THIS NOTICE DESCRIBES HOW MEDICAL [INCLUDING MENTAL HEALTH] INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY. During the process of providing services to you, Henry Dooley Psychological Services, LLC, D/B/A Center for the Connected Self, and Associates will obtain, record, and use mental health and medical information about you that is protected health information. Ordinarily, that information is confidential and will not be used or disclosed, except as described below.

I. USES AND DISCLOSURES OF PROTECTED INFORMATION:

A. General Uses and Disclosures Not Requiring the Client’s Consent. The provider will use and disclose protected health information in the following ways.

1. Treatment – Treatment refers to the provision, coordination, or management of health care and mental health care by one or more health care providers. For example, the provider will use your information to plan your course of treatment. As to other examples, the provider may consult with other professional colleagues or ask professional colleagues to cover calls or the practice for the provider and will provide the information necessary to complete those tasks.

2. Healthcare Operations - We can use and share your health information to run our practice, improve your care, and contact you when necessary. For example, we use health information about you to manage your treatment and services, for staff training and evaluation, for legal services, and for the planning of future operations.

3. Contacting the Client - The provider may contact you to tell you about treatments and other services that might benefit your or to remind you of appointments.

4. Payment – Payment refers to the activities undertaken by a health care provider [including a mental health provider] to obtain or provider reimbursement for the provision of health care. The provider will use your information to develop accounts receivable information, bill you, and with your consent, provide information to your insurance company or other third party payer for services provided. The information provided to insurers and other third party payers may include information that identifies you, as well as your diagnosis, type of service, date of service, provider name, and other information about your condition and treatment.

5. As Required By Law - The provider will disclose protected health care information when required by law or necessary for health care oversight. This includes, but is not limited to: (a) reporting child abuse or neglect; (b) when court ordered to release information; (c) when there is a legal duty to warn or take action regarding imminent danger to others; (d) when the client is a danger to self or others or gravely disabled; (e) when a coroner is investigating the client’s death; or (f) to health oversight agencies for oversight activities authorized by law and necessary for the oversight of health care system, government health care programs, or regulatory compliance.

6. Crimes on the Premises or Observed by the Provider – Crimes that are observed by the provider or the provider’s staff, crimes that are directed towards the provider or the provider’s staff, or crimes that occur on the premises will be reported to law enforcement.

7. Business Associates – Some of the functions of the provider may be provided by contracts with business associates. For example, some of the billing, legal, auditing, and practice management services may be provided by contracting with outside entities to perform those services. In those situations, protected health information will be provided to those contractors as is needed to perform their contracted tasks. Business associates are required to enter into an agreement maintaining the privacy of the protected health information released to them.

8. Research – The provider may use or disclosed protected health information for research purposes if the relevant limitations of the Federal HIPAA Privacy Regulation are followed. 45 CFR# 164.512(i).

9. Involuntary Clients – Information regarding clients who are being treated involuntarily, pursuant to law, will be shared with other treatment providers, legal entities, third party payers and others, as necessary to provide the care and management coordination needed.

10. Family Members – Except for certain minors, incompetent clients, or involuntary clients, protected health information cannot be provided to family members without the client’s consent. In situations where family members are present during a discussion with the client, it can reasonably be inferred from the circumstances that the client does not object, information may be disclosed in the course of that discussion. However, if the client objects, protected health information will not be disclosed.

11. Emergencies – In life threatening emergencies the provider will disclose information necessary to avoid serious harm or death.

B. Client Authorization or Release of Information. The provider may not use or disclose protected information in any other way without a signed authorization or release of information. When you sign an authorization, or release of information, it may later be revoked, provided that the revocation is in writing. The revocation will apply, except to the extent the provider has already taken action in reliance thereon.

II. YOUR RIGHTS AS A CLIENT:

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 protected health information that the provider has regarding you, in the designated record set. However, you do not have the right to inspect or obtain a copy of psychotherapy notes.
• 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. To make a request, ask your therapist.
• 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 or office phone) or to send mail to a different address.
• We will say “yes” to all reasonable requests. To make such a request, ask your therapist.
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” if it would affect your care.
• 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 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.
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 information on page 1.
• 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 www.hhs.gov/ocr/privacy/hipaa/complaints/.
• We will not retaliate against you for filing a complaint.

III. ADDITIONAL INFORMATION

Privacy Laws – The provider is required by State and Federal law to maintain the privacy of protected health information. In addition, the provider is required by law to provide clients with notice of the provider’s legal duties and privacy practices with respect to the protected health information. That is the purpose of this notice.

Terms of the Notice and Changes to the Notice – The provider is required to abide by the terms of this Notice, or any amended Notice that may follow. The provider reserves the right to change the terms of its Notice and to make the new Notice provisions effective for all protected health information that it maintains. When the Notice is revised, the revised Notice will be posted at the provider’s service delivery sites and will be available upon request.

Additional Information – If you desire additional information about your privacy rights, ask your therapist.

Contact Officer - Henry Dooley - Telephone: 720-441-3690 - Address: 1780 S. Bellaire St., Suite 407, Denver, CO 80222.

Effective Date - This notice is effective April 14, 2003

INVESTING IN THE FUTURE
I strive to be an investment in the future, not just a cost, for people who decide to work with me. I am here to help maximize people's health, performance and possibilities. I realize that personal psychological work is not easy and can be the most difficult kind. I have experience and training in a wide variety of approaches. If you want to know more about how I work with people, please ask.

Individual Therapy:
Individual diagnostic interviews and standard individual therapy sessions are 45 minutes in length. The standard fee for a 45 minute session is $180.00. Services provided at this rate are: therapeutic appointments, performance enhancement sessions, feedback sessions to clients or guardians, phone calls longer than five minutes, report writing, and third-party consultations. Services are pro-rated based on the time involved. Depending on availability, 80-minute extended sessions may be available at a rate of $320.00 per 80-minute session. All payments are due at the time of service.

Couples Therapy:

Couples therapy sessions are 80 minutes in length, at the rate of $375 per 80 minute session. There are occasions when partner may meet individually with their therapist. Such sessions last 45 minutes at a fee or $180. All payments are due at the time of service

Certain services are provided at two times the standard rate. These services are: forensic evaluations, depositions, court attendance, and court preparation. If asked to appear in court (including subpoenas), I charge for a minimum of four hours preparation and court time (this includes travel time). If given less than five business days' notice, I charge for a minimum of five hours time.

I reserve the right to change the standard fee at any time. However, existing clients will be notified of the change prior to their next appointment or service.

GOOD FAITH ESTIMATE

You have a right to request a Good Faith Estimate (GFE) of expected costs within a given year. Upon request, Dr. Dooley can provide a good faith estimate, which will be based on current pricing and expected treatment frequency. Please note that any extra sessions, case management, late payment fees, or similar charges cannot be anticipated and will not be included in any GFE that is provided.

CONTACT BETWEEN SESSIONS

There are time when clients may wish to contact Dr. Dooley between sessions, for a variety of reasons, including rescheduling or requesting a time to have a check-in. I encourage client's to check in between sessions, when needed, however, due to the communication limitations of email and the secure messaging on the client portal, I do not discuss therapeutic issues over this type of communication. Any non-emergent check-ins are conducted over the phone. Email and client portal messaging should be restricted to communication around scheduling, including scheduling any required phone check-ins. Clients may also wish to send an email or portal message to convey information that they wish to discuss in an upcoming session. In such cases, Dr. Dooley will acknowledge receipt of the message.

Please note that Dr. Dooley's phone number does not receive or transmit text messages. Any text messages sent will not be received.

CANCELLATIONS AND LATE CANCELLATION FEES
I strive to set time aside exclusively for a person or a family to deal with important life issues and cannot easily fill that time at the last minute. Please call to cancel or reschedule an appointment as soon as you know it will be necessary. If you do not give 24 hours notice to cancel an appointment, you will be charged for that appointment (in certain well documented emergencies, the fee may be waived). The 24 hour cancellation window is defined by time stamps on messages sent or voicemails left. This policy applies to any planned service, including: therapy, feedback sessions, performance enhancement sessions, evaluations, scheduled court hearings, and case management meetings. It is your responsibility to notify me by phone, voicemail, or email if you intend, or need, to cancel.

No shows are also charged the full fee for the session.

Please note that my phone number does not receive or send text messages, therefore texting the intent to cancel or change an appointment will not qualify as proper notice.

PAYMENTS
You are expected to pay for each session at the time of service (unless otherwise noted above, under Psychological Assessments). I currently accept cash, checks on a local bank, cashier's checks, and major credit cards. I am unable to provide change to clients, however, any excess payment can be applied toward future service. There will be a $50.00 charge on all checks returned on closed accounts or for insufficient funds, and checks will no longer be accepted from you. Unpaid balances will incur a late fee of $35 per week.

DELINQUENT ACCOUNTS
Please notify me of any circumstances that significantly affect your financial situation. After two sessions without payment, your account will be considered "Past Due", unless we have agreed to an alternate payment plan. I reserve the right to stop treatment if a person's account becomes Past Due, the person does not take action to rectify the situation, and/or refuses to pay for services - and to turn over "Past Due" accounts to a collection agency. Clients will be responsible for all costs of collection including a reasonable attorney fee.

CONSULTATION & CONFIDENTIALITY
In order to provide the best quality care, I reserve the right to consult with other mental health professionals regarding your treatment. In such consultations, personally identifying information will be withheld or changed to protect your identity, and we will only share as much information as is necessary to ensure the highest quality of care.

Confidentiality cannot be guaranteed when you use electronic media to contact us. If you would like to send an electronic mail (e-mail), please be aware of the limits to confidentiality. By sending us an e-mail you are giving us permission to respond to your message in kind (the same electronic manner). I do not accept "Friend Requests" from clients on social networking sites, mainly due to the fact that these sites can compromise confidentiality and privacy. For the same reasons, I request that clients do not communicate with me via any interactive or social networking websites.

THIRD PARTY CONFIDENTIALITY
I take very seriously the confidentiality that people expect when they work with a psychologist or therapist to improve their lives. Confidentiality is important in facilitating honest personal work. However, I have no control of, or responsibility for, confidentiality procedures employed by other parties who might gain mental or physical health information about you through an authorized release of information. Many third parties, including insurance companies, create computerized records and share data base information. If you have any questions about how information is used or shared, please ask.

INFORMED CONSENT
By signing this, I agree that treatment or evaluation needs to occur and I give my consent for the treatment or evaluation to proceed with Henry Dooley Psychological Services, LLC, D/B/A Center for the Connected Self. I have the right to have a copy of this agreement, and understand and agree to the terms as specified.

The practice of licensed or registered persons in the field of psychotherapy is regulated by the Mental Health Licensing Section of the Division of Registrations. The Board of Psychologist Examiners can be reached at 1560 Broadway, Suite 1350, Denver, Colorado, 80202, (303) 894-7800.

As to the regulatory requirements applicable to mental health professionals: a Licensed Clinical Social Worker, a Licensed Marriage and Family Therapist, and a Licensed Professional Counselor must hold a masters degree in their profession and have two years of post-masters supervision. A Licensed Psychologist must hold a doctorate degree in psychology and have one year of post-doctoral supervision. A Licensed Social Worker must hold a masters degree in social work. A Psychologist Candidate, a Marriage and Family Therapist Candidate, and a Licensed Professional Counselor Candidate must hold the necessary licensing degree and be in the process of completing the required supervision for licensure. A certified Addiction Counselor I (CAC I) must be a high school graduate, and complete required training hours and 1,000 hours of supervised experience. A CAC II must complete additional required training hours and 2,000 hours of supervised experience. A CAC III must have a bachelors degree in behavioral health, and complete additional required training hours and 2,000 hours of supervised experience. A Licensed Addiction Counselor must have a clinical masters degree and meet the CAC III requirements. A Registered Psychotherapist is registered with the State Board of Registered Psychotherapists, is not licensed or certified, and no degree, training or experience is required.

I earned a Doctor of Clinical Psychology degree from The Chicago School of Professional Psychology in 2011, as well as a Master's degree in Clinical Psychology in 2008. I received a Bachelor's degree in Psychology from the University of Colorado at Boulder in 2005. I have received training in hypnotherapy from the American Society of Clinical Hypnosis. I have also received EMDR training from the Maiberger Institute, which is an EMDRIA approved training provider.

You are entitled to received information from your therapist about: the methods of therapy, the techniques used, the duration of your therapy, if known, and the fee structure. You can seek a second opinion from another therapist or terminate therapy at any time.

In a professional relationship, sexual intimacy is never appropriate and should be reported to the board that licenses, registers, or certifies the licensee, registrant, or certificate holder.

As a mental health provider in the state of Colorado, I am required to maintain client records for 7 years after the conclusion of treatment. It is possible that client records may not be kept beyond this required time. If a client alleges that a mental health provider has violated a provision related to record keeping, they must file a complaint within 7 years of having discovered (or reasonably should have discovered) the alleged misconduct.

Generally speaking, the information provided by and to the client during therapy sessions is legally confidential and cannot be released with the client's consent. There are exceptions to this confidentiality, some of which are listed in section 12-43-218 of the Colorado Revised Statutes, and the Notice of Privacy Practices you were provided, as well as other exceptions in Colorado and Federal law. For example, mental health professionals are required to report child abuse to authorities. If a legal exception arises during therapy, if feasible, you will be informed accordingly.

In accepting this policy and beginning treatment, I am acknowledging that I have read the preceding information and understand my rights as a client.