CONFIDENTIALITY:

Be aware that even basic demographic details like your name, email, and location are

considered Protected Health Information (PHI) as is anything clinical in nature like your

diagnosis or clinical material. This includes information shared during sessions as well as

written records related to those sessions. This means that I do not share your information with

anyone except when legally or ethically required to do so, or when you provide me with

permission.

Legal/Ethical Limitations to Confidentiality:

· I am mandated under the law to report suspicion of child abuse or neglect.

· I am mandated under the law to report suspicion of abuse or neglect of elderly or disabled adults.

· I will share important and relevant information to protect a person to whom you appear

to be an imminent and/or immediate physical threat.

· I will share important and relevant information to protect you from imminent or

immediate physical threat to yourself.

· I may be required by Court Order to disclose treatment information.

· I may share information with a health care provider who is providing emergency

services.

· I may share information with my attorney to assist with lawsuits or other legal

Proceedings.

Additionally, communication with me via any online or electronic means (e.g. email, text, video)

is limited in security and thus your confidentiality cannot be guaranteed. Please consider the

limits of confidentiality in electronic communications outlined in more detail later.

I use services such as Grow, Doxy, Google Workspace, and Microsoft Office 365. Every service I use, I have ensured that there is a Business Associate Agreement, a contract agreement with these companies, signed to ensure that all information is being handled to meet HIPAA compliance. 

By providing your insurance information and requesting that claims be sent to your insurance

company, you understand that information needed for billing will be shared with your insurance

company and you consent to this release of information. This could include possible release of

treatment records (assessments and progress notes) in the case of a review or audit by your

insurance company.

I consult regularly with other professionals regarding my clients to ensure I am providing the

best care possible; however, the client’s name and other identifying information is never

disclosed. The client’s identity remains completely anonymous, and confidentiality is fully

maintained.

In the event of an injury, illness, or other unexpected emergency situation that results in me

becoming unavailable, your basic contact information (name and contact numbers or email)

may be provided to a fellow clinician or professional. This will allow for your timely notification

of appointment cancellations, as well as provide you with an opportunity to obtain further

information regarding your continued care.

Should we run into each other socially in person or online, I protect your privacy and will never

acknowledge working therapeutically with you. Your right to privacy and confidentiality is of the

utmost importance to me, and I do not want to jeopardize your privacy. However, if you

acknowledge me first, I will be more than happy to speak briefly with you, but I will not engage

in any lengthy discussions in public or outside of the therapy session.

Considering all of the above exclusions, if it is deemed appropriate, upon your written request, I

will release information to any agency/person you specify unless I conclude that releasing such

information might be harmful in any way.

You agree that there will be no audio or video recording of any of the online sessions

by either party.

TELETHERAPY: 

I further hereby consent to participate in teletherapy as part of my services, if applicable. I understand that teletherapy is the practice of delivering clinical health care services via technology assisted media or other electronic means between a practitioner and a client who are located in two different locations. I understand the following with respect to teletherapy health: 

1) I understand that I have the right to withdraw consent at any time without affecting my right to future care, services, or program benefits to which I would otherwise be entitled. 

2) I understand that there are risks and consequences associated with teletherapy, including but not limited to, disruption of transmission by technology failures, interruption and/or breaches of confidentiality by unauthorized persons, and/or limited ability to respond to emergencies. 

3) I understand that there will be no recording of any kind of the online sessions by either party. All information disclosed within sessions and written records pertaining to those sessions are confidential and may not be disclosed to anyone without written authorization, except where the disclosure is permitted and/or required by law.

 4) I understand that the privacy laws that protect the confidentiality of my protected health information (“PHI”) also apply to teletherapy unless an exception to confidentiality applies.

 5) I understand that if I am having suicidal or homicidal thoughts, actively experiencing psychotic symptoms or experiencing a mental health crisis that cannot be resolved remotely, it may be determined that teletherapy health services are not appropriate and a higher level of care is required.

 6) I understand that during a teletherapy health session, we could encounter technical difficulties resulting in service interruptions. If this occurs, end and restart the session. If we are unable to reconnect within ten minutes, please call Sadie Lipman at (813) 540-0601 to discuss since we may have to re-schedule.

NOTICE OF PRIVACY PRACTICES AND CLIENT RIGHTS: 

By signing this document, you agree that you have read and received a copy of the Notice of Privacy Practices and Client Rights document seen here.