Working with you to identify presenting issues and develop a plan of care is our goal. Your commitment to setting personal goals and addressing obstacles will largely determine the success of therapy. If a crisis develops after hours, call the National Suicide Prevention Lifeline at 1-800-273-8255 or go to your local emergency room. The Health Insurance Portability and Accountability Act (HIPAA) requires that we protect the confidentiality of your Personal Health Information (PHI).

Under United States and Minnesota law, your Personal Health Information (PHI) must be kept private. You are entitled to receive this notice and to have its terms followed while it is in effect. We may update these privacy practices as permitted by federal and state law; any changes may affect how your PHI is protected and may apply to information received before the change. If changes occur, an updated Notice of Privacy Practices will be provided to you.

Your PHI will not be used or disclosed for any purpose not listed below without your specific written authorization. You may revoke any authorization at any time by submitting a written request. • Health Care Provider – PHI may be shared with physicians or other health care providers who are treating you. • Payment – PHI may be disclosed to your health plan or other third parties for payment of services. This may include clinical diagnoses, treatment plans, summaries, or records if required by your insurer. • Health Care Operations – PHI may be used by staff for insurance eligibility, billing, and claim inquiries. • As Required by Law – PHI may be disclosed when lawfully required by federal, state, or local authorities. • Court Orders and Legal Proceedings – PHI may be disclosed in response to subpoenas or court orders when required. • Appointment Reminders and Cancellations – We may contact you by phone or email to remind you of appointments or notify you of cancellations; messages may be left on voicemail or answering machines. • Victims of Abuse, Neglect, or Domestic Violence – PHI may be disclosed to authorized state agencies when required by law. • Emergency Situations – PHI may be disclosed to a family member, caregiver, or personal representative if necessary in an emergency, using only the minimum information needed.

We are committed to protecting your privacy. If we ask you to provide personally identifying information via this website, it will be used only in accordance with this privacy statement. We will not intentionally share the contents of your email or online submissions with third parties. However, because electronic communications are not completely secure, we cannot guarantee that email contents will not become accessible to third parties. Please avoid sending confidential information via email, and take precautions to secure your email account if you choose to communicate this way.

Please type your name below to indicate consent to treatment.

Please review the information above and provide your signature or typed name below as confirmation.

If the patient is a minor, a parent or guardian must sign below to consent to the minor receiving treatment.

If you have any questions about this consent or the treatment process, please ask your provider before signing.