Outpatient Services Contract and Informed Consent for Services for Adults and Children
Federal regulations require me to provide this information about my professional services and business policies. I hope this description is both clear and welcoming. Please read it carefully and feel free to ask about any questions that you may have so that we can discuss them. Once you sign this, it will constitute a binding agreement between us.

Services
I am a Licensed Mental Health Counselor in the state of Indiana and am therefore authorized to provide mental health services to you and your family. I am also a Registered Play Therapist with the Association for Play Therapy. This designation is conferred to an individual who 1) holds at least a Masters degree in a mental health profession, 2) is licensed for independent practice in their state, 3) has completed 150 clock hours of play therapy training, 4) has completed a minimum of 5,000 hours of post-master's clinical experience, 500 supervised and 500 additional hours of play therapy experience, and 5) completes 40 hours of continuing education every two years.

I am ethically and legally bound to provide only those services for which I have a license and for which I have been trained. Should you require any service for which I am not qualified, I will refer you to someone with the required expertise. My responsibility is to facilitate arrangements for a referral. Your responsibility to continuity of care is to secure the best plan you can make based on all recommendations you gather.

Appointments
A counseling session is 50 minutes; a play therapy session is 45 minutes in length. We may at times make arrangements for a longer or shorter session. Younger children can have 25 minute sessions with a $70.00 fee per session. Once a session has been scheduled, you will be expected to pay the session fee of $145.00 unless you provide 24 hours notice of cancellation or unless we both agree that you were unable to attend due to circumstances beyond your control. You will be responsible for the full fee which is $145.00. Insurance will not reimburse you for missed appointments.

Contacting Me
Text and phone calls are the easiest way to contact me with short communication. Confidential voice mail typically will answer your call since I am usually in session with clients. I check my messages frequently and will make every effort to return your call on the same day you make it with the exception of weekends and holidays.

It is important to be aware that email, text, and cell phone communication can be accessed by unauthorized sources and hence can compromise the privacy and confidentiality of such communication. Emails, in particular, are vulnerable to such unauthorized access. I will communicate with you via email only if specifically authorized by you in advance and/or in response to your email to me.

Professional Fees and No Surprises Estimate
My hourly fee is $145.00 for individuals, couples, and families. This amount, on a prorated basis, will be charged for other professional services that you may require such as my attendance at school conferences, report writing, and preparation of records or treatment summaries. Should you require my professional time in any litigation, I will need to charge and receive payment of a $800 in advance, for preparation time, driving and wait time. In addition, I will charge my hourly rate of $145.00 per hour of appearance in litigation hearings.

As we work together we will decide on frequency of meeting and length of therapy as a team. If we decide to meet weekly you can expect to pay $580 a month for services. If we meet for a year at that interval you can expect to pay $7,000 for a year of weekly sessions. If we meet bi-weekly you can expect to pay $290 a month for services.  If we meet for a year at that interval. You can expect to pay $3,480 for a year of services.

Billing and Payment
Payment of the full hourly fee of $145.00 in cash, check, or credit card is expected at the time of service unless we agree otherwise. I require all clients to leave a card on file. I accept American Express, Discover, MasterCard and Visa credit and debit cards as well as medical spending/flex account cards for your convenience through. PayPal, and other apps as needed. I will ask you to sign a separate form should you choose to use this form of payment. This separate form becomes a legal part of this Contract and Consent and will be maintained in your client file. All late payments will be collected at the end of every month. If you are an adult client whose therapy bill is being paid by a third party (parent, guardian, spouse etc...) they have to sign the "Responsible Party" portion of this document in order for me to bill them.  You will also need to fill out a Release Of Information in order for me to send the invoice.

I do not file claims with your insurance. I am an out of network provider by choice. If you choose to file for reimbursement from your health insurance, I will provide you with the paperwork necessary to begin the process. Your reimbursement is based on your out of network benefits contract with your insurance company.

Social Media and Telecommunication.
Due to the importance of your confidentiality and the importance of minimizing dual relationships, I do not accept friend or contact requests from current or former clients on any social networking site (Facebook, LinkedIn, etc). I believe that adding clients as friends or contacts on these sites can compromise your confidentiality and our respective privacy. It may also blur the boundaries of our therapeutic relationship. If you have questions about this, please bring them up when we meet and we can talk more about it.

Professional Records and Confidentiality
Both law and the standards of my profession require that I keep appropriate treatment records and that I safeguard your privacy (see Notice of Privacy Practices). My best practice requires collaboration and consultation with my peers so that I am steadily evaluating my own thinking and effectiveness as well as adding resources. I will do my best to protect your identity while seeking consultation. I cannot maintain responsibility for who you may, or may not, come into contact with as you enter or leave the therapy office as it is public space.

Your child's counseling sessions and/or records are not intended to be used in any divorce litigation or custody matter. Should you choose to involve your child's private therapy sessions in divorce or custody litigation, you compromise your child's trust in you and in me as your child's therapist. Doing so will be discussed with you and may result in the termination of treatment. I will have you sign a separate form acknowledging the pitfalls of including me in custody proceedings.

There is no recording (video or audio) allowed in session without express consent of all parties.  Recording without permission can result in immediate dismissal from services.

What to Expect in Treatment
Most people come to therapy to heal suffering, increase well-being, love with more generosity, wisdom and skill, and contribute to a wider community. The greatest benefits come from self-reflection, exploration of desired possibilities, and thoughtfully dismantling habits that get in the way of effective living. Our goals will be determined by your desires, courage and openness to develop practices that invoke healing, honor limits, and enable growth.

As a Licensed Mental Health Counselor, I am responsible to advise you that in the process of therapy some people experience: 1) deep feelings, 2) frustration with the work and effort involved, 3) tension in relationships that are affected by the process of change, 4) disconcerting dreams and/or memories, and 5) challenges to old ways of doing things. The history of therapy tells us that change can involve work and struggle as well as satisfaction and resolution, but like most human endeavors, success in therapy is not always possible.

Your signature below indicates that you have read the information in this document and freely choose to abide by its terms during our professional relationship. In addition, your signature indicates that you have had an opportunity to ask any questions and to have your questions answered to your complete satisfaction prior to the onset of treatment.

Alexa Griffith, LMHC, LCAC, NCC, RPT

This notice went into effect on January 1,2022

NOTICE OF PRIVACY PRACTICES

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. I 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.

Acknowledgement of Receipt of Privacy Notice

Under the Health Insurance Portability and Accountability Act of 1996 (HIPAA), you have certain rights regarding the use and disclosure of your protected health information. By checking the box below, you are acknowledging that you have received a copy of HIPAA Notice of Privacy Practices.