The Therapy Process Working with you to identify presenting issues and develop a plan of care is the goal. However, it is your commitment to identifying personal goals towards which you desire to move and obstacles which may prevent that movement which will, in large part, determine the success of the therapy. Telehealth Hope Counseling office number is not an emergency number and Telehealth Hope Counseling does not offer 24 hour crisis coverage. Therefore the following procedure is to be followed if you experience a crisis: Call 911 if you are in immediate danger or go to the nearest emergency room. If you have a crisis situation develop after hours, call the national suicide prevention lifeline at (800) 273-8255 or go to your local emergency room. The privacy regulations of the Health Insurance Portability and Accountability Act of 1996 (HIPAA) require ethical and legal commitment to the confidentiality of your Personal Health Information. Legal Responsibility Under the laws of the United States and the state of Ohio your Personal Health Information (PHI) must be kept private. It is also required by law to give you this notice and to follow the terms of this notice while it is in effect. Changes in these privacy practices are allowed at any time as long as those changes are permitted or required by law. Any changes in these privacy practices will affect how the privacy of your PHI is protected, including any PHI received about you or created in the course of your therapy. These changes could also affect the protection of the privacy of any of your PHI received before the changes. If changes are made, a new notice will be available to you. Use and Disclosure of Your Personal Health Your PHI will not be used or disclosed for any purpose not listed below, without your specific written authorization. You must give written authorization to disclose your health information to anyone for any reason you want. Any specific written authorization you provide may be revoked at any time by your written request. · Health Care Provider - PHI may be used and disclosed to your physician or other healthcare provider who is also treating you. · Payment - Your PHI may be used and disclosed to your health insurance plan or other third party for payment of services provided for you. If your contract with your insurance company requires that information relevant to the services provided be given before payment, providing them with a clinical diagnosis, as well as clinical information such as treatment plans or summaries and/or copies of any records maintained about your therapy sessions may be required. · Health Care Operations - Your PHI may be used and disclosed to staff members for the purpose of obtaining insurance eligibility, billing health insurance and inquiring about claim status. · As Law Requires - Your PHI may be used and disclosed to any person required by federal, state, or local laws to have lawful access to your treatment program. · Court Orders, Judicial and Administrative Proceedings, and Law Enforcement - Your PHI may be disclosed as part of a court proceeding, in response to a subpoena, or in other situations as required by law. · Appointment Reminders - You may be contacted by phone or email for an appointment reminder. If contact is by phone, a recorded message may be left on your answering machine. · Therapist Cancellation – If for some reason an appointment must be cancelled, you will be contacted by phone or email. If contact is by phone, a recorded message may be left on your answering machine/voicemail. · Victims of Abuse, Neglect, or Domestic Violence - Your PHI may be used or disclosed to authorized persons from state agencies in cases of disclosures required by applicable state laws governing abuse, neglect, criminal activities, threats to the health/safety of the client and others, domestic violence, etc. In the case of minor children, the law requires such information to be disclosed. · Event of an Emergency - Your PHI may be disclosed to a family member, a person responsible for your care, or your personal representative in the event of an emergency. If you are present in such a case, you will be given an opportunity to object. If you object or are not present or are incapable of responding, your PHI will be used or disclosed in your best interest at that time. In so doing, only the aspects of your PHI that are necessary for response to the emergency will be used or disclosed. Mail, Text Messaging, and Cell Phones You may communicate with your counselor via email, text, or phone call to schedule or reschedule sessions. However please note that issues best suited for the counseling session will not be addressed in such communications unless there is an emergency involving potential physical danger to you. Please note that any phone calls made between sessions that last more than 5 minutes will be charged pro-rata at half your hourly rate. Court If there is a subpoena for court there is a $250 charge for appearing in court. TERMINATION Ending counseling may be initiated by you as the client, legal guardian of the client, or your counselor. A common occurrence for this event is when the goals the client and counselor have set out together have been sufficiently met. When counseling is coming to a close, a final session is strongly recommended to explore the ending process itself. If necessary, referrals to other providers or other suggestions can be offered at this time. Cancellation If you cancel less than 24 hours then there is a $50 dollar charge for cancellation. CONSENT FOR TREATMENT I hereby consent to the treatment provided by Telehealth Hope Counseling, LLC and its employees or designees. I authorize the services deemed necessary or advisable by my caregivers to address my needs. For Questions, Concerns, and Complaints As a mental health professional licensed by the State of Ohio Counselor, Social Worker Marriage and Family Therapist Board, I am committed to practice according to the ethics of my profession. You may contact the Counselor Board and/or the secretary of the United States Department of Health and Human Services with questions or to register complaints about any licensed mental health professional.

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