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Terms and Policy

HH Disclosure Statement

HEALING HARBOR COUNSELING'S DISCLOSURE STATEMENT & POLICIES
THIS NOTICE DESCRIBES HOW MENTAL HEALTH INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN ACCESS THIS INFORMATION. PLEASE REVIEW IT CAREFULLY

TERESA SAHHAR

1. Healing Harbor Counseling is located at 4585 Hilton Parkway, Suite 202, Colorado Springs, Colorado 80907, 719-201-1769. The mental health professional located at Healing Harbor Counseling is:

Teresa Sahhar, LPC #0015235
Masters is Community Counseling, Regis University, 2013
Bachelor of Arts in Ministry: Christian Counseling, Nazarene Bible College, 2010
National Certified Counselor, National Board for Certified Counselors, 2013

2. Everyone fifteen (15) years or age and older must sign this disclosure. A parent or legal guardian with the authority to consent to mental health services for their minor child/ren, must sign this disclosure of behalf of their minor child under the age of fifteen (15) years old. This disclosure statement contains the policies and procedures of Healing Harbor Counseling and is HIPAA compliant. No medical or psychotherapeutic information, or any other information related to your privacy, will be revealed without your permission unless mandated by Colorado law and Federal Regulations (42 C.F.R. Part 2 and Title 25, Article 4, Part 14 and Title 25, Article 1, Part 1, CRS and the Health Insurance Portability and Accountability Act (HIPAA), 45 C.F.R. Parts 142, 160, 162 and 164.)

3. The Colorado Department of Regulatory Agencies (DORA) has the general responsibility of regulating the practice of licensed psychologists, licensed clinical social workers, licensed professional counselors, licensed marriage and family therapists, certified school psychologists, and registered individuals who practice psychotherapy. The agency within DORA that has responsibility specifically is the Mental Health Section, 1560 Broadway, Suite #1350, Denver, CO 80202, (303) 894-2291. Clients are encouraged to resolve any grievances through our internal process. Specifically, the State Board of Licensed Professional Counselor Examiners, regulates licensed professional counselors and licensed professional counselor candidates, and can be reached at the address listed above.

4. You, as a client, may revoke your consent to treatment, release of confidential information, or disclosure in writing at any time during therapy.

5. Levels of Psychotherapy Regulation in Colorado include licensing (requires minimum education, experience, and examination qualifications), Certification (requires minimum training, experience, and for certain levels, examination qualifications), and Registered Psychotherapist (does not require minimum education, experience, or examination qualifications.) All levels of regulation require passing a jurisprudence take-home examination.

Certified Addiction Counselor I (CAC I) must be a high school graduate, complete required training hours and 1,000 hours of supervised experience.

Certified Addiction Counselor II (CAC II) must complete additional required training hours and 2,000 hours of supervised experience.

Certified Addiction Counselor III (CAC III) must have a bachelor's degree in behavioral health, complete additional required training hours and 2,000 hours of supervised experience.

Licensed Addiction Counselor must have a clinical master's degree and meet the CAC III requirements.
Licensed Social Worker must hold a masters degree in social work.

Psychologist Candidate, a Marriage and Family Therapist Candidate, and a Licensed Professional Counselor Candidate must hold the necessary licensing degree and be in the process of completing the required supervision for licensure.

Licensed Clinical Social Worker, a Licensed Marriage and Family Therapist, and a Licensed Professional Counselor must hold a masters degree in their profession and have two years of post-masters supervision.
A Licensed Psychologist must hold a doctorate degree in psychology and have one year of post-doctoral supervision.

CLIENT RIGHTS AND IMPORTANT INFORMATION

As a client you are entitled to receive information from me about my methods of therapy, the techniques I use, the duration of your therapy, if I can determine it, and my fee structure. Please ask if you would like to receive this information.

1. My fee structure and services provided are outlined as follows:
Fees
My fee is $95 per 50-minute session. This fee is the same for in-office, teletherapy [phone sessions], or couples therapy. For extended sessions the fee is increased. Therapy is an investment in self-care, and is a process that takes time. I ask that you meet my full fee unless you are facing serious financial hardship in which case we can discuss a possible reduced fee before the start of your first session. I have limited reduced fee session spots which may be filled at any point in time. If you are not able to afford my fee even if the reduced fee is available, we will not be able to work together, but I will be happy to provide you with three (3) therapy referrals for low cost clinics that offer lower fees. If you utilize my reduced fee, from time to time we will revisit your fee and discuss a possible increase. Should your financial situation improve, I will then discuss an increase in your fee that either meets or is closer to my full fee.

Fee Increases
Fees are reviewed each year, and may increase periodically. Every consideration to client's current finances will be made, the increase will be discussed with the client, and a 30-day notice will be given prior to the increase. I will be happy to answer any questions you may have about this fee agreement. Please understand that you have the right to terminate therapy at any point. If you have any questions regarding my fee policy, please do not sign until discussing with me. Your signature indicates that you understand and agree to these conditions.

2. It is the policy of my practice to collect all fees owed at the time of service, unless you make arrangements for payment and we both agree to such an arrangement. All accounts that are not paid within thirty (30) days from the date of service shall be considered past due. If your account is past due, please be advised that I may be obligated to turn past due accounts over to a collection agency or seek collection with a civil court action. Should this occur, I will provide the collection agency or Court with your Name, Address, Phone Number, and any other directory information, including dates of service or any other information requested by the collection agency or Court deemed necessary to collect the past due account. I will not disclose more information than necessary to collect the past due account.

3. Therapy fees and treatment are based on a 45-50 minute clinical hour instead of a 60 minute clock hour so that I may review my notes and assessments on your behalf.

4. You are entitled to request restrictions on certain uses and disclosures of protected health information as provided by 45 CFR 164.522(a), however Healing Harbor Counseling is not required to agree to a request restriction.

5. You are entitled to seek a second opinion from another therapist or terminate therapy at any time.

6. In a professional relationship (such as psychotherapy), sexual intimacy between a therapist and a client is never appropriate. If sexual intimacy occurs it should be reported to DORA at (303) 894-2291, Mental Health Section, 1560 Broadway, Suite 1350, Denver, Colorado 80202; State Board of Licensed Professional Counselor Examiners.

7. Generally speaking, the information provided by and to a client during therapy sessions is legally confidential if the therapist is a certified school psychologist, a licensed social worker, a licensed marriage and family therapist, a licensed professional counselor, a licensed psychologist, or a registered psychotherapist. If the information is legally confidential, the therapist cannot be forced to disclose the information without the client's consent.

8. Information disclosed to a licensed marriage and family therapist, a licensed social worker, a licensed professional counselor, a licensed psychologist, a registered psychotherapist, or a certified/licensed addition counselor is privileged communication and cannot be disclosed in any court of competent jurisdiction in the State of Colorado without the consent of the person to whom the testimony sought relates.

9. There are exceptions to this general rule of legal confidentiality. These exceptions are listed in the Colorado statutes (C.R.S. 12-43-218). You should be aware that provisions concerning disclosure of confidential communications shall not apply to any delinquency or criminal proceedings, except as provided in C.R.S 13-90-107. There are exceptions that I will identify to you as the situations arise during treatment or in our professional relationship. For example, I am required to report child abuse or neglect situations, I am required to report the abuse or exploitation of an at-risk elder or the imminent risk of abuse or exploitation, if I determine that you are a danger to yourself or others, I am required to disclose such information to the appropriate authorities or to warn the party you have threatened, if you become gravely disabled, I am required to report this to the appropriate authorities, if you confess to a felony or other serious crime, I may be required to report that information to the appropriate law enforcement agency. I may also disclose confidential information in the course of supervision or consultation, in the investigation of a complaint or civil suit filed against me, or if I am ordered by a court of competent jurisdiction to disclose such information. You should also be aware that if you should communicate any information involving a threat to yourself or to others, I may be required to take immediate action to protect you or others from harm.

Additionally, although confidentiality extends to communications by text, email, telephone, and/or other electronic means, I cannot guarantee that those communications will be kept confidential and/or that a third-party may access our communications. Even though I may utilize state of the art encryption methods, firewalls, and back-up systems to help secure our communication, there is a risk that our electronic or telephone communications may be compromised, unsecured, and/or accessed by a third-party. Please review and fill out Healing Harbor Counseling's Consent for Communication of Protected Health Information by Non-Secure Transmissions.

10. If you are unable to pay for therapy services, you may have an option of receiving services from students or interns. If you would like this as an option, I will discuss the rate of services and provide a written copy as well.

AS A CLIENT:

1. I understand that Healing Harbor Counseling may contact me to provide appointment reminders or information about treatment alternatives or other health-related benefits and services that may be of interest to me in accordance with Healing Harbor Counseling's Consent for Communication of Protected Health Information by Non-Secure Transmissions.

2. I understand that court testimony on my/our behalf is charged at a higher rate including testimony related matters like case research, report writing, travel, depositions, actual testimony and cross examination time and courtroom waiting time. My therapist will advise me of those fees should the situation arise.

3. I understand that there may be times when my therapist(s) may need to consult with a colleague or another professional, like an attorney or supervisor, about issues raised by me in therapy. My confidentiality is still protected during consultation by my therapist and the professional consulted. Signing this disclosure statement gives my therapist(s) permission to consult as needed to provide professional services to me as a client.

4. I understand that if I initiate communication via electronic means that I have not specifically consented to in Healing Harbor Counseling's Consent for Communication of Protected Health Information by Non-Secure Transmissions, I will need to amend the consent form.

5. I understand that, in general, Healing Harbor Counseling does not provide Teletherapy, such as therapy over Skype or other video chat. I understand that communications via email and text should be limited to administrative purposes and not used as an avenue for therapy. I understand that should I want Teletherapy, I will discuss my request with my therapist. I understand that it is in my therapist's discretion whether to accommodate my request for Teletherapy.

6. I understand that Healing Harbor Counseling, or my therapist, does not accept personal Facebook, LinkedIn, Twitter, Instagram, and/or other friend/connection/follow requests via Social Media. Any such request will be rejected in order to maintain professional boundaries. I understand that Healing Harbor Counseling has, or may have, a business Facebook Page. I understand that there is no requirement that I "like" or "follow" Healing Harbor Counseling's page. I understand that should I "like" or choose to "follow" Healing Harbor Counseling's Facebook page that others will see my name associated with "liking" or "following" Healing Harbor Counseling's Facebook page. I understand that this applies to any comments that I post on Healing Harbor Counseling's Facebook page as well. I understand that any comments I post regarding therapeutic work between my therapist and I, will be deleted. I agree that I will refrain from discussing, commenting, and/or asking therapeutic questions via any social media platform. I agree that if I have a therapeutic comment and/or question that I will contact my therapist through the mode I consented to and not through social media.

7. I understand that if I have any questions regarding social media, review website, or search engine in connection to my therapeutic relationship, I will immediately contact my therapist and address those questions.

8. I understand my therapist(s) provides non-emergency therapeutic services by scheduled appointment. If my therapist(s) believe(s) my therapeutic issues are above her or his level of competence, or outside of his or her scope of practice, he or she is legally required to refer, terminate, or consult. If, for any reason, I am unable to contact my therapist(s) by telephone number she provided me, 719-201-1769, and I am having a true emergency, I will call 911 or check myself into the nearest hospital emergency room. Healing Harbor Counseling does not provide after hours service without an appointment. If you must seek after hours treatment from any counseling agency or center, you will be responsible for any fees due.

9. I understand that I am legally responsible for payment for my therapy services, if for any reason, my insurance company, HMO, third-party payor, etc. does not compensate my therapist. I also understand that signing this form gives permission to my therapist to communicate with my insurance company, HMO, third-party payor, collections agency or anyone connected to my therapy funding source. Failure to pay will be a cause for termination of therapy services. I understand that should I require after hours emergency care, I am solely responsible for all costs arising from such care. I understand that third-party payors can be other individuals, a church, or other organizations. I further understand that if my therapist directly receives payment from a third-party payor that an agreement for payment by a third-party payor must be consented to in writing, by myself, my therapist, and the third-party payor, prior to receiving therapy services.

10. I understand that this form is compliant with HIPAA regulations and no medical or therapeutic information or other information related to my privacy, will be released without permission unless mandated by Colorado law as described in this form. Consistent with HIPAA guidelines authorization for release and consent for treatment will be automatically revoked one year after the signing date. I understand that I have received Healing Harbor Counseling's Notice of Privacy Policies and Practices and Compliance with HIPAA Regarding Confidentiality of Client Records and Dissemination of Information, and acknowledge receipt of the policy.

11. I understand that if I have any questions about my therapist's methods, techniques, or duration of therapy, fee structure, or would like additional information, I may ask at any time during the therapy process. By signing this disclosure statement I also give permission for the inclusion of my partners, spouses, significant others, parents, legal guardians, or other family members in therapy when deemed necessary by myself or my therapist(s). They will also have to sign separate disclosure statements.

12. I understand that should I discontinue therapy for more than 60 days, my treatment will be considered "terminated." I may resume therapy anytime after the 60 day period. This disclosure statement will remain in effect should I resume therapy and I may be asked to provide additional information to update your client records.

13. I understand that should I cancel within 24 hours of my appointment, excluding emergency situations, my therapist has a right to charge my credit card on file for the full amount of my session.

14. I also affirm, by signing this form that I am the legal guardian and/or custodial parent with legal right to consent to treatment for any minor child or children who is under the age of fifteen (15), for whom I am requesting therapy services here at Healing Harbor Counseling or that I am at least fifteen (15) years old and consent to treatment and therapy services here at Healing Harbor Counseling.

15. I understand that if I am consenting to treatment and therapy services for my minor child/ren, that my therapist may request that I produce the Court Order Custody Agreement that grants me the authority to consent to mental health services for my minor child.

16. My signature below affirms that the preceding information has been provided to me in writing by my primary therapist, or if I am unable to read or have no written language, an oral explanation accompanied the written copy. I understand my rights as a client/patient and should I have any questions, I will ask my therapist.

( Type Full Name )
Notice of Privacy Policies

NOTICE OF PRIVACY POLICIES AND PRACTICES AND COMPLIANCE WITH HIPAA REGARDING CONFIDENTIALITY OF CLIENT RECORDS AND DISSEMINATION OF INFORMATION
Given the nature of our work, it is imperative that we maintain the confidence of client information that we receive in the course of our work. Healing Harbor Counseling, PLLC (herein "HHC") is a private mental health counseling practice that provide mental health services to individuals, couples, and families. The practice works solely to provide the best counseling treatment options to its clients. HHC prohibits the release of any client information to anyone outside immediate staff, employees, interns, or volunteers except in limited circumstances. Discussions or disclosures of protected health information (PHI) within the organization is limited to the minimum necessary that is needed for the recipient of the information to perform their job. Please review this Notice of Privacy Policies and Practices and Compliance with HIPAA Regarding Confidentiality of Client Records and Dissemination of Information. It is the policy of HHCto:

1. fully comply with the requirements of the HIPAA General Administrative Requirements, the Privacy and Security Rules;
2. provide every patient who receives services with a copy of this Notice of Privacy Policies and Practices;
3. ask the patient to acknowledge receipt when given a copy of this Notice of Privacy Policies and Practices;
4. ensure the confidentiality of all patient records transmitted by facsimile;
5. provide each client with the individual therapists' informed Authorization for use or disclosure of Protected Health Information forms.

HHC is required to follow all state statutes and regulations including Federal Regulation 42 C.F.R. Part 2 and Title 25, Article 4, Part 14 and Title 25, Article 1, Part 1, CRS and the Health Insurance Portability and Accountability Act (HIPAA), 45 C.F.R. Parts 142, 160, 162 and 164, governing testing for and reporting of TB, HIV AIDS, Hepatitis, and other infectious diseases, and maintaining the confidentiality of protected health information.
Protected health information (PHI) refers to any information that is created or received by HHC, and relates to an individual's past, present or future physical or mental health or conditions and related care services or the past, present, or future payment for the provision of health care to an individual; and

1 That identifies the individual;
2. With respect to which there is a reasonable basis to believe the information can be used to identify the individual; or
PHI includes any such information described above that HHC transmits or maintains in any form, this includes Psychotherapy Notes. HIPAA and federal law regulates the use and disclosure of PHI when transmitted electronically.
YOUR RIGHTS AS A CLIENT:

When it comes to your health information, you have certain rights. This section explains your rights and some of our responsibilities to help you.

Get an electronic or paper copy of your mental health record
- You can ask to see or get an electronic or paper copy of your mental health record and other health information we have about you. Ask us how to do this.
- We will provide a copy or a summary of your health information, usually within 30 days of your request. We may charge a reasonable, cost-based fee.
Ask us to correct your mental health record
- You can ask us to correct health information about you that you think is incorrect or incomplete. Ask us how to do this.
- We may say "no" to your request, but we'll tell you why in writing within 60 days.
Request confidential communications
- You can ask us to contact you in a specific way (for example, home or office phone) or to send mail to a different address.
- We will say "yes" to all reasonable requests.
- Please review the Consent For Communication Of Protected Health Information By Non-Secure Transmissions
- You are required to "opt-in" to receive communications electronically as set-forth in the Consent for Communication of Protected Health Information by Non-Secure Transmissions. If you choose not to "opt-in" to receive electronic communications, we will not communicate with you via electronic means.
Ask us to limit what we use or share
- You can ask us not to use or share certain health information for treatment, payment, or our operations. We are not required to agree to your request, and we may say "no" if it would affect your care.
- If you pay for a service or health care item out-of-pocket in full, you can ask us not to share that information for the purpose of payment or our operations with your health insurer. We will say "yes" unless a law requires us to share that information.
Get a list of those with whom we've shared information
- You can ask for a list (accounting) of the times we've shared your health information for six years prior to the date you ask, who we shared it with, and why.
- We will include all the disclosures except for those about treatment, payment, and health care operations, and certain other disclosures (such as any you asked us to make). We'll provide one accounting a year for free but will charge a reasonable, cost-based fee if you ask for another one within 12 months.
Get a copy of this privacy notice
You can ask for a paper copy of this notice at any time, even if you have agreed to receive the notice electronically. We will provide you with a paper copy promptly.
Choose someone to act for you
- If you have given someone medical power of attorney or if someone is your legal guardian, that person can exercise your rights and make choices about your health information.
- We will make sure the person has this authority and can act for you before we take any action.
File a complaint if you feel your rights are violated
- You can complain if you feel we have violated your rights by contacting us using the information on page 1.
- You can file a complaint with the U.S. Department of Health and Human Services Office for Civil Rights by sending a letter to 200 Independence Avenue, S.W., Washington, D.C. 20201, calling 1-877-696-6775, or visiting www.hhs.gov/ocr/privacy/hipaa/complaints/.
- We will not retaliate against you for filing a complaint.
- You may also file a complaint with the Colorado Department of Regulatory Agencies, Division of Professions and Occupations, Mental Health Section; 1560 Broadway, Suite 1350, Denver, Colorado, 80202, 303-894-2291; DORA_Mentalhealthboard@state.co.us. Please note that the Department of Regulatory Agencies may direct you to file your complaint with the U.S. Department of Health and Human Services Office for Civil Rights listed above.

USES AND DISCLOSURES OF PROTECTED HEALTH INFORMATION

A use of PHI occurs within a covered entity (i.e., discussions among staff regarding treatment). A disclosure of PHI occurs when HHC reveals PHI to an outside party (i.e., HHC provides another treatment provider with PHI, or shares PHI with a third party pursuant to a client's valid written authorization). HIPAA and federal law regulate the disclosure of PHI by electronic transmissions.

HHC may use and disclose PHI, without an individual's written authorization, for the following purposes:

1. Treatment (including the provision and coordination of care with other professionals, etc.)
2. Payment (to bill and get payment from health plans or other entities, claims management, etc.)
3. Health Care Operations (general administrative activities and operation of HHC, resolution of internal grievances, customer service, etc.).

Uses and disclosures for payment and health care operations purposes are subject to the minimum necessary requirement. This means that HHC may only use or disclose the minimum amount of PHI necessary for the purpose of the use of disclosure (i.e., for billing purposes, a therapist would not need to disclose a patient's entire medical record in order to receive reimbursement. A therapist would likely only need to include a service code, etc.) Uses and disclosures for treatment purposes are not subject to the minimum necessary requirement.
HHC is required to promptly notify you of any breach that may occur that may have compromised the privacy or security of your information.

HHC's confidentiality of client records and substance abuse client records maintained is protected by federal law and regulations. It is HHC policy that a patient must complete an Authorization for use or disclosure of Protected Health Information (Attachment 1), provided by HHC, prior to disclosing health information for any purpose, except for treatment, payment or health care operations.

Absent the above referenced form, other than for treatment, payment, or health care operations purposes, HHC staff is prohibited from disclosing or using any PHI outside of or within the organization, including disclosing that the client is in treatment, unless one of the following exceptions arises:

HHC is permitted and/or required to report or disclose PHI if and when any of the following occur with any HHC client:

1. Responding to lawsuit and legal actions (Disclosure by a court order, in response to a complaint filed against a counselor of HHC, etc.)
2. Disclosure is made to medical personnel in a medical emergency or to qualified personnel for research, audit or program evaluation.
3. Help with public health and safety issues (Client commits or threatens to commit a crime either at the program or against any person who works for the program; A minor or elderly client reports having been abused; Client is planning to harm another person, including but not limited to the harm of a child; Client reports suicidal ideations or self harm).
4. Address workers' compensation, law enforcement, and other government requests
5. Respond to organ and tissue donation requests.
6. In compliance with other state and/or federal laws and regulations.

The above exceptions are subject to several requirements under the Privacy Rule, including the minimum necessary requirement (you may only use and disclose the minimum amount of PHI necessary for the intended purpose of the use and/or disclosure) and applicable federal and state laws and regulations. See 45 C.F.R. 164.512. Before using or disclosing PHI for one of the above exceptions, consult HHC's Privacy Officer to ensure compliance with the Privacy Rule. Violation of theses federal and state guidelines is a crime carrying both criminal and monetary penalties. Suspected violations may be reported to appropriate authorities in accordance with federal and state regulations. Know that HHC will never market or sell your personal information.

SPECIAL AUTHORIZATIONS

Certain categories of information have extra protections by law, and thus require special written authorizations for disclosures.

Psychotherapy Notes: I will obtain a special authorization before releasing your Psychotherapy Notes and test results. "Psychotherapy Notes" are notes I have made about our conversation during a private, group, joint, or family counseling session, which I have kept separate from the rest of your record. These notes are given a greater degree of protection than PHI.

HIV Information: Special legal protections apply to HIV/AIDS related information. I will obtain a special written authorization from you before releasing information related to HIV/AIDS.

Alcohol and Drug Use Information: Special legal protections apply to information related to alcohol and drug use and treatment. I will obtain a special written authorization from you before releasing information related to alcohol and/or drug use/treatment. You may revoke all such authorizations (of PHI, Psychotherapy Notes, HIV information, and/or Alcohol and Drug Use Information) at any time, provided each revocation is in writing, signed by you, and signed by a witness. You may not revoke an authorization to the extent that (1) I have relied on that authorization; or (2) if the authorization was obtained as a condition of obtaining insurance coverage, law provides the insurer the right to contest the claim under the policy.

As a covered entity under the Privacy and Security Rules, HHC is required to reasonably safeguard PHI from impermissible uses and disclosures. Safeguards may include, but are not limited to the following:

1. Not leaving lab results unattended where third parties without a need to know can view them.
2. Any PHI received as a HHC employee, intern, or volunteer about a client or potential HHC client, may not be used or disclosed for non-work purposes or with unauthorized individuals. HHC may only use and disclose such PHI as described above.
3. When speaking with a client about his or her PHI where third parties could possibly overhear, move the conversation to a private area.
4. Seek legal counsel in uncertain situations and/or incidences.

YOUR CHOICES:

For certain health information, you can tell us your choices about what we share. If you have a clear preference for how we share your information in the situations described below, talk to us. Tell us what you want us to do, and we will follow your instructions. We may request you sign a separate document if you authorize us to share certain PHI. You may revoke that authorization at anytime for future disclosure.

In these cases, you have both the right and choice to tell us to:
- Share information with your family, close friends, or others involved in your care
- Share information in a disaster relief situation
- Include your information in a hospital directory

If you are not able to tell us your preference, for example if you are unconscious, we may go ahead and share your information if we believe it is in your best interest. We may also share your information when needed to lessen a serious and imminent threat to health or safety.

In these cases we never share your information unless you give us written permission:
- Marketing purposes
- Sale of your information
- Most sharing of psychotherapy notes
In the case of fundraising:
- We may contact you for fundraising efforts, but you can tell us not to contact you again.

Changes to the Terms of this Notice
We can change the terms of this notice, and the changes will apply to all information we have about you. The new notice will be available upon request, in our office, and on our web site.

This notice is effective May 20, 2014.

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