Teletherapy and In-Person Services

RISKS OF THERAPY:

There are few known risks associated with these treatment modalities. However, some people report a heightened emotional awareness which can bring on stronger emotions. In some cases, people feel more depressed and have thoughts of suicide. Also, as you grow and learn things about yourself, your relationships with others may change.

CLIENT RIGHTS:

Clients have the right to: 1) be treated with respect and dignity in the therapeutic atmosphere; 2) confidentiality and privacy; 3) refuse or terminate counseling at any time; 4) not be discriminated against; 5) obtain a copy of client records or request to amend a record; 6) to file a formal complaint against the therapist. If the client desires to terminate the counseling contract, it would be helpful if this were discussed with me in advance so that I may ensure proper closure, including referrals where appropriate, and so that any misunderstandings may be resolved.

TREATMENT:

I typically see clients once a week unless sessions are arranged otherwise. Clients may schedule appointments as needed according to their therapeutic goals. Treatment may last anywhere from short term (10-12 sessions) to long term (up to several years), depending on client symptom relief and perceived change. Counseling is a process of change and will not happen overnight. A client may choose to continue maintenance counseling as desired unless it is determined that sessions are no longer helpful or otherwise unnecessary. I help clients develop a treatment plan to track their progress in life domains and create goals that are meaningful and measurable.

CONFIDENTIALITY:

I maintain the confidentiality guidelines of the Washington Administrative Code (WAC), the Health Insurance Portability and Accountability Act (HIPAA) and the American Counseling Association (ACA). See attached copies for detailed information. I will not disclose any personal or identifying information to anyone outside the therapist-client relationship without a client's written authorization. Exceptions to confidentiality include: 1) evidence suggests physical, sexual or emotional abuse and neglect of a child, a disabled individual, or the elderly, 2) the client presents with suicidal ideation and refused to comply with safety commitments, 3) the client reports a plan to harm a specific-named individual, 4) where permitted by or required by law (i.e., insurance agreement, legal subpoena), 5) consultations with a consult group and with my supervisor. These conversations with my consultants/supervisor will take place in an area and in a manner in which they will protect your privacy. My duty to provide confidentiality will survive the death of a client unless otherwise authorized by the client prior to death. In the event that a client and I have unplanned contact in a public setting, verbal acknowledgement will be left up to the client's discretion.

RECORD KEEPING POLICIES:

I will maintain documentation of all consents, authorizations, notices of privacy practices, Office Policies and Procedures, training, and patient requests for records or amendments to records. I will document complaints received and their disposition. Client records will be kept locked in my office or in a locked file cabinet offsite. I will keep client records for seven years from the date of the last treatment session. With respect to the records of a minor, I will keep those records for at least seven years or until the patient is twenty one years old, whichever is longer. Thereafter, I may destroy client records. When records are destroyed they will be done so in a manner that protects client privacy and confidentiality. If you do not want records kept, please inform me and I will discuss with you how to do this.

COVERAGE IN MY ABSENCE OR DEATH:

There may be times when I take a week vacation. If you feel you would like to meet with another clinician in my absence, I will talk to you about having access to one of my colleagues in the office. In the case of my death, the custodian of your records is a designated colleague in my office.

CRISIS CONTACT INFORMATION: If a client is in crisis and unable to reach me, please call the national Crisis and Suicide Lifeline at 988 or if you are in the Seattle area please call the Crisis Clinic Line at 206-461-3222 or toll free 1-866-427-4747 or TDD Line access 206-461-3219. If you have a life threatening emergency, call 911 immediately. I will designate an on-call therapist for coverage in the case of my own personal emergencies or vacation.

CLIENT RESPONSIBILITIES

FEES AND BILLING PRACTICES: My fee for a 50 minute session is $160. For an intern, the fee is $55 for 50 minutes. Fees are to be paid at the beginning of the session unless discussed otherwise.

Payment is due at the time of session. We accept all major credit cards and a card is required to remain on file. You can also pay online anytime through the client portal.

I authorize Perfectly Queer Counseling PLLC to charge my card on file for professional services up to 24 hours before our scheduled appointment. If I do not cancel before 24 hours, I authorize Perfectly Queer Counseling to charge my credit/debit card as a late cancel or no show if I do not show up for the appointment. I will be billed for the full session charge. I verify that my credit/debit card information, provided above, is accurate to the best of my knowledge. If this information is incorrect or fraudulent or if my payment is declined, I understand that I am responsible for the entire amount owed and any interest or additional costs incurred if denied. I also understand by signing and initialing this form that if no payment has been made by me, my balance may go to collections if another alternative payment is not made within thirty days.

CANCELLATION POLICY:

I have a 24 hour cancellation policy. If you are sick or otherwise unable to make it to the scheduled appointment, you must contact me at least 24 hours before the appointment. Failure to do so will result in being charged the full session rate.

CORRESPONDENCE:

If a client chooses to contact me via cellular phone, email, or fax, they understand complete client privacy and confidentiality will be at risk due to intercepted calls, technological hackers, or accidentally dialed fax numbers. Clients are responsible for advising me if there is not a safe phone number or address to be contacted, otherwise, I have the right to attempt contacting clients according to the information provided by the client on the registration form.

ACCOUNTABILITY:

Clients are expected to actively participate in each session in order to achieve significant progress or change. If a client does not maintain complete honesty and disclosure of critical information with me, I will be unable to assist them with making positive life changes.

CLIENT AGREEMENT

By signing this form below, I acknowledge I have read and understand the above therapist disclosure, consent to receive counseling services, client responsibilities and treatment contract. I have received copies of the HIPAA privacy practice guidelines. I agree to abide by the above client responsibilities and to actively participate in the counseling environment. I understand that if I withhold important critical information from my therapist, I will be interfering with my own counseling progress and I will potentially jeopardize the therapeutic process. I understand my rights as a client. I have been given the opportunity to ask questions. I understand this is a legal document and contract. I have been given a copy of this contract.

NOTICE:

We keep a record of the health care services we provide you. You may ask us to see and copy that record. You may also ask us to correct that record. We will not disclose your record to others unless you direct us to do so or unless the law authorizes or compels us to do so. You may see your record or get more information about it at 9030 35th Ave SW, Suite 100 Seattle, WA 98126.

THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY.

Your health record contains personal information about you and your health. State and Federal law protects the confidentiality of this information. Protected Health Information (PHI) is information about you, including demographic information, that may identify you and that relates to your past, present, or future physical and mental health, or condition, and related health care services. If you suspect a violation of these legal protections, you may file a report to the appropriate authorities in accordance with Federal and State regulations.

We are required by law to maintain the privacy of your PHI and to provide you with notice of our legal duties and privacy practices with respect to your PHI. This Notice of Privacy Practices describes how we may use and disclose your PHI in accordance with all applicable law. It also describes your rights regarding how you may gain access to and control your PHI. We are required by law to maintain the privacy of PHI and to provide you with notice of our legal duties and privacy practices with respect to PHI. We are required to abide by the terms of this Notice of Privacy Practices. We reserve the right to change the terms of our Notice of Privacy Practices at any time. Any new Notice of Privacy Practices will be effective for all PHI that we maintain at that time. We will make available a revised Notice of Privacy Practices by sending you an electronic copy, sending a copy to you in the mail upon your request, or providing one to you in person.

How We are permitted to Use and Disclose Your PHI

For Treatment. We may use medical and clinical information about you to provide you with treatment services.

For Payment. We may use and disclose medical information about you so that we can receive payment for the treatment services provided to you.

For Healthcare Operations. We may use and disclose your protected PHI for certain purposes in connection with the operation of my professional practice, including supervision and consultation.

Without Your Authorization. State and Federal law also permits us to disclose information about you without your authorization in a limited number of situations, such as with a court order. With Authorization. We must obtain written authorization from you for other uses and disclosures of your PHI. You may revoke such authorizations in writing in accordance with 45 CFR. 164.508(b)(5).

Incidental Use and Disclosure. We are not required to eliminate every risk of an incidental use or disclosure of your PHI. Specifically, a use or disclosure of your PHI that occurs as a result of, or incident to an otherwise permitted use or disclosure is permitted as long as we have adopted reasonable safeguards to protect your PHI, and the information being shared was limited to the minimum necessary.

Examples of How We May Use and Disclose Your PHI

Listed below are examples of the uses and disclosures that we may make of your PHI. These examples are not meant to be a complete list of all possible disclosures, rather, they are illustrative of the types of uses and disclosures that may be made.

Treatment. Your PHI may be used and disclosed by us for the purpose of providing, coordinating, or managing your health care treatment and any related services. This may include coordination or management of your health care with a third party, consultation or supervision activities with other health care providers, or referral to another provider for health care services. Payment. We may use your PHI to obtain payment for your health care services. This may include providing information to a third party payor, or, in the case of unpaid fees, submitting your name and amount owed to a collection agency. Healthcare Operations. We may use or disclose your PHI in order to support the business activities of our professional practice including; disclosures to others for health care education, or to provide planning, quality assurance, peer review, or administrative, legal, financial, or actuarial services to assist in the delivery of healthcare, provided we have a written contract with the business that prohibits it from re-disclosing your PHI and requires it to safeguard the privacy of your PHI. We may also contact you to remind you of your appointments. Other Uses and Disclosures That Do Not Require Your Authorization Required by Law. We may use or disclose your PHI to the extent that the use or disclosure is required by law, made in compliance with the law, and limited to the relevant requirements of the law. Examples of this type of disclosure include healthcare licensure related reports, public health reports, and law enforcement reports. Under the law, we must make certain disclosures of your PHI to you upon your request. In addition, we must make disclosures to the US Secretary of the Department of Health and Human Services for the purpose of investigating or determining our compliance with the requirements of privacy rules.

Health Oversight. We may disclose PHI to a health oversight agency for activities authorized by law, such as audits, investigations, and inspections. Oversight agencies seeking this information include government agencies and organizations that provide financial assistance to the program (such as third-party payors) and peer review organizations performing utilization and quality control. If we disclose PHI to a health oversight agency, we will have an agreement in place that requires the agency to safeguard the privacy of your information.

Abuse or Neglect. We may disclose your PHI to a state or local agency that is authorized by law to receive reports of abuse or neglect. However, the information we disclose is limited to only that information which is necessary to make the required mandated report.

Deceased Clients. We may disclose PHI regarding deceased clients for the purpose of determining the cause of death, in connection with laws requiring the collection of death or other vital statistics, or permitting inquiry into the cause of death.

Research. We may disclose PHI to researchers if (a) an Institutional Review Board reviews and approves the research and a waiver to the authorization requirement; (b) the researchers establish protocols to ensure the privacy of your PHI; and (c) the researchers agree to maintain the security of your PHI in accordance with applicable laws and regulations.

Criminal Activity or Threats to Personal Safety. We may disclose your PHI to law enforcement officials if we reasonably believe that the disclosure will avoid or minimize an imminent threat to the health or safety of yourself or any third party. Compulsory Process. We may be required to disclose your PHI if a court of competent jurisdiction issues an appropriate order, and if the rule of privilege has been determined not to apply. We may be required to disclose your PHI if we have been notified in writing at least fourteen days in advance of a subpoena or other legal demand, no protective order has been obtained, and a competent judicial officer has determined that the rule of privilege does not apply.

Essential Government Functions. We may be required to disclose your PHI for certain essential government functions. Such functions include: assuring proper execution of a military mission, conducting intelligence and national security activities that are authorized by law, providing protective services to the President, making medical suitability determinations for U.S. State Department employees, protecting the health and safety of inmates or employees in a correctional institution, and determining eligibility for or conducting enrollment in certain government benefit programs.

Law Enforcement Purposes. We may be authorized to disclose your PHI to law enforcement officials for law enforcement purposes under the following six circumstances, and subject to specified conditions: (1) as required by law (including court orders, court-ordered warrants, subpoenas) and administrative requests; (2) to identify or locate a suspect, fugitive, material witness, or missing person; (3) in response to a law enforcement official's request for information about a victim or suspected victim of a crime; (4) to alert law enforcement of a person's death, if we suspect that criminal activity caused the death; (5) when we believe that protected health information is evidence of a crime that occurred on our premises; and (6) in a medical emergency not occurring on our premises, when necessary to inform law enforcement about the commission and nature of a crime, the location of the crime or crime victims, and the perpetrator of the crime.

Psychotherapy Notes. If kept as separate records, we must obtain your authorization to use or disclose psychotherapy notes with the following exceptions. We may use the notes for your treatment. We may also use or disclose, without your authorization, the psychotherapy notes for our own training, to defend ourself in legal or administrative proceedings initiated by you, as required by the Washington Department of Health or the US Department of Health and Human Services to investigate or determine our my compliance with applicable regulations, to avoid or minimize an imminent threat to anyone's health or safety, to a health oversight agency for lawful oversight, for the lawful activities of a coroner or medical examiner or as otherwise required by law.

Uses and Disclosures of PHI With Your Written Authorization

Other uses and disclosures of your PHI will be made only with your written authorization. We will not make any other uses or disclosures of your psychotherapy notes, We will not use or disclose your PHI for marketing purposes, and We will not sell your PHI without your authorization. You may revoke your authorization in writing at any time. Such revocation of authorization will not be effective for actions we may have taken in reliance on your authorization of the use or disclosure.

Your Rights Regarding Your PHI

You have the following rights regarding PHI that we maintain about you. Any requests with respect to these rights must be in writing. A brief description of how you may exercise these rights is included.

Right of Access to Inspect and Copy. You may inspect and obtain a copy of your PHI that is contained in a designated record set for as long as we maintain the record. A "designated record set" contains medical and billing records and any other records that we use for making decisions about you. Your request must be in writing. We may charge you a reasonable cost-based fee for the copying and transmitting of your PHI. We can deny you access to your PHI in certain circumstances. In some of those cases, you will have a right of recourse to the denial of access. Please contact me if you have questions about access to your medical record.

Right to Amend. You may request, in writing, that we amend your PHI that has been included in a designated record set. In certain cases, we may deny your request for an amendment. If we deny your request for amendment, you have the right to file a statement of disagreement with us. We may prepare a rebuttal to your statement and will provide you with a copy of any such rebuttal.

Right to an Accounting of Disclosures. You may request an accounting of disclosures made for treatment purposes or made as a result of your authorization, for a period of up to six years, excluding disclosures made to you. We may charge you a reasonable fee if you request more than one accounting in any 12-month period. Please contact us if you have questions about accounting of disclosures.

Right to Request Restrictions. You have the right to ask us not to use or disclose any part of your PHI for treatment, payment or health care operations or to family members involved in your care. Your request for restrictions must be in writing and we are not required to agree to such restrictions. Please contact us if you would like to request restrictions on the disclosure of your PHI. You also have the right to restrict certain disclosures of your PHI to your health plan if you pay out of pocket in full for the healthcare we provide to you.

Right to Request Confidential Communication. You have the right to request to receive confidential communications from us by alternative means or at an alternative location. We will accommodate reasonable written requests. We may also condition this accommodation by asking you for information regarding how payment will be handled or specification of an alternative address or other method of contact. Please contact us if you would like to make this request.

Right to a Copy of this Notice. You have the right to obtain a copy of this notice from us. Any questions you have about the contents of this document should be directed to us.

Right to Opt Out. You have the right to choose not to receive fundraising communications. However, we will not contact you for fundraising purposes.

Right to Notice of Breach. You have the right to be notified of any breach of your unsecured PHI.

Contact Information

Our Privacy and Security Officer is designated below. If you have any questions about this Notice of Privacy Practices, please contact that person. The contact information is:
Leah Post, LICSW
9030 35th Ave SW, Suite 100

Seattle, WA 98126

206-586-8822

Complaints

If you believe we have violated your privacy rights, you may file a complaint in writing with our Privacy Officer, as specified above. You also have the right to file a complaint in writing to the Washington Department of Health or to the US Secretary of Health and Human Services. We will not retaliate against you in any way for filing a complaint.

Effective Date

Effective date of this notice: September 21, 2024