Vibrant Couples & Individual Counseling

HIPAA DISCLOSURES RE CONFIDENTIAL INFORMATION

THIS NOTICE CONTAINS INFORMATION CONCERNING HOW CONFIDENTIAL MENTAL HEALTH TREATMENT INFORMATION CONCERNING YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN OBTAIN ACCESS TO THIS INFORMATION.PLEASE REVIEW IT CAREFULLY AND LET US KNOW ANY QUESTIONS THAT YOU MAY HAVE CONCERNING THIS NOTICE.During the process of providing services to you, Vibrant Couples & Individual Counseling will obtain and use mental health and medical information concerning you that is both confidential and privileged.Ordinarily this confidential information will be used in the manner that is described in this statement, and will not be disclosed without your consent, except for the circumstances described in this Notice.

I.    USES AND DISCLOSURES OF PROTECTED INFORMATION

A.  General Uses and Disclosures Not requiring the Client's Consent.Vibrant Couples & Individual Counseling will use and disclose protected health information in the following ways.

1.   Treatment.Treatment refers to the provision, coordination, or management of mental health care and related services by one or more health care providers.For example, Vibrant Couples & Individual Counseling Therapists and staff involved with your care may use your information to plan your course of treatment and consult with other health care professionals or their staff concerning services needed or provided to you.

2.   Payment.Payment refers to the activities undertaken by a health care provider to obtain or provide reimbursement for the provision of health care.For example, Vibrant Couples & Individual Counseling and other health care professionals will use information that identifies you, including information concerning your diagnosis, services provided to you, dates of services, and services needed by you, and may disclose such information to insurance companies, to businesses that review bills for health care services and handle claims for payment of health care benefits in order to obtain payment for services.If you are covered by Medicaid, information may be provided to the State of Colorado's Medicaid program, including but not limited to your treatment, condition, diagnosis, and services received.

3.   Health Care Operations.Health Care Operations means activities undertaken by health insurance companies, businesses that administer health plans, and companies that review bills for health care services in order to process claims for health care benefits.These functions include management and administrative activities.For example, such companies may use your health information in monitoring of service quality, staff training and evaluation, medical reviews, legal services, auditing functions, compliance programs, business planning and Accreditation, certification, licensing and credentialing activities.

4.   Contacting the Client.Vibrant Couples & Individual Counseling may contact you to remind you of appointments and to tell you about treatments or other services that might be of benefit to you.

5.   Required by Law. Vibrant Couples & Individual Counseling will disclose protected health information when required by law.This includes, but is not limited to: (a) reporting child abuse or neglect to the Department of Human Services or to law enforcement; (b) when court ordered to release information; (c) when there is a legal duty to warn of a threat that a client has made of imminent physical violence, health care professionals are required to notify the potential victim of such a threat, and report it to law enforcement; (d) when a client is imminently dangerous to herself/himself or to others, or is gravely disabled, health care professionals may have a duty to hospitalize the client in order to obtain a 72-hour evaluation of the client; and (e) when required to report a threat to the national security of the United States.

6.   Health Oversight Activities.Your confidential, protected health information may be disclosed to health oversight agencies for oversight activities authorized by law and necessary for the oversight of the health care system, government health care benefit programs, regulatory programs or determining compliance with program standards.

7.   Crimes on the premises or observed by Vibrant Couples & Individual Counselingpersonnel.Crimes that are observed by Vibrant Couples & Individual Counseling staff, that are directed toward staff, or occur on Vibrant Couples & Individual Counseling premises will be reported to law enforcement.

8.   Business Associates.Confidential health care information concerning you, provided to insurers or to plans for purposes or payment for services that you receive may be disclosed to business associates.For example, some administrative, clinical, quality assurance, billing, legal, auditing and practice management services may be provided by contracting with outside entities to perform those services.In those situations, protected health information will be provided to those contractors as is needed to perform their contracted tasks.Business associates are required to enter into an agreement maintaining the privacy of the protected health information released to them.

9.   Involuntary Clients.Information regarding clients who are being treated involuntarily, pursuant to law, will be shared with other treatment providers, legal entities, third party payers and others, as necessary to provide the care and management coordination needed in compliance with Colorado law.

10.   Emergencies.In life threatening emergencies Vibrant Couples & Individual Counseling staff will disclose information necessary to avoid serious harm or death.

B.   Client Release of Information or Authorization.Vibrant Couples & Individual Counseling and other health care professionals may not use or disclose protected health information in any way other than those situations outlined above without a signed release of information or authorization.When you sign a release of information, or an authorization, it may later be revoked, provided that the revocation is in writing.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.

II.   YOUR RIGHTS AS A CLIENT

A.  Right to Inspect and Copy. You have the right to inspect or obtain a copy (or both) of PHI in my mental health and billing records used to make decisions about you for as long as the PHI is maintained in the record.  I may deny your access to PHI under certain circumstances, but in some cases you may have this decision reviewed.  On your request, I will discuss with you the details of the request and denial process.

B.   Amendment of Your Record.You have the right to request that Vibrant Couples & Individual Counseling or your health care professionals amend your protected health information.Vibrant Couples & Individual Counseling is not required to amend the record if it is determined that the record is accurate and complete.There are other exceptions, which will be provided to you at the time of your request, if relevant, along with the appeal process available to you.To make a request, ask Vibrant Couples & Individual Counseling staff for the appropriate request form.

C.  Accounting of Disclosures.You have the right to receive an accounting of certain disclosures Vibrant Couples & Individual Counseling has made regarding your protected health information.However, that accounting does not include disclosures that were made for the purpose of treatment, payment, or health care operation or disclosures made pursuant to a signed Authorization.There are other exceptions that will be provided to you, should you request an accounting.To make a request, ask Vibrant Couples & Individual Counseling staff for the appropriate request form.

D.  Additional Restrictions.You have the right to request additional restrictions on the use or disclosure of your health information. Vibrant Couples & Individual Counseling does not have to agree to that request, and there are certain limits to any restriction, which will be provided to you at the time of your request.To make a request, ask Vibrant Couples & Individual Counseling staff for the appropriate request form.

E.   Alternative Means of Receiving Confidential Communications.You have the right to request that you receive communications of protected health information fromVibrant Couples & Individual Counseling by alternative means or at alternative locations.For example, if you do not want Vibrant Couples & Individual Counseling to mail bills or other materials to your home, you can request that this information be sent to another address.There are limitations to the granting of such requests, which will be provided to you at the time of the request process.To make a request, ask Vibrant Couples & Individual Counseling staff for the appropriate request form.

F.   Copy of this Notice.You have a right to obtain a paper copy of this Notice upon request.

III.   ADDITIONAL INFORMATION

A.  Privacy Laws. Vibrant Couples & Individual Counseling is required by State and Federal law to maintain the privacy of protected health information.In addition, Vibrant Couples & Individual Counseling is required by law to provide clients with notice of its legal duties and privacy practices with respect to protected health information.That is the purpose of this Notice.

B.   Terms of the Notice and Changes to the Notice.Vibrant Couples & Individual Counseling is required to abide by the terms of this Notice, or any amended Notice that may follow. Vibrant Couples & Individual Counseling reserves the right to change the terms of its Notice and to make the new Notice provisions effective for all protected health information that it maintains.When the Notice is revised, the revised Notice will be posted in Vibrant Couples & Individual Counseling service delivery sites and will be available upon request.

C.  Complaints Regarding Privacy Rights.If you believe Vibrant Couples & Individual Counseling has violated your privacy rights, you have the right to complain to Vibrant Couples & Individual Counseling management.Please submit a statement, in writing, addressed to Vibrant Couples & Individual Counseling, concerning your complaint and the basis for it.You also have the right to complain to the United States Secretary of Health and Human Services by sending your complaint to the Office of Civil Rights, U.S. Department of Health and Human Services, 200 Independence Avenue, S.W., Room 515F, HHH Bldg., Washington, D.C. 20201.It is the policy of Vibrant Couples & Individual Counseling that there will be no retaliation for your filing of such complaints.

D.  Additional Information.If you desire additional information about your privacy rights at Vibrant Couples & Individual Counseling, please ask us any questions that you may have.

IV. CONFIDENTIALITY OF ALCOHOL AND DRUG ABUSE PATIENT RECORDS

A.  The confidentiality of alcohol and drug abuse patient records maintained by Vibrant Couples & Individual Counseling is protected by Federal law and regulations.Generally, the program may not say to a person outside the program that a patient attends the program, or disclose any information identifying a patient as an alcohol or drug abuser unless:

1.     The patient consents in writing;

2.     The disclosure is allowed by a court order; or

3.     The disclosure is made to medical personnel in a medical emergency or to qualified personnel for research, audit, or program evaluation.

B.   Violation of the Federal Law and regulations by a program is a crime.Suspected violations may be reported to appropriate authorities in accordance with Federal regulations.

C.  Federal law and regulations do not protect any information about a crime committed by a patient either at the program or against any person who works for the program or about any threat to commit such a crime.Disclosure may be made concerning any threat made by a client to commit imminent physical violence against another person to the potential victim who has been threatened and to law enforcement.

D.  Federal law and regulations do not protect any information about suspected child abuse or neglect from being reported under State law to appropriate State or local authorities.

V.    EFFECTIVE DATE, THIS NOTICE IS EFFECTIVE:

I understand these disclosures.I have received a copy of this Disclosure Statement and Notice of Privacy Rights.

LICENSES/ DEGREES/EXPERIENCE
I received my B.A. in Applied Psychology from Regis University, Denver, CO in 2008.
I received my M.A. in Clinical Counseling with the emphasis on Marriage and Family therapy from University of Northern Colorado, Denver, CO in 2011.
I received a post-graduate and advance training in Marriage and Family Therapy from Denver Family Institute in 2012
I have been a Marriage and Family Therapist in the state of Colorado since 2013 (License #1101).
I am an AAMFT Approved Clinical Supervisor since November, 2017.
I am a clinical member in good standing of The American Association for Marriage and Family Therapy (AAMFT).
I am a clinical member of the International Centre for Excellence in Emotionally Focused Therapy.
I am a Certified Emotionally Focused Therapist (EFT) and Supervisor 

Professional Experiences include working for Denver Family Institute, Touchstone Health Partners, Evergreen Psychotherapy Center, Attachment Treatment and Training Institute.

REGULATION OF PSYCHOTHERAPISTS & CLIENT RIGHTS
Levels of regulations of mental health professionals in Colorado include licensing (requires minimum education, experience, and examination qualifications), certification (requires minimum training, experience, and for certain levels, examination qualifications), and registration (does not require minimum education, experience, or training.) All levels of regulation require passing a jurisprudence take-home examination.

The practice of licensed or registered persons in the field of psychotherapy is regulated by the Mental Health Licensing Section of the Division of Registrations. The regulatory boards can be reached at 1560 Broadway, Suite 1350, Denver, Colorado 80202, (303) 894-7800. The regulatory requirements for mental health professionals provide that a 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. A Licensed Social Worker must hold a masters degree in social work. A 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. A Certified Addiction Counselor I (CAC I) must be a high school graduate, and complete required training hours and 1000 hours of supervised experience. A CAC II must complete additional required training hours and 2,000 hours of supervised experience. A CAC III must have a bachelor's degree in behavioral health, and complete additional required training hours and 2,000 hours of supervised experience. A Licensed Addiction Counselor must have a clinical masters degree and meet the CAC III requirements. A Registered Psychotherapist is listed in the State's Database and is authorized by law to practice psychotherapy in Colorado, but is not licensed by the state and is not required to satisfy any standardized educational or testing requirements to obtain a registration from the state.

CLIENT RIGHTS AND IMPORTANT INFORMATION

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

b.   You can seek a second opinion from another therapist or terminate therapy at any time.

c.   In a professional relationship (such as ours), sexual intimacy between a therapist and a client is never appropriate. If sexual intimacy occurs, it should be reported to the Board that licenses, certifies, or registers the therapist.

d.   Generally speaking, information provided by and to a client in a professional relationship with a psychotherapist is legally confidential, and the therapist cannot disclose the information without the client's consent. There are several exceptions to confidentiality, which include: (1) I am required to report any suspected incident of child abuse or neglect to law enforcement, including incidents of a child witnessing domestic violence; (2) I am required to report any threat of imminent physical harm by a client to law enforcement and to the person(s) threatened, including threats against people identifiable by their association with a specific location or entity; (3) I am required to initiate a mental health evaluation of a client who is imminently dangerous to self or to others, or who is gravely disabled, as a result of a mental disorder; (4) I am required to report any suspected threat to national security to federal officials; (5) I am required to report abuse of an at-risk adult or senior, who is 70 years of age or older, which I believe has probably occurred, including institutional neglect, physical injury, financial exploitation, or unreasonable restraint; and (6) I may be required by Court Order to disclose treatment information.

e.   When I am concerned about a client's safety, it is my policy to request a Welfare Check through local law enforcement. In doing so, I may disclose to law enforcement officers information concerning my concerns. By signing this Disclosure Statement and agreeing to treat with me, you consent to this practice, if it should become necessary.

f.    Under Colorado law, C.R.S. 14-10-123.8, parents have the right to access mental health treatment information concerning their minor children, unless the court has restricted access to such information. If you request treatment information from me, I may provide you with a treatment summary, in compliance with Colorado law and HIPAA Standards.

g.   I agree not to record our sessions without your written consent; and you agree not to tape record a session or a conversation with me without my written consent. If you agree for me to record your sessions, please sign a separate form called: INFORMED CONSENT TO VIDEO TAPE AND RELEASE INFORMATION.

DISCLOSURE REGARDING DIVORCE AND CUSTODY LITIGATION

If you are involved in divorce or custody litigation, my role as a therapist is not to make recommendations to the court concerning custody or parenting issues. By signing this Disclosure Statement, you agree not to subpoena me to court for testimony or for disclosure of treatment information in such litigation; and you agree not to request that I write any reports to the court or to your attorney, making recommendations concerning custody. The court can appoint professionals, who have no prior relationship with family members, to conduct an investigation or evaluation and to make recommendations to the court concerning parental responsibilities or parenting time in the best interests of the family's children.

CONFIDENTIALITY:

For Consultation or Clinical Supervision: To provide the best possible treatment for our clients, the staff at VCIC may consult with other professionals concerning your treatment. This includes consultation with clinical supervisors, attorneys, consultants or other treatment team members at VCIC. The same confidentiality laws detailed herein apply to all professionals with whom we may consult.

We are also required to report when: 1) you or your representative files a lawsuit or grievance against your primary therapist. 2) if your primary therapist is compelled by a court to appear or provide documentation. 3) if a legal exception to confidentiality arises during therapy. If feasible, you will be informed accordingly. 4) if we are require by Court Order to disclose treatment information.

Also, if you are 18 years or older and disclose to me that you were abused as a minor, I do have a duty to report if there is reasonable cause to know or suspect that the perpetrator has subjected another child currently under 18 to abuse or neglect or to circumstances that would likely result in abuse or neglect or if the perpetrator is   currently in a position of trust as defined in C.R.S. 18-3-4-1(3.5) with regard to any child currently under 18.

EMAILS/ TEXT MESSAGES/ EMERGENCIES
Emails or texts should only be used for logistical purposes to schedule appointments. Although confidentiality extends to emails and text messages, I cannot guarantee that these communication methods will not be compromised. If you choose to email or text me any treatment issues, I will read that correspondence, but I might not respond until I see you in person.

I provide non-emergency therapeutic services by scheduled appointments only. If you are experiencing a true emergency and are unable to contact me by the telephone number provider, you will call 911, check yourself into the nearest hospital emergency room, or call Colorado Crisis Hotline at (844) 493-8255. I do not provide after-hours treatment without an appointment.

COORDINATION OF CARE
If you are seeing another mental health care provider for treatment and you are in treatment with me, I will require that you sign a release to exchange information in order to coordinate treatment.

DURATION OF THERAPY AND CANCELLATIONS
Duration of therapy can vary from brief to long-term, depending on the nature of your treatment issues. The length of treatment depends on the efforts of both you and I. Throughout therapy we will discuss your progress. You are encouraged to discuss any concerns about lack of progress with me. I cannot guarantee a cure and if I believe that you are not benefiting from treatment, it is my ethical duty to terminate and refer. It is important that if you need to cancel an appointment that you contact me 48 hours in advance. If you do not do this you will be charged a full session fee. In the event of a bona fide emergency I will waive the 48-hour cancellation requirement. If you choose to discontinue therapy for more than 60 days by not communicating with your primary therapist, your treatment will be considered "terminated." Your therapist may be able to resume therapy after 60 days, however, that will depend on therapist's availability and will be within that therapist sole discretion.

COLLECTING PAYMENTS AND ENDING SESSIONS ON TIME.

You will be expected to pay for each session at the time it is held unless we have agreed otherwise in advance.  If your account has not been paid for more than thirty (30) days and payment arrangements have not been agreed upon, your account will be considered past due and I have the option of using legal means to secure the payment.  This may involve using a collection agency or filing a claim in small claims court.  In collection situations, I will make all efforts to release the minimum information necessary to proceed with collections or a claim, which will include the client name, dates, times, and the nature of services, and the amount due.  Before I engage a collection agency, I will provide you with written notice of my intent to do so, sent to your last address I have on record, and give you an opportunity to make payment arrangements.

My current fees are: 60min Individual Session: $125; 75min Individual Session: $150; 90min Individual Session: $175; 60min Couples/Family Session: $150; 75min Couples/Family Session: $175; 90min Couples/Family Session: $220.

I do my best to end my sessions on time, however, if clinically advised, I might extend our session by 15min in order to provide you with appropriate closure/insight/time to process and integrate what we worked on in session. In that case, I will pro-rate your fee.

You will be billed for non-covered and non-routine services such as extended telephone consultation, crisis intervention, non-legal report- writing, and extended care coordination with other providers at a rate of $250.00 per hour. You will be informed of events involving additional billing prior to the event. Any legal report writing, court appearances, or legal consultations (including preparation time and drive time for these legal matters) will be billed at a rate of $500.00 per hour.

HEALTH INSURANCE

I do not accept insurance for mental health services and am not in network with any insurance provider.  I will provide you with documentation that you can submit to your insurance company for reimbursement for services provided.

NO SECRETS POLICY

When treating a couple or a family, the couple or family is considered to be the client.  If one member of the couple or family discloses information that is directly relevant to the treatment of the couple or family, it may be necessary to share that information with the other members of the couple or family for the sake of facilitating treatment.  I will use my best judgement in deciding when or if such disclosures will be made and, whenever possible, I will first give you the opportunity to share the information yourself.  In addition, if a request is made for the records of couple or family therapy, records will only be released with the consent of all parties, and any information that is released will be released to both members of the couple or to all adults engaging in family therapy.  This "no secrets" policy is intended to allow me to continue to provide therapy to the family or couple by preventing, as much as possible, conflicts of interest that may arise. If you feel it necessary to talk about matters that you do not wish to have disclosed, you should consult with a separate therapist for individual treatment.

DUAL RELATIONSHIPS

I do not provide individual counseling to a client who is receiving couples counseling from me. However, while I am working on a behalf of the couple relationship, I will be seeing each partner individually when clinically advised and needed. I will do my best to provide an equal number of sessions for each partner.  

If I saw you for couples counseling, you terminated treatment, your relationship ended, and you decided to come back to see me for individual counseling, it is my policy to get a permission from your ex partner to enter this new type of individual counseling relationship with you. In that case, you and your ex partner both understand that if you decide to get back together and continue couples counseling work, I will have to refer you out to a different couples therapist.

RECORD KEEPING AND RETENTION

I store your records electronically with CounSol, which is a HIPPA complaint platform for mental health professionals. To help maintain the security of the electronically stored information, I have entered into a HIPAA Business Associates Agreement with CounSol under which the company is required by federal law to protect the electronic information from unauthorized use or disclosure.  It may be necessary for other individuals to have access to the electronically stored information, such as CounSol's workforce members, in order to maintain the system itself. Federal law protecting the electronically stored information extends to these workforce members. If you have any questions about the security measures I employ, please ask.   

Records are maintained and will be destroyed in accordance with state and federal laws and regulations.  Currently, Colorado law requires that I maintain your records for a period of seven (7) years commencing on the date of termination of services or the date of last contact with the client, whichever is later.  After this time, your records will be destroyed.  If you would like further information about the maintenance of your records, please ask.

Any person who alleges that a mental health professional has violated the licensing laws related to the maintenance of records of a client eighteen years of age or older, must file a complaint or other notice with the licensing board within seven years after the person discovered or reasonably should have discovered this.

ONLINE SESSIONS/ PHONE SESSIONS REGULATIONS

In general, I do not provide teletherapy such as therapy over the phone or other electronic means.  Communications over text or email should be limited to administrative purposes such as appointment scheduling.  If you want teletherapy, you can discuss that with me and I will determine if teletherapy is appropriate at my sole discretion.  If we do engage in teletherapy, I will require that you sign a separate Informed Consent for Teletherapy form.

INTERRUPTION OF SERVICES - PROFESSIONAL DESIGNEE

In the event that I am disabled, die, or become incapacitated, the following provider will act as my Professional Designee and will have access to my client files.  The Professional Designee will contact you to notify you of the event and will assist in continuing your care and treatment with the least amount of disruption possible by providing you with referrals and transferring your client record, if requested, to your new provider.  If you are not comfortable with the below listed Professional Designee for any reason, please let me know and we will discuss alternatives.

Name: Heather Talbot

Address: 80 Garden Center #128 Broomfield, CO 80020

Telephone: (818) 324-4800

Credentials: LPC

INFORMED CONSENT FOR TREATMENT

I have read this Disclosure Statement, understand the disclosures that have been made, and acknowledge that I know how to access the copy of this disclosure via CounSol portal. Also, key points from this Disclosure Statement have been presented to me verbally.