APPOINTMENTS AND CANCELLATIONS
Please remember to cancel or reschedule 24 hours in advance. You will be responsible for the entire fee if cancellation is less than 24 hours.

The standard meeting time for psychotherapy is 50 minutes. It is up to you, however, to determine the length of time of your sessions. Requests to change the 50-minute session needs to be discussed with the therapist in order for time to be scheduled in advance.

We require payment in full at the time of session based on our sliding scale rate of 75-150$ per session.

Cancellations and re-scheduled session will be subject to a full charge if NOT RECEIVED AT LEAST 24 HOURS IN ADVANCE. This is necessary because a time commitment is made to you and is held exclusively for you. If you are late for a session, you may lose some of that session time.

TELEPHONE ACCESSIBILITY

If you need to contact me between sessions, please leave a message on my voice mail. I am often not immediately available; however, I will attempt to return your call within 72 hours. Please note that Face- to-face sessions are highly preferable to phone sessions. However, in the event that you are out of town, sick or need additional support, phone sessions are available. If a true emergency situation arises, please call 911, 211 or any local emergency room.

SOCIAL MEDIA AND TELECOMMUNICATION
Due to the importance of your confidentiality and the importance of minimizing dual relationships, I do not accept friend or contact requests from current or former clients on any social networking site (Facebook, LinkedIn, etc). I believe that adding clients as friends or contacts on these sites can compromise your confidentiality and our respective privacy. It may also blur the boundaries of our therapeutic relationship. If you have questions about this, please bring them up when we meet and we can talk more about it.

ELECTRONIC COMMUNICATION
I cannot ensure the confidentiality of any form of communication through electronic media, including text messages. If you prefer to communicate via email or text messaging for issues regarding scheduling or cancellations, I will do so. While I may try to return messages in a timely manner, I cannot guarantee immediate response and request that you do not use these methods of communication to discuss therapeutic content and/or request assistance for emergencies.

Services by electronic means, including but not limited to telephone communication, the Internet, facsimile machines, and e-mail is considered telemedicine by the State of Connecticut. Under the Connecticut Telemedicine Act of 1996, telemedicine is broadly defined as the use of information technology to deliver medical services and information from one location to another. If you and your therapist chose to use information technology for some or all of your treatment, you need to understand that: (1) You retain the option to withhold or withdraw consent at any time without affecting the right to future care or treatment or risking the loss or withdrawal of any program benefits to which you would otherwise be entitled. (2) All existing confidentiality protections are equally applicable. (3) Your access to all medical information transmitted during a telemedicine consultation is guaranteed, and copies of this information are available for a reasonable fee. (4) Dissemination of any of your identifiable images or information from the telemedicine interaction to researchers or other entities shall not occur without your consent. (5) There are potential risks, consequences, and benefits of telemedicine. Potential benefits include, but are not limited to improved communication capabilities, providing convenient access to up-to-date information, consultations, support, reduced costs, improved quality, change in the conditions of practice, improved access to therapy, better continuity of care, and reduction of lost work time and travel costs. Effective therapy is often facilitated when the therapist gathers within a session or a series of sessions, a multitude of observations, information, and experiences about the client. Therapists may make clinical assessments, diagnosis, and interventions based not only on direct verbal or auditory communications, written reports, and third person consultations, but also from direct visual and olfactory observations, information, and experiences. When using information technology in therapy services, potential risks include, but are not limited to the therapist's inability to make visual and olfactory observations of clinically or therapeutically potentially relevant issues such as: your physical condition including deformities, apparent height and weight, body type, attractiveness relative to social and cultural norms or standards, gait and motor coordination, posture, work speed, any noteworthy mannerism or gestures, physical or medical conditions including bruises or injuries, basic grooming and hygiene including appropriateness of dress, eye contact (including any changes in the previously listed issues), sex, chronological and apparent age, ethnicity, facial and body language, and congruence of language and facial or bodily expression. Potential consequences thus include the therapist not being aware of what he or she would consider important information, that you may not recognize as significant to present verbally the therapist.

MINORS
If you are a minor, your parents may be legally entitled to some information about your therapy. I will discuss with you and your parents what information is appropriate for them to receive and which issues are more appropriately kept confidential.

TERMINATION
Ending relationships can be difficult. Therefore, it is important to have a termination process in order to achieve some closure. The appropriate length of the termination depends on the length and intensity of the treatment. I may terminate treatment after appropriate discussion with you and a termination process if I determine that the psychotherapy is not being effectively used or if you are in default on payment. I will not terminate the therapeutic relationship without first discussing and exploring the reasons and purpose of terminating. If therapy is terminated for any reason or you request another therapist, I will provide you with a list of qualified psychotherapists to treat you. You may also choose someone on your own or from another referral source.

Should you fail to schedule an appointment for three consecutive weeks, unless other arrangements have been made in advance, for legal and ethical reasons, I must consider the professional relationship discontinued.

Notice of Privacy Practice

Notice of Therapists’ Policies and Practices to Protect the Privacy of Your Health Information

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

I. Uses and Disclosures for Treatment, Payment, and Health Care Operations

Your therapist may use or disclose your protected health information (PHI) for treatment, payment, and health care operations purposes with your consent. To help clarify these terms, here are some definitions: 

• “PHI” refers to information in your health record that could identify you.

• “Therapist” refers to any licensed mental health professional.

• “Treatment, Payment and Health Care Operations”

• Treatment is when your therapist provides, coordinates, or manages your health care and other services related to your health care. An example of treatment would be when your therapist consults with another healthcare provider, such as your family physician or another psychotherapist.

  1. Payment occurs when your therapist obtains reimbursement for your healthcare. Examples of payment are when your therapist discloses your PHI to your health insurer to obtain reimbursement for your healthcare or to determine eligibility or coverage.

  2. Health Care Operations are activities that relate to the performance and operation of this practice. Examples of health care operations are quality assessment and improvement activities, business-related matters, such as audits and administrative services, and case management and care coordination.

• "Use" applies only to activities within this practice, such as sharing, employing, applying, utilizing, examining, and analyzing information that identifies you.

• "Disclosure" applies to activities outside of this practice, such as releasing, transferring, or providing access to information about you to other parties.

II. Uses and Disclosures Requiring Authorization

Your therapist may use or disclose PHI for purposes outside of treatment, payment, or health care operations when your appropriate authorization is obtained. An "authorization" is written permission above and beyond the general consent that permits only specific disclosures. In those instances when your therapist is asked for information for purposes outside of treatment, payment or health care operations, your therapist will obtain an authorization from you before releasing this information. Your therapist will also need to obtain an authorization before releasing your psychotherapy notes. "Psychotherapy notes" are notes your therapist may have made about your conversation during a private, group, joint, or family counseling session, which have been kept separate from the rest of your medical record. These notes are given a greater degree of protection than PHI.

You may revoke all such authorizations (of PHI or psychotherapy notes) at any time, provided each revocation is in writing. You may not revoke an authorization to the extent that (1) your therapist has relied on that authorization; or (2) if the authorization was obtained as a condition of obtaining insurance coverage, and the law provides the insurer the right to contest the claim under the policy. 

​III. Uses and Disclosures with Neither Consent nor Authorization

Your therapist may use or disclose PHI without your consent or authorization in the following circumstances:

• Child Abuse: If your therapist knows or has reason to believe a child is being or has been neglected or abused, or that a child has been threatened with neglect or abuse that is likely to occur, he or she must immediately report the information to the relevant county department, police, or sheriff's department.

• Vulnerable Adult Abuse:  If your therapist has reason to believe that a vulnerable adult is being or has been maltreated, abused, or neglected, or has knowledge that a vulnerable adult has sustained a physical injury which is not reasonably explained, your therapist must immediately report the information to the appropriate agency in this county. Your therapist may also report the information to a law enforcement agency. 

• Vulnerable Adult means a person who, regardless of residence or whether any type of service is received, possesses a physical or mental infirmity or other physical, mental, or emotional dysfunction (i) that impairs the individual's ability to provide adequately for the individual's own care without assistance, including the provision of food, shelter, clothing, health care, or supervision; and (ii) because of the dysfunction or infirmity and the need for assistance, the individual has an impaired ability to protect the individual from maltreatment.

• Judicial or Administrative Proceedings: If you are involved in a court proceeding and a request is made for information about your diagnosis and treatment and the records thereof, such information is privileged under state law and your therapist will not release the information without written authorization from you or your personal or legally-appointed representative, or a court order. This privilege does not apply when you are being evaluated for a third party or where the evaluation is court ordered. You will be informed in advance if this is the case.

• Serious Threat to Health or Safety: If your therapist has reason to believe that you may cause harm to yourself or another person, he or she must make a reasonable effort to warn the third party (if any) and/or contact law enforcement.

• Worker’s Compensation: If you file a worker’s compensation claim, your therapist may be required to release records relevant to that claim to your employer or its insurer.

​IV. Patient’s Rights and Psychotherapist’s Duties

Patient’s Rights:

• Right to Request Restrictions: You have the right to request restrictions on certain uses and disclosures of protected health information. However, your therapist is not required to agree to a restriction you request.

• Right to Receive Confidential Communications by Alternative Means and at Alternative Locations: You have the right to request and receive confidential communications of PHI by alternative means and at alternative locations. For example, you may not want a family member to know that you are seeing a therapist. On your request, your therapist will send your bills to another address.

• Right to Inspect and Copy: You have the right to inspect or obtain a copy (or both) of PHI in the mental health and billing records used to make decisions about you for as long as the PHI is maintained in the record. On your request, your therapist will discuss with you the details of the request and denial process.

• Right to Amend: You have the right to request an amendment of PHI for as long as the PHI is maintained in the record. Your therapist may deny your request. On your request,  your therapist will discuss with you the details of the amendment process.

• Right to an Accounting: You generally have the right to receive an accounting of PHI disclosures regarding you. On your request, your therapist will discuss with you the details of the accounting process.

• Right to a Paper Copy: You have the right to obtain a paper copy of this notice from your therapist upon request, even if you have agreed to receive the notice electronically.

Psychotherapist’s Duties: 

• Your therapist is required by law to maintain the privacy of PHI and to provide you with a notice of his or her legal duties and privacy practices with respect to PHI.

• Your therapist reserves the right to change the privacy policies and practices described in this notice. Unless he or she notifies you of such changes, however, your therapist is required to abide by the terms currently in effect.

• If your therapist revises his or her policies and procedures, you will be provided with a copy of the revised version at your next scheduled therapy session. 

​V. Complaints

If you are concerned that your therapist has violated your privacy rights, or you disagree with a decision made by your therapist about access to your records, you may further discuss this with your therapist. If you are not satisfied, please contact Brian Crim, LMFT (HIPAA Security Officer) at 715-410-5822.

You may also send a written complaint to the Secretary of the U.S. Department of Health and Human Services at www.hhs.gov/ocr/privacy/hipaa/complaints or the applicable state board of your therapist. 

​

VI. Effective Date, Restrictions, and Changes to Privacy Policy 

Rainbow Recovery reserves the right to change the terms of this notice and to make the new notice provisions effective for all PHI that it maintains. If this should take place, Rainbow Recovery will provide you with a revised notice by posting a revised copy in a prominent place in the waiting room and providing a copy at your next therapy session (if applicable).