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.

Welcome to Integrative Healing Counseling Service, PLLC. This document is a consent to treatment and includes information regarding services and business policies. This document also includes information regarding your privacy and protected health information. This document must be reviewed and understood. Please do not hesitate to ask questions if needed.

PSYCHOTHERAPY SERVICES
Psychotherapy has been proven to have benefits for individuals who undertake it.  Therapy often leads to a significant reduction in feelings of distress, increased satisfaction in interpersonal relationships, improved sense of self-worth, greater personal awareness and insight, increased skills for managing stress and resolutions to specific problems.  However, often but not always, difficult thoughts and emotions may arise in the process such as sadness, guilt, anxiety, anger, frustration, loneliness and helplessness. The process of psychotherapy requires discussing the more vulnerable and difficult aspects of our life. Psychotherapy will challenge you at times to think differently about certain situations, to respond to certain situations in a different way, to make choices in your life that may be difficult.  There are no guarantees about what will happen.  Psychotherapy requires a very active effort on your part. In order to be most successful, you will need to be honest and open. You will need to work on things we discuss outside of sessions.

The staff at Integrative Healing Counseling Service, Pllc has training in many modalities of therapy including cognitive, behavioral, somatic experiencing, mindfulness, psychodynamic, solution focused, humanistic, psycho-educational, strengths-based, trauma informed, internal family systems, post induction, and family systems. Your questions are always welcome, and you have a right to decline at any time throughout the therapeutic process.

The first 1-3 sessions will involve identifying goals of therapy. You and your clinician will collaborate in identifying specific goals for the next several months of treatment. An official treatment plan will be created and once completed, signed by both you and your clinician. Your questions, concerns, and feedback are welcome at any time throughout this process.

MOOD ALTERING CHEMICALS AND ADDICTION
Actively abusing alcohol, prescription medication, and/or illegal drugs will create a barrier in the effectiveness of therapy. Actively engaging in process addictions including, but not limited to, compulsive sex, gambling, and shopping will also have the same negative impact. You will need to honestly disclose any and all use and/or behaviors. This disclosure WILL NOT be judged. However, it may require a higher or different level of care before outpatient therapy can begin. In these cases, your clinician will offer assistance with providing you resources and referrals to agencies that can assist you with the treatment needed. Your clinician may encourage you to attend 12 steps, or another addiction recovery focused program, in addition to therapy. In some cases, your clinician may choose to not provide therapy unless you are actively participating in such programs.

APPOINTMENTS
Sessions will ordinarily last 45-55 minutes in duration once per week or every other week, although some sessions may be more or less frequent as needed. The most convenient way to schedule is via counsol.com and a link to this system is available through ihcounselingservice.com, see "client login". You may also cancel your session via counsol.com. If you need to cancel or reschedule a session, you must provide 24 hour notice. If 24 hour notice is not given, you will be charged the cost of the session. It is important to arrive on time so you can take advantage of the full 55 minutes. If you arrive late, your appointment will still need to end on time.

In order to successfully meet treatment goals, attending sessions consistently is vital. The brain needs consistency and repetition to create new patterns. The staff at Integrative Healing Counseling Service, Pllc want to maintain a consistent therapeutic relationship to ensure you are receiving the care you deserve. If you choose to stop attending sessions or do not reschedule after 30 days, your chart will be closed unless you and your clinician have an agreement in place.

PROFESSIONAL FEES
Integrative Healing Counseling Service, Pllc employs counselors who have obtained an independent license, meaning they have completed their supervision and can provide psychotherapy independently, and counselors who are licensed as an associate, meaning they are accruing their supervised hours and can provide psychotherapy while meeting regularly with a board approved supervisor. The standard fee for each session, including telehealth sessions, from an independent licensed clinician is $170.00 for an individual and $220 for couples, unless another agreement has been made.  The standard fee for each session, including telehealth sessions, from an associate level clinician is $100.00 for an individual and $130 for couples, unless another agreement has been made.  There is a discount fee schedule available if needed and only if you cannot afford the full fee (exceptions apply, see VICTIM FUNDS). Integrative Healing Counseling Service, Pllc reserves the right to increase fees as well as discontinue the discount fee scale, however you will be given prior notice. You are responsible for paying at the time of your session unless prior arrangements have been made. Payments can be made by cash, check, most HSA funded cards, or most major credit cards. You are responsible for paying for missed sessions, or sessions where a 24- hour notice was not provided. Insurance companies cannot be billed for missed sessions or lastminute cancellations and you cannot use HSA funds to pay for missed sessions. Any payments made and returned to this agency are subject to an additional fee of up to $35.00 to cover the bank fee. If you refuse to pay your debt, Integrative Healing Counseling Service, Pllc reserves the right to use an attorney or collection agency to secure payment. If there has been an overpayment to your account and a credit is due to you, you will receive a refund.

In addition to therapy sessions, there may be coordination that may take place such as coordination with your medical doctor, psychiatrist, or a family member (see CONFIDENTIALITY). If you are an active client, your clinician will provide up to 15 minutes per month of coordination at no charge. If coordination exceeds 15 minutes, you will be charged the same session fee amount on a prorated basis (breaking down the hourly cost). If your clinician is court ordered to appear, testify, or present information, you will be charged for time spent including, but not limited to, telephone conversations, travel time, consulting with other professionals, site visits, reading records and documents.

INSURANCE
At this time, Integrative Healing Counseling Service, Pllc is contracted with Aetna and Blue Cross Blue Shield of Arizona only. Some of the staff is credentialed with TriWest VAMC Program (VA referrals). Please be aware that insurance companies dictate what conditions they will treat (diagnosis) and, at times, will require that only certain therapeutic modalities be used, as well as limit the number of sessions. Insurance companies usually require that your personal information, such as diagnosis, treatment plan, and summaries be submitted. Some of this information can be shared by insurance companies and become part of your official medical record.

If you are a member of another insurance company and you feel comfortable with your information being shared with your insurance company, you may request a "superbill" to submit to your insurance company for out-of-network reimbursement. It is your responsibility to communicate with your insurance company regarding coverage limits and how your protected health information is secured. Integrative Healing Counseling Service, Pllc is not responsible for how your insurance provider reimburses or handles your protected health information.

VICTIM FUNDS
If you are a victim of a crime and have been awarded financial assistance for trauma focused psychotherapy from a victim fund, please be aware that this is a third-party payor and, much like an insurance company, certain records may be required to be submitted to the organization that sponsors the victim fund. Organizations often require copies of clinical notes, copy of treatment plans, discharge plans, invoices, and/or written or verbal updates. A release will need to be signed by you giving permission to send required information BEFORE any information is provided. Integrative Healing Counseling Service, Pllc reserves the right to decline working with a victim fund and/or sponsoring organization.

Due to the paperwork involved and the extended wait times for payment to be received when working with these organizations, the discount fee scale is NOT offered to victim fund recipients. You are responsible for the amount that the victim fund will not cover per session. This amount is due at the time of session.

When treating a specific traumatic event, it is common that the traumatic event also triggers past trauma and unresolved grief that you may not realize is related. Please be aware that there will, most likely, be more to resolve than the specific traumatic event. Treatment can take time and it is usually important to move slowly. Your clinician will educate you on trauma theory as well as treatment modalities. As always, you have the right to choose to stop treatment at any time.

COURT
It is important that you feel safe in disclosing personal information and vulnerable thoughts and emotions. Because of the importance of this, it must be agreed upon, that you, your attorney, or anyone acting on your behalf will not ask or summons your clinician, or any staff member of Integrative Healing Counseling Service, Pllc, to testify in any proceedings or provide clinical records. If you are receiving couples therapy, you and your partner will need to sign an agreement with your clinician that he or she will not be asked or ordered to testify or release records.

PROFESSIONAL RECORDS
It is required by law that providers keep clinical records on file for 7 years. Integrative Healing Counseling Service, Pllc, like many practices, uses an online platform to store and manage these records. Counsol.com was chosen due to its security features. If there is a document that cannot be stored electronically for some reason, Integrative Healing Counseling Service, Pllc will store this document in a locked storage container. Any loose papers that contain personal information (for example, a piece of paper with a phone number written on it) will be shredded and disposed of. You have a right to review your records and share your records with a signed release, unless your clinician deems this to pose possible harm. Because these are professional records, they may be misinterpreted and/or upsetting to untrained readers.  For this reason, it is strongly advised that you initially review them with your clinician or another staff member, or have them forwarded to another mental health professional to discuss the contents.

CONFIDENTIALITY
It is required by law that your personal information, including what is disclosed in sessions, and your clinical records be kept private and not disclosed to anyone without your written consent (SEE HIPPA NOTICE OF PRIVACY PRACTICES). However, there are exceptions to this and the law requires that there be action taken immediately if there is reasonable suspicion that someone is at risk of hurting himself/herself or someone else, or if anyone who is considered vulnerable (such as a child, an elderly man or woman, or someone who has a disability and is not able to protect themselves) might be being abused or neglected. In order to keep you and others safe, if there is reasonable suspicion that you or someone else is at risk, your clinician will do everything in his or her power, within the limits of the law, to take action. This may include, however not limited to, calling the police, contacting family members, and making a report to local authorities.

If this agency receives a subpoena or court order for your records, law requires that your clinical records be released.

CONSULTATION
It is best practice for clinicians to participate in regular consultation with colleagues and other trained professionals. Staff members at Integrative Healing Counseling Service, Pllc do participate in consultation with other professionals who are also required to maintain confidentiality. Your personal identifying information will never be disclosed. Your confidentiality will be maintained.

CONTACTING US
Your clinician is rarely immediately available. You may leave a message on the agency's confidential voicemail (623-277-0228 0r 520-221-4918) and your call will be returned as soon as possible during business hours. However, if you are in crisis and need immediate attention, call 1) Maricopa County Crisis Response Network at 602-222-9444 2) Call 911 or 3) go to the nearest emergency room.

Integrative Healing Counseling Service, Pllc uses a cell phone that is password protected and uses iplum.com application that provides encryption. However, texting can pose risks. Cell phones can be lost or stolen and passwords can be broken. Your clinician may not discuss personal matters or private matters using text messaging and may request a time to discuss. Do not use text messaging for emergency purposes. If you choose to text, it will be assumed that you understand these risks and are comfortable with communicating via text messaging. Texts will be returned during business hours.

You may also contact your clinician via email. You may reach the owner of Integrative Healing Counseling Service, Pllc via email: sophia@ihcounselingservice.com or through the "contact me" section on the website: ihcounselingservice.com. Be aware that email poses some risks. At this time, ihcounselingservice.com is encrypted. However, it cannot be guarantee that emails cannot be hacked. Important emails are considered part of your record. If you contact a staff member via email, it will be assumed that you understand these risks and are comfortable with communicating via email. It cannot be guaranteed that your email will be read immediately. Do not use email for emergency purposes.

You may send secure messages through client portal, Counsol.com. Again, messages are not read immediately, however will be read and returned during business hours. Once you have established an account log in to counsol.com (access this from "Client Login" from website ihcounselingservice.com). You are able to select if and how you would like to receive messages, updates, and notices. By selecting how you would prefer to communicate and by signing this statement, Integrative Healing Counseling Service, Pllc will assume that you are making an informed decision when selecting a communication preference. If, at any time, you wish to change your communication preference, you may request this and it will be honored.

CLIENT-THERAPIST RELATIONSHIP
Due to the importance of protecting your privacy and protecting the client-therapist relationship, the staff at Integrative Healing Counseling Service, Pllc will not accept friend requests via social media. In addition, there is a chance that you may see your clinician or a staff member out in public (such as a restaurant, a community event, a grocery store, etc.). To respect your anonymity, you will not be approached and a greeting will not be initiated by your clinician or staff member. If you initiate a greeting, your clinician or staff member will assume that you are making an informed decision and will acknowledge the greeting. Conversation will need to remain superficial to protect you and your right to confidentiality.

OTHER RIGHTS
You have the right to considerate, safe and respectful care, without discrimination as to race, ethnicity, color, gender, sexual orientation, age, religion, or national origin. You have the right to ask questions about any aspects of therapy and about your clinician's specific training and experience. You have the right to expect that your clinician will not have social or sexual relationships with any current or former clients.

If you are unhappy with or are questioning what is happening in therapy, a discussion with your clinician is necessary. Your thoughts and concerns will be taken seriously and handled with care and respect. You have the right to end therapy at any time. Your clinician or other staff members can assist you with referrals to other providers if desired.

DISPUTES
Any disputes in relation to this agreement and in regard to psychotherapy sessions will be referred to mediation prior to any initiation of arbitration. The mediator will be a third party that both you and Integrative Healing Counseling Service, Pllc have agreed upon. The cost of any mediation will be shared equally between the client and this agency. If mediation is unsuccessful, the complaint should be submitted in Arizona following the rules of the American Arbitration Association. If your account is unpaid, and if there is no payment agreement established, Integrative Healing Counseling Service, Pllc reserves the right to use an attorney or collection agency to secure payment.

CONSENT TO PSYCHOTHERAPY
Your signature below indicates that you have read, understand, and agree to these terms, as well as consent to receiving 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.