Client Forms & Therapy Policies

Original effective date: August 1, 2022
Revision prepared: September 24, 2026

Your Information. Your Rights. Our Responsibilities.

This notice describes how medical information about you may be used and disclosed and how you can get access to this information. Please review it carefully.

Your Rights

You have the right to:

• Get a copy of your paper or electronic medical record
• Correct your paper or electronic medical record
• Request confidential communication
• Ask us to limit the information we share
• Get a list of those with whom we’ve shared your information
• Get a copy of this privacy notice
• Choose someone to act for you
• File a complaint if you believe your privacy rights have been violated

Your Choices

You have some choices in the way that we use and share information as we:

• Tell family and friends about your condition
• Provide disaster relief
• Provide mental health care

Our Uses and Disclosures

We may use and share your information as we:

• Treat you
• Run our organization
• Bill for your services
• Help with public health and safety issues
• Do research
• Comply with the law
• Respond to organ and tissue donation requests
• Work with a medical examiner or funeral director
• Address workers’ compensation, law enforcement, and other government requests
• Respond to lawsuits and legal actions

To the extent that we have your substance use disorder patient records, subject to 42 CFR part 2, we will not share that information for investigations or legal proceedings against you without (1) your written consent or (2) a court order and a subpoena.

Your Rights

When it comes to your health information, you have certain rights. This section explains your rights and some of our responsibilities to help you.

Get an electronic or paper copy of your medical record

• You can ask to see or get an electronic or paper copy of your medical record and other health information we have about you. Ask us how to do this.
• We will provide a copy or a summary of your health information, usually within 30 days of your request. We may charge a reasonable, cost-based fee.

Ask us to correct your medical record

• You can ask us to correct health information about you that you think is incorrect or incomplete. Ask us how to do this.
• We may say “no” to your request, but we’ll tell you why in writing within 60 days.

Request confidential communications

• You can ask us to contact you in a specific way (for example, home, office, or cell phone) or to send mail to a different address.
• We will say “yes” to all reasonable requests.

Ask us to limit what we use or share

• You can ask us not to use or share certain health information for treatment, payment, or our operations. We are not required to agree to your request, and we may say “no,” for example, if it could affect your care. If we agree to your request, we may still share this information in the event that you need emergency treatment.
• If you pay for a service or health care item out-of-pocket in full, you can ask us not to share that information for the purpose of payment or our operations with your health insurer. We will say “yes” unless a law requires us to share that information.

Get a list of those with whom we’ve shared information

• You can ask for a list (accounting) of the times we’ve shared your health information for six years prior to the date you ask, who we shared it with, and why.
• We will include all the disclosures except for those about treatment, payment, and health care operations, and certain other disclosures (such as any you asked us to make). We’ll provide one accounting a year for free but will charge a reasonable, cost-based fee if you ask for another one within 12 months.

Get a copy of this privacy notice

You can ask for a paper copy of this notice at any time, even if you have agreed to receive the notice electronically. We will provide you with a paper copy promptly.

Choose someone to act for you

• If someone has authority to act as your personal representative, such as if someone has your 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.

File a complaint if you feel your rights are violated

• You can complain if you feel we have violated your rights by contacting us using the Privacy Officer contact information above.
• You can file a complaint with the U.S. Department of Health and Human Services Office for Civil Rights by sending a letter to 200 Independence Avenue, S.W., Washington, D.C. 20201, calling 1-877-696-6775, or visiting https://www.hhs.gov/hipaa/filing-a-complaint/index.html.
• We will not retaliate against you for filing a complaint.

Your Choices

For certain health information, you can tell us your choices about what we share. If you have a clear preference for how we share your information in the situations described below, talk to us. Tell us what you want us to do, and we will follow your instructions.

In these cases, you have both the right and choice to tell us to:

• Share information with your family, close friends, or others involved in your care or payment for your care
• Share information in a disaster relief situation

If you are not able to tell us your preference, for example if you are unconscious, we may go ahead and share your information if we believe it is in your best interest. We may also share your information when needed to lessen a serious and imminent threat to health or safety.

High Thrive Counseling does not use or disclose your protected health information for marketing and does not sell it. Most sharing of psychotherapy notes requires your written authorization.

High Thrive Counseling does not use your health information for fundraising.

Our Uses and Disclosures

How do we typically use or share your health information?

We typically use or share your health information in the following ways.

Treat you

We can use your health information and share it with other professionals who are treating you.

Example: A doctor treating you for an injury asks another doctor about your overall health condition.

Run our organization

We can use and share your health information to run our practice, improve your care, and contact you when necessary.

Example: We use health information about you to manage your treatment and services.

Bill for your services

We can use and share your health information as permitted by law to collect payment and administer billing. High Thrive Counseling does not bill insurance directly. A superbill is available for you to submit to your insurer if you seek out-of-network reimbursement.

Example: We use appointment and service information to prepare your bill or a requested superbill.

How else can we use or share your health information?

We are allowed or required to share your information in other ways – usually in ways that contribute to the public good, such as public health and research. We have to meet many conditions in the law before we can share your information for these purposes.

In all cases, including those listed below, if we have substance use disorder patient records about you, subject to 42 CFR part 2, we cannot use or share information in those records in civil, criminal, administrative, or legislative investigations or proceedings against you without (1) your consent or (2) a court order and a subpoena.

Help with public health and safety issues

We can share health information about you for certain situations such as:

• Preventing disease
• Helping with product recalls
• Reporting adverse reactions to medications
• Reporting suspected abuse, neglect, or domestic violence
• Preventing or reducing a serious threat to anyone’s health or safety

Do research

We can use or share your information for health research.

Comply with the law

We will share information about you if state or federal laws require it, including with the Department of Health and Human Services if it wants to see that we’re complying with federal privacy law.

Respond to organ and tissue donation requests

We can share health information about you with organ procurement organizations.

Work with a medical examiner or funeral director

We can share health information with a coroner, medical examiner, or funeral director when an individual dies.

Address workers’ compensation, law enforcement, and other government requests

We can use or share health information about you:

• For workers’ compensation claims
• For law enforcement purposes or with a law enforcement official
• With health oversight agencies for activities authorized by law
• For special government functions such as military, national security, and presidential protective services

Respond to lawsuits and legal actions

• We may share health information in response to legal process only when the applicable legal requirements have been met. A subpoena does not automatically authorize disclosure of every record. High Thrive Counseling typically seeks a protective order or client authorization before producing records when possible, consistent with applicable law.

Our Responsibilities

• We are required by law to maintain the privacy and security of your protected health information.
• We will let you know promptly if a breach occurs that may have compromised the privacy or security of your information.
• We must follow the duties and privacy practices described in this notice and give you a copy of it.
• We will not use or share your information other than as described in this notice unless you tell us we can in writing. If you tell us we can, you may change your mind at any time. Let us know in writing if you change your mind.

For more information see: www.hhs.gov/ocr/privacy/hipaa/understanding/consumers/noticepp.html.

Changes to the Terms of this Notice

We can change the terms of this notice, and the changes will apply to all information we have about you. The new notice will be available upon request, in our office, and on our web site.

Additional Protections

When applicable state law or other law gives your information greater protection than HIPAA, we follow the more protective requirements. Requests involving mental health records, psychotherapy notes, minors, or substance use disorder records are evaluated under the rules applicable to those records.

High Thrive Counseling is an out-of-network practice and does not bill insurance directly. A superbill is available for possible reimbursement; your insurance plan determines coverage.

Intake appointments, extended sessions, and intensives may have different fees. Confirm the fee for your appointment with your therapist and review your individualized estimate.

You may pay by check, cash, debit/credit card, or HSA. Your credit card will be charged the morning of your scheduled session. Checks should be made payable to High Thrive Counseling.

If you plan to seek out-of-network reimbursement, contact your insurer to verify benefits and any authorization requirements.

Fees are subject to annual increases in April, reflecting inflation, overhead costs, and professional credentials and experience.

See fees and frequently asked questions.

You have the right to receive a Good Faith Estimate explaining how much your care is expected to cost.

If you do not have insurance or are not using insurance to pay for care, you can request a written estimate before scheduling. An estimate outlines expected charges based on the services anticipated for you.

For care scheduled 3–9 business days ahead, an estimate is generally due within 1 business day of scheduling. For care scheduled at least 10 business days ahead, it is generally due within 3 business days. An estimate requested before scheduling is generally due within 3 business days.

Your estimate should reflect your anticipated care. It is not a commitment to a fixed number of sessions. Discuss changes to your schedule or treatment plan with your therapist.

If a provider’s bill is at least $400 above that provider’s estimated charges, you may qualify for the federal patient-provider dispute resolution process. You generally must start that process within 120 calendar days of the initial bill. Keep your estimate and bills.

Contact hello@highthrivecounseling.com or 317-210-0112 with questions about your estimate.

Information and resources

• CMS: No Surprises Act and Good Faith Estimate information
• American Psychological Association: length of treatment
• Good Faith Estimate document (PDF)

For federal assistance, call 800-985-3059.

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 in your intake paperwork.

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 the corresponding intake form, 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 the corresponding intake form, 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.