If you’re a new client, you will need to read some terms of service, then fill out and sign the intake form. You will receive the link for that form after booking an appointment.

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: High Thrive Counseling typically seeks a protective order or client Authorization before producing records when possible, consistent with applicable law. 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:

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.

Marketing Purposes. As a psychotherapist, I will not use or disclose your PHI for marketing purposes.

Authorization & Revocation. You may revoke any Authorization in writing at any time. Revocation will not apply to disclosures already made in reliance on your Authorization.

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:

• 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.

• 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.

• For health oversight activities, including audits and investigations.

• 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.

• For law enforcement purposes, including reporting crimes occurring on my premises, coroners or medical examiners, when such individuals are performing duties authorized by law.

• 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. 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.

• 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.

• Appointment reminders and health-related benefits or services. I may use and disclose your PHI to remind you of appointments. I may also 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.

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:

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.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.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.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. Designated record set” includes records used to make decisions about you (e.g., intake forms, treatment plans, progress notes kept as part of the clinical record). It does not include psychotherapy notes, which are kept separately.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.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.The Right to Get a Paper or Electronic Copy of this Notice. You have the right to 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.

VII. Breach Notification
If a breach occurs that compromises the privacy or security of your unsecured PHI, I will notify you in writing without unreasonable delay and no later than 60 days after discovery, and will follow all required mitigation and reporting steps.

VIII: How to File a Complaint (HIPAA requirement)

If you believe your privacy rights have been violated, you may file a complaint with me, or with the U.S. Department of Health and Human Services, Office for Civil Rights, 200 Independence Ave SW, Washington, DC 20201; phone (800) 368-1019; online complaint portal. You will not be retaliated against for filing a complaint.

IX: Business Associates

I may disclose PHI to vendors who perform services for my practice (e.g., EHR, billing, telehealth platforms) under Business Associate Agreements that require them to safeguard your PHI as required by HIPAA.

X: Record Retention

I retain adult client records for at least seven (7) years after the last date of service. For minors, records are retained until at least the client’s 21st birthday, or longer if required by law, after which they may be securely destroyed.

FEES: You may pay by Check, Cash, Debit/Credit Card, or HSA. Your credit card will be charged the morning of your scheduled session. Checks are to be made out to High Thrive Counseling. If you are filing insurance, you will need to be responsible for verifying authorization of counseling services and finding out your Co-pay and Co-Insurance fee for each visit. Please note that the fee for each session is $200.00 per 55 min.

Fees are subject to annual increase in April of each year.  The rate increase will reflect inflation, increased overhead costs, and market rates for my credentials and experience level. This rate increase will allow me to sustain a consistent quality of care.

Good Faith Estimate (No Surprises Act): Because you are not using insurance, you are entitled to a written Good Faith Estimate of expected charges before services. Actual costs may vary based on clinical need. Learn more here in the accordion tab below.

I agree that my credit card can be charged for any session that is not canceled at least 24 hours prior to the scheduled session.

I understand that this authorization will remain in effect until I cancel it in writing, and I agree to notify High Thrive Counseling in writing of any changes in my account information or termination of this authorization.

I certify that I am an authorized user of this credit card and will not dispute these scheduled transactions with my bank or credit card company as long as the transactions correspond to the terms indicated in this authorization form. I acknowledge that credit card transactions could be linked to Protected Health Information.

The therapeutic relationship is unique in that it is a highly personal and at the same time, a contractual agreement. Given this, it is important for us to reach a clear understanding about how our relationship will work, and what each of us can expect. This consent will provide a clear framework for our work together. Feel free to discuss any of this with me. Please read and indicate that you have reviewed this information and agree to it by filling in the checkbox at the end of this document.

Legal/Forensic Services: All therapists at High Thrive Counseling Jill Frame or any employee of High Thrive Counseling do not provide forensic evaluations (e.g., custody, fitness-for-duty) and do not make recommendations to a court. If I am subpoenaed or retained to participate in legal matters, my fee is $400/hour for all related professional time (preparation, travel, waiting, testimony, consultation), billed in 30-minute increments with a 3-hour minimum, due within 30 days. Therapy records are created for clinical purposes, not for litigation

The Therapeutic Process
You have taken a very positive step by deciding to seek therapy. The outcome of your treatment depends largely on your willingness to engage in this process, which may, at times, result in considerable discomfort. Remembering unpleasant events and becoming aware of feelings attached to those events can bring on strong feelings of anger, depression, anxiety, etc. There are no miracle cures. I cannot promise that your behavior or circumstance will change. I can promise to support you and do my very best to understand you and repeating patterns, as well as to help you clarify what it is that you want for yourself.

The session content and all relevant materials to the client’s treatment will be held confidential unless the client requests in writing to have all or portions of such content released to a specifically named person/persons. 

No Recording: To protect confidentiality and create a safe therapeutic environment, recording of sessions by any party is not permitted without my prior written consent.

If a session is recorded without written consent, the client agrees to pay liquidated damages of $2,000 per occurrence (not as a penalty) to cover the administrative, legal, and ethical costs associated with the breach of confidentiality. This amount represents a reasonable pre-estimate of the harm caused by unauthorized recording and is not intended as punishment.

Unauthorized recording may also result in termination of services and other remedies available under applicable law.

Limitations of such client held privilege of confidentiality exist and are itemized below:

1. If a client threatens or attempts to commit suicide or otherwise conducts themselves in a manner in which there is a substantial risk of incurring serious bodily harm.

2. If a client threatens grave bodily harm or death to another person.

3. If the therapist has a reasonable suspicion that a client or other named victim is the perpetrator, observer of, or actual victim of physical, emotional or sexual abuse of children under the age of 18 years.

4. Suspicions as stated above in the case of an elderly person who may be subjected to these abuses.

5. Suspected neglect of the parties named in items #3 and # 4.

6. If a court of law issues a legitimate subpoena for information stated on the subpoena.

7. If a client is in therapy or being treated by order of a court of law, or if information is obtained for the purpose of rendering an expert’s report to an attorney.

Occasionally I may need to consult with other professionals in their areas of expertise in order to provide the best treatment for you. Information about you may be shared in this context without using your name.

If we see each other accidentally outside of the therapy office, I will not acknowledge you first. Your right to privacy and confidentiality is of the utmost importance to me, and I do not wish to jeopardize your privacy. 

However, if you acknowledge me first, I will be more than happy to speak briefly with you, but feel it appropriate not to engage in any lengthy discussions in public or outside of the therapy office.

I understand that High Thrive Counseling may contact me using the following methods. I acknowledge that I have read and understood the risks described below and agree to these forms of communication:

• Secure client portal

• Encrypted email

• Unencrypted email (I accept the risks described below)

• Text message (I accept the risks described below)

• Phone call / voicemail

By signing below, I acknowledge that I have read and understood the risks associated with these forms of communication, and I consent to being contacted through any of the methods listed above. I understand that I may revoke this consent at any time in writing.

All emails sent from High Thrive Counseling use encryption in transit to help protect confidentiality. However, you are responsible for the security of your own email accounts and devices. Emails that you send to High Thrive Counseling may not be encrypted.

Text communication with High Thrive Counseling may occur through unencrypted methods such as standard SMS text messaging. If you choose to use unencrypted communication options, please be aware that these methods can be accessed by unauthorized persons and may compromise the privacy or confidentiality of such communications.

Unencrypted emails and texts are vulnerable because communication companies may have access to their servers, and messages could be misdirected or viewed by unintended recipients. Computers, tablets, and cell phones can also be lost or stolen. These risks apply both to messages you send and those you receive.

High Thrive Counseling takes reasonable precautions to protect your information, including password-protected devices, antivirus software, and secure cloud-based storage in a HIPAA-compliant environment. Emails may include a confidentiality disclaimer” (some systems don’t append it to every message) that may become part of your clinical record are subject to the same privacy laws as any other treatment record.

You are not required to use any of these methods of communication to receive treatment. You have the right to request only encrypted communication. If you initiate communication via unencrypted methods, I will assume that you have made an informed decision to do so and will honor your preference.

Opt-Out: You may restrict or revoke consent for any method (email, text, voicemail) at any time by notifying me in writing.

Telehealth services involve the use of electronic communications (including video conferencing, phone calls, email, and other digital means) to deliver therapy services when the client and therapist are in different physical locations. Before starting telehealth treatment, it is important that you understand the following:

1. Voluntary Participation: You have the right to withhold or withdraw consent for telehealth at any time without affecting your right to future care, access to services, or program benefits.

2. Confidentiality: The laws that protect the confidentiality of your personal health information also apply to telehealth. No information obtained in the course of therapy will be disclosed to outside parties without your consent, except as permitted or required by law.

3. Technology and Security: I use HIPAA-compliant, encrypted platforms for telehealth sessions. However, there are inherent risks to electronic communication, including potential interruptions, technical failures, or unauthorized access despite reasonable security measures.

4. Client Responsibilities: You agree to participate in sessions from a quiet, private space where confidentiality can be maintained. You must confirm your location at the start of each session in case of emergency.

5. Risks and Benefits: Telehealth allows for increased access to services, continuity of care, and convenience. However, it may limit my ability to observe certain nonverbal or environmental cues that can be clinically important. Technical problems may interrupt sessions, and in rare cases, sensitive information could be compromised despite safeguards.

6. Emergency Situations: If you experience an emergency during a telehealth session, I may contact emergency services at your location. If you are in crisis outside of a session, please call or text 988, go to your nearest emergency department, or call 911.

7. Prohibition on Recording: To protect confidentiality, recording of telehealth sessions by either party is not permitted without prior written consent.

By signing below, you acknowledge that you have read and understood the information above, that you have had an opportunity to ask questions, and that you consent to participate in telehealth services provided by High Thrive Counseling.

If you need to contact your therapist between sessions, please leave a voicemail message. We are often not immediately available; however, we will make every effort to return your call within 48 hours during business days and 72 hours on weekends.

High Thrive Counseling is not an emergency or crisis service.

If you are experiencing a true emergency, please call 911, go to your nearest emergency department, or contact the Suicide and Crisis Lifeline by dialing or texting 988.

Ending relationships can be difficult. Therefore, it is important to have a termination process in order to achieve some closure. The appropriate length of the termination depends on the length and intensity of the treatment. I may terminate treatment after appropriate discussion with you and a termination process if I determine that the psychotherapy is not being effectively used or if you are in default on payment. I will not terminate the therapeutic relationship without first discussing and exploring the reasons and purpose of terminating. If therapy is terminated for any reason or you request another therapist, I will provide you with a list of qualified psychotherapists to treat you. You may also choose someone on your own or from another referral source.

Should you fail to schedule an appointment for three consecutive weeks, unless other arrangements have been made in advance, for legal and ethical reasons, I must consider the professional relationship discontinued.