(the “COMPANY”)





Effective Date:

Our Duty Regarding Your Health Information: 

With limited exceptions, information about you and your health is confidential. Confidential information includes all individually identifiable information, whether in electronic or physical form, that is in our possession or is derived from information you share in confidence with us regarding your medical or mental health history, a mental or physical condition, your mental or physical health treatment or payment for treatment. More specifically, the health information we create and maintain in our possession is information that relates to your participation in outpatient treatment with a psychotherapist. All such information is “Confidential Information”. We are committed to protecting the privacy of this information. This notice tells you about some of the ways in which we may use and disclose health information about you, as well as certain obligations we have regarding the use and disclosure of your health information. It also describes your rights regarding your health information. 

Our Responsibilities:

It is our responsibility to safeguard your health information. We are required to give you this Notice of Privacy Practices and to follow the terms of the notice currently in effect. We will notify you if we become aware of an unauthorized access, use or disclosure of your health information. 

Changes to this Notice: 

We reserve the right to change this Notice. We reserve the right to make the revised or changed notice effective for health information we already have about you as well as any information we receive in the future. A copy of the current notice is posted on our web site at  We are also providing you with a copy of this Notice of Privacy Practices as part of your initial intake documentation.  

How We Protect Your Confidential Information:

The Company will protect your Health Information by:

  • Treating all information about you that we collect as confidential. This means that with limited exceptions, as discussed below, we will not share your information with anyone without your consent or written authorization;
  • Restricting access to your Health Information to those clinical staff only who have a legitimate need for access in order for us to provide services to you;
  • Only disclosing when required or permitted, that information which is necessary under the circumstances; 
  • Obtaining reasonable assurances in writing through a Business Associate Agreement with any  outside services or other business associates which we may use in order to provide you with services or conduct necessary business operations; and 
  • Maintaining physical, electronic, and procedural safeguards to comply with federal and state regulations guarding your Health Information.

How We May Use and Disclose Health Information About You:

  The following categories describe different ways that we may use your health information and disclose your health information to other persons and entities.  Not every use or disclosure in a category will be listed.   However, all the ways we are permitted to use and disclose your health information will fall within one of the following categories. If you have any specific concerns, please bring them to our attention, and we will be happy to discuss them with you. 

  • Treatment:  Your Confidential Information may be disclosed to providers of health care, health care service plans, contractors, or other health care professionals or facilities for purposes of diagnosis or treatment. However, as a practical matter, we will request authorization from you in writing before we disclose your Confidential Information to another provider who is not associated with the Company or to any other third-party. We may also disclose your health information to a family member, other relative, domestic partner or a close personal friend, or any other person identified by you, if the information is directly relevant to that person’s involvement with your care or payment related to your care, after obtaining your consent or providing you with the opportunity to object to the disclosure and you express no objection. Note that in the event of an emergency, we may disclose such information which we determine based upon our professional judgment to be in your best interest without obtaining your consent or providing you with the opportunity to object. 
  • Payment: We may use and disclose your health information to bill for services and to obtain payment from you, including, if necessary, the reporting of limited information necessary to pursue collection through a collection agency. With your consent, we may also disclose health information to your insurance company or other third-third party payor or guarantor. This may include the disclosure of health information to obtain prior authorization for treatment. Your health information may also be disclosed in response to requests from your insurer, health care service, employee benefit plan or any governmental authority responsible for paying for health care services provided to you, to the extent necessary to allow responsibility for payment to be determined. In such cases you have a right to be provided with a copy of the request in writing within 30 days of the requestor’s receipt of the information requested. Any information disclosed pursuant to this section will be limited to the minimum information necessary, and generally includes the nature of the services provided, the dates of services, the amount due and other relevant financial information.  
  • For Health Care Operations:  We may use or disclose your health information for health care operations. For example, we may use a billing service, IT support, document management services, storage providers or other essential services. These uses and disclosures are necessary for the internal operation of the Company. When these operations involve third-parties who are not employees of the Company, we call them “Business Associates” (as discussed below) and enter into agreements with them to protect your confidentiality.
  • Marketing. The Company will not use or disclose your health information for marketing purposes or sell your health information for any reason.

Written Authorization Required:

Generally, we are not permitted to use or disclose your health information without your written authorization, except where disclosure is required or permitted by law. The authorization must state what information can be released, to whom, and for what purpose. It must be dated. You have the right to refuse to consent to disclosure without fearing any kind of pressure or retaliation. If you authorize us to use or disclose health information about you, you may limit the information to be used and/or disclosed and you may revoke the authorization in writing at any time. You also have the right to revoke your written authorization by providing us with notice, except to the extent that we have already acted in reliance on your authorization.

Psychotherapy Notes. Your psychotherapist may at their discretion keep Psychotherapy Notes in addition to your treatment record. Psychotherapy Notes are the personal notes of your psychotherapist. Sometimes called “process notes”, Psychotherapy Notes means notes recorded (in any medium) by a mental health professional documenting or analyzing the contents of conversation during a private counseling session or a group, joint, or family counseling session and that are separated from the rest of the individual’s medical record. Psychotherapy notes exclude medication prescription and monitoring, counseling session start and stop times, the modalities and frequencies of treatment furnished, results of clinical tests, and any summary of your diagnosis, functional status, treatment plan, symptoms, prognosis, and progress to date. To be considered “psychotherapy notes”, the notes must be separate from the medical record. These notes may capture your therapist’s impressions about you, contain details of psychotherapy conversations considered to be inappropriate for the medical record, and are used by your psychotherapist for future sessions. It is because of the sensitivity of these notes that they are kept separate from your medical record and not included in records which may be sent to insurers for payment.

Psychotherapy Notes cannot be disclosed without your written authorization, including disclosure for treatment purposes to a health care provider, except where used by (i) the originator of the psychotherapy notes for treatment; (ii) the Company for its own training programs in which students, trainees, or practitioners in mental health learn under supervision to practice or improve their skills in group, joint, family, or individual counseling; (iii) the Company to defend itself in a legal action or other proceeding brought by or on behalf of the patient; or (iv) where otherwise required by law.

When Disclosure Is Required by Law:  

There are times when we are required by law to disclose certain Confidential Information about you whether we want to or not. Some of the circumstances where disclosure is required by law are: 

  • Where we reasonably suspect physical, emotional or sexual abuse, neglect or abandonment of a child, dependent adult or person 65 or older. You should know that sexual abuse of a child includes the creation of or streaming, downloading, storing or transmitting electronic images sexually depicting a child. This law is implicated even when a minor creates, streams, stores or transmits images of themselves such as when sexting with a friend.
  • Where we have reason to believe that you may present a danger to others. If we believe that you are threatening serious bodily harm to another, we are required to take protective actions. These actions may include notifying the potential victim, contacting the police, or seeking hospitalization for you;
  • Where we have reason to believe that you present a danger to yourself.  If you threaten to harm yourself, we may be obligated to seek hospitalization for you or to contact family members or others who can help provide you with protection;
  • For certain specialized governmental functions related to the military, national security and intelligence, and the protection of the President and others; 
  • For Workers Compensation to the extent necessary to comply with state workers compensation laws governing job-related injuries or illnesses;
  • Upon request by your legal representative such as your attorney prior to the filing of a legal action, conservators authorized to access behavioral health records, persons having durable powers of attorney for healthcare decisions under circumstances where you have been determined to lack capacity to make healthcare decisions, or the personal representative, executor, or administrator of your estate or beneficiary potentially including any person who may have a present or future interest under a trust;
  • When required by the Secretary of the Department of Health and Human Services or any of its offices, including the Office of Civil Rights to investigate or determine the Company’s compliance with HIPAA or any of its implementing regulations.

 When Disclosure May Be Required:

Some of the circumstances where disclosure may be required are: 

  • Pursuant to a legal proceeding that is initiated by or brought against you.  For example, if you place your mental status at issue in litigation, such as in a lawsuit seeking damages for severe emotional distress, the defendant may have the right to obtain your psychotherapy records and/or the testimony of your psychotherapist by issuing a subpoena. Your personal health information may then be shared with retained experts in the case and shared with other parties in the litigation. Potentially that information may even be shared with a jury or other fact finder.  Please note that we will not release your protected health information in response to a subpoena without your written authorization, unless ordered to do so by a court order, except in cases where the records are sought for a workers’ comp determination or proceeding, and even then, such release of information shall be reasonably limited to only that information necessary for the determination or proceeding.
  • Business Associates.  Some services in our Company we obtain through contracts with business associates. For example, we may contract with outside companies to provide legal services, accounting services, or billing services.  When we contract with a business associate, we may disclose health information to the business associate so it can do the job we have asked it to do.  To protect your health information, we enter into “Business Associate” agreements with them to require them to appropriately safeguard your health information.
  • For Data Breach Notification Purposes. We may use limited Confidential Information such as your contact information to provide legally required notices of unauthorized acquisition, access or disclosure of your Confidential Information, if such were to occur. We may send notices directly to you or provide notice to the sponsor of a health plan through which you receive coverage.
  • Comply with the law.  We may disclose health information about you if otherwise required by state or federal laws. 


Confidential treatment information may also be disclosed in the rare event of a medical or psychological emergency, meaning a sudden change in condition that may result in physical or psychological harm to you if left untreated. 

Your Rights Regarding Medical Information About You:

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

  • To obtain a copy of our Notice of Privacy Practices. 
  • To request a restriction on certain uses and disclosures of your information. This request must be in writing. 
  • To inspect and request a copy of your health record other than Psychotherapy Notes so long as the record is maintained. We are required to act on your request for access to your information no later than 30 calendar days after receipt of the request. If we are not able to act within this timeframe, we may have up to an additional 30 calendar days, as long as we provide you – within that initial 30-day period – with a written statement of the reasons for the delay and the date by which we will complete its action on the request.
    • The Company has the right to deny access to your health records if we determine in the exercise of professional judgment that the access requested is reasonably likely to endanger the life or physical safety of you or another person.  
    • The Company may provide you with a summary of the information requested, in lieu of providing access to the records, if you agree in advance to receive the summary and you agree to pay any fees that may be charged for preparing the summary. 
    • You have the right to request that the information contained in your records be amended.  Your request must be made in writing and it must include a reason that supports the request.
  • To obtain an accounting of disclosures to others of your health information. The accounting will provide information about disclosures made for purposes other than treatment, payment, health care operations, disclosures required by law or those you have authorized. 
  • To request confidential communications. You have the right to request that we communicate with you about medical matters in a certain way or at a certain location. For example, you may ask that we only contact you at work or by mail. Your request must be in writing and specify the exact changes you are requesting. 
  • To revoke your authorization. You have the right to revoke your authorization for the use or disclosure of your health information except to the extent that action has already been taken. 
  • To choose someone to act for you.   If you have given someone medical power of attorney or if someone is your legal guardian, that person can exercise your rights and make choices about your health information. We will make sure the person has this authority and can act for you before we take any action. 
  • To complain about any aspect of our health information practices to the United States Department of Health and Human Services without fear of retaliation. Complaints about this notice should be directed in writing to: 

Centralized Case Management Operations

U.S. Department of Health and Human Services

200 Independence Avenue, S.W.

Room 509F HHH Bldg.

Washington, D.C. 20201