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 Rights:

When it comes to your health information, you have certain rights. This section explains your rights and some of our responsibilities to help you.

Get an electronic or paper copy of your medical record
- You can ask to see or get an electronic or paper copy of your medical record and other health information we have
about you. Ask us how to do this.
- We will discuss with you the pros and cons of obtaining your information prior to preparing your record.
- We will provide a copy or a summary of your health information, usually within 30 days of your request. Your weekly
progress notes will not be included.

Ask us to correct your medical record
- You can ask us to correct health information about you that you think is incorrect or incomplete. Ask us how to do
this.
- We may say "no" to your request, but we'll tell you why in writing within 60 days.

Request confidential communications
- You can ask us to contact you in a specific way (for example, home or office phone) or to send mail to a different
address.
- We will say "yes" to all reasonable requests.

Ask us to limit what we use or share
- You can ask us not to use or share certain health information for treatment, payment, or our operations. We are not
required to agree to your request, and we may say "no" if it would affect your care.
- If you are using your health insurer to obtain services, this agency is required to provide protected health information
including diagnosis and interventions used.
- If you pay for services out-of-pocket in full, you can ask us not to share that information for the purpose of payment
or our operations with your health insurer. We will say "yes" unless a law requires us to share that information.

Get a list of those with whom we've shared information
- You can ask for a list (accounting) of the times we've shared your health information for six years prior to the date
you ask, who we shared it with, and why.
- We will include all the disclosures except for those about treatment, payment, and health care operations, and certain
other disclosures (such as any you asked us to make).

Get a copy of this privacy notice
- You can ask for a paper copy of this notice at any time, even if you have agreed to receive the notice electronically.
We will provide you with a paper copy promptly.

Choose someone to act for you
- If you have given someone medical power of attorney or if someone is your legal guardian, that person can exercise
your rights and make choices about your health information.
- We will make sure the person has this authority and can act for you before we take any action.

File a complaint if you feel your rights are violated
- You can complain if you feel we have violated your rights by contacting us using the information on page 1.
- You can file a complaint with the U.S. Department of Health and Human Services Office for Civil Rights by sending a
letter to 200 Independence Avenue, S.W., Washington, D.C. 20201, calling 1-877-696-6775, or visiting
www.hhs.gov/ocr/privacy/hipaa/complaints/.
- We will not retaliate against you for filing a complaint.

Your Choices:
For certain health information, you can tell us your choices about what we share. If you have a clear preference for how we share your information in the situations described below, talk to us. Tell us what you want us to do, and we will follow your instructions.

In these cases, you have both the right and choice to tell us to:
- Share information with your family, close friends, or others involved in your care. If you request or agree to sharing
your information, a Release of Information must be completed and signed.

If you are not able to tell us your preference, for example if you are unconscious, we may go ahead and share your information if we believe it is in your best interest. We may also share your information when needed to lessen a serious and imminent threat to health or safety.

In these cases we never share your information unless you give us written permission:
- Marketing purposes (please note: If you "Like" us on Facebook, or any other form of social media, you are taking full
responsibility for your decision).
- Psychotherapy notes (progress notes and communication notes are not part of the client record unless a separate
release has been signed).

Our Uses and Disclosures:
How do we typically use or share your health information?

We typically use or share your health information in the following ways.

Treat you
We can use your health information and share it with other professionals who are treating you.
Example: A psychiatrist who monitors your medication.

Run our organization
We can use and share your health information to run our practice, improve your care, and contact you when necessary.
Example: We use your phone number and/or email to provide you with appointment reminders and notices.

Bill for your services
We can use and share your health information to bill and get payment from health plans or other entities.

Example: We give information about you to your health insurance plan so it will pay for your services.
How else can we use or share your health information?
We are allowed or required to share your information in certain circumstances required by law. However, we have to meet many conditions in the law before we can share your information for these purposes. For more information see: www.hhs.gov/ocr/privacy/hipaa/understanding/consumers/index.html.
Help with public health and safety issues

We can share health information about you for certain situations such as:
- Reporting suspected abuse, neglect, or domestic violence
- Preventing or reducing a serious threat to anyone's health or safety
- Court order to release protected health information

Address workers' compensation, law enforcement, and other government requests
We can use or share health information about you:
- For workers' compensation claims
- For law enforcement purposes or with a law enforcement official
- With health oversight agencies for activities authorized by law
- For special government functions such as military, national security, and presidential protective services

Respond to lawsuits and legal actions
We can share health information about you in response to a court or administrative order, or in response to a subpoena.
Our Responsibilities
- We are required by law to maintain the privacy and security of your protected health information.
- We will let you know promptly if a breach occurs that may have compromised the privacy or security of your
information.
- We must follow the duties and privacy practices described in this notice and give you a copy of it.
- We will not use or share your information other than as described here unless you tell us we can in writing. If you tell
us we can, you may change your mind at any time. Let us know in writing if you change your mind.

For more information see: www.hhs.gov/ocr/privacy/hipaa/understanding/consumers/noticepp.html.

Changes to the Terms of this Notice
We can change the terms of this notice, and the changes will apply to all information we have about you. The new notice will be available upon request and you will be notified by writing or secure messaging via Counsol.com.

Effective Date
This notice is in effect as of March 1, 2017.

Sophia Krell, LCSW, owner of Integrative Healing Counseling Service, PLLC, is required by law to provide you with this HIPPA NOTICE OF PRIVACY PRACTICES. By signing this, you acknowledge that you have received a copy and reviewed HIPPA NOTICE OF PRIVACY PRACTICES.

CONSENT TO TREATMENT AGREEMENT

Welcome to Integrative Healing Counseling Service, PLLC. This document outlines your consent to treatment, including information about our services, communication methods, and business policies. It also explains your rights concerning privacy and protected health information (PHI). Please review it carefully and ask any questions if needed. Your signature indicates your understanding and consent to treatment.

PSYCHOTHERAPY SERVICES

Psychotherapy can be highly beneficial, leading to reduced distress, improved relationships, increased self-worth, better stress management, and resolution of specific issues. However, it can also bring up difficult emotions like sadness, guilt, anxiety, and frustration as we explore challenging aspects of your life.

Therapy may challenge you to think differently about certain situations, respond in new ways, and make changes that may feel uncomfortable or difficult. While psychotherapy can be transformative, there are no guarantees regarding specific outcomes or its overall efficacy. Success in therapy requires an active and engaged effort on your part, including being honest, open, and willing to reflect and work on issues discussed during sessions, even outside of therapy.

Our clinicians are trained in various evidence-based modalities, such as cognitive therapy, behavioral therapy, somatic experiencing, mindfulness, trauma-informed therapy, post-induction therapy, exposure and response prevention therapy, acceptance and commitment therapy, and more. Your questions are always welcome, and you have the right to decline services or a specific therapeutic approach at any time during the course of treatment. In rare cases, services may be terminated, and you may be referred to another provider if the clinician determines that the declined course of treatment is essential to your recovery.

The first 1-3 sessions will focus on setting goals, which will be collaboratively established and documented in a treatment plan. We will work together on identifying goals and these goals will be updated at least once per year. Feedback and questions are always encouraged throughout the process.

MOOD-ALTERING CHEMICALS AND ADDICTIONS

The use of alcohol, prescription medication, illegal drugs, or engaging in process addictions (such as compulsive sex, gambling, or shopping) can interfere with the effectiveness of therapy. You must fully disclose any such behaviors, which will not be judged. However, these may require a higher level of care before beginning therapy.

If needed, your clinician will assist you with resources and referrals to agencies that specialize in addiction treatment. In some cases, participation in programs like 12-step groups may be encouraged or required before therapy can continue.

APPOINTMENTS

Sessions typically last 45-55 minutes, occurring once per week or bi-weekly, although frequency may vary based on individual needs. Appointments can be scheduled or canceled via Counsol.com, with a link available through ihcounselingservice.com under "Client Login."

To cancel or reschedule, 24 hours' notice is required. If notice is not provided, the full session fee will be charged. Arriving on time ensures you can utilize the full session. If you arrive late, the session will still end at the scheduled time.

Consistent attendance is vital to achieving treatment goals, as the brain needs repetition to form new patterns. If you miss sessions or fail to reschedule within 30 days, your chart will be closed, unless otherwise agreed upon with your clinician.

PROFESSIONAL FEES

Sessions last around 45-55 minutes. Session fees vary based on the clinician's licensure level:

Independent Licensed Clinician Fees: Individual sessions: $190.00 and Couples coaching/therapy sessions: $225.00 

Associate-Level Clinician Fees: Individual sessions: $110.00 and Couples coaching/therapy sessions: $140.00

Payment is due at the time of service. We accept most FSA/HSA-funded cards and major credit cards. You are responsible for paying missed sessions or sessions canceled with less than 24 hours' notice. You cannot be reimbursed through insurance and you cannot use FSA/HSA funds for missed sessions. Returned payments will incur a $35.00 bank fee. There are no refunds.

If your clinician coordinates with other professionals, such as your medical doctor or psychiatrist, your clinician will provide up to 15 minutes of coordination per month at no charge. If coordination exceeds 15 minutes, you will be charged a prorated fee based on the session rate.

In the event that your clinician is required to appear in court, testify, or participate in legal proceedings, you will be billed for all related time at the stated hourly session rate, including telephone consultations, travel time, reading records, or consulting with other professionals.

INSURANCE

Integrative Healing Counseling Service, PLLC is not contracted with insurance companies. If your insurance offers out-of-network benefits for mental health services and you wish to submit your invoices for reimbursement, your clinician will provide you with a "Superbill" containing the necessary codes.

Please note that payment is due at the time of service. If your insurance provider reimburses you, the amount will be determined by them and paid directly to you. Insurance companies often require personal information, including your diagnosis, and may request additional treatment details, such as your treatment plan and session notes. This information could be shared and become part of your official medical record.

Integrative Healing Counseling Service, PLLC is not responsible for how your insurance provider reimburses or manages your protected health information. We encourage you to contact your insurance company for information about your coverage, reimbursement process, and how your privacy is protected.

VICTIM FUNDS

If you are a victim of a crime and have been awarded financial assistance for trauma-focused psychotherapy through a victim fund, please note that, like insurance, the victim fund may require certain records to process payments. This may include clinical notes, treatment plans, discharge plans, invoices, and written or verbal updates. You will need to sign a release form before any information is shared with the funding organization.

Integrative Healing Counseling Service, PLLC reserves the right to decline working with a victim fund or sponsoring organization. You will be responsible for paying any amount not covered by the fund at the time of service.

Trauma-focused therapy may bring up past unresolved trauma and grief. It's common for additional issues to emerge, and treatment can take time. Your clinician will provide education on trauma theory and treatment approaches. You always have the right to discontinue therapy at any time.

COURT

It is essential that you feel safe sharing personal and vulnerable information in therapy. To maintain this safety and confidentiality, you agree that neither you, your attorney, nor anyone acting on your behalf will request or require your clinician or any staff member of Integrative Healing Counseling Service, PLLC to testify in any legal proceedings or provide clinical records.

For couples therapy, both you and your partner must sign an agreement acknowledging that your clinician will not be asked or ordered to testify or release records.

In the event that your clinician is required to appear in court, testify, or participate in legal proceedings, you will be billed for all related time at the stated hourly session rate, including telephone consultations, travel time, reading records, or consulting with other professionals.

CONFIDENTIALITY

Your personal information, including what is discussed in sessions and your clinical records, is protected by law and will remain confidential unless you provide written consent for disclosure (SEE HIPAA NOTICE OF PRIVACY PRACTICES). However, there are exceptions to this confidentiality. If there is reasonable suspicion that you or someone else may be at risk of harm, or if a vulnerable person (such as a child, elderly individual, or someone with a disability) may be experiencing abuse or neglect, the law requires that action be taken immediately to ensure safety.

In such cases, your clinician may need to contact authorities, family members, or other professionals, within the bounds of the law, to protect you or others. Additionally, if this agency receives a subpoena or court order, your clinical records may be released as required by law.

PROFESSIONAL RECORDS

By law, clinical records must be kept for 7 years. Integrative Healing Counseling Service, PLLC uses a HIPAA-compliant Electronic Health Record (EHR) system, Counsol.com, to store records. If any documents cannot be stored electronically, they are kept in a locked container behind a locked door. Personal information is shredded after use.

You can request your records from your clinician and you may be asked to put the request in writing. You have the right to your records with a signed release, unless access could cause harm. We recommend reviewing records with your clinician or another professional to ensure accurate understanding.

CONSULTATION

To ensure the highest quality of care, clinicians at Integrative Healing Counseling Service, PLLC engage in regular consultations with other trained professionals. These consultations are confidential, and your personal identifying information will never be shared. Your confidentiality will always be upheld.

CONTACTING US

Your clinician is rarely available immediately. All calls and messages will be returned during business hours, and no later than 48 hours. If you are in crisis and need immediate attention, please contact:

988 (Crisis Helpline) 

911 

Visit the nearest emergency room

You may reach us by phone at 623-277-0228. You can leave a voicemail or send a text message. We use Spruce, a HIPAA-compliant platform for secure phone and text communication, providing security on our end. For additional security on your end, you can download the Spruce app here: https://spruce.care/integrativehealingcounselingservicepllc. Downloading the app is optional; you can still call and text without it. Please note, texting carries risks, such as the possibility of lost or stolen phones.

Other than leaving a voicemail, the most secure way to communicate is sending a message through the client portal, Counsol.com. If needed, you can find a link to the client portal at the footer of our website: ihcounselingservice.com.

You can email the owner of Integrative Healing Counseling Service, PLLC, at sophia@ihcounselingservice.com. However, please be aware that email poses risks.  Google LLC security but we cannot guarantee that your information won't be hacked or read by others with access to your email.

Per law, important messages will be recorded in your clinical record. You and your clinician will determine your communication preferences, and you may change your preference at any time upon request. By signing this form, you acknowledge and accept the associated risks.

CLIENT-THERAPIST RELATIONSHIP

To protect your privacy, staff at Integrative Healing Counseling Service, PLLC will not accept friend requests or follow your personal social media accounts. Your clinician's social media must remain private as well. Engaging with your clinician's personal social media may lead to termination of services.

If you see your clinician or staff in public, they will not approach you. If you initiate a greeting, they will acknowledge it, but conversation will remain superficial to protect your confidentiality.

OTHER RIGHTS

You have the right to receive considerate, safe, and respectful care, free from discrimination based on race, ethnicity, gender, sexual orientation, age, religion, or national origin. You may ask questions about any aspect of your therapy, including your clinician's training and experience.

Your clinician will not engage in social or sexual relationships with current or former clients. If you have concerns or feel dissatisfied with therapy, it's important to discuss this with your clinician. Your feedback will be handled with care and respect.

You have the right to end therapy at any time. If you choose to do so, your clinician can assist with referrals to other providers if needed.

DISPUTES

Any disputes regarding therapy sessions or this agreement will be referred to mediation with a mutually agreed-upon third party. The cost of mediation will be shared equally between you and Integrative Healing Counseling Service, PLLC.

If mediation is unsuccessful, the matter will be submitted to arbitration in Arizona under the rules of the American Arbitration Association.

If your account remains unpaid and no payment arrangement is in place, Integrative Healing Counseling Service, PLLC reserves the right to use an attorney or collection agency to secure payment.

CONSENT TO PSYCHOTHERAPY

By signing below, you acknowledge that you have read, understand, and agree to the terms outlined in this consent form. You also give your consent to receive psychotherapy services.

Telemental health is the practice of delivering counseling services via technology assisted media or other electronic means between a practitioner and a client who are located in two different locations. Video and/or telephone session can be included as a part of my psychotherapy in the event that meeting virtually is needed or chosen due to schedule conflicts, transportation issues, illness, or possible threat of exposure to an illness. 

Your signature below indicates that you have read, understand, and agree to these terms:

1)      I understand that participating in telemental health is my choice and I can discontinue remote sessions at any time.

2)      I understand there are potential risks to this technology, including interruptions, technical difficulties, and unauthorized access.

3)      I understand that if sessions are conducted telephonically, I will be asked to verify my identity by answering questions regarding         

         identifying information on file such as my address, family members names, birthdate, etc.

4)      I understand that recording video sessions is prohibited.

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 telemental health services are not appropriate and a higher 

         level of care is required.

6)      I understand that if I am experiencing a mental health crisis between remote sessions and my counselor is not available, I am to call 

         Suicide and Crisis Line @ 988.

7)      I understand that I must verify my location at the beginning of each session and provide an address, if different than my home address 

         that I have listed on file in the client portal.

8)      I understand that my therapist will contact my emergency contact that I have listed on file in the client portal in case of an emergency.

9)      I understand that I am able to ask questions or address any concerns regarding telemental health, record keeping, technical platforms 

         being used, etc. at any time.