Privacy & Policy


The law protects the relationship between a client and a psychotherapist, and information cannot be disclosed without written permission.

Exceptions include:

  • Suspected child abuse or dependant adult or elder abuse, for which I am required by law to report this to the appropriate authorities immediately.
  • If a client is threatening serious bodily harm to another person/s, I must notify the police and inform the intended victim.
  • If a client intends to harm himself or herself, I will make every effort to enlist their cooperation in ensuring their safety. If they do not cooperate, I will take further measures without their permission that are provided to me by law in order to ensure their safety.
  • Through court subpoena.


This notice describes how medical information about you may be used and disclosed, and how you can get access to this
information. This information will include Protected Health Information (PHI), as that term is defined in privacy regulations
issued by the United States Department of Health and Human Services pursuant to the Health Insurance Portability and
Accountability Act of 1996 (“HIPAA”)  Please review it carefully.

We respect your privacy. We understand that your personal health information is very sensitive. We will not disclose your
information to others unless you tell us to do so, or unless the law authorizes or requires us to do so. The law protects the
privacy of the health information we create and obtain in providing our care and services to you. For example, your
protected health information includes your symptoms, test results, diagnoses, treatments, health information from other
providers, and billing and payment information relating to these services. Federal and state law allows us to use and disclose
your protected health information for purposes of treatment and health care operations. State law requires us to get your
authorization to disclose this information for payment purposes.

Protected Health Information:
Protected health information means individually identifiable health information:
• Transmitted by electronic media.
• Maintained in any medium described in the definition of electronic media; or
• Transmitted or maintained in any other form or medium.

Examples of Use and Disclosures of Protected Health Information for Treatment, Payment, and Health Operations
For treatment:

• Information obtained by a nurse, physician, clinical psychologist, MSW, therapist, or other member of our
healthcare team will be recorded in your medical record and used to help decide what care may be right for
• We may also provide information to others providing you care. This will help them stay informed about
your care.
For payment:
• Written patient permission is required to use or disclose PHI for payment purposes, including
to your health insurance plan. We will have you sign another form Assignment of Benefits or similar form for this
purpose. Health plans need information from us about your medical care. Information
provided to health plans may include your diagnosis, procedures performed, or recommended care.
For health care operations:
• We use your medical records to assess quality and improve services.
• We may use and disclose medical records to review the qualifications and performance of our healthcare
providers and to train our staff.
• We may contact you to remind you about appointments and give you information about treatment alternatives or
other health-related benefits and services.
• We may use and disclose your information to conduct or arrange for
services, including a medical quality review by your health plan.
Accounting, legal, risk management, and insurance services.
Audit functions, including fraud and abuse detection and compliance programs.

Good Faith Estimate Notice

You have the right to receive a “Good Faith Estimate” explaining how much your medical and mental health care will cost.
Under the law, health care providers need to give patients who don’t have insurance or who are not using insurance an estimate of the expected charges for medical services, including psychotherapy services.You have the right to receive a Good Faith Estimate for the total expected cost of any non-emergency healthcare services, including psychotherapy services. You can ask your health care provider, and any other provider you choose, for a Good Faith Estimate before you schedule a service. If you receive a bill that is at least $400 more than your Good Faith Estimate, you can dispute the bill. Make sure to save a copy or picture of your Good Faith Estimate.

For questions or more information about your right to a Good Faith Estimate

Helpful Forms

Click here to view and print forms for your appointment.

Click Here