PSYCHOTHERAPY INTAKE FORM – CHERYL FELIX

I. FEDERAL LAW REQUIRES US TO PROVIDE YOU WITH THIS NOTICE ABOUT OUR PRIVACY PROCEDURES. PLEASE REVIEW IT CAREFULLY.

II. IT IS OUR LEGAL DUTY TO SAFEGUARD YOUR PROTECTED HEALTH INFORMATION (PHI). By law, we are required to ensure that your PHI (protected health information) is kept private. The PHI constitutes information created or noted by us that can be used to identify you. It contains data about your past, present, or future health or condition, the provision of health care services to you, or the payment for such health care. This Notice must explain when, why, and how we would use and/or disclose your PHI. Use of PHI means when we share, apply, utilize, examine, or analyze information within our practice; PHI is disclosed when we release, transfer, give, or otherwise reveal it to a third party outside our practice. With some exceptions, we may not use or disclose more of your PHI than is necessary to accomplish the purpose for which the use or disclosure is made; however, we are always legally required to follow the privacy practices described in this Notice. Please note that we reserve the right to change the terms of this Notice and our privacy policies at any time. Any changes will apply to PHI already on file with us. Before we make any important changes to our policies, we will immediately change this Notice, which you may view in our office, or your may request a copy.

III. HOW WE WILL USE AND DISCLOSE YOUR PHI. We will use and disclose your PHI for many different reasons. Some of the uses or disclosures will require your prior written authorization; others, however, will not. Below you will find the different categories of our uses and disclosures, with some examples.
Uses and Disclosures Related to Treatment, Payment, or Health Care Operations Do Not Require Your Prior Written Consent. We may use and Disclose your PHI without your consent for the following reasons:
For treatment. We may disclose your PHI to physicians, psychiatrists, psychologists, and other licensed health care providers who provide you withhealth care services or are otherwise involved in your care. Example: If a psychiatrist is treating you, we may disclose your PHI to her/him in order to coordinate your care.
For health care operations. We may disclose your PHI to facilitate the efficient and correct operation of our practice. Examples: Quality control – we might use your PHI in the evaluation of the quality of health care services that you have received or to evaluate the performance of the health care professionals who provided you with these services. We may also provide your PHI to our attorneys, accountants, consultants, and others to make sure that we are in compliance with applicable laws.
To obtain payment for treatment. We may use and disclose your PHI to bill and collect payment for the treatment and services we provided you. Example: we might send your PHI to your insurance company or health plan in order to get payment for the health care services that we have provided to you. We could also provide your PHI to business associates, such as billing companies, claims processing companies, and others that process health care claims for our office.
Other disclosures. Examples: Your consent isn’t required if you need emergency treatment provided that we attempt to get your consent after treatment is rendered. In the event that we try to get your consent but you are unable to communicate with us (for example, if you are unconscious or in severe pain) but we think that you would consent to such treatment if you could, we may disclose your PHI.
Certain Other Uses and Disclosures Do Not Require Your Consent. We may use and/or disclose your PHl without your consent or authorization for the following reasons: (Note: The following list is a compilation of federal and California laws).
When disclosure is required by federal, state, or local law; judicial, board, or administrative proceedings; or, law enforcement. Example: we may make a disclosure to the appropriate officials when a law requires us to report information to government agencies, law enforcement personnel and/or in an administrative proceeding.
If disclosure is compelled by a party to a proceeding before a court of an administrative agency pursuant to its lawful authority.
If disclosure is required by a search warrant lawfully issued to a governmental law enforcement agency.
If disclosure is compelled by the patient or the patient’s representative pursuant to California Health and Safety Codes or to corresponding federal statutes of regulations, such as the Privacy Rule that requires this Notice.
To avoid harm. We may provide PHI to law enforcement personnel or persons able to prevent or mitigate a serious threat to the health or safety of a person or the public.
If disclosure is compelled or permitted by the fact that you are in such mental or emotional condition as to be dangerous to yourself or the person or property of others, and if we determine that disclosure is necessary to prevent the threatened danger.
If disclosure is mandated by the California Child Abuse and Neglect Reporting law. For example, if we have a reasonable suspicion of child abuse or neglect.
If disclosure is mandated by the California Elder/Dependent Adult Abuse Reporting law. For example, if we have a reasonable suspicion of elder abuse or dependent adult abuse.
If disclosure is compelled or permitted by the fact that you tell us of a serious/imminent threat of physical violence by you against a reasonably identifiable victim or victims.
For public health activities. Example: In the event of your death, if a disclosure is permitted or compelled, we may need to give the county coroner information about you.
For health oversight activities. Example: we may be required to provide information to assist the government in the course of an investigation of inspection of a health care organization or provider.
For specific government functions. Examples: we may disclose PHI of military personnel and veterans under certain circumstances. Also, we may disclose PHI in the interests of national security, such as protecting the President of the United States or assisting with intelligence operations.
For research purposes. In certain circumstances, we may provide PHI in order to conduct medical research.
For Workers’ Compensation purposes. We may provide PHI in order to comply with Workers’ Compensation laws.
Appointment reminders and health related benefits or services. Examples: we may use PHI to provide appointment reminders. We may use PHI to give you information about alternative treatment options, or other health care services or benefits we offer.
If an arbitrator or arbitration panel compels disclosure, when arbitration is lawfully requested by either party, pursuant to subpoena duces tectum (e.g., a subpoena for mental health records) or any other provision authorizing disclosure in a proceeding before an arbitrator or arbitration panel.
We are permitted to contact you, without your prior authorization, to provide appointment reminders or information about alternative or other health-related benefits and services that may be of interest to you.
If disclosure is required or permitted to a health oversight agency for oversight activities authorized by law. Example: When compelled by U.S. Secretary of Health and Human Services to investigate or assess our compliance with HIPAA regulations.
If disclosure is otherwise specifically required by law.
Certain Uses and Disclosures Require You to Have the Opportunity to Object.
Disclosures to family, friends, or others. We may provide your PHI to a family member, friend, or other individual who you indicate is involved in your care or responsible for the payment for your health care, unless you object in whole or in part. Retroactive consent may be obtained in emergency situations.
Other Uses and Disclosures Require Your Prior Written Authorization. In any other situation not described in Sections IIIA, IIIB, and IIIC above, we will request your written authorization before using or disclosing any of your PHI. Even if you have signed an authorization to disclose your PHI, you may later revoke that authorization, in writing, to stop any future uses and disclosures (assuming that we haven’t taken any action subsequent to the original authorization) of your PHI by us.


IV. WHAT RIGHTS YOU HAVE REGARDING YOUR PHI These are your rights with respect to your PHI:
The Right to See and Get Copies of Your PHI. In general, you have the right to see your PHI that is in our possession, or to get copies of it; however, you must request it in writing. If you do not have your PHI but we know who does, we will advise you how you can get it. You will receive a response from us within 30 days of our receiving your written request. Under certain circumstances, we may feel we must deny your request, but if we do, we will give you, in writing, the reasons for the denial. We will also explain your right to have our denial reviewed.
The Right to Request Limits on Uses and Disclosures of Your PHI. You have the right to ask that we limit how we use and disclose your PHI. While we will consider your request, we are not legally bound to agree. If we do agree to your request, we will put those limits in writing and abide by them except in emergency situations.
The Right to Choose How we Send Your PHI to You. It is your right to ask that your PHI be sent to you at an alternate address (for example, sending information to your work address rather than your home address) or by alternate method (for example, via email instead of by regular mail). We am obliged to agree to your request providing that we can give you the PHI, in the format you requested, without undue inconvenience.
The Right to Amend Your PHI. If you believe that there is some error in your PHI or that important information has been omitted, it is your right to request that we correct the existing information or add the missing information. Your request and the reason for the request must be made in writing. You will receive a response within 60 days of our receipt of your request. We may deny your request, in writing, if we find that: the PHI is (a) correct and complete, (b) forbidden to be disclosed, (c) not part of our records, or (d) written by someone other than us. My denial must be in writing and must state the reasons for the denial. It must also explain your right to file a written statement objecting to the denial. If you do not file a written objection, you still have the right to ask that your request and our denial be attached to any future disclosures of your PHI. If we approve your request, we will make the change(s) to your PHI. Additionally, we will tell you that the changes have been made, and we will advise all others who need to know about the change(s) to your PHI.
The Right to Get This Notice by Email. You have the right to get this notice by email. You have the right to request a paper copy of it, as well.
V. HOW TO COMPLAIN ABOUT MY PRIVACY PRACTICES If, in your opinion, we may have violated your privacy rights, or if you object to a decision we made about access to your PHI, you are entitled to file a complaint with the person listed in Section VI below. You may also send a written complaint to the Secretary of the Department of Health and Human Services at 200 Independence Avenue S.W. Washington, D.C. 20201. If you file a complaint about our privacy practices, we will take no retaliatory action against you.

VI. PERSON TO CONTACT FOR INFORMATION ABOUT THIS NOTICE OR TO COMPLAIN ABOUT MY PRIVACY PRACTICES If you have any questions about this notice or any complaints about our privacy practices, or would like to know how to file a complaint with the Secretary of the Department of Health and Human Services, please contact us at the address and phone number above.

VII. EFFECTIVE DATE OF THIS NOTICE This notice went into effect on April 14, 2003.

THE PROCESS OF THERAPY/EVALUATION: Participation in therapy can result in a number of benefits to you including improving interpersonal relationships and resolution of the specific concerns that led you to seek therapy. Working toward these benefits, however, requires effort on your part. Active involvement in your therapy, honesty, and openness are necessary in order to change your thoughts, feelings and/or behavior. Your therapist will ask for your feedback on your therapy and its progress, and he will expect you to respond openly and honestly. During therapy, remembering or talking about unpleasant events, feelings, or thoughts may result in experiencing considerable discomfort or strong feelings of anger, sadness, worry, or fear. It is possible to experience an increase in symptoms of anxiety, depression, insomnia, etc. during the course of treatment. Your therapist may challenge some of your assumptions or perceptions or propose different ways of looking at, thinking about, or handling situations that may cause you to feel upset, angry, depressed, challenged, or disappointed. Attempting to resolve issues that brought you to therapy in the first place may result in changes that were not originally intended, such as decisions about changing behaviors, employment, substance use, schooling, housing, or relationships.

Sometimes a decision that is positive for one family member if viewed quite negatively by another. Change can be easy and swift, or slow and even frustrating. There is no guarantee that psychotherapy will yield positive or intended results. During the course of therapy, your therapist is likely to draw on various psychological approaches according, in part, to the problem that is being treated and his assessment of what will best benefit you. These approaches may include psychodynamic, psychoanalytic, family systems, cognitive-behavioral, existential, or psycho-educational approaches, as appropriate.

TELEPHONE & EMERGENCY PROCEDURES: If you need to contact your therapist between sessions, please leave a message with his/her voicemail, and your call will be returned as soon as possible. Your therapist checks his/her messages a few times a day, unless he/she is out of town. If an emergency situation arises, please indicate it clearly in your message, and call your therapist’s cell phone. If you need to talk to someone right away, you can call the Suicide Prevention Hotline at 877-727-4747, the Police (911), or you can appear at any emergency room and say you are in crisis.

PAYMENTS & INSURANCE REIMBURSEMENT: Payment is expected at the end of each session. Telephone conversations, site visits, report writing and reading, consultation with other professionals, release of information, reading records, longer sessions, travel time, etc., will be changed at the same rate, unless indicated and agreed otherwise. Please notify your therapist if any problem arises during the course of therapy regarding your ability to make timely payments. Not all issues/conditions/problems, which are the focus of psychotherapy, are reimbursed by insurance companies. It is your responsibility to verify specifics of your coverage. YOUR CREDIT CARD WILL BE CHARGED IN THE EVENT YOUR HEALTH INSURANCE DOES NOT PAY FOR SERVICES.

DISCUSSION OF TREATMENT PLAN: Within a reasonable period of time after the initiation of treatment, your therapist will discuss with you (patient) his/her working understanding of the problem, treatment plan, therapeutic objectives, and his/her view of the possible outcomes of treatment. If you have any unanswered questions about any of the procedures used in the course of your therapy, your therapist’s abilty in employing them, or about the treatment plan, please ask, and you will be answered fully. You also have the right to ask about other treatments for your condition and their risks and benefits.

TERMINATION: As set forth above, early in treatment, your therapist will assess whether he/she can be of benefit to you. If at any point during psychotherapy, he/she assesses that he/she is not effective in helping you reach the therapeutic goals, he/she is obliged to discuss it with you and, if appropriate, to terminate treatment and provide referrals to other therapists. If you request it and authorize it in writing, your therapist will talk to a psychotherapist of your choice to help with the transition. You have the right to terminate therapy at any time, though it is recommended that, rather than stopping suddenly, it is helpful to have a least one session in-person, to process the ending stages of treatment, to assess progress, and to address any follow-up care of referrals. Your therapist will offer to provide you with names of other qualified professionals with whom to consult, if you choose.

CONFIDENTIALITY: Psychotherapy is a personal and confidential process. Your therapist takes your privacy very seriously, and he/she has a legal and ethical obligation not to share your information with anyone. However, there are exceptions and rare circumstances in which it may be required for your therapist to disclose your personal information, including:
You present a danger to yourself, another person or property.
You become gravely disabled.
You disclose information leading to the reasonable suspicion of child or elder abuse/neglect.
Please note that there may be other circumstances in which your therapist may disclose your identifying information and diagnosis with your expressed verbal consent, such as:

- To your insurance company for reimbursement.
- To another medical provider to coordinate treatment.

CANCELLATION POLICY: If you need to cancel a session, you must do so at least 48 hours in advance, or you will be financially responsible for the missed session. With 48 hours’ notice, if you have a scheduling conflict, you may request that your appointment be rescheduled for another time that week, provided your therapist has another appointment available. YOUR THERAPIST WILL CHARGE YOUR CREDIT CARD FOR MISSED SESSIONS.

*Please note that the 48-hour cancellation policy should be used sparingly. Frequent cancellations may result in you losing your reserved appointment time.
*Insurance companies do not reimburse for missed session.
*YOUR CREDIT CARD WILL BE CHARGED IN THE EVENT YOUR HEALTH INSURANCE DOES NOT PAY FOR SERVICES. YOU ARE RESPONSIBLE FOR ALL FEES THAT ARE NOT COVERED BY THE HEALTH INSURANCE YOU PROVIDED.

services provided at Downtown Mind Wellness.
Informed Consent for Conducting TeleTherapy/TeleMedicine/TeleHealth

The clinicians at Downtown Mind Wellness may offer to meet you via video or telephone rather than in-person.
Teletherapy/telemedicine/telehealth allows us to provide services with convenience, accessibility, and effectiveness. However, State of California regulations require us to review and acknowledge with you the following potential risks, issues, limitations, and criteria in order to engage in telehealth services:

You confirm that you are physically located within the State of California when receiving telehealth services from the clinicians at Downtown Mind Wellness. We may provide services if you are temporarily located out-of-State, but this must be discussed with your treating provider prior to meeting.

Communicating via telephone or video creates unique risks to confidentiality. While we take all reasonable measures to ensure your confidentiality is protected, we cannot guarantee that unauthorized third parties may attempt or succeed to acquire your personal information.
A disruption in services may occur due to technological failure or error.

Your health insurance benefits and coverage may be different than for in-person sessions. Please be aware; your health insurance may not cover telehealth services.

While receiving telehealth services from our clinicians, you are responsible for creating and securing a safe and confidential physical space. If your provider determines that you are located in a physically inappropriate space for conducting confidential services, the session may be terminated at any time.

You take full responsibility for the security of your communication device, computer, telephone, or iPad.

Whether you qualify as an appropriate candidate to receive telehealth services is determined by both parties, you and the provider. While your provider takes into account patient requests and preferences, the provider may choose not to engage in telehealth services related to your particular diagnosis, history, and possible risk factors.

You understand that telehealth sessions may not be as complete, comprehensive, and as effective as face-to-face sessions. Additionally, your provider may not be able to respond as rapidly via telehealth in case of an emergency.

Telehealth services are a new and burgeoning mode of rendering mental health services, and all risks, variations, and possible limitations have not been fully examined and explored at this time. You and your provider agree to discuss any possible concerns or questions related to telehealth if any issues arise.

Your provider may determine that due to certain circumstances, telehealth is no longer appropriate, and we should resume our sessions in‑person.

We recommend you use a secure internet connection rather than public/free Wi‑Fi.
You and your provider agree to develop a safety plan in the event of a crisis situation.