Clinical Forms

ACKNOWLEGEMENTS OF ALL FORMS

After reading Informed Consent & Agreement for Psychotherapy Services, Notice of Privacy Practices, Professional Disclosure Statement, & Financial Policy by signing this document this acknowledges that you have read, understood, and have been offered copies of all forms for your records: Informed Consent, Professional Disclosure Statement (PDS), Financial Responsibility, & Notice of Privacy Practices.

INFORMED CONSENT

By signing below, Patient(s) acknowledge that Patient(s) have reviewed and fully understand the terms and conditions of this Agreement and have been offered a copy of the Informed Consent. Patient(s) have discussed such terms and conditions with the therapist, and have had any questions with regard to its terms and conditions answered to the Patient(s)’ satisfaction. If there are three cancellations in a row or no appointments in the last 30 days, then counseling services will be closed. If Patient(s) agree to abide by the terms and conditions of this agreement and consent to participate in psychotherapy with the Therapist. Moreover, Patient(s) agree to hold Therapist free and harmless from any claims, demands, or suits for damages from any injury or complications whatsoever, save negligence, that may result from such treatment.

NOTICE OF PRIVACY PRACTICES

By signing below, Patient(s) have been offered a copy of the Notice of Privacy Practices pursuant to HIPPAA laws.

PROFESSIONAL DISCLOSURE STATEMENT (PDS)

Your signature below indicates that this information has been reviewed under the conditions listed in PDS.

FINANCIAL POLICY AGREEMENT

Your signature below indicates that this information has been reviewed, and same day cancellations will result in a charge of $50.00 unless due to illness, work, or other unforeseen circumstance out of your control.

Client’s Name or Parent/Guardian

Signature of Client or Parent/Guardian

Thanks for submitting!

Financial Policy

Payment is required at the beginning of each session and payable by cash or check.

Current Rates:

Intake appointment (50-80 minutes) $250

Individual/Couple/Family therapy session (60-minutes) $225

Individual/Couple therapy session (45-minutes) $185

Please ask me if you wish to discuss a written agreement that specifies any alternative payment procedure.

Cancellations:
If you need to cancel or reschedule an appointment, please notify me no later than 5:00 p.m. on the day BEFORE your appointment. If you fail to cancel a scheduled appointment, I cannot use this time for another client, and you will be billed/charged $45.00 for the cost of your missed session. Special consideration is given for emergencies and must be negotiated.

Insurance:

I accept most insurance. If out of network all fees are due at time of service.

Other fees:

A fee of $35 will be assessed for all returned checks. In addition to session rates listed above, I charge $85/hr for other professional services you may need, though I will break down the hourly cost into 15-minute segments if I work for periods of less than one hour. Other services include report writing, telephone conversations lasting longer than 15 minutes, attendance at meetings with other professionals you have authorized, preparation of records or treatment summaries, and the time spent performing any other service you may request of me. If you become involved in legal proceedings that require my participation, you will be expected to pay for my professional time. Because of the difficulty of legal involvement, I charge $325 per hour for preparation and attendance at any legal proceeding.

I have read and understand the above information. I agree to submit payment at the beginning of each session as outlined by the current rates listed above. I agree to provide notification of a cancellation no later than 5:00 p.m. on the day before my appointment, and if I fail to do so, I agree to pay $45.00 for the missed session. Signing for this document acknowledging you have read, understood, and asked any questions that you may have is found on the ACKNOWLEGEMENTS PAGE

NOTICE OF PRIVACY PRACTICES

THIS NOTICE DESCRIBES HOW INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION.

PLEASE REVIEW IT CAREFULLY.

If you have any questions about this notice, please contact administrative offices at:

Salem Counseling Place

Barbara A. Norton, MS., LPC

3482 Liberty Rd. S. Salem, OR 97302

503-510-3127

WHO WILL FOLLOW THIS NOTICE

This notice describes the privacy practices followed by the practitioner, administrator and office personnel at the practice listed above.

YOUR HEALTH INFORMATION

This notice applies to the information and records we have about your health, health status, and the counseling and care services you have received through Barbara Norton, MS., LPC. Your health information may include information created and received by your therapist. This information may be in the form of written or electronic records or spoken words, and may include information about your health history, health status, symptoms, counseling, evaluations, test results, prescriptions, diagnoses, treatments, procedures and related billing activity and/or similar types of health-related information.

I am required by law to give you this notice. It will tell you about ways in which I may use and disclose health information about you and describes your rights and my obligations regarding the use and disclosure of that information.

HOW I MAY USE AND DISCLOSE HEALTH INFORMATION ABOUT YOU

I may use and disclose health information for the following purposes:

For treatment.

With your written consent, I may release information to your primary care physician and/or other treating physicians, therapists, counselors, care givers, office staff or other personnel who are involved in taking care of you and your health.

For example, your therapist may be treating you for a condition and may need to know if you have medical issues or problems that may complicate your treatment. The clinician may use this information to decide what treatment is best for you. I may need to confer with your doctor or another clinician in the field of practice to assist us in a choice of treatment that would be best for you.

Different personnel may share information about you and disclose information to people who do not work in your therapist’s office in order to coordinate your care, such as scheduling appointments and tests. Family members and other health care providers may be part of your medical care and may require information about you that I have.

For payment.

I may use and disclose health information about you so that the treatment and services you receive may be billed to and payment may be collected from you, an insurance company or a third party.

For example, I may need to give your health plan information about a service you received so your health plan will pay us or reimburse you for service. We may also tell your health plan about a treatment you are going to receive to obtain prior approval, or to determine whether your plan will pay for the treatment.

For health care operations.

I may use and disclose health information about you in order to make sure that you and our other clients receive quality health care. For example: I may use your health information to evaluate the performance of the office personnel who are caring for you. I may also use health information about all or many of my clients to help decide what additional services I should offer, how I can be more efficient, or whether certain new treatments are effective.

I may also disclose your health information to health plans that provide you insurance coverage and other health care providers that care for you. My disclosures of your health information to plans and other providers may be for the purpose of helping these plans and providers provide or improve care, reduce cost, coordinate and manage health care and services, train staff and comply with the law.

Appointment reminders.

l will text an appointment reminder 1 day prior to your appointment for counseling. Please specify on the intake form what phone numbers may be used to remind you of appointments. Please notify me if you do not wish to be contacted for appointment reminders.

Treatment alternatives.

I may tell you about or recommend possible treatment options or alternatives that may be of interest to you.

Health-related products and services.

I may tell you about health related products or services that may be of interest to you.

SPECIAL SITUATIONS:

I may use or disclose health information about you for the following purposes, subject to all applicable legal requirements and limitations:

To avert a serious threat to health or safety.

I may use and disclose health information about you when necessary to prevent a serious threat to your health and safety or the health and safety of the public or another person.

Required by law.

I will disclose health information about you when required to do so by federal, state or local law.

Military, veterans, national security and intelligence.

If you are or were a member of the armed forces, or part of the national security or intelligence communities, I may be required by military command or other government authorities to release health information about you. I may also release information about foreign military personnel to the appropriate foreign military authority.

Worker’s compensation.

I may release health information about you for worker’s compensation or similar programs. These programs provide benefits for work-related injuries or illness.

Public health risks.

I may disclose health information about you for public health reasons in order to prevent or control disease, injury or disability; or report births, deaths, suspected abuse or neglect, non-accidental physical injuries, reactions to medications or problems with products.

Health oversight activities.

I may disclose health information to a health oversight agency for audits, investigations, inspections, or licensing purposes. These disclosures may be necessary for certain state and federal agencies to monitor the health care system, government programs, and compliance with civil rights laws.

Lawsuits and disputes.

If you are involved in a lawsuit or a dispute, we may disclose health information about you in response to a court or administrative order. Subject to all applicable legal requirements, I may also disclose health information about you in response to a subpoena.

Law enforcement.

I may release health information if asked to do so by a law enforcement official in response to a court order, subpoena, warrant, summons or similar process, subject to all applicable legal requirements.

Coroners, Medical Examiners, and Funeral Directors.

I may release health information to a coroner or medical examiner. This may be necessary, for example, to identify a deceased person or determine cause of death.

Information not personally identifiable.

I may use or disclose health information about you in a way that does not personally identify you or reveal who you are.

Family and friends.

I may disclose health information about you to your family members or friends if we obtain your verbal agreement along with your written authorization to do so. We will give you an opportunity to object to such a disclosure and request you state this in writing. I may also disclose information to your family and friends if I can infer from circumstances, based on my professional judgment that you would not object. For example, I may assume you agreed to limited disclosure of information to your spouse when you bring your spouse with you to a counseling session and have not requested in writing that any form of disclosures cannot be made.

In situations where you are not capable of giving consent (because you are not present or due to your incapacity or medical emergency), I may, using my professional judgment, determine that a disclosure to your family member or friend is in your best interest. In that situation, I will disclose only the health information relevant to the person’s involvement in your care. For example: I may inform the person who accompanied you to the emergency room that you may have attempted suicide and provide updates and prognosis. I may also use my professional judgment and experience to make reasonable inferences that are in your best interest to allow another person to act on your behalf.

OTHER USES AND DISCLOSURES OF HEALTH INFORMATION

I will not use or disclose your health information for any purpose other than those identified in the previous sections without your specific, written authorization. If you give us authorization to use or disclose health information about you, you may revoke that authorization, in writing, at any time. If you revoke your authorization, we will no longer be able to use or disclose information about you for the reasons covered by your written authorization, but we cannot take back any uses or disclosures already made with your permission.

I will need specific, written authorization from you in order to disclose certain types of specially protected information such as HIV, substance abuse, mental health, and genetic testing information.

YOUR RIGHTS REGARDING HEALTH INFORMATION ABOUT YOU

You have the following rights regarding health information we maintain about you:

Right to inspect and copy.

You have the right to inspect and copy your health information, such as medical and billing records, that I keep and use to make decisions about your care. You must submit a written request to your therapist or our administrative office in order to set up an appointment to inspect and/or copy records of your health information. If you request a copy of the information, I may charge a fee for the costs of copying, mailing or other associated supplies.

I may deny your request to inspect and/or copy records in certain limited circumstances. If you are denied copies or access to information that I keep about you, you may ask that our denial be reviewed. If the law gives you a right to have our denial reviewed, I will select a licensed health care professional to review your request and my denial. The person conducting the review will not be the person who denied your request, and I will comply with the outcome of the review.

Right to amend.

If you believe health information I have about you is incorrect or incomplete, you may ask to amend the information. You have the right to request and amendment as long as your therapist keeps the information.

To request an amendment, complete and submit an amendment/corrections request to your therapist at 3482 Liberty Rd. S. Salem, OR 97302

We may deny your request for an amendment if your request in not in writing or does not include a reason to support the request. In addition, we may deny your request if you ask us to amend information that:

Your therapist did not create, unless the person or entity that created the information is not longer available to make the amendment,
Is not part of the information that I keep,
You would not be permitted to inspect and copy,
Is accurate and complete.

Right to an accounting of disclosures.

You have the right to request an “accounting of disclosures.” This is a list of the disclosures we have made of information about you for purposes other than treatment, payment, health care operations, and a limited number of special circumstances involving national security, correctional institutions and law enforcement. The list will also exclude any disclosures I have made based on your written authorization.

To obtain this list, you must submit your request in writing to your therapist at 3482 Liberty Rd. S. Salem, OR 97302.

It must state a time period, which may be no longer than six years subsequent to the date of signature. Your request should indicate in what form you want the list (for example, on paper or electronically). The first list you request within a twelve month period will be free. For additional lists, I may charge you for the costs of providing the list. I will notify you of the cost involved and you may choose to withdraw or modify your request at that time before any costs are incurred.

Right to request restrictions.

You have the right to request a restriction or limitation on the health information we use or disclose about you for treatment, payment or health care operations. You also have the right to request a limit on the information we disclose about you to someone who is involved in your care or the payment for it, like a family member or friend. For example, you could ask that I not use or disclose information about a hospitalization you had.

We are not required to agree with your request.

If we do agree, I will comply with your request unless the information is needed to provide you emergency treatment or I am required by law to use or disclose the information.

To request restrictions, you can complete a request for restriction on use/disclosure of medical information to your therapist at 3482 Liberty Rd. S. Salem, OR 97302. I will not ask you the reason for your request. I will accommodate all reasonable requests. Your request may specify how or where you wish to be contacted.

Right to a paper copy of this notice.

You have the right to a paper copy of this notice. You may ask your therapist or our office personnel to give you a copy of this notice at any time.

CHANGES TO THIS NOTICE

I reserve the right to change this notice, and to make the revised or changed notice effective from information we already have about you as well as any information I receive in the future. I will post the current notice in our office with the effective date in the top, right hand corner. You are entitled to a copy of the current notice in effect.

COMPLAINTS

If you believe your privacy rights have been violated, you may file a complaint with the Secretary of the Department of Health and Human Services. To file a complaint with my office, please contact Barbara Norton, MS.,LPC Salem Counseling Place at 3482 Liberty Road. S. Salem, OR 97302.

After reading HIPPA form: The signing for this document acknowledging you have read, understood, asked any questions that you may have regarding this document, and have been offered a copy of this form for your own records is found on the ACNOWLEGEMENT PAGE, which you are to print and bring a copy at your first appointment.

INFORMATION, AUTHORIZATION & CONSENT OF TECHNOLOGY IN THERAPY

This document is to inform you about confidentiality, emergencies, and other details regarding your treatment using TeleMental Health. TeleMental Health is becoming more widely used, so using this technology needs an extra level of protection to avoid a breach in confidentiality. To provide you with the highest level of care, I have implemented several policies and protective measures to assure your Protected Health Information (PHI) remains confidential.

How to contact me

I can be reached by phone/text 503-510-3127 or email at salemcounselingplace@gmail.com

I will return your calls, text and email as soon as possible.

Emergency Procedures Specific to TeleMental Health Services

You understand if you are having suicidal or homicidal thoughts, experiencing psychotic symptoms, or in a crisis that we cannot solve remotely, I may determine that you need a higher level of care and TeleMental Health services are not appropriate. I require an Emergency Contact Person (ECP) who I may contact on your behalf in a life-threatening emergency only. Please write this person’s name and contact information below. Either you or I will verify that your ECP is willing and able to go to your location in the event of an emergency. Additionally, if either you, your ECP, or I determine necessary, the ECP agrees to take you to a hospital or Psychiatric Crisis Center. Your signature at the end of this document indicates that you understand I will only contact this individual in the extreme circumstances stated above.

Please list your Emergency Contact Person here:

Name

Phone

You agree to inform me of the address where you are at the beginning of every TeleMental Health Session. You agree to inform me of the nearest hospital or crisis center to your primary location that you prefer to go to in the event of a mental health emergency (usually located where you will be during a TeleMental Health session). Please list this hospital and contact number here:

Hospital

Hospital Phone

We will use the following safe word to indicate that someone is in range of hearing our counseling session or someone has entered your therapeutic space during the session:

If you have a mental health emergency, I encourage you not to wait for communication back from me but contact one or more of the following:

Salem Crisis Center: 503-585-4949

Youth Hotline: 1-877-968-8491

Family Resource Hotline: 1-800-829-3777

National Crisis Line: 1-800-560-5535

Recovery/Addiction: 1-800-273-8255 or text 273Talk to 839863

Español Crisis: 1-888-628-9454

9-1-1 or go to the Emergency Room

Suicide & Crisis Lifeline: 9-8-8

In Case of Technology Failure:

If a technological failure occurs during our TeleMental Health session, the most reliable backup plan is to call one another via telephone. Please make sure you have a phone with you and I have that phone number. If we get disconnected from a session, please restart the session. If we are unable to reconnect within ten minutes, please call me. If we are on a phone session and we get disconnected, please call me back or contact me to schedule another session.

The Different Forms of Technology-Assisted Media Explained

Landline Telephone:

It is important for you to know that even landline telephones may not be completely secure and confidential. There is a possibility that someone could overhear or even intercept your conversations with special technology. Individuals who have access to your telephone or your telephone bill may be able to determine who you have talked to, who initiated that call, and how long the conversation lasted. If you have a landline and you provided me with that phone number, I may contact you on this line from my cell phone. If this is not an acceptable way to contact you, please let me know.

Cell Phones:

In addition to landlines, cell phones may not be completely secure or confidential. There is also a possibility that someone could overhear or intercept your conversations. Be aware that individuals who have access to your cell phone or yor cell phone bill may be able to see who you have talked to, who initiated that call, how long the conversation was, and where each party was located when that call occurred. Additionally, I keep your phone number in my cell phone, but it is listed by a combination of initials and letters only and my phone is password protected. If this is a problem, please let me know, and we will discuss our options.

Text Messaging:

Text messaging is not a secure means of communication and may compromise your confidentiality. Also, sometimes people misinterpret the meaning of a text message and/or the emotion behind it. If you happen to send me a text message, you need to know that I am required to keep a copy of all texts as part of your clinical record that address anything related to therapy.

E-mail:

E-mail is not a secure means of communication, and may compromise your confidentiality. Therefore, please do not bring up any therapeutic content via email. I am required to keep a copy or summary of all emails as part of your clinical record that address anything related to therapy. I also strongly suggest that you only communicate through a device that you know is safe and technologically secure (e.g., has firewall, anti-virus software installed, is password protected, not accessing the internet through a public wireless network, etc.). If you are in a crisis, please do not communicate this to me via email because I may not see it in a timely matter. Instead, please see steps under “Emergency Procedures.”

Social Media- Facebook, Twitter, LinkedIn, Instagram, Pinterest, Etc.:

It is my plicy not to accept “friend” or “connection” request from any current or former client on my personal social networking sites such as Facebook, Twitter, Instagram, Pinterest, etc. because it may compromise your confidentiality and blur the boundaries of our professional relationship. Please refrain from contacting me using social media messaging systems such as Facebook messenger. These methods have limited security and I do not watch them closely.

Google, etc.:

It is my policy not to search for my clients on Google or any other search engine. I respect your privacy and make it a policy to allow you to share information about yourself with me. If there is content on the Internet that you would like to share with me for therapeutic reasons, please bring it to your session.

Video Conferencing (VC):

Video Conferencing is an option for us to conduct remote sessions over the internet where we not only can speak to one another, but we may also see each other on a screen. I utilize Doxy.Me/bnorton and VSee (initiated by invite only via phone). These VC platforms are encrypted to the federal standard, HIPAA secure, and they have signed a HIPAA Business Associate Agreement (BAA) with me. The BAA means that Doxy.Me and VSee are willing to attest to HIPAA compliance and assumes responsibility for keeping our VC interaction secure and confidential.

If we choose to utilize this technology, I can provide you with a demonstration how to log in securely. I also ask that you please sign on at least five minutes prior to your session time so we get started promptly. You are responsible for initiating the connection with me at the time of your appointment. I strongly suggest that you only communicate through a computer or device thar ou know is safe (e.g., has a firewall, anti-virus software installed, is password protected, not accessing the internet through a public wireless network, etc.)

Recommendations to Websites or Applications (Apps):

During therapy, I may recommend that you visit certain websites for information or self-help. I may also recommend certain apps that could be of assistance to you. Please be aware that websites and apps may have tracking devices that allow others to know that you have visited these sites or applications. They may use your information to attempt to sell you other products. Additionally, anyone who has access to the device you used to visit these sites/apps, may be able to see that you have been to these sites by viewing the history on your device. Therefore, it is your responsibility to decide if you would like this information or if you prefer that I do not make these recommendations.

Your Responsibilities:

I encourage you to communicate only through devices that you know are secure (e.g., has a firewall, anti-virus software installed, is password protected, not accessing the internet through a public wireless network, Virtual Private Network (VPN), etc.). It is also your responsibility to choose a secure location to interact with technology-assisted media and to be aware that family, friends, employers, co-workers, strangers, and hackers could either overhear your communications or have access to the technology. Additionally, you agree not to record any TeleMental Health sessions.

You are also responsible for the cost of any technology you may use at your own location. This includes your computer, cell phone, tablet, internet or phone charges, software, headset, etc. If you are unable to afford these, please let me know as we can discuss alternative options for care.

Limitations of TeleMental Health Therapy Services:

TeleMental Health services are another form of therapy and it has limits. There is a risk of misunderstanding one another when communication lacks visual or voice cues. For example, if video quality is bad for some reason, I might not see a tar in your eye. Or, if sound quality is poor, I might not hear the crack in your voice that I could easily pick up if you were in my office. There may also be a disconnection (e.g., phone gets cut off or video drops). This can be frustrating and interrupt the normal flow of personal interaction. Please know that I have the utmost respect and positive regard for you and your well-being. Please let me know if you think that I may be missing important information.

Consent:

In summary, technology is constantly changing, and there may be parts that we do not realize at this time. Feel free to ask questions, and please know that I am open to any feelings or thoughts.

You may stop your authorization to use any of these services at any time during therapy just by notifying me in writing.

Please print, date, and sign your name below indicating that you have read and understand this form, you have asked any questions and they were addressed, you agree to these policies, and you are authorizing me to utilize the technology discussed.

Technology you do not want included in your therapy:

Client’s Name

Signature of Client

If Applicable:

Parent’s or Legal Guardian’s Signature

My signature below indicates that I have discussed this form with you and have answered any questions you have regarding this information.

Parent’s or Legal Guardian’s Name

Thanks for submitting!

NOTICE OF PRIVACY PRACTICES

Philosophy and Approach:

I believe everyone can improve their level of functioning and reach an optimum level of health when adequate community supports are in

place to meet their financial, medical, educational, and social needs. Because everyone is unique with the issues they present; I employ an eclectic approach with a strong emphasis on cognitive-behavioral strategies. I find this approach allows people to fully understand their destructive thinking patterns and subsequent emotions that often lead to maladaptive choices in behavior which impacts functioning on multiple levels. People presenting with grief, anxiety, adjustments, and depression can reach an optimum level of functioning using cognitive behavioral techniques as I have witnessed in my years of practice.

Formal Education and Training:

I hold a Masters Degree in Guidance & Counseling from Texas A & M University. Major coursework included human growth and development with an emphasis on early childhood and adolescent development, assessment, family and group dynamics. I also hold a Post Masters Certificate in Clinical Community Counseling from Johns Hopkins University. Major coursework included advanced application of individual, group, marriage, DSM, psychological assessments, alcohol and drug counseling. I have 7 years assessment and crisis response counseling in hospital and community settings. 27 years’ experience providing individual, family therapy in school, home, and clinic-based settings.

As a Licensee of the Oregon Board of Licensed Professional Counselors and Therapists, I abide by its Code of Ethics. To maintain my license I am required to participate in continuing education, taking classes dealing with subjects relevant to this profession.

Fees:

Intake appointment (50-60 minutes) $250

Individual/Couple/Family therapy session (60-minutes) $225

Individual/Couple therapy session (45-minutes) $175

Individual/Couple therapy session (30-minutes) $130

As a client of an Oregon licensee, you have the following rights:

∗To expect that a licensee has met the qualifications of training and experience required by state law;

∗To examine public records maintained by the Board and to have the Board confirm credentials of a licensee;

∗To obtain a copy of the Code of Ethics;

∗To report complaints to the Board;

∗To be informed of the cost of professional services before receiving the services;

∗To be assured of privacy and confidentiality while receiving services as defined by rule and law, with the following exceptions: 1) Reporting suspected child abuse;

2) Reporting imminent danger to client or others;

3) Reporting information required in court proceedings or by client’s insurance company, or other relevant agencies;

4) Providing information concerning licensee case consultation or supervision; and

5) Defending claims brought by client against licensee;

∗To be free from discrimination because of age, color, culture, disability, ethnicity, national origin, gender, race, religion, sexual orientation, marital status, or socioeconomic status.

You may contact the Board of Licensed Professional Counselors and Therapists at 3218

Pringle Rd SE, Suite 120, Salem, OR 97302-6312 Telephone: (503) 378-5499

Email: lpct.board@state.or.us Website: www.oregon.gov/OBLPCT

Authorization to Use and Disclose Protected Health Information

Patient Name:

DOB:

With my signature below, I authorize Salem Counseling Place, LLC and Barbara Norton, MS.,LPC to

Obtain information from:

Person/organization:

Disclose information to:

Address

Phone

Fax

Information to be used/disclosed consists of mental healthcare information including: Required

Assessment/Evaluation

Progress Notes

Treatment Plan

Other

The purpose for the disclosure/communication is for coordination of care or other: I understand the additional laws about mental health, and alcohol/drug treatment information may apply. I understand and agree that this information will be disclosed Required

Mental Health Information

Medical Information

Drug/alcohol diagnosis, treatment, referral information

Other:

I understand that the information used or disclosed pursuant to this authorization may be subject to redisclosure and no longer be protected under federal law. However, I also understand that federal or state law may restrict redisclosure of mental health, and drug/alcohol diagnosis, treatment or referral information.

I understand I do not have to sign this authorization. Refusal to sign the authorization will not adversely affect my ability to receive health care services or reimbursement for services. The only circumstance when refusal to sign means I will not receive health care services is if the health care services are solely for the purpose of providing health information to someone else and the authorization is necessary to make that disclosure.

I understand I may revoke this authorization in writing at any time. If I revoke my authorization, the information described above may no longer be used or disclosed for the purposes described in this written authorization. The only exception is when a covered entity has taken action in reliance on the authorization or the authorization was obtained as a condition of obtaining insurance coverage. If information has already been used or disclosed, that cannot be undone.

I have read this authorization and I understand it. Unless revoked, this authorization expires one month following termination of services with Salem Counseling Place, LLC. To revoke this authorization, I will provide a written statement to Barbara Norton, MS.,LPC and state that I am revoking this authorization.

Patient signature:

Guardian signature (if applicable):

Thanks for submitting!

Guardian printed name (if applicable):

Relationship to patient:

SPOUSAL/PARTNER INFORMATION

EMPLOYMENT INFORMATION:

INSURANCE INFORMATION:

SPIRITUALITY/ RELIGION:

Thanks for submitting! Please continue with Counseling history form.

COUNSELING HISTORY:

GENERAL HEALTH & MENTAL HEALTH INFORMATION:

FAMILY MENTAL HEALTH HISTORY:

Thanks for submitting! Please continue with ADDITIONAL INFORMATION Form

ADDITIONAL INFORMATION:

ACKNOWLEGEMENTS OF ALL FORMS

Financial Policy

NOTICE OF PRIVACY PRACTICES

SPECIAL SITUATIONS:

OTHER USES AND DISCLOSURES OF HEALTH INFORMATION

YOUR RIGHTS REGARDING HEALTH INFORMATION ABOUT YOU

CHANGES TO THIS NOTICE

COMPLAINTS

If you believe your privacy rights have been violated, you may file a complaint with the Secretary of the Department of Health and Human Services. To file a complaint with my office, please contact Barbara Norton, MS.,LPC Salem Counseling Place at 3482 Liberty Road. S. Salem, OR 97302.

INFORMATION, AUTHORIZATION & CONSENT OF TECHNOLOGY IN THERAPY

NOTICE OF PRIVACY PRACTICES

Authorization to Use and Disclose Protected Health Information

CONSENT