INFORMED CONSENT FOR TREATMENT
Statement of Professional Disclosure for therapists at The CARE Center: Hannah Griffis, M. Ed. LPC, Nancy Martinez, M.A., LPC and/or Chloe Byrd, M. Ed. LPC in the state of Oklahoma governed by the State Board of Behavioral Health Licensure.
You may access the laws and regulations which govern said professionals at the following websites: https://www.ok.gov/behavioralhealth/documents/ACT%20-%20LPC%20-%2009-11-2015.pdf
General 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 with both you and/or your child. Feel free to discuss any of this with us. 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. The outcome of your treatment depends largely on you and your child’s willingness to engage in this process, which may, at times, result in potential discomfort. Remembering unpleasant events and becoming aware of feelings attached to those events can bring on strong feelings of anger, depression, anxiety, etc. Making changes affects you, your child, and those around you and sometimes increases resistance and/or discomfort. There are no miracle cures. We cannot promise that behavior or circumstance will change and we cannot guarantee the results of treatment. We use evidence-based treatment models (including but not limited to TF-CBT, PCIT, and CBT). We can promise to support you and do our very best to understand you, as well as to help you clarify what it is you want for yourself and your family.
No Violence Policy
We have a “Zero Tolerance” policy for any violent/aggressive actions, words (threats), gestures, and the like. At the discretion of the attending therapist these actions will result in immediate termination. We will not compromise safety and will maintain this boundary for the benefit of all.
As you and your child’s therapist, we will keep all information confidential. However, sharing in family or group therapy always carries the risk that another member of group could share something outside of the session. It is expected that all group members will agree to keep all information in group therapy confidential, but this cannot be guaranteed.


Confidentiality
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. 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 him/her self 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 or disabled 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 we 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, we will not acknowledge you first. Your right to privacy and confidentiality is of the utmost importance to us, and we do not wish to jeopardize your privacy. However, if you acknowledge us first, we 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.
The CARE Center mental health services including individual and family counseling. Services do not include: Ability or vocational interest testing or evaluations. · Custody evaluations · Prescription of medications or treatment of problems for which medication or hospitalization may be the treatment of choice, such as major depression, suicidal intention, hallucinations, delusions, etc.
Emergency Services
The CARE Center, is not an emergency service. Therefore, in the event of an emergency, you are advised to contact the Oklahoma County Crisis Line at 405-522-8100, Suicide Prevention Hotline at 1-800-SUICIDE (1-800-784-2433), Reachout National Hotline Crisis and Information Line at 1-800-522-9054 , dial 911, or go to the emergency room of the nearest hospital.
Counseling, Legal Issues, Court Reports and Testimony
As counselors, we are frequently asked to provide counseling services to a child or family, who parents or guardians are involved with legal disputes or challenges involving custody, visitation or other court related issues. The regulations and codes of ethics under which we practice my profession specifically describe how we legally may or may not conduct my services in matters involving legal decisions. If we accept a child, adult or family as a client for counseling services, we cannot be used as an expert witness for any forensic purposes. As your counselor, we would only be able to serve as a “fact” witness in any legal report, deposition or testimony. We could only provide factual information about services you received, and only when the client and/or legal guardian gives her/his written permission to waive confidentiality. Waivers of privilege/ confidentiality must describe what specific information is to be released, to whom, for what purpose and for how long the release is valid. As a factual witness, we may not offer any conclusions, opinions or recommendations. We can report that we provided X number of sessions; that we have developed a counseling plan; what the goals and objectives of the plan are, and other “facts”.
LENGTH OF TREATMENT
Due to the specialized nature of the work done at The CARE Center is able to provide up to 6 calendar months of services, free of cost. This is contingent upon client following cancellation policies appropriately. After that period, a referral to a partner agency will be provided, if needed or requested.
TERMINATION
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. We may terminate treatment after appropriate discussion with you and/or your child and implement a termination process if we determine that the psychotherapy is no longer serving you well. We 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, we 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.
By signing and dating below, I agree to the terms of this document.

Hannah Griffis, M. Ed. LPC
Chloe Byrd, M. Ed., LPC
Nancy Martinez, LPC

The CARE Center – 1405 N. Ashton Place, OKC OK 73117

NOTICE OF PRIVACY PRACTICES 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: We understand that health information about you and your health care is personal. We are committed to protecting health information about you. We create a record of the care and services you receive from me. We 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 agency. This notice will tell you about the ways in which we may use and disclose health information about you. We also describe your rights to the health information we keep about you, and describe certain obligations we have regarding the use and disclosure of your health information. We are 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.
II. HOW I MAY USE AND DISCLOSE HEALTH INFORMATION ABOUT YOU:
The following categories describe different ways that we use and disclose health information. For each category of uses or disclosures we will explain what we mean and try to give some examples. Not every use or disclosure in a category will be listed. However, all of the ways we am permitted to use and disclose information will fall within one of the categories.
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.
We 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 person 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:
If you are involved in a lawsuit, we may disclose health information in response to a court or administrative order. We 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:
1. Psychotherapy Notes. We 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 our use in treating you/your child. b. For our use in defending ourselves in legal proceedings instituted by you. c. For use by the Secretary of Health and Human Services to investigate my compliance with HIPAA. d. Required by law and the use or disclosure is limited to the requirements of such law. e. Required by law for certain health oversight activities pertaining to the originator of the psychotherapy notes. f. Required by a coroner who is performing duties authorized by law. g. Required to help avert a serious threat to the health and safety of others. 2. Marketing Purposes: We will not use or disclose your PHI for marketing purposes. 3. Sale of PHI. We will not sell your PHI.
DISCLOSURES DO NOT REQUIRE YOUR AUTHORIZATION. Subject to certain limitations in the law, we can use and disclose your PHI without your Authorization for the following reasons: 1. 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. 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. For judicial and administrative proceedings, including responding to a court or administrative order, although our 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 patients 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 our preference is to obtain an Authorization from you, we may provide your PHI in order to comply with workers’ compensation laws. 10. Appointment reminders and health related benefits or services. We may use and disclose your PHI to contact you to remind you that you have an appointment with us.
V. CERTAIN USES AND DISCLOSURES REQUIRE YOU TO HAVE THE OPPORTUNITY TO OBJECT.
1. Disclosures to family, friends, or others. We may provide your PHI to a family member, friend, or other person that you indicate is involved in 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:
1. 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, or health care operations purposes. We are not required to agree to your request, and we may say “no” if we believe it would affect your health care. 2. The Right to Choose How we 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 we will agree to all reasonable requests. 3. The Right to See and Get Copies of Your PHI. 4. The Right to Get a List of the Disclosures I Have Made. You have the right to request a list of instances in which we have disclosed your PHI for purposes other than treatment, payment, or health care operations, or for which you provided me with an Authorization. We will respond to your request for an accounting of disclosures within 60 days of receiving your request. The list we will give you will include disclosures made in the last six years unless you request a shorter time. 5. 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. We may say “no” to your request, but we will tell you why in writing within 60 days of receiving your request. 6. 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. EFFECTIVE DATE OF THIS NOTICE This notice went into effect on September 20, 2013 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. By signing below, you are acknowledging that you have received a copy of HIPPA Notice of Privacy Practices.