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Terms and Policy

NOTICE OF PRIVACY PRACTICES
This notice describes how medical and mental health information about you may be used and disclosed, and how you can get access to this information. Please review it carefully.

It is my professional and ethical responsibility to hold your personal information in the strictest confidence. I am required by applicable Federal and State of Washington law to maintain the privacy of your health information. I am also required to give you this Notice about my privacy practices, legal obligation, and your rights concerning your health information (Protected Health Information, or "PHI"). I must follow the privacy practices described in this Notice (which may be amended from time to time).

I. USES AND DISCLOSURES OF PROTECTED HEALTH INFORMATION

A. Permissible Uses and Disclosures Without Your Written Authorization:
I may use and disclose PHI without your written authorization, excluding Psychotherapy Notes and Reports, as described in Section I-B, for certain purposes described below. The examples provided are not meant to be exhaustive, but instead are meant to describe the types of uses and disclosures that are permissible under Federal and State of Washington law.

1. Treatment: I may use and disclose PHI in order to provide treatment to you. For example, I may use PHI to diagnose and provide counseling service to you. In addition, I may disclose PHI to other health care providers involved in your treatment. This includes clinical supervisors and case consultants who assist in my professional development and are bound to mental health confidentiality laws. I participate in supervision and consultation so that I may provide high quality services for your benefit.

2. Health care operations: I may use and disclose PHI in connection with my health care operations, including accreditation, certification, licensing or credentialing activities. I will notify you in advance of any such disclosure.

3. Required or permitted by law: I may use or disclose PHI when I am required or permitted to do so by law, or in the following situations:

a) Duty to warn: Your PHI may be disclosed if I determine a need to alert an intended victim of a serious threat to their health. For example, if you reveal intentions to kill or harm another person, I am obligated to take necessary action to avert a serious threat to the health or safety of others.

b) Danger to self: Your PHI may be disclosed if I determine that you may kill or seriously harm yourself. For example, if you reveal that you are planning to commit suicide, I am obligated to take necessary action to avert a serious threat to your health or safety.

c) Child or elder abuse or neglect: Your PHI may be disclosed if you report or I reasonably suspect any child or elder abuse or neglect. For example, if you reveal that you have physically harmed a child, I will need to notify Children's Protective Services (CPS).

d) Court order: Your PHI may be disclosed if I am presented with a court order to do so. For example, if you have any legal involvement and a judge or law enforcement agency has called me to testify or release records.

e) Crime against me or within office premises: Your PHI may be disclosed if you commit or threaten to commit a crime against me or within my office premises. This includes damage to property.

f) Other disclosures: Your PHI may be disclosed for public health activities, health oversight activities, including disclosures to State or Federal agencies authorized to access PHI.

g) Your PHI may be disclosed for research when approved by an institutional review board, to military or national security agencies, coroner, medical examiners, and correctional institutions or otherwise as authorized by law. Your PHI may be disclosed to necessary parties involved if you file a legal or administrative claim against me. Your identifying information may be disclosed to debt collection agency personnel if you fail to pay for my professional services by our agreed upon time period.

B. Uses and Disclosures Requiring Your Written Authorization:

1. Psychotherapy notes: Notes recorded by me documenting the contents of a counseling session with you ("Psychotherapy notes") will be used only by me and will not otherwise be used or disclosed without your written authorization.

2. Marketing communications: I will not use your health information for marketing communications without your written authorization.

3. Payment: I may not disclose PHI to your insurance company for payment purposes without your written authorization.

4. Other Uses and Disclosures: Uses and disclosures other than those described in Section I-A above will only be made with your written authorization. For example, you will need to sign an authorization form before I can send PHI to your life insurance company, a school, your attorney, or your health care providers. You may revoke any such authorization at any time.

II. YOUR INDIVIDUAL RIGHTS

A. Right to Inspect and Copy: You may request access to your medical and/or billing records maintained by my office in order to inspect and request copies of the records. All requests for access must be made in writing. Under limited circumstances, I may deny access to your records. Otherwise, this information must be released within 15 days. I may charge a fee for the costs of copying and sending you any records requested. If you are a parent or legal guardian of a minor 13 years of age or older, please note that certain portions of the minor's medical record will not be accessible to you, such as records relating to mental health treatment (age 13 and older), substance abuse treatment (age 16 and older), sexually transmitted diseases (age 14 and older), or abortions (age 14 and older).

B. Right to Alternative Communications: You may request, and I will accommodate, any reasonable written request for you to receive PHI by alternative means of communication or at alternative locations.

C. Right to Request Restrictions: You have the right to request a restriction on PHI used for disclosure for treatment, payment or health care operations. You must request any such restriction in writing addressed to me, the "Privacy Officer," as indicated below. I am not required to agree to any such restriction you may request.

D. Right to Accounting of Disclosures: Upon written request, you may obtain an accounting of certain disclosures of PHI made by me. This right applies to disclosures for purposes other than treatment, payment of health care operations, excludes disclosures made to you or disclosures otherwise authorized by you, and is subject to other restrictions and limitations.

E. Right to Request Amendment: You have the right to request that I amend your PHI. Your request must be in writing and it must explain why the information should be amended. I must respond to your request within ten (10) days. I may deny your request under certain circumstances. In this event, a "Statement of Disagreement," based upon your proposed amendment, must be added to your record.

F. Right to Obtain Notice: You have the right to obtain a paper copy of this Notice by submitting a request to me, the Privacy Officer, at any time.

G. Questions and Complaints: If you desire further information about your privacy rights, or you are concerned that I have violated your privacy rights, you may contact me, Leslie Fleming, MA LMHC, by telephone at (206) 949-9391, or in writing at 687 Strander Blvd., Tukwila, WA 98188. You may also file written complaints with the Director, Office of Civil Rights of the U.S. Department of Health and Human Services, or with the state Department of Health, Health Professions Quality Assurance Division at (360) 2364900, P.O. Box 47869, Olympia, WA 98504. I will not retaliate against you if you file a complaint with me or the Department of Health.

III. EFFECTIVE DATE AND CHANGES TO THIS NOTICE

A. Effective Date: This Notice is effective on February 1, 2011.

B. Changes to this Notice: I may change the terms of this Notice at any time. If I change this Notice, I may make the new Notice terms effective for PHI that I maintain, including any information created or received prior to issuing the new notice. If I change this Notice, I will inform you, and you may obtain any revised notice by contacting me.
( Type Full Name )
THERAPIST DISCLOSURE STATEMENT & CLIENT INFORMED CONSENT
You have the right to choose a counselor who best suits your needs and purposes. With that in mind, the following disclosure is provided to you. Please read each section carefully and initial each page.

I. THERAPIST DISCLOSURE TO CLIENT

- Credentials: I am a Licensed Mental Health Counselor in Washington State (#LH60647368)

- Education, Training, and Experience: I received a Bachelor of Arts in Acting and a Dance Minor from Ithaca College. I completed my Master of Arts in Psychology with a Specialization in Systems Counseling from Leadership Institute of Seattle, Saybrook Graduate University. I completed my internship hours at Seattle Counseling Service. I currently have 6 years of experience as a mental health counselor, three years experience in crisis intervention as a leader and trainer in an anti-violence organization and 3 decades experience supporting healing and personal mastery journeys through indigenous spiritual modalities.

- Professional Memberships: I am a member of the Society for Shamanic Practitioners, International Institute of Complementary Therapists, and Seattle Counselor's Association.

- Services Provided: I provide psychotherapy and shamanic healing for individuals (aged 14 and older), couples, and groups. I specialize in working with LGBTQ clients; non-traditional relationships and families; trauma survivors (psychological and physical injury recovery); personal and spiritual growth, self-awareness and fulfillment; and grief and loss.

II. WORKING RELATIONSHIP

- Confidentiality: The privacy of your personal information is of utmost importance. I am compliant with current Federal and Washington State laws, including the Health Insurance Portability and Accountability Act of 1996. Federal and State laws set the limits on confidentiality. Please review these limits in my Notice of Privacy Practices.

- Health Care Coordination: It is important to make sure that the problems you present are not related to a physical health difficulty. Since I am not a medical provider, I cannot determine if you have physical conditions that might be related to your health and our work. Therefore, it is helpful if you get a physical examination from a physician. It would be best to tell your medical provider that you will be working with me so we might begin to coordinate your health care. With your written authorization, I may obtain your medical records so I have a better understanding of your overall health.

- Risks and Benefits: During the course of our therapeutic work we will be exploring challenging territory in your life. As you get to the root of issues, you may experience periods of increased severity in your symptoms or greater struggle with your problems. I cannot offer any promise or guarantee about the results you will experience. However, as you commit yourself to work through your areas of difficulty and build upon your strengths, it is likely that you will see improvements throughout our work and in the future.

- Appointments: Scheduling appointments may be made via the secure client portal, which may be accessed through my website (www.medicinedancecounseling.com), phone, email, or in person at the end of a session. I require a minimum 24 hour notification to cancel your appointment without charging the session fee. You will be responsible for the entire session fee if you do not provide 24 hours notice of any cancellations. This is true even if you are an insurance client, as insurance companies will not pay for missed sessions. You can notify me of your need to cancel or reschedule via the secure client portal, phone, or email. If you do not receive a confirming message or return call from me, please assume that the message cancelling the appointment was not received and try again. Likewise, I will notify you if I should need to cancel our appointment. You will not be charged if I cancel our appointment.

When you arrive for an appointment, please remain in the waiting area and I will be with you, shortly. Our sessions will typically be 60 minutes long, and will need to end on time. I charge the full session fee for any sessions that are shortened due to your late arrival or early departure. I cannot accommodate making up for lost session time unless it is due to my error. Please be prepared to pay the full session fee from a missed or late-cancelled appointment at your next appointment.

- Fee for Services: My standard fee is $120.00 per 60-minute session. This is the same fee charged for any missed or late cancelled appointments. In certain circumstances, I might arrange a reduced fee for you. Additional fees include: preparation of requested documents, or copying and sending records. I will discuss any fees with you at the time of a request. Please inform me of any change in your financial situation that impacts your ability to pay for services.

- Payment for Services: I accept cash, credit card, or personal checks made payable to Leslie Fleming or Medicine Dance Counseling. Payments are due directly to me at the time of service (at the end of each session). If payments are not made at the time of service or in a timely manner that we have agreed upon, then I may notify debt collectors. I will charge a $30 fee for any returned checks.

- Insurance: I am currently contracted with Regence and AETNA. I am happy to bill them directly for payment. You will be responsible for your co-pay or co-insurance at the time of service.

If you are with another insurance company, I am able to provide you with a Statement of Service which you can submit to request reimbursement through any out of network benefits you may have. You will be responsible for the full fee at the time of service. Requesting reimbursement is a relatively easy process. I am happy to assist you in finding the appropriate forms for your carrier, but I will not bill, or make submissions for reimbursement to your health insurance provider if they are not Regence or AETNA.

- Record-keeping: I keep all of my records electronically on my secure client portal. My purpose in maintaining records is to aid therapy by recording the topics discussed and my impressions. In addition, the Washington Department of Health instructs me to document according to a medical model, which they in part define as recording "what happens in a session." I make an effort to summarize what we discuss in each session, but I make no effort to capture sessions verbatim. Washington State law requires the retention of records for seven years after last contact.

- Emergency, Urgent, or Other Contacts: You may call me anytime and leave a message on my voicemail, or send me an e-mail or text message and I will get back to you as soon as I can. I retrieve my messages daily, and whenever possible, I will get back to you within 24 hours. Do not use email or text to communicate emergent or crisis information. Please remember that anything you send over email or text is not confidential.

I am not able to provide on-call crisis or emergency services. If you have a physically or psychologically life-threatening emergency, please immediately call 911, and/or a 24-hr crisis hotline (Seattle Crisis Clinic at (206) 461-3222 / Care Crisis Line at (425) 258-4357). They offer 24-hour availability to crisis counseling, community resources, and emergency assistance. If you have any suicidal thoughts, I strongly encourage you to put these numbers into your phone or carry them with you at all times.

If I will be out of town or otherwise unavailable for an extended period of time, I will provide you with alternate contact information should you need support during my absence.

- Therapy Relationship and Professional Boundaries: It is my intention to maintain a warm, safe, and professional environment where I consider your best interests my priority. Because I have the utmost respect for you and our therapeutic relationship, professional boundaries are essential so that no harm or damage is done. I uphold the following practices regarding professional relationship boundaries:

1. I will not have a social relationship with you outside of my office; this includes personal contact on social networking sites, like Facebook. You may follow my business page on Facebook, if you like.

If you wish to invite me to an important life event, we will discuss the possible impact of my attending the event and make a decision together about the wisest course of action. This all comes from caring for you and your well-being and the recognition of the importance of appropriate boundaries in this therapeutic relationship.

2. I will not, at any time, have erotic or sexual contact with you. Physical contact will be limited to gestures such as greetings (i.e. a handshake or hug), consolation (i.e. holding your hand or arm around your shoulder) reassurance (i.e. pat on the shoulder) grounding, or instructional touch. All physical contact will happen only with your express consent.

3. I will not accept gifts from you. I may accept a card or note from you.

4. If I see you in public at any time, I will not initiate contact or familiarity with you. This is to ensure your confidentiality as my client. If you choose to initiate a greeting, I will reciprocate, but I will not attempt further communication unless you request it.

5. I will not have a relationship with you beyond my range of psychotherapy, counseling, shamanic sessions, and referrals, and the collection of fees for these professional services. While this includes not having any social or sexual relationships with you, it also includes any business or financial relationships. Additionally, I will not provide any services beyond my expertise, including legal or medical advisement.

6. I will only provide appropriate referrals to other health professionals, with your consent. I do not make referrals to non-healthcare or wellness-related individuals and agencies. I do not accept payments for giving referrals.

7. I will uphold confidentiality standards pertaining to Federal and State of Washington law during the course of therapy and thereafter. By law, our sessions are considered "privileged." Neither your death nor mine terminates your confidentiality rights.

- Therapeutic Work, Duration, and Termination: You have the freedom to make decisions as you please. You may engage in therapy for as long as you like. You may, at any time, change your goals for therapy, and/or you may choose to end our relationship, no matter where you are in the process of goal achievement. I respect and promote your right to make your own decisions. If you would like to end therapy, I ask that we first discuss this in person giving us the opportunity to review your progress and close our relationship in a healthy way. If more than 30 days have passed since our last contact, and I have not received any word from you, I will accept that as your notice that you no longer wish to continue counseling and that our therapeutic relationship is terminated.

- Complaints: If you have a complaint or inquiry about my professional service that cannot be resolved with me directly, please contact the Washington State Department of Health. Complaints or inquiries can be sent to: The Department of Health, Health Professions Quality and Assurance Division, P.O. Box 47869, Olympia, WA 98504-7869.
( Type Full Name )
Credit Card Authorization
Terms and Conditions:
Medicine Dance Counseling, PLLC requires that a valid credit card be provided upon agreeing to service.
This card will be held as security for payment and will only be charged in cases where there has been non-payment on an account for greater than 30 days or a check stop payment has occurred.

Authorization:
I hereby authorize Medicine Dance Counseling, PLLC to use the credit card provided. I understand that by signing this credit card authorization form that all charges as indicated will be placed on this credit card.
( Type Full Name )