Professional Disclosure Statement

Kristie Fuller, MA, NCC, LMHC
Florida License MH20191
321-209-2332
kristie@theswearytherapist.com

DISCLOSURE STATEMENT:
The following disclosure statement is provided to give you information about my background and the nature of our professional relationship. This document is meant to explain your counselor’s training, offer information about the counseling relationship, provide information about client rights and responsibilities, and outline the limits of confidentiality. This document must be signed by the client or by the client’s parent/legal guardian before counseling may begin. Some information contained in this document is clarified further in the additional intake documents you may have already reviewed.

Introduction:
Your counselor is a graduate of the Master of Arts in Mental Health Counseling program at Wake Forest University (WFU). Wake Forest University’s counseling program is accredited by the Council for the Accreditation of Counseling and Related Educational Programs (CACREP) and consists of 60 semester hours of study, including the practicum and internship courses. This program includes training in many areas including the following: counseling theories and practice, human growth and development, diagnosis and treatment of psychopathology, human sexuality, group theories and practice, individual evaluation and assessment, career and lifestyle assessment, research and program evaluation, social and cultural foundations, counseling in community settings, substance abuse, and legal, ethical, and professional standards issues. Your counselor also holds a master’s degree in Psychology from American Public University and a Bachelor’s degree in Liberal Studies from the University of Central Florida.

Your counseling services will be based on a relationship characterized by trust and respect. The counselor and client will work together to both identify goals for counseling and to move toward meeting those goals. The counseling sessions may include an exploration of thoughts, feelings, personal history, communication styles, attitudes and beliefs about self and others, and personal development needs. Some of these experiences may be uncomfortable for some clients. Your counselor is trained primarily to utilize person-centered, mindfulness-based cognitive-behavioral therapy, and wellness approaches in counseling.

Clients have the right to receive counseling in which the individual’s dignity, worth, and uniqueness are respected. Your counselor will provide you with quality informed services that are offered under close supervision. Additionally, however, the success of the counseling relationship depends on your willingness to be open and involved in the process. Individuals who participate in counseling can experience changes in personal views, attitudes, and coping skills. Sometimes those close to you may need time to adjust to the new perspectives and positive behavioral changes that may evolve during your counseling. Finally, clients have the right to receive services that are confidential, with the following exceptions.

Confidentiality:
Confidentiality is a crucial aspect of the professional counselor’s role and is therefore important for the client to understand the limits to this confidentiality.
It is important to clarify the special circumstances where confidentiality cannot be maintained. Confidentiality will conform to state guidelines and the ethical guidelines of the American Counseling Association. All counselors-in-training, their supervisors, and group supervision members will not disclose information except under the following conditions:

• The client or guardian gives written consent to release information to a designated individual or agency;
• The client makes specific violent threats to harm him-or herself or to harm an identifiable victim;
• The counselor and/or their supervisors are named as defendants in a civil, criminal, or disciplinary action arising from the counseling session;
• The counselor receives an authentic subpoena backed by judicial authority that requires the disclosure of information; The counselor has reasonable cause to believe that a child or adult with a disability has suffered abuse or neglect; and
• The counselor may discuss the content of counseling sessions under the direction of a Qualified Supervisor who is held to the same professional standards of confidentiality and its limits.
• The counselor may share your information with other clinicians employed at this site for the purposes of case consultation. This sharing of information will only occur if it presents as beneficial for your development and growth. All clinicians are bound by the governing HIPAA laws and will comply with this confidentiality agreement.
• If you are under eighteen years of age, please be aware that the law may provide your parents the right to examine your treatment records. It is your counselor’s general policy to provide your parents/guardians only with general information about our work together, unless it is felt that there is a high risk that you are being harmed, will seriously harm yourself or will harm someone else. In this case, your parents will be notified of my concern, as well as the appropriate authorities if necessary. Before giving them any information, your counselor will discuss the matter with you, if possible, and do her best to handle any objections you may have with what she is prepared to disclose.

Fees & Expectations:
Session fees and length of service shall be determined by the counselor and/or the counseling agency where your counselor is contracted. Your counselor is not contracted with any insurance companies and is self-pay only and does not provide superbills for clients.. The current fees are posted to your counselor's website and can be found online at www.swearytherapy.com.

Your participation and attendance of each session is very important in order to obtain the greatest benefits of counseling. In addition, your counselor will spend time preparing for your visit to ensure that you have the maximum opportunity for growth in every session. In return, it is expected that if you have a challenge that prevents you from attending an appointment please contact your therapist to reschedule the appointment with a minimum of 24 hours’ notice in order to avoid the cancellation fee.

After the first incident of late cancellation/no show, the client will no longer be able to schedule re-occurring appointments and may lose their “spot” on the calendar. After three incidents, the client may be discharged from the practice. If you have not had contact with your counselor’s office and you fail to show for an appointment, all appointments that may have been scheduled in advance will be removed from the calendar to avoid additional cancellation fees.

Please know that your counselor understands that there may be incidences that arise that make your attendance unavoidable and these will be reviewed on a case-by-case basis.

Payment for services is required the same day as services are rendered. After each session, your counselor will send you an invoice to pay. If a client payment is late more than two times, the client will be required to pay for services at the start of the session.

Intake paperwork and consent forms are required from each client. The client will have until the start of the first session to complete the paperwork on their own and return it to the counselor. If by the start of the first session, the paperwork is incomplete, the session will be spent completing paperwork together.  If the paperwork cannot be completed, the client will be discharged from the practice.


Boundaries:
Although the session may be very intimate psychologically, it is important for clients to realize that we have a professional relationship. Contact will be limited to the sessions you arrange with me. It is vital for you to know that if the counselor sees you in public, she will protect your confidentiality by greeting you only if you greet her first.

In order to promote a healthy therapeutic relationship certain boundaries and policies have been established to ensure the safety, respect, and independence necessary for growth, nurture and understanding. Once we have entered into the counseling relationship together this will become our priority relationship and all other interactions will become secondary in nature and avoided if they do not directly contribute to the benefits of our therapeutic relationship.

Additionally, it is your counselor's policy to limit the duration of outside contact that is deemed unrelated to counseling such as "running into each other" in public and/or "friending" on Facebook or similar social network sites.

Emergency Contact:
Your counselor may not always be immediately available for contact by phone or email. Please feel free to leave a message and every effort will be made to return your call within 24 hours on weekdays and within 48 hours on weekends. If, for any reason, you feel that you need to speak with someone immediately, please see the emergency resources below:

• Emergency Service: 911
• Brevard County Crisis Hotline: 211
• National Suicide Prevention Lifeline: 988
• National Domestic Violence Hotline: 1-800-799-7233
• Crisis Text Line: text the word “home” to 741741

Termination:
You are free to end, take a break from, or request a referral for treatment at any time. It is encouraged that you discuss your reasons for your decision with your counselor so that sufficient closure can be given to our therapeutic relationship, as well as allow for referrals to be made for treatment options that will best meet your needs. The laws and standards of my profession require that treatment records are kept for a minimum of 7 years. If you wish to see your record

Questions or Concerns:
If you have any questions or concerns, please contact your counselor. Your counselor may be reached directly at (321)-209-2332. You may also choose to email your counselor at kristie@theswearytherapist.com, however, please be aware that your counselor cannot guarantee confidentiality of email communication. If you choose to communicate confidential information with your counselor via email, it will be assumed that you have made an informed decision and your counselor will view it as your agreement to take the risk that email may be intercepted.

Please be aware that email is never an appropriate vehicle of emergency communication. Do not use text, email or voicemail to communicate in a crisis. Please call 911 or Go to the nearest Emergency Room or use the crisis contact numbers listed above.

Although clients are encouraged to discuss any concerns with the counselor, you may file a complaint against the counselor with the organization listed below should you, the client, feel she is in violation of any of these codes of ethics. The Florida Department of Health has the general responsibility of regulating the practice of licensed psychologists, licensed social works, licensed mental health counselors, licensed marriage and family therapists, licensed school psychologists practicing outside the school setting, licensed or certified addiction counselors, and unlicensed interns who practice psychotherapy.

Board of Clinical Social Work, Marriage & Family Therapy, and Mental Health Counseling
Department of Health
4052 Bald Cypress Way, Bin C75
Tallahassee, FL 32399-3290
Phone: 850-245-4339
Email: MQA.ConsumerServices@flhealth.gov
Website: http://www.floridahealth.gov/licensing-and-regulation/enforcement/index.html

You may obtain a copy of the Code of Ethics from the American Counseling Association at www.counseling.org or by calling 1-800-347-6647

---

Notice of Privacy Practices

This is provided to all clients at intake.

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

I. MY PLEDGE REGARDING HEALTH INFORMATION:
I understand that health information about you and your health care is personal. I am committed to protecting health information about you. I create a record of the care and services you receive from me. I need this record to provide you with quality care and to comply with certain legal requirements. This notice applies to all of the records of your care generated by this mental health care practice. This notice will tell you about the ways in which I may use and disclose health information about you. I also describe your rights to the health information I keep about you, and describe certain obligations I have regarding the use and disclosure of your health information. I am required by law to:

• Make sure that protected health information (“PHI”) that identifies you is kept private.
• Give you this notice of my legal duties and privacy practices with respect to health information.
• Follow the terms of the notice that is currently in effect.
• I can change the terms of this Notice, and such changes will apply to all information I have about you. The new Notice will be available upon request, in my office, and on my website.

II. HOW I MAY USE AND DISCLOSE HEALTH INFORMATION ABOUT YOU:

The following categories describe different ways that I use and disclose health information. For each category of uses or disclosures I will explain what I mean and try to give some examples. Not every use or disclosure in a category will be listed. However, all of the ways I am permitted to use and disclose information will fall within one of the categories.

For Treatment Payment, or Health Care Operations:
Federal privacy rules (regulations) allow health care providers who have direct treatment relationship with the patient/client to use or disclose the patient/client’s personal health information without the patient’s written authorization, to carry out the health care provider’s own treatment, payment or health care operations. I may also disclose your protected health information for the treatment activities of any health care provider. This too can be done without your written authorization. For example, if a clinician were to consult with another licensed health care provider about your condition, we would be permitted to use and disclose your personal health information, which is otherwise confidential, in order to assist the clinician in diagnosis and treatment of your mental health condition.

Disclosures for treatment purposes are not limited to the minimum necessary standard. Because therapists and other health care providers need access to the full record and/or full and complete information in order to provide quality care. The word “treatment” includes, among other things, the coordination and management of health care providers with a third party, consultations between health care providers and referrals of a patient for health care from one health care provider to another.

Lawsuits and Disputes:
If you are involved in a lawsuit, I may disclose health information in response to a court or administrative order. I may also disclose health information about your child in response to a subpoena, discovery request, or other lawful process by someone else involved in the dispute, but only if efforts have been made to tell you about the request or to obtain an order protecting the information requested.

III. CERTAIN USES AND DISCLOSURES REQUIRE YOUR AUTHORIZATION:

1. Psychotherapy Notes.
    do keep “psychotherapy notes” as that term is defined in 45 CFR § 164.501, and any use or disclosure of such notes requires your Authorization unless the use or disclosure is:
   a. For my use in treating you.
   b. For my use in training or supervising mental health practitioners to help them improve their skills in group, joint, family, or individual counseling or therapy.
   c. For my use in defending myself in legal proceedings instituted by you.
   d. For use by the Secretary of Health and Human Services to investigate my compliance with HIPAA.
   e. Required by law and the use or disclosure is limited to the requirements of such law.
   f. Required by law for certain health oversight activities pertaining to the originator of the psychotherapy notes.
   g. Required by a coroner who is performing duties authorized by law.
   h. Required to help avert a serious threat to the health and safety of others.
   
2. Marketing Purposes.
   As a psychotherapist, I will not use or disclose your PHI for marketing purposes.
3. Sale of PHI.
   As a psychotherapist, I will not sell your PHI in the regular course of my business.

IV. CERTAIN USES AND DISCLOSURES DO NOT REQUIRE YOUR AUTHORIZATION.
Subject to certain limitations in the law, I can use and disclose your PHI without your Authorization for the following reasons:

1. When disclosure is required by state or federal law, and the use or disclosure complies with and is limited to the relevant requirements of such law.
2. For public health activities, including reporting suspected child, elder, or dependent adult abuse, or preventing or reducing a serious threat to anyone’s health or safety.
3. For health oversight activities, including audits and investigations.
4. For judicial and administrative proceedings, including responding to a court or administrative order, although my preference is to obtain an Authorization from you before doing so.
5. For law enforcement purposes, including reporting crimes occurring on my premises.
6. To coroners or medical examiners, when such individuals are performing duties authorized by law.
7. For research purposes, including studying and comparing the mental health of patients who received one form of therapy versus those who received another form of therapy for the same condition.
8. Specialized government functions, including, ensuring the proper execution of military missions; protecting the President of the United States; conducting intelligence or counter-intelligence operations; or, helping to ensure the safety of those working within or housed in correctional institutions.
9. For workers’ compensation purposes. Although my preference is to obtain an Authorization from you, I may provide your PHI in order to comply with workers’ compensation laws.
   10 Appointment reminders and health related benefits or services. I may use and disclose your PHI to contact you to remind you that you have an appointment with me. I may also use and disclose your PHI to tell you about treatment alternatives, or other health care services or benefits that I offer.

V. CERTAIN USES AND DISCLOSURES REQUIRE YOU TO HAVE THE OPPORTUNITY TO OBJECT.

1. Disclosures to family, friends, or others. I may provide your PHI to a family member, friend, or other person that you indicate is involved in your care or the payment for your health care, unless you object in whole or in part. The opportunity to consent may be obtained retroactively in emergency situations.

VI. YOU HAVE THE FOLLOWING RIGHTS WITH RESPECT TO YOUR PHI:

1. The Right to Request Limits on Uses and Disclosures of Your PHI. You have the right to ask me not to use or disclose certain PHI for treatment, payment, or health care operations purposes. I am not required to agree to your request, and I may say “no” if I believe it would affect your health care.
2. The Right to Request Restrictions for Out-of-Pocket Expenses Paid for In Full. You have the right to request restrictions on disclosures of your PHI to health plans for payment or health care operations purposes if the PHI pertains solely to a health care item or a health care service that you have paid for out-of-pocket in full.
3. The Right to Choose How I Send PHI to You. You have the right to ask me to contact you in a specific way (for example, home or office phone) or to send mail to a different address, and I will agree to all reasonable requests.
4. The Right to See and Get Copies of Your PHI. Other than “psychotherapy notes,” you have the right to get an electronic or paper copy of your medical record and other information that I have about you. I will provide you with a copy of your record, or a summary of it, if you agree to receive a summary, within 30 days of receiving your written request, and I may charge a reasonable, cost based fee for doing so.
5. The Right to Get a List of the Disclosures I Have Made.You have the right to request a list of instances in which I have disclosed your PHI for purposes other than treatment, payment, or health care operations, or for which you provided me with an Authorization. I will respond to your request for an accounting of disclosures within 60 days of receiving your request. The list I will give you will include disclosures made in the last six years unless you request a shorter time. I will provide the list to you at no charge, but if you make more than one request in the same year, I will charge you a reasonable cost based fee for each additional request.
6. The Right to Correct or Update Your PHI. If you believe that there is a mistake in your PHI, or that a piece of important information is missing from your PHI, you have the right to request that I correct the existing information or add the missing information. I may say “no” to your request, but I will tell you why in writing within 60 days of receiving your request.
7. The Right to Get a Paper or Electronic Copy of this Notice. You have the right get a paper copy of this Notice, and you have the right to get a copy of this notice by e-mail. And, even if you have agreed to receive this Notice via e-mail, you also have the right to request a paper copy of it.