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Terms and Policy

Informed Consent
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 requires effort on your part. Psychotherapy requires your very active involvement, honesty, and openness in order to change your thoughts, feelings and/or behavior. I will ask for your feedback and views on your therapy, its progress, and other aspects of the therapy and I will expect you to respond openly and honestly.

Sometimes more than one approach can be helpful in dealing with a certain situation. During evaluation or therapy, remembering or talking about unpleasant events, feelings, or thoughts can result in your experiencing considerable discomfort or strong feelings of anger, sadness, worry, fear, etc. or experiencing anxiety, depression, insomnia, etc. I may challenge some of your assumptions or perceptions or propose different ways of looking at, thinking about, or handling situations that can cause you to feel upset, angry, depressed, challenged, or disappointed.

Attempting to resolve issues that brought you to therapy in the first place, such as personal or interpersonal relationships, may result in changes that were not originally intended. Psychotherapy may result in decisions about changing behaviors, employment, substance use, schooling, housing, or relationships. Sometimes another family member views a decision that is positive for one family member quite negatively. Change will sometimes happen quickly, but more often it will take time and patience on your part. There is no guarantee that psychotherapy will yield positive or intended results.

During the course of therapy, I will utilize various psychological and motivational approaches according, in part, to the problem that is being treated and my assessment of what will best benefit you. These approaches include but are not limited to behavioral, cognitive-behavioral, psychodynamic, existential, system/family, developmental (adult, child, family), psycho- educational or coaching techniques.

DISCUSSION OF TREATMENT PLAN

During the first session and throughout this process, I will discuss with you your understanding of the problem, treatment plan, therapeutic objectives, and your 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, their possible risks, my expertise 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. If you could benefit from any treatment that as your therapist I do not provide, I have an ethical obligation to assist you in obtaining those treatments.

DUAL RELATIONSHIPS

Not all dual relationships are unethical or avoidable. However, sexual involvement between therapist and client is never part of the therapy process as well as other actions or dual relationship situations that might impair your therapist's objectivity, clinical judgment, or therapeutic effectiveness or that could be exploitative in nature. In addition, I will never acknowledge working therapeutically with anyone without his/her written permission. In some instances, even with permission, I will preserve the integrity of our working relationship. For this reason I will not accept any invitations via social networking sites such as Facebook, Twitter, Linkedin or Pinterest, nor will I respond to blogs written by clients or accept comments on my blog from clients.

TERMINATION AND REFERRAL

During the initial intake process and the first couple of sessions, I will assess if I can be of benefit to you. If you have requested online counseling, my assessment will include your suitability to psychotherapy delivered via technology. I do not accept clients who, in my opinion, I cannot help. In such a case, I will give you a number of referrals that you may contact. If at any point during psychotherapy, I assess that I am not effective in helping you reach your therapeutic goals, I am obliged to discuss this with you up to and including termination of treatment. 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. If at any time you want another professional's opinion or wish to consult with another therapist, I will assist you in finding someone qualified, and, if I have your written consent, I will provide her or him with the essential information needed. 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.

Please note that you will no longer be considered an active client if I have not seen you for therapy for more than 3 months since our last appointment. In that case, your file will be closed and I will no longer be responsible for your care. You are, of course, always welcome to return to therapy as needed and I will be happy to complete forms or meet other requests for you once you meet with me for re-evaluation of your mental health status.

PRIVACY & CONFIDENTIALITY

All information disclosed within sessions and the written records pertaining to those sessions are confidential and may not be revealed to anyone without your written permission, except where disclosure is required by law. Likewise, you are expected to keep our communications confidential and you understand that all records of communication between client and therapist remain the property of Dr. Kathryn S. Castle. Verbatim material from therapy sessions remains in the client record and should never be revealed publically unless both client and therapist agree.

Most of the provisions explaining when the law requires disclosure were described to you in the Notice of Privacy Practices that you received with this form.

When Disclosure Is Required By Law

Some of the circumstances where disclosure is required by the law are: where there is a reasonable suspicion of child, dependent or elder, abuse or neglect; and/or where a client presents a danger to self, to others, to property, or is gravely disabled (for more details see also Notice of Privacy Practices form).

When Disclosure May be Required

Disclosure may be required pursuant to a legal proceeding. If you are involved in a custody dispute or if you place your mental status at issue in litigation initiated by you, the defendant may have the right to obtain the psychotherapy records and/or testimony by me. In couple and family therapy, or when different family members are seen individually, confidentiality and privilege do not apply between the couple or among family members. I will use my clinical judgment when revealing such information. I will not release records to any outside party unless I am authorized to do so by all adult family members who were part of the treatment.
Harm to Self or Others

If there is an emergency during our work together, or in the future after termination, in which I become concerned about your personal safety, the possibility of you injuring someone else, or about you receiving proper psychiatric care, I will do whatever I can within the limits of the law, to prevent you from injuring yourself or others and to ensure that you receive the proper medical care. For this purpose, I may also contact the police, hospital or an emergency contact whose name you have provided.

Confidentiality of Online, Cell Phone and Fax Communication

- I offer in-office and distance counseling modes of counseling, using an encrypted email/video conferencing service. I will determine your suitability for distance counseling based upon a number of factors. Distance counseling is delivered via my practice management system, CounSol.com, a HIPAA-compliant cloud-based website. When you first contact me for an appointment, you will be provided with a password vial email to enable you to access your confidential page. To ensure your privacy, please be sure to log in upon receiving your initial communication from me when I set you up in my practice management system.

Please note:

- When we speak on the telephone, please be aware that I use a cell phone for my business number. Cell phone conversations, text messaging, and the use of email via public servers (such as Google, Yahoo, etc.) are not compliant with HIPAA regulations. While I am happy to communicate with you via phone, text, or email regarding appointments or other matters, you should know that I cannot guarantee complete privacy. If you agree to a text or email reminder, or communicate with me regarding other matters via phone, text or email, your signature on this form will be considered permission to waive compliance with HIPAA regulations in this matter. Please note that I do not store your contact information in my phone; this is only stored on my encrypted practice management system, which meets HIPAA regulations. My phone is locked at all times with a passcode known only to me.
- I prefer not to respond to personal and clinical concerns via phone, regular email, or text due to confidentiality issues. Messages sent via my practice management system, Counsol.com, are HIPAA-compliant and therefore confidential.
- If you send a fax to me, it is confidential. My fax service meets HIPAA regulations; however, it is possible that human error can occur in sending and receiving documents. Please double check to be sure that you are sending documents to the correct number; I will do the same.
- Any computer files referencing our communication are maintained using secure and encrypted measures.
- If you wish to use my practice management system, Counsol.com, as a way to "journal" information between sessions, you understand that I may not have the opportunity to review your journal emails until our next scheduled session.

I make every effort to keep all information confidential. Likewise, if we are working online together, I ask that you determine who has access to your computer and electronic information from your location. This would include family members, co-workers, supervisors and friends and whether or not confidentiality from your work or personal computer may be compromised due to such programs as a keylogger. I encourage you to only communicate through a computer that you know is safe, i.e. wherein confidentiality can be ensured. Be sure to fully exit all online counseling sessions.

If you use location-based services on your mobile phone, you may wish to be aware of the privacy issues related to using these services. I do not place my practice as a check-in location on various sites such as Foursquare. However, if you have GPS tracking enabled on your device, it is possible that others may surmise that you are a therapy client due to regular check-ins at my office on a weekly basis. Please be aware of this risk if you are intentionally "checking in" from my office or if you have a passive LBS app enabled on your phone.

It is not a regular part of my practice to search for client information online through search engines such as Google or social media sites such as Facebook. Extremely rare exceptions may be made during times of crisis. If I have a reason to suspect that you are in danger and you have not been in touch with me via our usual means (coming to appointments, phone, or email) there might be an instance in which using a search engine (to find you, find someone close to you, or to check on your recent status updates) becomes necessary as part of ensuring your welfare. These are unusual situations and if I ever resort to such means, I will fully document it and discuss it with you when we next meet

Limitations Regarding Online Therapy:

You as the client understand that distance therapy is a different experience as compared to in- person sessions, among those being the lack of "personal" face-to-face interactions, the lack of visual and audio cues in the therapy process to which you may have previously come to expect. You understand that telephone/online psychotherapy with me is not a substitute for medication under the care of a psychiatrist or doctor. You understand that online and telephone therapy is not appropriate if you are experiencing a crisis or having suicidal or homicidal thoughts.

As stated previously, if a life-threatening crisis should occur, you agree to contact a crisis hotline, call 911, or go to a hospital emergency room.

You also understand that I follow the laws and professional regulations of the State of New York (USA) and the psychotherapy treatment will be considered to take place in the state of New York (USA). Typically, I do not conduct online therapy with clients whose permanent domicile is located outside my license jurisdiction.

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.

Consultation and Peer Supervision

I consult regularly with other professionals regarding my clients; however, the client's name or other identifying information is never disclosed. The client's identity remains completely anonymous, and confidentiality is fully maintained.

Considering all of the above exclusions, if it is still appropriate, upon your request, I will release information to any agency/person you specify unless I conclude that releasing such information might be harmful in any way.

TELEPHONE & EMERGENCY PROCEDURES

If you need to speak with me between sessions to alert me of an emergency, please call 585- 746-0607. Do not leave details of your crisis on this telephone, as it is a cellular phone. Your call will be returned as soon as possible. Messages are checked daily Monday through Thursday (but never during the night time). Messages are checked less frequently on Fridays, weekends, and holidays. If an emergency situation arises that requires immediate attention, you may call the emergency National Suicide Hotline at 800-784-2433 or dial 911. You can reach Lifeline by calling 211. You may also check the crisis hotline page on my website for additional resources (www.drkathycastle.com). If a life-threatening crisis should occur, you agree to contact a crisis hotline, call 911, or go to a hospital emergency room. Please see my crisis hotline web page for further information.

FEE FOR SERVICE, USE OF CREDIT/DEBIT CARDS, AND CANCELLATION POLICY

Current rates for therapeutic services are discussed when you call for our first appointment. My practice is "fee for service" and that means that fees are due at the time of your appointment. I do not participate on insurance panels. Due to unreasonable administrative costs and time involved, in order to keep your fee as low as possible, I will not communicate with clients' insurance companies at any time for any reason. I will, however, issue a Superbill receipt that outlines diagnostic criteria and other information necessary in order for my services to potentially be reimbursable. Payment by your insurance company is at their discretion; I cannot guarantee reimbursement. Fees will be collected at the end of the session and are expected to be paid in full.

Occasional and reasonable requests for simple reports, letters, or communications with other professionals will be accommodated at no charge. However, if these are requested more than once every few months, or the report is complicated, a fee will be charged for my time. This will be discussed at the time of your request.

Session payments via credit or debit card are processed through Square. While I am happy to send you an electronic receipt via text or email, you should know that I cannot guarantee complete privacy (just as with any other text or email.) If you request an electronic receipt, your signature on this form will be considered permission to waive compliance with HIPAA regulations in this matter.

Since scheduling of an appointment involves the reservation of time specifically for you, a minimum of 24-hour notice is required for re-scheduling or canceling an appointment. Unless we reach a different agreement, the full fee will be charged for sessions missed without such notification. You will be asked to provide a credit card number to be used only in this instance: you will be notified prior to processing the charge.

If we are scheduled for an online synchronous videoconference and we are unable to connect or are disconnected during a session due to a technological breakdown, please try to reconnect within 10 minutes. If reconnection is not possible, contact me to schedule a new session time.

DISPUTES, COMPLAINTS AND RATINGS

All disputes arising out of or in relation to this agreement to provide psychotherapy services shall first be referred to mediation, before, and as a pre-condition of the initiation of arbitration. The mediator shall be a neutral third party chosen by agreement of Dr. Kathryn S. Castle and the client(s). The cost of such mediation, if any, shall be split equally, unless otherwise agreed. In the event that mediation is unsuccessful, any unresolved controversy related to this agreement should be submitted to and settled by binding arbitration in accordance with the rules of the American Arbitration Association which are in effect at the time the demand for arbitration is filed. Notwithstanding the foregoing, in the event that your account is overdue (unpaid) and there is no agreement on a payment plan, I can use legal means (court, collection agency, etc.) to obtain payment. The prevailing party in arbitration or collection proceedings shall be entitled to recover a reasonable sum for attorneys' fees. In the case of arbitration, the arbitrator will determine that sum.

You may find my psychotherapy practice on sites such as Psychology Today, Yelp, Healthgrades, Yahoo Local, Bing, or other places that list businesses. Some of these sites include forums in which users rate their providers and add reviews. Many of these sites comb search engines for business listings and automatically add listings regardless of whether the business has added itself to the site. If you should find my listing on any of these sites, please know that my listing is not a request for a testimonial, rating, or endorsement from you as my client. Asking for a testimonial from you is unethical practice on my part.

If you do choose to write something on a business review site, I hope you will keep in mind that you may be sharing personally revealing information in a public forum. I urge you to create a pseudonym that is not linked to your regular email address or friend networks for your own privacy and protection. Please be aware that if you have a complaint that you want me to know about, I may not see your post on a review site. I hope you will discuss your concerns with me personally. If you do have a complaint or concern about my services and you are not comfortable discussing the matter with me you may make inquiry to my license/certification boards:

New York's Professional Misconduct Enforcement System: Complaint Hotline 1-800‐8106;
conduct@mail.nysed.gov

American Counseling Association: To file a complaint: Ethics Committee; The American Counseling Association, 5999 Stevenson Ave., Alexandria, VA 22304

National Board of Certified Counselors (NBCC): ethics@nbcc.org


***You may access a copy of this form through your account on my practice management web portal. If you need a reminder to enter the system, please let me know and I will send you your User Name and/or Password.

I have read and understand the above conditions to participating in treatment with Dr. Kathryn
S. Castle:
( Type Full Name )
HIPAA Notice of Privacy Practices For Protected Health Information
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.

This office is required to maintain the privacy of your health information and to provide you with notice of its legal duties and privacy practices. This office will not use or disclose your health information except as described in this Notice. If you consent, the office is permitted by federal privacy laws to make uses and disclosures of your health information for purposes of treatment, payment, and health care operations. Protected health information is the information I create and obtain in providing my services to you. Such information may include documenting your symptoms, medical history, examination and test results, diagnoses, treatment, and applying for future care or treatment. It also includes billing documents for those services.

Examples of uses of your health information for treatment purposes are:
• I obtain treatment information about you and record it in a health record.
• During the course of your treatment, I determine that I will need to consult with another specialist in the area. I will obtain your signed authorization before sharing information with such specialists to obtain his/her input.
• Referral information may be forwarded to Diagnostic Testing Labs for further treatment or testing where I will want results of such treatment or testing reported back to me.
• Your health information and progress may be reported back to your primary care provider or referring provider, upon receipt of your written authorization.

Example of use of your health information for payment purposes:
• You submit requests for payment to your health insurance company for my services as an out-of-network provider. If the health insurance company requests health information from me regarding medical care given, I will provide information to them about you and the care given. For example, a superbill given to you that you submit to your health insurance company may include information that identifies your diagnosis, and the procedures and supplies used.

Example of use of your health information for health care operations:
• If I am on an Insurer’s Provider’s list, I may share health information to obtain services from insurers business associates (an individual or entity under contract with me to perform or assist me in a function or activity that necessitates the use or disclosure of health information) such as quality assessment, quality improvement, outcome evaluation, protocol and clinical guidelines development, training programs, credentialing, medical transcription, medical review, legal services, and insurance. I will share health information about you with insurers or other business associates as necessary to obtain these services. I require my insurers and other business associates to protect the confidentiality of your health information.

YOUR HEALTH INFORMATION RIGHTS
The health and billing records I maintain are the physical property of the treating provider. The information in it, however, belongs to you. You have the right to:

• Request a restriction on certain uses and disclosures of your health information by delivering the request in writing to my office. I am not required to grant the request but I will comply with any request granted as required by law:
• Obtain a paper copy of the Notice of Privacy Practices for Protected Health information ("Notice") by making a request at my office.
• Obtain a copy of your paper or electronic medical record
• Correct your paper or electronic medical record
• Request confidential communication
• Choose someone to act for you
• Request that you be allowed to inspect and copy your billing record - you may exercise this right by delivering the request in writing to my office;
• Obtain an accounting of disclosures of your health information as required to be maintained by law, upon request. An accounting will not include internal uses of information for treatment, payment, operations, or disclosures made to you; and
• Revoke authorizations that you made previously to use or disclose information except to the extent information or action has already been taken by delivering a written revocation to my office.
• File a complaint if you believe your privacy rights have been violated

If you want to exercise any of the above rights, please contact Dr. Kathryn Castle, 46 Prince Street, LL004, Rochester, NY 14607, in person or in writing, during normal business hours. I will provide you with assistance on the steps to take to exercise your rights.

You have the right to review this Notice before signing the consent authorizing use and disclosure of your protected health information for treatment, payment, and health care operations purposes.

MY RESPONSIBILITIES:
I am required to:
• Maintain the privacy of your health information as required by law;
• Provide you with a notice as to our duties and privacy practices as to the information I collect and maintain about you;
• Abide by the terms of this Notice;
• Notify you if I cannot accommodate a requested restriction or request; and
• Accommodate your reasonable requests regarding methods to communicate health information with you.

I reserve the right to amend, change, or eliminate provisions in my privacy practices and access practices and to enact new provisions regarding the protected health information I maintain. If my information practices change, I will amend my Notice. You are entitled to receive a revised copy of the Notice by calling and requesting a copy of my "Notice" or by visiting my office and picking up a copy. For more information see: www.hhs.gov/ocr/privacy/hipaa/understanding/consumers/noticepp.html.

TO REQUEST INFORMATION OR FILE A COMPLAINT
If you have questions, would like additional information, or want to report a problem regarding the handling of your information, you may contact Dr. Kathryn Castle at 585-746-0607. Additionally, if you believe your privacy rights have been violated, you may file a written complaint at my office by delivering the written complaint to me. You may also file a complaint by mailing it to the Secretary of Health and Human Services. I cannot, and will not, require you to waive the right to file a complaint with the Secretary of Health and Human Services (HHS) as a condition of receiving treatment from the office. Likewise, I cannot, and will not, retaliate against you for filing a complaint with the Secretary of Health and Human Services.

OTHER DISCLOSURES AND USES
Notification of Family/Friends: My office does NOT disclose protected health information or any other information to family members without prior written consent from you. If you wish someone to have access to your records, please let me know.

Appointment Reminders: I may contact you and/or leave a message on your telephone answering machine or via text or email to provide you with appointment reminders.

Workers Compensation: If you are seeking compensation through Workers Compensation, I may disclose your health information to the extent necessary to comply with laws relating to Workers Compensation.

Technology Limitations: Please be aware that the use of cell phones, texting, emails, chat, or video-based counseling have limitations. Although I use a secure online site with encryption for chat, video-based counseling, client contact information, record keeping, and the exchange of completed documents, I cannot completely guarantee your privacy. Cell phones, texting, and email via Gmail or other entities are not secure. I will only use these technologies for contacting you regarding appointment scheduling and other non-personal information.

Abuse, Neglect & Domestic Violence: I may disclose your health information to public authorities as allowed by law to report abuse, neglect, or domestic violence.

Inmates: If you are an inmate of a correctional institution or under the custody of a law enforcement officer, I may disclose to the institution or law enforcement official health information necessary for your health and safety or the health and safety of other individuals.

Law Enforcement: I may disclose your health information for law enforcement purposes as required by law, such as when required by a court order; for identification of a victim of a crime if certain protective requirements are met; to report a crime in emergencies; and other appropriate situations as permitted by law.

Judicial/Administrative Proceedings: I may disclose your health information in the course of any judicial or administrative proceeding as allowed or required by law or as directed by a proper court order or in response to a subpoena, discovery request or other lawful process if certain specific requirements are met. To avert a serious threat to health or safely, I may disclose your health information consistent with applicable law to prevent or lessen a serious, imminent threat to the health or safety of a person or the public.

Other Uses: Any other uses and disclosures of your health information besides those identified in this Notice will be made only as otherwise authorized by law or with your written authorization and you may revoke the authorization as previously provided.


I acknowledge that I have received, read, and understand the Privacy Practices as outlined in this document:
( Type Full Name )