Introduction
 Seeking help is an important but, sometimes daunting, step for many. I am honored to have this opportunity to listen and help you and your family through these difficult times.

The information below is very important. The first section, "Practice Policies," contains information on my practice, including fees, correspondence, and other policies. The second section, "Notice of Privacy Practices and Patient Rights," reviews the legal and ethical guidelines of patient confidentiality that I will follow throughout our time together and beyond. Please take the time to read and understand, and should you have any questions, just let me know. My direct phone number is (626) 600-2068 and email is karla@karlamft.com. 
Practice Policies
Fees and Payment
Therapy Fees: Payment by cash, credit card, or check is due at the time of your session.  A $35 charge will be due for all returned checks.  If you are late for a session, you will be given the remainder of the session and will be charged for a full session. Clients are required to place a credit card on file to cover missed visit or returned check fees. Sliding scale is available for clients who can demonstrate financial hardship.
Fees for services are as follows:
•	Initial Evaluation/ Assessment (55 + minutes): $120
•	Standard 1 Hour (50 minute session): $100
•	Standard 1.5 Hour (80 minute session): $150
•	30 Minute Consultation: $50 (30 minute session is appropriate for parent consultations, client phone sessions, crises management, and coordination of care.)

Cancellations and Missed Appointments: A 24-hour advance notice is required for cancellations.  If you cancel less than 24 hours before your appointment, or do not show for a scheduled appointment, you will be charged the FULL FEE for that session.  

Insurance Reimbursement: I am considered an “out-of-network” provider and do NOT bill insurance for services. Should you wish to go through insurance, I can provide you a detailed bill (often called a super bill) that contains the information an insurance company will require. It is the client’s responsibility to handle all insurance related tasks. As I understand it, most insurance companies do not currently reimburse for online therapy.

Administrative Fees: Should a client request or require time spent outside of therapy appointments, administrative fees may apply. This includes coordination of care with outside doctors and other providers, writing letters, and other activities that require a significant amount of time.
•	Progress letters and Letters of participation- with 5-7 business days notice: $25
•	Progress letters and Letters of participation- with 24 hour or less notice: $50

CONFIDENTIALITY
Confidentiality means that your therapist has a responsibility to safeguard information obtained during counseling. All identifying information about your assessment and treatment is kept confidential, except as mandated by law. You must sign a release of information before any information about you is given to anyone, except as mandated by law. In certain situations, mental health professionals are required by law to reveal information obtained during therapy to other persons or agencies without your consent. In such situations, your therapist is not required to inform you of his/her actions. 
Please note the following exceptions to confidentiality:
 • Confidentiality does not apply to cases of suspected abuse/neglect of children or the elderly.
 • Confidentiality does not apply to cases of potential harm to self or others.
 • A mental health professional may disclose confidential information in proceedings brought by a client against a professional. 
• Confidentiality does not apply to cases involving criminal proceedings, except communications by a person voluntarily involved in a substance abuse program.
 • Confidentiality may not apply in cases involving legal proceedings affecting the parent-child relationship.
• Confidentiality may not apply to cases involving a minor child. In such cases, the mental health professional may advise a parent, managing conservator or guardian of a minor, with or without minor’s consent, of the treatment needed by or given to the minor. 

Insurance and managed care companies require personal identification information, diagnosis, symptoms, treatment goals, prognosis, evaluation of progress, and other information before reimbursement is considered. Such companies may also maintain the right to have a copy of your records.

Confidentiality and Minors
Children under 18 years of age are considered minors and cannot consent to therapy. Parents of minors have a right to their child's PHI at any time. However, there are times when it is in the best interest of the minor that discussions in therapy are kept confidential between the minor and therapist. This is especially important for adolescents/teens. When the adolescent client believes there is confidentiality in therapy, the therapeutic relationship is strengthened and they are confident to disclose personal information to work on in session. If there is something you need to know, I first talk with the adolescent about how they want this information shared. For example, do they want to talk with you, me to talk to your, or we tell you together? 

Forensic Rates and Court Appearances: My focus in providing counseling and psychotherapy is on treatment and healing.  It is NOT my intention to become involved in cases that require evaluation (either written or otherwise) or my testifying in court. When subpoenaed, I may obtain my own legal counsel. If I am required to appear in court or conference via telephone, the client or guardian associated with the subpoena/court request will be REQUIRED to pay my normal hourly fee, travel time and all time at the courthouse or waiting to testify. I require a minimum of 3 hours ($270) plus estimated travel time be paid 48 hours in advance.  Because I must cancel all other appointments for these appearances, this payment will NOT be refunded for any reason. If I am requested or required to clear a full day, I will charge for all hours requested.

Electronic Correspondence
Email and texting are popular mediums of communication today and very convenient ways to handle administrative issues like scheduling, but neither are not 100% secure. 
Some of the potential risks you might encounter if we email or text include:
•	Misdelivery of email or text to an incorrectly typed address or phone number.
•	Email accounts can be “hacked,” giving a 3rd party access to email content and addresses.
•	Email providers (i.e., Email, Comcast, and Yahoo) and phone providers (i.e., AT&T, Verizon) keep a copy of each email or text on their servers, where it might be accessible to employees, etc.

Email Policy: Email is a convenient way to maintain a stream of communication between clients, especially with parents who are not present during their child’s individual session. In my experience, this ongoing communication is very beneficial for the client, guardians, and provider. If you agree to email as a mode of communication regarding scheduling and/or clinical issues, I will email in return. I will also email detailed receipts for insurance, which include clinical information, if requested by the client.

Texting Policy: Texting is only acceptable to communicate non-clinical issues. These include topics such as scheduling an appointment, changing an appointment, notification of running late to an appointment, receipt requests, and directions to the office. Texts regarding clinical issues, such as a family issue, personal difficulties, etc., are not acceptable. I will not respond to these texts and will delete them immediately.

Social Media and the Internet
So much information about a person can be found online, either through company websites, social media, business reviews, and more. It’s the age we live in, and therefore it’s important we understand boundaries with regards to social media and any other information online. 
•	Client and therapist will NOT perform online researches on one another for the purpose of gathering personal information. This does not pertain to a client researching the professional background of a therapist and other service/practice information.
•	Client and therapist will not request or agree to be “friends” on social media sites, including Facebook. Clients may “like” or “follow social media pages that are offered by the therapist as a part of their professional work. 
•	If a client follows the therapist on a professional social media site, comments should not indicate there is a client-therapist relationship. Any comments made that potentially disclose such a relationship will be removed immediately.
•	Websites or social media sites that Karla Rodriguez uses for professional purposes are the following:
www.karlamft.com (Professional services website and Blog)
www.facebook.com/karlarodriguezlmft83

Online Therapy (sessions via video conference) and Phone Sessions
Online therapy is a newly emerging and wonderful way to help individuals get the help they need when it may not be feasible to come into a therapist's office. Online therapy and/or sessions via phone, while it may be suitable for many, is not recommended for everyone's needs. If I assess that you would benefit more from face-to-face therapy I will offer an appointment or provide you referrals.
Online therapy is not suitable for the following individuals:
•	If you are having thoughts of harming yourself (self- harm or suicidal), or someone else.
•	If you are in an abusive or violent relationship.
•	If you have attempted suicide within the last 12 months.
•	If you have a serious substance abuse dependence.
Confidentiality notice for online therapy:
While I have taken many steps to protect the confidentiality of participating members during video sessions, these are not 100% secure. Some potential risks you might encounter with video sessions include:
•	Video profiles can be compromised, giving third-party access to profile Information.
•	If not logged out properly after each use, user profiles can be used by third-party members and can gain private information from this profile.
•	Misdelivery of video "call" to incorrectly typed username or number.
To reduce breaches to confidentiality and ensure the best outcome for sessions, all parties engaging in online or phone therapy agree to the following:
1.	Client and therapist take all possible steps to protect confidentiality, such as using passwords only used by the individual, and by controlling access to computers, phones, and other electronic devices that may contain Protected Health Information (PHI).
2.	Client and therapist conduct sessions in a private area where third party individuals cannot obtain confidential information discussed in session.
3.	Client and therapist prepare for sessions 5 minutes before the scheduled appointment time by sitting in session location, logging online, and minimizing distractions.
4.	Client and therapist log out immediately after session is over.
5.	Should the video conference fail for any reason, such as technical or internet difficulties, the client will phone the therapist immediately at (626) 600-2068 to complete session. Session fees are not adjusted should these difficulties arise and all efforts will be made to reconnect by video or phone.

In Case of Emergency
Should you find yourself or a loved one in an emergency, please contact 911 immediately. Emergencies include, but may not be limited to, self-harm/suicidal thoughts, threats, and attempts; physical or psychological concerns of medication; fear of harming self or others; inability to keep yourself or family safe around aggressive or out-of-control behaviors or rage.

If you have questions or problems
If you need more information or have questions about the privacy practices described above, please let me know. If you have a problem with how your Protected Health Information (PHI) has been handled, or if you believe your privacy rights have been violated, contact me right away. As stated above, you have the right to file a complaint with the Secretary of the U.S. Department of Health and Human Services. I promise that I will not in any way limit my care here or take any actions against you if you complain. If you have any questions or problems about this notice or my health information privacy policies, please contact me directly.

Notice of Privacy Practices and Patient Rights
Privacy is a very important concern for all those who come to this office. It is also complicated, because of the many Federal and state laws and my professional ethics. If you have any questions, I will be happy to help you understand my procedures. 

This form is an agreement between you and Karla Rodriguez, M.S., LMFT. When I use the words “you” and “your” below, this can mean you, your child, a relative, or some other person for whom you are consenting. If you do not sign this form agreeing to my privacy practices, I cannot treat you. In the future, I may change how I use and share your information, and so I may change my notice of privacy practices. If I do change it, you can get a copy from my website, www.karlamft.com.

Each time you visit me or any doctor’s office, hospital, clinic, or other health care provider, information is collected about you and your physical and mental health. It may be information about your past, present, or future health or conditions, or the tests and treatment you got from me or from others, or about payment for health care. The information I collect from you is called “PHI,” which stands for “protected health information.” This information goes into your records in my office. In this office, your PHI is likely to include information such as personal history, reasons you came in for treatment, clinical diagnoses, treatment plan, and progress notes.

Although health care records in my office are my physical property, the information belongs to you. You can read my records, and if you want a copy I can make one for you (there is an additional charge you for the costs of copying and mailing, if you want it mailed to you). In some very rare situations, you cannot see all of what is in my records. If you find anything in my records that you think is incorrect or believe that something important is missing, you can ask me to amend (add information to) my records, although in some rare situations I don’t have to agree to do that.

I am required to tell you about privacy because of a federal law, the Health Insurance Portability and Accountability Act of 1996 (HIPAA). HIPAA requires us to keep my PHI private and to give you this notice about my legal duties and my privacy practices. I will obey the rules described in this notice.

Except in some special circumstances, when I use your PHI in this office or disclose it to others, I share only the minimum necessary. The law gives you rights to know about your PHI, to know how it is used, and to have a say in how it is shared. 

How I use your PHI in my office:
For treatment. I use my medical information to provide you with psychological treatments or services. These might include individual, family, or group therapy; psychological, educational, or vocational testing; treatment planning; or measuring the benefits of my services. With your written consent, I may share PHI with others who provide treatment to you, such as your personal physician. If you are being treated by a team, I can share some PHI with the team members, so that the services you receive will work best together. 
For payment. I may use this information to bill you, such as using online billing services or depositing checks. I do not bill insurance companies, but if you choose to seek out-of-network reimbursement, they may contact me for Information, such as your progress, dates of service, and other similar things.
Appointment scheduling and reminders. I may use and disclose your PHI to reschedule or remind you of appointments by phone or email. If you want me to call or write to you only at home or work, or you prefer some other way to reach you, I usually can arrange that. The appointment software I use is a HIPPA compliant company, but there can still be limitations to confidentiality.
Business associates. I may hire other businesses or individuals to do some jobs for me. In the law, they are called my “business associates.” Examples may include an office assistant. These business associates may have access to some of my PHI to do their jobs properly. To protect privacy, they have agreed in their contract with me to safeguard your information.

If I want to use my information for any purpose besides those described above, I need your permission on a written authorization form (also called a "consent for communication"). Examples include consenting to communicate with a physician, teacher, or any other treatment providers. If you do allow me to use or disclose PHI, you can cancel that permission in writing at any time. I would then stop using or disclosing your information for that purpose. Of course, I cannot take back any information I have already disclosed or used with your permission.

Uses and disclosures that DO NOT require consent or authorization:
The law lets us use and disclose some of your PHI without consent or authorization in some cases. Here are some examples of when I might do this.
•	If I suspect abuse or neglect, I am legally required to report these suspicions. If a minor discloses to me, or another individual, that they have been physically or sexually abused, I am required to notify Child Protective Services within 48 hours of receiving the information.
•	If you are involved in a lawsuit or legal proceeding, and I receive a subpoena, discovery request, or other lawful process. 
•	If I have to disclose some information to the government agencies that check on us to see that I am obeying the privacy laws.
•	For law enforcement purposes, such as if asked to do so by a law enforcement official to investigate a crime or criminal.
•	To prevent a serious threat to health or safety. For example, if I come to believe that there is a serious threat to your health or safety during our session, I can disclose some of your PHI to contact emergency personnel. I will only do this to persons who can provide the immediate aid. 
•	As an accounting of disclosures I have made when I disclose PHI, I may keep some records of whom I sent it to, when I sent it, and what I sent. You can get an accounting (a list) of many of these disclosures.

Your rights concerning your PHI:
1. You can ask me to communicate with you about your health and related issues in a particular way or at a certain place that is more private for you. For example, you can ask me to call you at home, and not at work, to schedule or cancel an appointment. I will try my best to do as you ask.
2. You have the right to ask me to limit what I tell people involved in your care, or with payment for your care, such as family members and friends
3. You have the right to look at the health information I have about you, such as my medical and billing records. You can get a copy of these records for an additional charge. 
4. If you believe that the information in my records is incorrect or missing something important, you can ask me to make additions to my records to correct the situation. You have to make this request in writing. You must also tell me the reasons you want to make the changes.
5. You have the right to a copy of this notice. If I change this notice, I will post the new one in my waiting area, and you can always get a copy at www.karlamft.com.
6. You have the right to file a complaint if you believe your privacy rights have been violated. You can file a complaint with the Secretary of the U.S. Department of Health and Human Services. All complaints must be in writing. Filing a complaint will not change the health care I provide to you in any way.