are not custody evaluators and therefore do not provide opinions, insight, or recommendations regarding custody or parental visitation or rights. Should a legal guardian wish to change the custody arrangement, this is to be handled through the courts. Therapists at SLC are not custody evaluators and will not participate in custody evaluation. Guardians may contact the Friend of the Court for a court-appointed custody evaluator.
• Should the client’s SLC therapist be subpoenaed to testify in family court, legal guardians acknowledge and agree to the fee schedule of $200 per hour of any court-related services provided by the therapist. These services include, but are not limited to, time spent in preparation of court attendance and documentation, time travelling to and fromcourt proceedings, time spent in court proceedings of any kind, time spent consulting with lawyers and/or experts, etc.
• Should a legal guardian request their child client's (SLC’s client) health record to be released, the therapist will adhere to the laws of HIPAA and the directions of the divorce decree/custody agreement before appropriately responding to this request. This may require consent by all guardians for the release. Should a therapist believe releasing such records would be harmful to the child client, guardians should be aware that the therapist reserves the right to deny release of the records.
• Legal guardians understand that at any time these agreements are violated, services may be suspended or terminated.
   

Your signature below indicates that you have read this form and you willingly consent to the requirements stated in the form. Your signature also indicates that you have asked any questions to clarify the information in the form and that those questions have been sufficiently answered and resolved.
 

SLC requires a backup card on file if the primary card on the account is an HSA. Please fill out another Payment Authorization Acknowledgement form for your backup card, and contact our office to place the backup card on file. Additionally, please let us know if there is a certain day of the month that your HSA gets reloaded (if known).

By signing this form:

• I understand that Silver Linings Counseling has my credit card number on file, and requires all clients to have a form of payment on file.
   
• I understand that Silver Linings Counseling has stored the credit card number given to them in lieu of me signing their payment authorization form and filling out my information myself in their client portal.
   
• I understand that Silver Linings Counseling will charge any copays, account balances, and missed appointment fee to this card.
   
• I understand that payment is expected at the time of service and that Silver Linings Counseling will automatically charge my card for session fees, copays, or missed appointment fees. If appointments go towards my deductible, they will be charged as they process through insurance.
   
• I understand that an appointment is deemed "missed" if at least 24 hours advanced notice is not given to my therapist and/or the front office staff (with the exception of emergencies).

We’re so glad you’re here. At Silver Linings Counseling, PLLC, our licensed and caring providers partner with you to support your mental health, help reduce symptoms, and improve daily life.

Starting therapy can feel intimidating, and we want you to feel comfortable asking questions at any point — about your care, your options, or our policies.

SLC offers individual therapy/counseling, group therapy, family/relationship therapy, teletherapy, and psychological testing/assessment. Medication evaluations and medication management services are not offered and clients are encouraged to consult their primary care physician and/or a psychiatric provider to learn more about psychopharmacological treatment options. Referrals for prescribers are available upon request.

Psychotherapy/counseling, commonly referred to as “therapy”, is individualized and may look different to each client. While the majority of this information applies to individual therapy additional information regarding our other services is also included in this section. Therapists rely on a variety of theoretical approaches, often integrating techniques from different schools of thought to provide individualized treatment. Therapy also occurs in different modalities, such as individual, couples, family, and group settings.

While therapy has many benefits, it also may come with some risks. Because therapy often involves discussing unpleasant aspects of your life, you may experience uncomfortable feelings like sadness, guilt, anger, frustration, loneliness, and helplessness. Nonetheless therapy has shown to promote better relationships, solutions to specific problems, and significant reductions in feelings of distress. While SLC clinicians are dedicated to helping people heal and grow, there are no guarantees that you (or your child) will benefit from therapy. Therapy may involve a substantial commitment of time, money, and effort outside of sessions. As such, it is important that you carefully consider several factors when deciding if therapy is right for you. We encourage you to consider your own level of motivation, your ability to commit to attending sessions and working between sessions to meet your goals, what type of therapist would be best for you, whether a different form of treatment (e.g., medication management) might better serve your needs, or whether a different agency might better meet your needs (e.g., sliding scale, location, hours of operation, etc.). After considering these factors, we hope that you still decide to work with an SLC therapist, however  we are also happy to discuss alternatives that might better meet your needs.

If, after considering whether therapy is right for you at this time, you will be asked to participate in an intake appointment. During the intake, your therapist will ask questions about your current functioning, your background, and your goals for treatment. Therapists will ask about things such as physical health, substance use, past mental health treatment, family relationships, traumatic experiences, current symptoms, and other aspects of your life to gain a good understanding of you and your life history.

Please feel free to let your therapist know if you are uncomfortable answering a question. While the intake serves as a starting point for understanding your concerns, the evaluation process is ongoing. After the intake, you may choose to schedule a follow up appointment, request to work with a different therapist, or discontinue services at SLC. If you choose to work with a therapist at SLC, you can expect to collaborate with your therapist to set goals for your treatment (or the treatment of your child). To work toward your goals, most people meet with their therapist on a weekly basis for 45 to 55 minutes, however, session frequency varies depending on client needs. In sessions, your therapist and you (or your child) will likely explore life events, attitudes, relationship styles, and ways of thinking and behaving that cause problems for you (or your child). At times, in consultation with your therapist, you may choose to invite others into therapy sessions. If this occurs, you (or your child) remain the focus of the session – therapists work primarily for the benefit of the identified client.

In addition to individual therapy, SLC may offer the following:

• Child Therapy: Many SLC therapists offer services for children. Minors under the age of 18 are required to have a parent/guardian at the intake appointment. Parental/guardian involvement in therapy will be discussed at the intake and will be reassessed as needed. In some cases, the parent or guardian may be referred for personal therapy so that the child’s session can focus on their needs and growth.

Additionally, when a child’s parents are divorced/separated, guardians may be required to consent to SLC’s Divorced Parent Policy.

• Family/Relationship Therapy: SLC therapists may offer family or relationship therapy. Please note, that when family/relationship therapy is scheduled, one person must be identified as the primary client. While the goal of family/relationship therapy is to benefit all those involved, the main goal of therapy will be to work toward the benefit of the identified client. Additionally, services will only be documented for and available to the identified client (or, if the identified client is a minor, to a legal guardian).
• Group Therapy: SLC therapists may offer group therapy services. Please be aware that SLC cannot guarantee that other group members will maintain confidentiality, however SLC therapists are committed to practicing ethically and maintaining your confidentiality. The therapist will also set clear expectations regarding privacy and confidentiality among group members. If a group member is found to have broken confidentiality of another group member, they may be terminated from the therapy group.
• Specialized Therapies: Some SLC therapists may offer specialized therapy services, such as EMDR for trauma, play therapy for children, sex therapy. In such instances, it is important that you review possible benefits and risks with the therapist to determine whether you would like to proceed with treatment; additional consent processes may be necessary.
• Teletherapy: Teletherapy refers to providing therapy services remotely using telecommunications technologies, such as video conferencing or telephone. One of the benefits of teletherapy is that the client and clinician can engage in services without being in the same physical location; however, clients must be in the state of Michigan while receiving services. Teletherapy has some unique risks. For example, because teletherapy sessions take place outside of the therapist’s private office, there is potential for other people to overhear sessions. It is the client’s responsibility to ensure they are in a private place for each session and to protect the privacy of sessions by only using secure devices. SLC therapists will also take reasonable steps to ensure privacy, including using HIPAA-compliant video conferencing software to conduct sessions. There are ways in which technology issues might impact teletherapy. For example, technology may stop working during a session, other people might be able to get access to private conversations, or stored data could be accessed by unauthorized people or companies. Teletherapy may not be appropriate in all situations. SLC therapists may determine that treatment can only be provided in- office, or may choose to refer clients out to other providers if they determine that teletherapy does not facilitate meeting treatment goals for any reason.
• Psychological/Neuropsychological Testing & Assessment: Testing and assessment includes three steps. In step one, you will meet with a qualified health provider to complete an intake. During the intake, the assessor will obtain background information about you (or your child), including the reason testing is being sought, information about development, physical health concerns, family relationships, substance use/exposure, legal background, trauma history, and more. In some situations, more than one session is needed to complete the intake process. Following the intake, your assessor will select tests appropriate to answer the referral question(s) that led to the request for psychological testing/assessment. In step two, the assessor will work with the client and others as necessary to complete administration of various psychological tests. Please note that for adults, it is common to ask for input from significant others or professionals involved in the client’s life (e.g., probation officers, physicians, etc.). For children, it is best practice to include others in the assessment process, including parents/guardians, teachers, others who have close relationships with the child, and other professionals (e.g., pediatricians, neurologists, speech and language pathologists, etc.) who may have specialized knowledge concerning the child’s functioning. Once all interviews, tests, and evaluation methods have been completed, the assessor will prepare a written report. In step threet, the assessor will schedule a feedback session with the client (or the client’s guardians if the client is a child) to review findings and discuss recommendations based on the results of the assessment. Like therapy, testing and assessment includes a significant commitment of time and financial resources. Results of assessments cannot be guaranteed. While the assessor will work diligently to address the referral question or reason for seeking testing and to provide evidence-based treatment recommendations, in some cases, testing does not allow the examiner to make a conclusive diagnosis or determination. Additionally, in some cases, the assessor may offer a diagnosis that is difficult to receive. For example, SLC assessors routinely include measures of intellectual ability and academic achievement. Learning that your (or your child’s) intellectual ability or academic achievement falls in the below average, average, or above average range can cause unanticipated shifts in how you see yourself (or your child). Clients (or their guardians) are urged to carefully consider whether the benefits of completing the assessment process are worth the investment and whether they are prepared to learn more about their (or their child’s) functioning. While risks exist, identifying underlying concerns for poor academic, employment, and/or relational performance can serve as a crucial first step in determining intervention strategies. Testing can help clarify diagnosis, which may lead to better informed therapy strategies, medication management strategies, or development of educational intervention plans (i.e., IEP or 504b plans). Please note that in most cases, the client (or the client’s guardians) is responsible for costs associated with assessment and retains confidentiality rights to the results. In some cases, however, assessment services may be covered by a school, court, or other agency. In those cases, the assessor will be sure to clarify with the person being evaluated the limits to confidentiality and who will be obtaining a copy of the assessment results.

• You have the right to receive services from qualified professionals who are appropriately licensed in the state of Michigan, who adhere to their respective ethical codes, and who comply with state and federal laws.
• You have the right to privacy and confidentiality regarding the service you receive. All information about you and your treatment, whether written or verbal, is protected under federal and state laws, including the HIPAA Privacy Rule.
• You have the right to informed consent (see above) regarding services and a right to ask questions and receive honest responses to help you make decisions regarding your care.
• You have a right to receive treatment recommendations and to have those recommendations explained to you, including possible outcomes of participating in and refusing treatment.
• You have a right and a responsibility to actively collaborate with your clinician(s) regarding coordination of care and treatment planning at every stage.
• You have a right to refuse services at any time. You have a right to withdraw your consent to receive services and discontinue treatment at any time.
  You have the right to express any concerns or complaints regarding the services you receive.
• You have the right to know that your clinician may terminate services in the event that you repeatedly cancel or fail to attend scheduled sessions.
• You have the right to know we may contact law enforcement should an individual, client or otherwise, come to SLC under the influence of drugs or alcohol and attempt to leave SLC by driving a motor vehicle.
• You have a right to know that SLC is a non-smoking environment. Illicit drugs, alcohol, vaporizers, and weapons are not allowed on the premises. Persons in possession of any of these will be asked to leave immediately.
• You have the right to know that no clinician or member of our staff is allowed to date or have a personal relationship with current or former clients of the practice.
• You have the right to know that staff and therapists are typically not allowed to accept gifts from clients of the practice, nor are they permitted to enter into any business relationships with past or current clients.
• You have a right to know that when a minor is identified as the client, guardians are typically encouraged to participate in the treatment process.
• You have the right to request an estimate of costs associated with treatment, as outlined in the No Surprises Act.

 

• You have the responsibility to be present and punctual for your appointments. Arriving at in-person sessions or logging in to telehealth sessions more than 10 minutes late may result in your therapy appointment being canceled and rescheduled. You may be charged a practice fee of up to $125 for each cancellation that occurs with less than a 24-hour notice and up to $125 for each scheduled appointment that you fail to attend. For psychological testing and assessment, you may be charged up to $125 per scheduled hour of testing (i.e., if you are scheduled for a four-hour testing session, you may be charged up to $500 for a canceled or missed testing session. Because insurance companies and other third-party payers do not cover missed appointments, you will be personally responsible for costs incurred due to late cancellation of or failure to attend scheduled appointments.
• You are responsible for knowing and understanding your insurance benefits. While insurance benefits may be checked as a courtesy, you are ultimately responsible for knowing your insurance benefits and SLC cannot guarantee benefits or coverage of services. In the event that your insurance company declines to pay for care, you as the client are responsible for any charges related to provision of care. You are encouraged to contact your insurance provider to learn more about your benefits.
• You are responsible for communicating any insurance changes with SLC. SLC clinicians are not considered in-network with all insurance companies, and participation may vary by clinician. Failure to update insurance changes prior to the first appointment after the change may result in denied session coverage and you may be charged the full out-of-pocket cost for the session(s). 
• You are responsible for maintaining contact with your clinician. Your file will be closed following 60 days of inactivity, unless other arrangements have been made. You may resume treatment at any time; however, you may be required to complete a new initial appointment depending on how long it has been since your last appointment.
  You are responsible to promptly notify SLC of any insurance changes. Not all SLC providers are in- network with all insurance companies and changes in insurance may result in your clinician being out-of-network with your policy. Failure to update insurance changes prior to appointments may result in denied session coverage and you may be charged the full out-of-pocket cost for the session(s).
• You are responsible to assist SLC/SLC Front Office Staff regarding Coordination of Benefits (COB) issues with your insurance. SLC Front Office Staff may reach out to you when the insurance provider we have on file for you notifies SLC that there may be other health insurance that is active. You will have to call your insurance to update them with any other insurance policies (or lack thereof).
• You have the responsibility to conduct yourself in a non-disruptive and non-aggressive manner while on the premises. Emergency responders will be contacted if necessary.

Federal and State laws protect the privacy of communications between a client and a clinician. In most situations, a signed Authorization to Release form is required before your information will be shared. However, there are limits to confidentiality. Confidentiality will be broken in the event that your therapist believes you intend to harm yourself or others, if your therapist becomes concerned about possible harm/abuse/neglect of a dependent person, if your therapist is legally compelled to provide information, or if an insurance company audits your records. Additional standards and practices regarding your confidentiality are set forth in the Notice of Privacy Practices. State law requires therapists to report SUSPECTED abuse or neglect of children and vulnerable/elderly adults.

 

Parents or guardians of minor clients who are not emancipated may be allowed by law to examine the minor’s treatment records. Clients over the age of 14 may consent to and may control access to information pertaining to their mental health treatment; however, this treatment may not extend beyond 12 sessions or 4 months without the consent of a guardian. The same limits to confidentiality, as described above, apply to minors.

 

The best care is typically achieved by collaboration by you, your mental health provider(s), and your medical provider(s) working together. As such, we routinely request your permission to inform your Primary Care Physician and/or Psychiatrist that you are receiving services at SLC. Unless otherwise required by your insurance company, you have the right to decline coordination of your care in part or whole. If you receive services from multiple providers at SLC, they will have access to your full record to coordinate care. They may also discuss your care amongst themselves to meet your treatment goals.

 In compliance with state law, your therapist(s) will keep records of each service provided. Records will not be shared except with respect to the limits discussed in the Confidentiality section. Should you wish to have your or your child’s records released, an Authorization to Release Information must be completed. Records will be maintained for at least 7 years.

SLC complies with the Health Insurance Portability and Accountability Act (HIPAA) and other federal and state guidelines. It is important for you to know that your identifying information will be shared with certain companies that provide services for SLC. Specifically, to facilitate receipt of payment from third party payers and aid in account management, your contact information, insurance information, diagnosis, etc. will be provided to a billing company who also complies with HIPAA. Only information necessary for submitting for financial purposes will be made available to the billing company. Identifying information or client records may also be reviewed in the case of an insurance audit or as part of a credentialing process, or be made accessible to companies with which SLC is affiliated for specific purposes (e.g., electronic medical record maintenance). Additional standards and practices regarding your identifying information are set forth in the Notice of Privacy Practices.

Payment is expected at the time services are rendered, unless otherwise agreed or if covered by insurance. If costs of services go towards your deductible, they will be processed through insurance before payment is collected. Please note, this may result in several appointments processing together. Payment for other professional or administrative services may be required; please see ‘Fee Schedule’ below. A fee adjustment or a payment installment plan may be negotiated in circumstances of unusual financial hardship. Although a benefit summary may be provided, the client is ultimately responsible for knowing benefit information and for paying for service in full. If your client balance exceeds $200.00, service may be suspended, and a referral may be offered. If your account has not been paid for more than 90 days and arrangements for payment have not been agreed upon, legal action may be used to secure payment. This may involve hiring a collection agency or going through small claims court, which will require disclosure of otherwise confidential information. In most collection situations, the only information released regarding a client's treatment is his/her name, the nature of services provided, and the amount due. If such legal action is necessary,costs charged by the collection agency, courts, and other legal or associated fees will be the responsibility of the client. Upon request, you will be provided with the name and contact information of the current billing company and/or collections agency utilized by SLC. SLC may, without notice, opt to end its agreement with the current billing and/or collections company and enter into an agreement with an alternative company. In such situations, clients will be provided with the name and contact information for the new company upon request.

Mental health services can be processed two different ways by your insurance company – either with a copay or towards your deductible. While SLC will provide a complimentary benefit check for all clients, it is not a guarantee of benefits or coverage. It is the responsibility of each client to call their insurance company and verify benefits directly. Please note that SLC does not set the maximum allowable rates for services, and owed amounts are determined by your insurance.

The following table outlines the standard rates charged to insurance companies (when applicable) and clients for various services. SLC reserves the right to contract with insurance companies to provide services at different rates. Supplemental service codes, in addition to regular sessions, may be billed when deemed appropriate by the therapist.

Services Billable to Insurance	Length	CPT Code	Cost
Intake	approx. 60 mins	90791	$225
Individual Psychotherapy	53+ min	90837	$205
	37-52 min	90834	$140
	16-36 min	90832	$110
Crisis Psychotherapy	60 min	90839	$195
	each additional 30 mins	90840	$95
Family Therapy; client not present	25-50 min	90846	$200
Family Therapy; client present	25-50 min	90847	$200
Group Therapy	-	90853	$60
Psychological Testing	60 min	96130	$195
	each additional 60 min	96131	$170
Neuropsychological Testing	60 min	96132	$210
	each additional 60 min	96133	$180
Test Administration & Scoring	30 min	96136	$85
	each additional 30 min	96137	$85
Services - Not Billable to Insurance	Length		Cost
No Show/Late Cancel	-	-	up to $125
Phone Consultation	15 min	-	$20
Email	per conversation	-	$35
Text	per text	-	$1
Letter (probation, attendance, etc)	per letter	-	$35
Form (return to work, disability, etc.)	per form	-	up to $50
Medical Records	-	-	$35+
Court Appearance (including travel, prep, appearance)	60 min	-	$200
IEP, Wraparound, or other meeting	30 min	-	$50
Other Services	-	-	Varies

 

Fee schedule revies 9/16/25

→ At Silver Linings Counseling, we periodically review our fees to ensure they reflect current industry standards and the level of care we provide. While fees may be adjusted from time to time, this page will always have the most up-to-date information.

All non-medicaid clients at SLC are required to have a signed Payment Authroization and working credit card on file for all account balances. SLC’s office team is generally available to answer calls, take messages and reschedule appointments from 9:00 AM to 5:00 PM Monday through Thursday and from 9:00 AM to 3:00 PM on Fridays. If calling after hours, clients may leave messages regarding canceling sessions on the SLC voicemail; however, payments cannot be made via voicemail. SLC’s office team may contact clients regarding outstanding balances, cancellation of appointments, or other matters to support the treatment process. Contact may be made via phone call, text message, or email.

In the event of an emergency, you can contact or go (if able) to the nearest crisis center (Macomb County: 586-307-9100; Oakland County: 248-456-0909; National Suicide Prevention Lifeline: 988 (call or text). You may also contact the nearest emergency room or call 911.

SLC therapists are generally not available for consultation outside of scheduled sessions. In the event that a clinician accepts phone calls or text messages between appointments, a fee for service may be assessed. Please ask your clinician(s) about how they would prefer to handle communication between sessions if this is a service you feel would be beneficial/necessary for your treatment.

Your health information is contained in a medical record that is the physical property of Silver Linings Counseling, PLLC. This notice describes how health information about you may be used and disclosed, and how you can obtain access to this information. Please carefully review this revised statement.

 

We May Use or Disclose Your Health Information for:

• Treatment. We may use your health information to provide you with mental health treatment or services. For example, information obtained by a mental health provider, such as a psychologist, social worker, or other person providing mental health services to you, will record information in your record that is related to your treatment. This information is necessary for mental health providers to determine what treatment you should receive. Mental health providers also record actions taken by them in the course of your treatment and note how you respond to the actions.
• Payment. We may use and disclose your health information to others for purposes of receiving payment for treatment and services that you receive. For example, a bill may be sent to you of a third-party payer, such as an insurance company or health plan. The information on the bill may contain information that identifies you, your diagnosis, and treatment or supplies used in the course of treatment or service.
• Health Care Operations. We may use and disclose health information about you for operational purposes. For example, your health information may be disclosed to members of the clinical staff, risk or quality improvement personnel, and other to evaluate the performance of staff; assess the quality of care and outcomes in your case and similar cases; learn how to improve our facilities and services; determine how to continually improve quality and effectiveness of the mental health care we provide.
• Appointments. We may use your information to provide appointment reminders or information about treatment alternatives or other health-related benefits and services that may be of interest to you.
• Required by Law. We may use and disclose information about you as required by law. For example, we may disclose information for the purposes of judicial and administrative proceedings pursuant to legal authority; to report information related to victim of abuse, neglect or domestic violence; or to assist law enforcement officials in their law enforcement duties.
• Public Health. Your health information may be used or disclosed for public health authorities or other legal authorities to prevent or control disease, injury, or disability or for other health oversight activities.
• Decedents. Health information may be disclosed to funeral directors or coroners to enable them to carry out their lawful duties.
• Research. We may use your de-identified mental health information for research projects. Consistent with HIPAA, “de-identified means the information neither identifies you nor providers a reasonable basis to identify you as an individual. De-identified data carries a very low risk that it could be linked back to the individual. To the extent that information is needed, an institutional review board or privacy board will review the research proposal and established protocols to ensure compliance with HIPAA privacy standards regarding the de-identification of your health information.
• Government Functions. Your health information may be disclosed for specialized government functions such as protection of public officials or reporting to various branches of the armed forces.
• Workers’ Compensation. Your health information may be used or disclosed in order to comply with laws and regulations related to Workers’ Compensation.
• Health and Safety. Your health information may be disclosed to avert a serious threat to the health and safety of you or any other person pursuant to applicable law.
• Other Uses. Other uses and disclosures will be made only with your written authorization and you may evoke the authorization except to the extent we have relied on it.

 

You have the right to:

• request restriction on certain uses and disclosures or your information as provided; however, we are not required to agree to a requested restriction;
• obtain a paper copy of this Notice of Privacy Practices upon request
• inspect, and obtain a copy of your health record as provided by law and any agreements you may have with Silver Linings Counseling, PLLC;
• request communications of your health information by alternative means or at alternative locations;
• evoke your authorization to use or disclose health information except to the extent we have already taken action based upon your authorization; and
• receive an accounting of disclosures made of your health information.

 

If you have questions or complaints, please contact your clinician or submit a request for:

Dustin Shepler, PhD, LP, HSP, CST

President/Owner

info@silverliningspllc.com

 

You may also complain to the Dept. of Health and Human Services if you believe your privacy rights have been violated. You will not be retaliated against for filing a complaint. We reserve the right to change our privacy practices and to make the new provisions effective for all protected health information we maintain. Revised notices will be made available via our website and at our offices, and, upon request via email or mail.

 

By signing this document, I acknowledge that:

✓ I have read and understand that there are risks and benefits to receiving therapy and/or psychological testing and assessment services.
✓ I understand my rights and responsibilities as a client of Silver Linings Counseling, including attendance, financial, and otherwise.
✓ I have received a copy of Silver Linings Counseling Notice of Privacy Practices, which were most recently revised on February 23, 2023.
✓ I consent to treatment for myself/my child at Silver Linings Counseling.
✓ I understand that Silver Linings Counseling requires a form of payment on file to charge for all copays, account balances, and missed appointment fees. This must be provided to Silver Linings Counseling before the first appointment via a payment authorization form that will be sent to your email. (Medicaid Clients N/A)