Welcome to my practice. This document contains important information about my professional services and business policies. It also contains summary information about the Health Insurance Portability and Accountability Act (HIPAA), a new federal law that provides new privacy protections and new patient rights with regard to the use and disclosure of your Protected Health Information (PHI) used for the purpose of treatment, payment, and health care operations. HIPAA requires that I provide you with a Notice of Privacy Practices (the Notice) for use and disclosure of PHI for treatment, payment and health care operations. The Notice, which is attached to this Agreement, explains HIPAA and its application to your personal health information in greater detail, and my practice is in general accordance with HIPAA policies. The law requires that I obtain your signature acknowledging that I have provided you with this information at the end of this session. Although these documents are long and sometimes complex, it is very important that you read them carefully before our first session. We can discuss any questions you have about the procedures at that time. When you sign this document, it will also represent an agreement between us. You may revoke this Agreement in writing at any time. That revocation will be binding on me unless I have taken action in reliance on it or if you have not satisfied any financial obligations you have incurred.

PSYCHOLOGICAL SERVICES

Therapy is a relationship between people that works in part because of the clearly defined rights and responsibilities held by each person. This frame helps to create the safety to take risks and the support to become empowered to create change. As a client in psychotherapy, you have certain rights and responsibilities that are important for you to know about. There are also legal limitations to those rights that you should be aware of. I, as your therapist, have corresponding responsibilities to you. These respective rights are described in the following section. Psychotherapy has both benefits and risks. Risks sometimes include experiencing uncomfortable feelings, such as sadness, guilt, anxiety, anger, frustration, loneliness and helplessness. Psychotherapy often requires discussing unpleasant aspects of your life. However, psychotherapy has been shown to have benefits for individuals who undertake it. Therapy often leads to a significant reduction in feelings of distress, increased satisfaction in interpersonal relationships, greater personal awareness and insight, increased skills for managing stress, and resolutions to specific problems. However, 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 have to work on things that we discuss outside of sessions.

APPOINTMENTS

Sessions are approximately 50 minutes and are typically scheduled on the hour.  Initially, sessions are scheduled on a weekly basis if schedules permit. Session frequency lessens as symptoms lessen until sessions are ultimately terminated. Some clients need only a few counseling sessions to achieve their goals, others may require months or even years of counseling. As a client, you are in complete control and may end our relationship at any time, although I do ask that you participate in a termination session. You are responsible for coming to your session on time and at the time scheduled. If you are late, your appointment will still need to end on time. I make every effort to end each appointment on time. In rare instances, some sessions do run over which causes me to start my next appointment late. If this is the case and if your schedule permits, I will make every effort to ensure your full 50 minute session.

FEES, BILLING, AND PAYMENT

Psychotherapy sessions are 50 minutes and billed at $200 per initial session and $180 for subsequent sessions.  Half hour sessions are billed at $90.  90 minutes sessions are $275.  Telephone calls that exceed 15 minutes are billed at $2 per session.  Session fees or insurance co-pays are payable at the time of service unless alternative arrangements have been arranged. Fees will be reevaluated periodically. Legal fees ($250 per hour of service provided) are not billable to insurance companies and will be charged to the patient directly (eg. court evaluations, court appearances). My therapy practice utilizes Ivy Pay for accepting payment. Ivy Pay is a card payment system designed specifically for psychotherapists and their clients. Following our initial appointment, I will send you an invitation text via Ivy Pay's system with a charge for our session. The text you receive will come from a phone number in Ivy Pay's system (not me) and will be worded similarly to the following: "Ivy: You've been invited to use Ivy. To accept and pay for sessions with a card on file, go to [link]".I ask that you use that link to set yourself up in the system at your convenience. It is quick, easy, and very secure.  Your card will be encrypted and stored on Ivy Pay's secure servers, and you will be charged for your session.  I personally will not have access to your financial information - it will be on file and securely maintained through Ivy Pay. On your card statement it will appear as "I V Y Labs, Inc."  I will charge your card after each session and you will receive a text message confirmation of the charge.

CANCELLATION POLICY

Psychological services are most effective when meeting times are regular and consistent. The time scheduled for your appointment is assigned to you and you alone. If you need to cancel or reschedule a session, it is required that you provide 24 hours notice. If you miss a session without canceling, or cancel with less than 24 hours notice, you are responsible to pay the full fee ($180) for the time that was reserved. I do this for your benefit as well as other clients. Evening sessions are particularly coveted appointment times and if I have sufficient notice of a cancellation, I am often able to fill that spot with someone in need of that time. It is important to note that insurance companies do not provide reimbursement for cancelled/missed sessions. I require a credit card be kept on file to pay for missed appointments. I understand that there may be an occasional emergency that interferes with your notifying me within the 24-hour window of time and will always take these circumstances into consideration.

DUAL RELATIONSHIPS

Not all dual relationships are unethical or avoidable. However, sexual involvement between therapist and client is never part of the therapy process, nor are any other actions or dual relationship situations that might impair my objectivity, clinical judgment, or therapeutic effectiveness or that could be exploitative in nature. I will never acknowledge working therapeutically with anyone without his/her written permission. This means that if I see you in public, I will not acknowledge that I know you unless you approach me first. Additionally, I will not accept any invitations via social networking sites including Facebook, TikTok, Instagram  and LinkedIn. It is my policy not to participate in any school or extracurricular fundraisers (ie candy, gift wrap, candle, or magazine sales). All of these instances may compromise your confidentiality and our respective privacy. It may also blur the boundaries of our therapeutic relationship.

CONTACTING ME

You may telephone me at 404 849-6586. Due to my work schedule, I am often not immediately available to receive calls, but my phone will be answered by confidential voicemail. I will make every effort to return your call on the same day you make it, with the exception of weekends and holidays. If you are difficult to reach, please leave me times when you might be available. If there is an emergency, contact your family physician or the nearest emergency room for crisis treatment. In the event that I must be unavailable for an extended period of time, I will provide you with the name of a colleague to contact. You may also contact me via email for housekeeping issues only (scheduling or changing of an appointment, billing questions) at kerri@coffeehousecounselingatl.com. Please do not include any pertinent clinical information to emails at that address as it is not encrypted or secure (and thus your confidentiality may be compromised). If you would like to share pertinent case information, please do so via my web portal at www.kg.clinicprn.org by logging into the messages section of the portal. This is a HIPPA-compliant, secure site that will enable us to communicate in a safe and private manner. You must use the password given to you when the initial appointment was made in order to log in to the site.

PROFESSIONAL RECORDS

I am required to keep appropriate records of the psychological services that I provide. Although psychotherapy often includes discussions of sensitive and private information, normally very brief records are kept noting that you have been here, what was done in session, and a mention of the topics discussed. You have the right to a copy of your file at any time. You have the right to request that a copy of your file be made available to any other health care provider at your written request.

CONFIDENTIALITY

The confidentiality of all communications between a client and a therapist is generally protected by law and I, as your therapist, cannot and will not tell anyone else what you have discussed or even that you are in therapy without your written permission. In most situations, I can only release information about your treatment to others if you sign a written Authorization form that meets certain legal requirements imposed by HIPAA. With the exception of certain specific situations described below, you have the right to confidentiality of your therapy. You, on the other hand, may request that information is shared with whomever you choose and you may revoke that permission in writing at any time.

There are, however, several exceptions in which I am legally bound to take action even though that requires revealing some information about a patient's treatment. If at all possible, I will make every attempt to inform you when these will have to be put into effect. The legal exceptions to confidentiality include, but are not limited, to the following:

1. If there is good reason to believe you are threatening serious bodily harm to yourself or others. If I believe a client is threatening serious bodily harm to another, I may be required to take protective actions, which may include notifying the potential victim, notifying the police, or seeking appropriate hospitalization. If a client threatens harm to him/herself or another, I may be required to seek hospitalization for the client, or to contact family members or others who can provide protection.

2. If there is good reason to suspect, or evidence of, abuse and/or neglect toward children, the elderly or disabled persons. In such a situation, I am required by law to file a report with the appropriate state agency.

3. In response to a court order or where otherwise required by law.

4. To the extent necessary, to make a claim on a delinquent account via a collection

agency.

5. To the extent necessary for emergency medical care to be rendered.

Finally, there are times when I find it beneficial to consult with colleagues as part of my practice for mutual professional consultation. Your name and unique identifying characteristics will not be disclosed. The consultant is also legally bound to keep the information confidential.

MINORS AND PARENTS

Patients under 18 years who are not emancipated and their parents should be aware that the law allows parents to examine their child's treatment records unless the therapist believes that doing so would endanger the child or the parents and child agree otherwise. I will provide parents only general information about the progress of the child's treatment and his/her attendance at scheduled sessions. If there is something discussed that I believe is really important, I will encourage the child to share this information with his/her parents in my presence. If he/she is unwilling to do so, I will share this information. Otherwise content of sessions will be kept confidential. Please note that child custody may influence a parent's ability to consent to, direct, and participate in their child's medical care. For this reason, in the case of a divorced family I require a copy of the divorce decree in order to determine the rights of both parents. Please bring a copy with you to the initial session.

LITIGATION LIMITATION

Due to the nature of the therapeutic process and the fact that it often involves making a full disclosure with regard to many matters which may be of a confidential nature, it is agreed that should there be legal proceedings (such as, but not limited to divorce and custody disputes, injuries, lawsuits, etc.), neither you (client) nor your attorney, nor anyone else acting on your behalf will call on me to testify in court or at any other proceeding, nor will a disclosure of the psychotherapy records be requested.

TERMINATION

During the initial intake process and the first couple of sessions, I will assess if I can be of benefit to you. I do not accept clients who, in my opinion, I am not qualified to help.  If at any point during psychotherapy, I assess that I am not effective in helping you reach your therapeutic goals, I will discuss this with you and consider termination. In such a case, I would give you a number of referrals that may be of help to you. If you request and authorize in writing, I will talk to the psychotherapist of your choice in order to help with the transition.  You have the right to terminate therapy at any time. If you choose to do so, I will offer to provide you with names of other qualified professionals whose services you might prefer. You are always welcome to resume services at any time if you desire to seek treatment at a later date.

By signing this form, I agree to begin treatment with Kerri Golding Oransky and agree to the above policies.

Notice Policies and Practices to Protect the Privacy of Your Health Information (HIPAA)

THIS NOTICE DESCRIBES HOW YOUR MENTAL HEALTH RECORDS MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE READ IT CAREFULLY.

I. Preamble

A recent United State Supreme Court decision held that communications between psychotherapists and their clients are privileged and, therefore, are protected from forced disclosure in cases arising under federal law. There is a difference between privileged conversations and documentation in your mental health records. Records are kept documenting your care as required by law, professional standards, and other review procedures. HIPAA very clearly defines what kind of information is to be included in your "Designated Medical Record" as well as some material, known as "Psychotherapy Notes" which is not accessible to insurance companies and other third- party reviewers and in some cases, not to the client himself/herself. HIPAA provides privacy protections about your personal health information, which is called "protected health information" (PHI) which could personally identify you. PHI consists of three (3) components: treatment, payment, and health care operations.

Treatment refers to activities in which I provide, coordinate or manage your mental health care or other services related to your mental health care. Examples include a psychotherapy session, psychological testing, or talking to your primary care physician about your medication or overall medical condition.

Payment is when I obtain reimbursement for your mental health care.

Health care operations are activities related to the performance and operations of my practice such as quality assurance. The use of your protected health information refers to activities my office conducts for, scheduling appointments, keeping records and other tasks within my office related to your care. Disclosures refer to activities you authorize which occur outside my office such as the sending of your protected health information to other parties (i.e., your primary care physician, the school your child attends).

II. Uses and Disclosures of Protected Health Information Requiring Authorization

 I 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 I am asked for information for purposes outside of treatment, payment or health care operations, I will obtain an authorization from you before releasing this information. An example of this may be if you wanted me to speak with your child's teacher about their behavior at school. You may, in writing, revoke all authorizations to disclose protected health information at any time. You cannot revoke an authorization for an activity already done that you instructed me to do or if the authorization was obtained as a condition for obtaining insurance and the insurer has the right to contest the claim under the policy.

III: Uses and Disclosures with Neither Consent nor Authorization

By law, protected health information may be released without your consent or authorization for  the following reasons:

Child Abuse 

Suspected Sexual Abuse of a Child

Adult and Domestic Abuse

Health Oversight Activities (i.e., licensing board for Professional Counselors in Georgia)     Judicial or Administrative Proceedings (i.e., if you are ordered here by the court)

Serious Threat to Health or Safety (i.e., out "Duty to Warn" Law, national security threats) 

Workers Compensation Claims (if you seek to have your care reimbursed under Workers Compensation, all of your care is automatically subject to review by your employer and/or insurer(s).

IV. Client's Rights and My Duties

You have a right to the following: 

The right to request restrictions on certain uses and disclosures of your protected health information, which I may or may not agree to, but if I do, such restrictions shall apply unless our agreement is changed in writing

The right to receive confidential communications by alternative means and at alternative locations. For example, you may not want your bills sent to your home address so I will send them to another location of your choosing; 

The right to inspect and receive a copy of your protected health information in my designated mental health record set and any billing records for as long as protected health information is maintained in the records; 

The right to amend material in your protected health information, although I may deny an improper request and/or respond to any amendment(s) you make to your record of care;

The right to an accounting of non-authorized disclosures of your protected health information;  The right to a paper copy of notices/information from me, even if you have previously requested electronic transmission of notices/information; and 

The right to revoke your authorization of your protected health information except to the extent that action has already been taken.

V. Questions and Complaints

If you have questions about this notice, disagree with a decision this office makes about access to your records, or have other concerns about your privacy rights, you may contact your provider at 404-849-6586. If you believe that your privacy rights have been violated and wish to file a complaint with this office, you may send your written complaint to Kerri Golding Oransky at 533 W. Howard Ave Decatur, GA 30030.  You may also send a written complaint to the Secretary of the U.S. Department of Health and Human Services. You have specific rights under the Privacy Rule. This office will not retaliate against you for exercising your right to file a complaint.

VI. Effective Date, Restrictions, and Changes to Privacy

This notice is effective as of August 23, 2018. Georgia Therapy, INC reserves the right to change the terms of this notice, make restrictions or limitations, and to make the new notice provisions effective for all PHI that is maintained. A written copy will be provided upon

request.

I, the undersigned, acknowledge that I have received, read, and understand the "Notice of Policies and Practices to Protect the Privacy of Your Health Information" from Georgia Therapy, INC. This policy is required by law under Health Insurance Portability and Accountability Act (HIPAA).

I incorporate my therapy dog, Freddie Freeman Mercury in my psychotherapy work.  Freddie is an Australian Labradoodle which is a mix of labrador retriever, poodle and cocker spaniel. He is hypoallergenic and does not shed.  Freddie was selected as an ideal candidate for a therapy dog when he was just eight weeks old due to his calm and gentle nature, his love of learning and his love of people.  I adopted Freddie when he was 11 weeks old and immediately began his training.  We did both individual and group training sessions working on basic obedience skills as well as learning various tricks.   At nine months old, Freddie obtained his Canine Good Citizen certification and later earned his AKC Intermediate Trick Dog Certification. Freddie and I are honored to have been one of the founding cohorts to obtain certification as a Therapy Animal Team through the Association for Animal-Assisted Intervention Professional (AAAIP). The Certified Professional Therapy Animal Team certification opportunity was recently released in it's pilot stages through the Association of Animal-Assisted Intervention Professionals after experts from the association completed an empirical scope identifying the skills essential for professionals partnering with therapy animals in their practice. Completion of this certification is evidence of having been assessed on my ability to partner with Freddie and on Freddie's degree of fit for the role of a therapy animal. Freddie will be re-assessed every two years aligning with the field's suggestions for best practice.

The use of animals by health professionals in their work is called Animal Assisted Therapy (AAT).  There are many benefits associated with AAT. Some benefits that have been found in utilizing therapy animals include: 

- Animals help improve motivation and engagement in therapy. 

- Animals provide a sense of security and emotional support. 

-Dogs offer unconditional acceptance and positive regard. -

-Animals can promote relaxation. Research has demonstrated that petting an animal can help lower blood pressure, heart rate, and increase oxytocin (a feel-good chemical in the brain). 

- Animals can help the client learn frustration tolerance and other anger management techniques.

- Animals can help in the areas of focus and attention. 

- Animals can be instruments of learning, which can increase self-confidence and self-esteem.

 - Animals offer humor and fun due to their playful nature. 

This consent form outlines the risks & rules needed to ensure your health & safety (as well as Freddie's) as we work together.

What you need to know:

 1. You may always opt to not have Freddie in your sessions.  If you choose to not have Freddie join you in session he will remain in his crate or at home if time allows.

2. While Freddie has been screened by a veterinarian before commencing work as a therapy animal, animals do sometimes carry disease. Because your contact is minimal, this risk is very small. Freddie is up to date on all his vaccinations.

 3. While Freddie is a "hypoallergenic" dog (he has hair, not fur) there may still be a risk of an allergic reaction. Please let me know if you typically have allergies to animals. 

4. If you or your child have a fear of dogs (however mild) then animal assisted therapy may not be appropriate for you. Let's discuss potential risks & benefits prior to the start of our work together.

 5. As Freddie's handler and as your therapist I will be looking out for your welfare as well as his. However, it is important to remember that Freddie is an animal and as such can be unpredictable. Freddie is a gentle dog & affectionate dog, however, scratches, jumping, mouthing & unwanted kisses are all possible.

 6. Animals have individual rights, just as each client has rights. Freddie gets to decide how and when he participates in the sessions. It is important for everyone's benefit (as well as safety) that he is not coerced or mistreated. He typically greets people enthusiastically and invites clients to play and then often retreats to his crate to rest.

8. Confidentiality is important to both Freddie and me. In order to protect your confidentially, I will not typically approach you if I see you in public. However, it is possible that Freddie may recognize you outside of a session and want to greet you.  If this occurs, we will both act like he is simply greeting a friendly stranger and will not reveal that either of us know you.

While I have listed some common risks, I cannot foresee all potential risks. By signing this form you are stating your acceptance of the above rules and risks and agree to accept full liability in the event that Freddie harms you or your child in any way in the course of treatment or as a result of treatment. By signing this form, you are releasing Kerri Golding Oransky, LCSW from any liability should any injury occur as part of your animal assisted therapy.