E.T.C. & Psychotherapy, Inc.

The following forms you are being asked to complete request information that we feel is critical to your care. By completing the forms, we will be better able to attend to your issues in the clinical sessions.

If you feel that an item does not apply or is confusing, please feel free to proceed to another item and discuss with your clinician.

Please keep in mind that all information is strictly confidential. Your cooperation is greatly appreciated!

INFORMATION AND CONSENT

Please read the following information carefully. Welcome to Candy Marcum Counseling. We are pleased you have selected one of our clinicians with which to work. This document is designed to inform you of our policies and procedures, which might affect your relationship with us.

Our clinicians are licensed and credentialed in a variety of mental health fields. Some of the licenses held are identified as follows: Licensed Professional Counselor (LPC); Licensed Chemical Dependency Counselor (LCDC); and Licensed Marriage Family Therapist (LMFT). Please feel free to question your individual clinician regarding his or her credentials and professional experience.

Our clinicians see a variety of clients with a wide range of issues. Our practice includes counseling for Individual, Groups, Families and Couples. Your counselor may recommend a variety of treatment modalities or settings. Our standard session is ​50 minutes in length.

The cost of your counseling session will be discussed and set either prior to your first session or in the first session with your counselor. Payment for each session will be due and must be paid at the conclusion of each session. Cash, credit cards, and personal checks are acceptable for payment. IN THE EVENT YOU ARE UNABLE TO KEEP AN APPOINTMENT YOU ​MUST​ NOTIFY YOUR COUNSELOR AT LEAST 24 HOURS IN ADVANCE OF YOUR APPOINTMENT TIME OR YOU WILL BE CHARGED THE FULL FEE FOR THE MISSED OR LATE CANCELLATION OF SAID APPOINTMENT. We do not double book our appointment times, so this time is saved for you. We can fill your appointment time if you will give us 24 hours notice. Thank you.

It is our philosophy that we only accept clients whom we believe have the capacity to resolve their own problems with our assistance. We believe that as people become more accepting of themselves, they are more capable of finding happiness and contentment in their lives. Self-awareness and self-acceptance are goals that may take time to achieve. Some clients need only a few counseling sessions, while others may require more sessions. As a client, you are in complete control and may end the counseling relationship at any point. We will be supportive of that decision. If counseling is successful, you should feel you are able to face life’s present and future challenges in a healthier manner.

Although counseling sessions may be very intimate psychologically, it is important for you to realize you and your counselor have a professional relationship rather than a social one. Your contact will be limited to sessions you arrange with your counselor. Please do not invite your counselor to social gatherings, offer them gifts, or ask them to relate to you in ways other than in the professional context of your counseling sessions. YOU will be best served by this strictly professional relationship and having your sessions concentrate exclusively on your concerns.

Our clinicians are held to the highest counseling industry ethical standards. If at any time, for any reason, you are dissatisfied with our services, please let your counselor know. If your counselor is not able to resolve your concerns, you may report your complaints to the Board of Professional Counselors or appropriate licensing board.

We agree to provide counseling services to you under the conditions as indicated above. You agree to render the designated fee to be paid at the conclusion of each counseling session. If you have any questions, feel free to ask your counselor.

CONFIDENTIAL STATEMENT OF UNDERSTANDING

Your counselor will not share information with any person outside of the clinical practice group without your written permission, except as required by law or in a situation deemed potentially life-threatening (i.e. harm to another person or self).

Federal and state laws and regulations may also protect the confidentiality of your participation in counseling. The violation of federal requirements is a crime, and suspected violations may be reported. Federal regulations do not protect from disclosure of information related to a client’s commission of a crime against E.T.C. & Psychotherapy, Inc. property or personnel, or reports under state law of suspected child abuse or neglect. (See 42 U.S.C. 290-3 for federal laws and 42 CFR Part 2 for federal regulations.) Federal regulations also do not protect from disclosure of information related to a client’s threat of harm towards self or others.

While I have been training in the Gottman Method Couples Therapy, I want you to know that I (or my agency) am completely independent in providing you with clinical services and I alone am fully responsible for those services. The Gottman Institute or its agents have no responsibility for the services you receive.

CONSENT FOR VIDEO COUNELING

I understand my health care provider may want me to engage in Video Counseling.

My health care provider explained to me how the video conferencing technology that will be used to affect Video Counseling will not be the same as a direct client/health care provider visit due to the fact that I will not be in the same room as my counselor.

I understand that Video Counseling has potential benefits including easier access to care and the convenience of meeting from a location of my choosing.

I understand there are potential risks to this technology, including interruptions, unauthorized access, and technical difficulties.

I understand my counselor or I can discontinue the Video Counseling if it is felt the videoconferencing connections are not adequate for the situation.

I have communicated with my counselor, during which I had the opportunity to ask questions in regard to this procedure. My questions have been answered and the risks, benefits and any practical alternatives have been discussed with me in a language in which I understand.

Video Counseling by RingCentral is the technology service we will use to conduct Video Counseling appointments.

By signing this document, I acknowledge: Video Counseling by RingCentral is NOT an Emergency Service and in the event of an emergency, I will use a phone to call 911.

The Video Counseling by RingCentral facilitates videoconferencing and is not responsible for the delivery of any healthcare, medical advice or care.

To maintain confidentiality, I will not share my Video Counseling appointment link with anyone unauthorized to attend the appointment.

I certify:

CLIENT INFORMATION

HIPAA Notice of Privacy Practices Statement

E.T.C. & Psychotherapy, Inc. and Candy Marcum Counseling staff collect data through a variety of means including but not necessarily limited to letters, phone calls, emails, voice mails, and from the submission of applications that is either required by law, or necessary to process inquiries, billing, and applications for licensure to state licensing agencies.

Information about your financial situation, mental health and or medical conditions and care that you provide to us in writing, via email, on the phone (including information left on voice mails), contained in or attached to applications, intake paperwork or directly or indirectly given to us, is held in strictest confidence.

We do not give out, exchange, barter, rent, sell, lend, or disseminate any information about applicants or clients who inquire for or actually receive our services that is considered patient confidential, is restricted by law, or has been specifically restricted by a patient/client in a signed HIPAA consent form.

Information is only used as is reasonably necessary to process billing or to provide you with health or counseling services which may require communication between and health care providers, insurance companies, and other providers necessary to: verify your information is accurate; determine the type of services you need including, but not limited to; or to obtain care outside of our standard of practice or care. Your non-medical information can be given to legal authorities including police, investigators, courts, and/or attorneys or other legal professionals, as well as any other information as permitted by law if there is a duty to report situation. Counselors in our practice may be required by law to report intentional acts, past acts against elderly, or children.

We do not use cookies on our website to collect date from our site visitors. We do not collect information about site visitors except for one hit counter on the main index page (www.candymarcum.com) that simply records the number of visitors and no other data. We do use some affiliate programs that may or may not capture traffic date through our site. To avoid potential data capture that you visited a diabetes website simply do not click on any of our outside affiliate links.

Limited Right to Use Non-Identifying Personal Information From Biographies, Letters, Notes, and Other Sources: Any pictures, stories, letters, biographies, correspondence, or thank you notes sent to us become the exclusive property of E.T.C. & Psychotherapy, Inc and Candy Marcum Counseling. We reserve the right to use non-identifying information about our clients (those who receive services or us) for promotional purposes that are directly related to our mission.

Clients will not be compensated for use of this information and no identifying information (photos, addresses, phone numbers, contact information, last names or uniquely identifiable names) will be used without client’s express advance permission.

You may specifically request that NO information be used whatsoever for promotional purposes, but you must identify any requested restrictions in writing. We respect your right to privacy and assure you no identifying information or photos that you send to us will ever be publicly used without your direct or indirect consent

We are required by law to maintain the privacy and security of your protected health information (“PHI”) and to provide you with this Notice of Privacy Practices (“Notice”). We must abide by the terms of this Notice, and E.T.C. & Psychotherapy, Inc and Candy Marcum Counseling must notify you if a breach of your unsecured PHI occurs. We can change the terms of this Notice, and such changes will apply to all information E.T.C. & Psychotherapy, Inc. and Candy Marcum Counseling has about you. The new Notice will be available upon request, in my office, and on our website. The website will always have the most recent version.

Except for the specific purposes set forth below, E.T.C. & Psychotherapy,Inc. and Candy Marcum Counseling will use and disclose your PHI only with your written authorization (“Authorization”). It is your right to revoke such Authorization at any time by giving us written notice of your revocation.

Uses (Inside Practice) and Disclosures (Outside Practice) Relating to Treatment, Payment, or Health Care Operations Do Not Require Your Written Consent. E.T.C. & Psychotherapy, Inc. and Candy Marcum Counseling can use and disclose your PHI without your Authorization for the following reasons:

1. For your treatment. E.T.C. & Psychotherapy, Inc. and Candy Marcum Counseling can use and disclose your PHI to treat you, which may include disclosing your PHI to another health care professional. For example, if a physician or a psychiatrist is treating you, E.T.C. & Psychotherapy, Inc. and Candy Marcum Counseling can disclose your PHI to him or her to help coordinate your care, although our preference is for you to give us an Authorization to do so. For example, Candy Marcum Counseling might send your PHI to your insurance company to get paid for the health care services that E.T.C. & Psychotherapy, Inc. have provided to you, although my preference is for you to give us an Authorization to do so.
2. To obtain payment for your treatment. E.T.C. & Psychotherapy, Inc. and Candy Marcum Counseling can use and disclose your PHI to bill and collect payment for the treatment and services provided by us to you.
3. For health care operations. E.T.C. & Psychotherapy, Inc. and Candy Marcum Counseling can use and disclose your PHI for purposes of conducting health care operations pertaining to my practice, including contacting you when necessary. For example, E.T.C. & Psychotherapy, Inc. and Candy Marcum Counseling may need to disclose your PHI to my attorney to obtain advice about complying with applicable laws. Certain Uses and Disclosures Require Your Authorization.
4. Psychotherapy Notes. E.T.C. & Psychotherapy, Inc. and Candy Marcum Counseling do not keep “psychotherapy notes” as that term is defined in 45 CFR §164.501; rather, E.T.C. & Psychotherapy, Inc. and Candy Marcum Counseling keep a record of your treatment and you may request a copy of such record at any time, or you may request that E.T.C. & Psychotherapy, Inc. and Candy Marcum Counseling prepare a summary of your treatment. There may be reasonable, cost-based fees involved with copying the record or preparing the summary.
5. Marketing Purposes. As a licensed counselor, E.T.C. & Psychotherapy, Inc. and Candy Marcum Counseling will not use or disclose your PHI for marketing purposes. Marketing is defined as receiving financial remuneration for communicating about other businesses’ health-related services or products to clients.
6. Sale of PHI. As a licensed counselor, E.T.C. & Psychotherapy, Inc. and Candy Marcum Counseling will not sell your PHI in the regular course of my business. Certain Uses and Disclosures Do Not Require Your Authorization. Subject to certain limitations mandated by law, E.T.C. & Psychotherapy, Inc. and Candy Marcum Counseling can use and disclose your PHI without your Authorization for the following reasons:
   1. When state or federal law, and the use require disclosure 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 clients 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, E.T.C. & Psychotherapy, Inc. and Candy Marcum Counseling may provide your PHI in order to comply with workers' compensation laws.
   10. Appointment reminders and health related benefits or services. E.T.C. & Psychotherapy, Inc. and Candy Marcum Counseling may use and disclose your PHI to contact you to remind you that you have an appointment with me. E.T.C. & Psychotherapy, Inc. and Candy Marcum Counseling may also use and disclose your PHI to tell you about treatment alternatives, or other health care services or benefits that E.T.C. & Psychotherapy, Inc. and Candy Marcum Counseling offer.

Disclosures to family, friends, or others. E.T.C. & Psychotherapy, Inc. and Candy Marcum Counseling 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.

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 us not to use or disclose certain PHI for treatment, payment, or health care operations purposes.
2. E.T.C. & Psychotherapy, Inc. and Candy Marcum Counseling are not required to agree to your request, and I may say “no” if E.T.C. & Psychotherapy, Inc. and Candy Marcum Counseling believe it would affect your health care.
3. 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 healthcare 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.
4. The Right to Choose How E.T.C. & Psychotherapy, Inc. and Candy Marcum Counseling Send PHI to You. You have the right to ask us to contact you in a specific way (for example, home or office phone) or to send mail to a different address, and E.T.C. & Psychotherapy, Inc. and Candy Marcum Counseling will agree to all reasonable requests.
5. 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 E.T.C. & Psychotherapy, Inc. and Candy Marcum Counseling have about you. E.T.C. & Psychotherapy, Inc. and Candy Marcum Counseling 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 E.T.C. & Psychotherapy, Inc. and Candy Marcum Counseling may charge a reasonable, cost based fee for doing so.
6. The Right to Get a List of the Disclosures E.T.C. & Psychotherapy, Inc. and Candy Marcum Counseling Have Made. You have the right to request a list of instances in which E.T.C. & Psychotherapy, Inc. and Candy Marcum Counseling have disclosed your PHI for purposes other than treatment, payment, or health care operations, or for which you provided us with an Authorization. E.T.C. & Psychotherapy, Inc. and Candy Marcum Counseling will respond to your request for an accounting of disclosures within 60 days of receiving your request. The list E.T.C. & Psychotherapy, Inc. and Candy Marcum Counseling will give you will include disclosures made in the last six years unless you request a shorter time. E.T.C. & Psychotherapy, Inc. and Candy Marcum Counseling will provide the list to you at no charge, but if you make more than one request in the same year, E.T.C. & Psychotherapy, Inc. and Candy Marcum Counseling will charge you a reasonable cost-based fee for each additional request.
7. 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 E.T.C. & Psychotherapy, Inc. and Candy Marcum Counseling correct the existing information or add the missing information. E.T.C. & Psychotherapy, Inc. and Candy Marcum Counseling may say “no” to your request, but E.T.C. & Psychotherapy, Inc. and Candy Marcum Counseling will tell you why in writing within 60 days of receiving your request.
8. 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.

If you think E.T.C. & Psychotherapy, Inc. and Candy Marcum Counseling may have violated your privacy rights, you may file a complaint with me, as the Privacy Officer, Candy Marcum is the Privacy Officer for this practice. The address and telephone number are at the beginning of this document.

You can also file a complaint with the U.S. Department of Health and Human Services Office for Civil Rights by:

1. Sending a letter to 200 Independence Avenue, S.W., Washington, D.C. 20201;
2. Calling 1-877-696-6775; or,
3. Visiting www.hhs.gov/ocr/privacy/hipaa/complaints.

E.T.C. & Psychotherapy, Inc. and Candy Marcum Counseling will not retaliate against you if you file a complaint about my privacy practices.

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