Affordable Counseling Services
517-819-4542
Informed Consent & HIPPA
I believe in a firm and continuing commitment to the privacy of personal information provided by those receiving or inquiring about services. I hold the privacy of your personal information in the highest regard. The following discloses my information gathering practices, as well as the terms and conditions of my services. This policy will be continuously assessed against new technologies, licensing practices, and our client’s needs.
What Information Do I Collect? Basic demographic information such as: name, address, contact number and presenting problem. In addition, I may ask you to provide me with personal information you knowingly choose to disclose that is to be used to help you with your current dilemma. For safety reasons I do require that you give your home address. In the unlikely event of a mental health or other threatening emergency this will allow me to send local emergency assistance. Any other personal information you choose to share with us will be recorded and securely stored in locked files for up to 5 years.
Credit Card Information (Through PayPal) If you choose to use my online services, you may need to give personal information and authorization to obtain information from various credit services. For example, you may need to provide the following information: Name, mailing address & credit card billing address, Email address, credit card number & name on credit card, credit card billing address
Email Information If you choose to correspond through email, I will retain the content of your email messages together with your email address and our responses. I provide the same protections for these electronic communications that I employ in the maintenance of information received by mail, telephone, and in person.
How Do I Use the Information That You Provide? Broadly speaking I use your information to tailor the services you requested & to process your payment. Personally identifiable information or business information will not be shared with parties except as required by law. Read more about this in the HIPPA guideline.
What About Legally Compelled Disclosure of Information? I may disclose information when legally compelled to do so, in other words, when I, in good faith, believe that the law requires it or for the protection of legal rights. I may also disclose account information when I have reason to believe that disclosing this information is necessary to identify, contact or bring legal action against someone who may be violating Terms of Service or to protect the safety of my clients and the public.
What About Other Web Sites Linked to Web my Site? I am not responsible for the practices employed by Web sites linked to or from my Web site or the information or content contained therein. Often links to other Web sites are provided solely as pointers to information on topics that may be useful to the users of my Web site. Please remember that when you use a link to go from my Website to another web site, my Privacy Policy is no longer in effect. Your browsing and interaction on any other web site, including web sites, which have a link on my Website, is subject to that Web site's own rules and policies. Please read over those rules and policies before proceeding.
Commitment To Data Security Please note that your information will be stored and processed on our computers in the United States. The laws on holding personal data in the United States may be less stringent than the laws of your Country of residence or citizenship. To prevent unauthorized access, maintain data accuracy, and ensure the correct use of information, I have put in place appropriate physical, electronic, and managerial procedures to safeguard and secure the information I collect online. However, please be aware that nothing on the internet is 100% secure.
A Special Note about Children Children are not eligible to use my online services unsupervised and I ask that children (under the age of 18) do not submit any personal information. If you are a minor, you can use this service only in conjunction with permission and guidance from your parents or guardians. That permission must be given verbally by calling 517-819-4542.
Policy Modifications I may change this Privacy Policy from time to time. I will post any changes on my web site, so be sure to check periodically. However, please be assured that if the Privacy Policy changes in the future, I will not use the personal information you have submitted to me under this Privacy Policy in a manner that is materially inconsistent with this Privacy Policy, without your prior consent.
Fees for service Sessions are $50 per hour and fees are paid at time of services. There is a $25 fee for appointments that are not canceled within 24 hours of the schedules time. Court time is charged at a rate of $150 an hour.
Client Responsibility Consulting services are intended to provide suggestions to resolve stated challenges. The effectiveness of consulting services, and intervention practices, depends largely on the willingness of the client to implement the suggested interventions on a regular and consistent basis.
I reserve the right to amend this privacy policy at any time with or without notice. You have the right to terminate services at any time. By using my services you consent to my collection and use of your personal information as described in this Privacy Policy. By signing this document you agree to the terms and conditions of services.
Signature of client_______________________ Date______________________
Affordable Counseling Services HIPPA Notice
THIS DOCUMENT DESCRIBES HOW INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN HAVE ACCESS TO THIS INFORMATION. EFFECTIVE BEGINNING APRIL 14, 2003. PLEASE REVIEW CAREFULLY.
MY PLEDGE REGARDING YOUR PERSONAL INFORMATION-This notice of privacy describes how I may use and disclose your protected information to carry out services, payment and for other purposes permitted or required by law. It also describes your right to access and control your protected information. The following categories describe different ways that I may use and may disclose information. Information may be disclosed in writing, orally or electronically.
USES AND DISCLOSURES OF PROTECTED INFORMATION-Your protected information may be used and disclosed for the purpose of providing services to you. With your proper permission, I may disclose your information to doctors, nurses, technicians, medical students, psychotherapists, or other personnel who may become involved as a result of your consult.
To Avert a Serious Threat to Health or Safety-I may use and disclose information about you when necessary to prevent a serious threat to your health and safety or the health and safety of the public or another person. Any disclosure, however, would only be to someone able to help prevent the threat.
Mental Health Oversight Activities- I may disclose your information to a health oversight agency for activities authorized by law. These oversight activities include, for example, audits, investigations and licensure.
Communicable Disease- I may disclose your protected information, if authorized, to a person who may have been exposed to a communicable disease or may otherwise be at risk for contracting or spreading the disease or condition.
Abuse or Neglect- I may disclose your protected information to a public health agent authorized by law to receive reports of child abuse or neglect. In addition, I may disclose your health information to a governmental entity or agency authorized to receive such information if I believe that you have been the victim of abuse, neglect or domestic violence. Disclosure would be consistent with the requirements of applicable federal and state law.
Lawsuits and Disputes- If you are involved in a lawsuit or a dispute, I may disclose information about you in response to a court order. I may also disclose information about you in response to a valid 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.
Law Enforcement- I may release health information if asked to do so by a law enforcement official; In response to a court order, subpoena, warrant, summons, or similar process; to identify or locate a suspect, fugitive, material witness, or missing person; about the victim of a crime if, under certain circumstances, I am unable to obtain the person’s agreement; about a death I believe may be the result of criminal conduct; about criminal conduct ; and in emergency circumstances to report a crime; the location of the crime or victims; or the identity, description or location of the person who committed the crime.
Right to Inspect, Copy and Amend-You have a right to inspect and copy all disclosures of information, including treatment summaries. This does not include psychotherapy notes. If you feel any information from any disclosure is incorrect, you have the right to request an amendment. All requests to inspect and copy disclosures must be made in writing. Denial of requests may occur with some requests. For instance, a request made by one spouse for disclosures occurring during marital counseling will be denied.
Right to Request Restrictions- You have the right to request a restriction or limitation on the ways your health record information is used. I am not required to agree to your request. If I agree, I will comply with your request, with the exception of emergency care. Specific request must be made in writing.
Right to a Paper Copy of This Notice- You have the right to a paper copy of this notice. You may ask for a copy any time.
Other Uses of Medical Information- Other disclosures and uses of your information will be made only with your written permission. You may revoke that permission, in writing, any time. Be aware that I will be unable to take back any disclosures I have already made with your permission, and I am required to retain records of the care that was provided to you.
Changes to this Notice: I reserve the right to change this notice. Upon your request, we will provide you with any revisions.
Complaints: If you believe your privacy rights have been violated, you may contact the Michigan Board of Counseling P.O. Box 30018 Lansing MI 48909-7518. All complaints must be submitted in writing.
I have read and understand the above document:
Signature of client____________________________Date_________________________
Please sign and return to:
Affordable Counseling Services
6743 Richard Rd
Lansing MI 48911
If you have any questions about this notice contact Affordable Counseling Services 1-517-819-4542
