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Confidentiality & Privacy Policy

The law protects the relationship between a client and a psychotherapist, and information cannot be disclosed without written permission.

Exceptions include:

  • Suspected child abuse or dependent adult or elder abuse, for which I am required by law to report this to the appropriate authorities immediately.
  • If a client is threatening serious bodily harm to another person/s, I must notify the police and inform the intended victim.
  • If a client intends to harm himself or herself, I will make every effort to enlist their cooperation in ensuring their safety. If they do not cooperate, I will take further measures without their permission that are provided to me by law in order to ensure their safety.


Your privacy is important. This privacy statement provides information about the personal information that is collected, and the ways in which this business uses that personal information.

Personal information collection

We may collect and use the following kinds of personal information: Information that you provide using for the purpose of counseling or mediating. Any other information that you send to the counselors or mediators, regarding address, financial data, and personal information.

Using personal information to:

Supply to you services that you purchase . Send you statements and invoices collect payments from you. Send you marketing communications. Bill for services and collect payments from a third party payer, to be disclosed to collateral contacts with signed releases from yourself.

In addition to the disclosures reasonably necessary for the purposes identified elsewhere above, we may disclose your personal information to the extent that it is required to do so by law, in connection with any legal proceedings or prospective legal proceedings, and in order to establish, exercise or defend its legal rights.

  We will take reasonable technical and organizational precautions to prevent the loss, misuse or alteration of your personal information.

We will store all the personal information you provide on its own record for a period of seven years. This notice tells you how we make use of your health information , how we might disclose your health information to others, and how you can get access to the same information.

Please review this notice carefully and feel free to ask for clarification about anything in this material you might not understand. The privacy of your health information is very important to us and we want to do everything possible to protect that privacy.

We have a legal responsibility under the laws of the United States to keep your health information private. Part of our responsibility is to give you this notice about our privacy practices. Another part of our responsibility is to follow the practices in this notice.

We have the right to change any of these privacy practices as long as those changes are permitted or required by law.

Any changes in our privacy practices will effect how we protect the privacy of your health information. This includes health information we will receive about you or that we create here at this practice. These changes could also effect how we protect the privacy of any of your health information we had before the changes.

When we make any of these changes, we will also change this notice and give you a copy of the new notice.

When you are finished reading this notice, you may request a copy of it at no charge to you.

If you request a copy of this notice at any time in the future, we will give you a copy at no charge to you.

If you have any questions or concerns about the material in this document, please ask us for assistance which we will provide at no charge to you.

Here are some examples of how we use and disclose information about your health information.

We may use or disclose your health information…

  • To your physician or other healthcare provider who is also treating you.
  • To anyone on our staff involved in your treatment program.
  • To any person required by federal, state, or local laws to have lawful access to your treatment program.
  • To receive payment from a third party payer for services we provide for you.
  • To our own staff in connection with our operations. Examples of these included, but are not limited to the following: evaluating the effectiveness of our staff, supervising our staff, improving the quality of our services, meeting accreditation standards, and in connection with licensing, credentialing, or certification activities.
  • To anyone you give us written authorization to have your health information, for any reason you want. You may revoke this authorization in writing anytime you want. When you revoke an authorization it will only effect your health information from that point on.
  • To a family member, a person responsible for your care, or your personal representative in the event of an emergency. If you are present in such a case, we will give you an opportunity to object. If you object, or are not present, or are incapable of responding, we may use our professional judgment, in light of the nature of the emergency, to go ahead and use or disclose your health information in your best interest at that time. In so doing, we will only use or disclose the aspects of your health information that are necessary to respond to the emergency.
  • By law, we may disclose private health information in a number of circumstances in which you do not have to consent, give authorization, or otherwise have an opportunity to agree or object. Those circumstances include:

· When the disclosure relates to victims of abuse, neglect or domestic violence.

· For judicial and administrative proceedings. For example, we may disclose PHI about you in response to an order of a court or administrative tribunal or to defend ourselves against a lawsuit or legal proceedings brought against us by yourself.

· To avert a serious threat to health or safety. For example, we may disclose PHI about you to prevent or lessen a serious and eminent threat to the health or safety of yourself or others.

We will not use your health information in marketing, development, public relations, or related activities without your written authorization.

We cannot use or disclose your health information in any ways other than those described in this notice unless you give us written permission.

As a client , you have these important rights:

  • With limited exceptions, you can make a written request to inspect your health information that is maintained by use for our use.
  • You can ask us for photocopies of the information in part “A” above.
  • We will not charge you for making these photocopies.
  • You have a right to a copy of this notice at no charge.
  • You can make a written request to have us communicate with you about your health information by alternative means, at an alternative location. (An example would be if your primary language is not spoken at our office and we are treating a child of whom you have lawful custody.) Your written request must specify the alternative means and location.
  • You can make a written request that we place other restrictions on the ways we use or disclose your health information. We may deny any or all of your requested restrictions. If we agree to these restrictions, we will abide by them in all situations except those which, in our professional judgment, constitute an emergency.
  • You can make a written request that we amend the information in part “A” above.
  • If we approve your written amendment, we will change our records accordingly. We will also notify anyone else who may have received this information, and anyone else of your choosing.
  • If we deny your amendment, you can place a written statement in our records disagreeing with our denial of your request.
  • You may make a written request that we provide you with a list of those occasions where we or our business associates disclosed your health information for purposes other than treatment, payment, or our operations. If you request the accounting in “J” above more than once in a 12 month period we may charge you a fee based on our actual costs of tabulating these disclosures.
  • If you believe we have violated any of your privacy rights, or you disagree with a decision we have made about any of your right in this notice you may complain to us in writing to the following:

  You may also submit , a written complaint to the United States Department of Health and Human Services. We will provide you with that address upon written request.

Advice is provided according to counseling principles and staff may refer clients’ to other sources if they are in need of a higher level of care,

I , _______________________, the undersigned agree to hold Debra Ouimette harmless of any incurred emotional or physical harm that may come to my person as a result of my own decisions based on the advice received from the designated sessions of counseling or mediation or any time period thereafter.

I understand that services conducted are to be respectful with the absence of any vulgarity and profanity. Individual sessions are conducted in a professional manner with a maximum of two clients participating. If self inflicted harm , verbal, or physical violence is present or implied , this may result in the counselor placing an automatic telephone call to police municipality to investigate. I agree that no sessions will be recorded or video-graphed by myself, the therapist, a third party, or this agency.

I the undersigned have read and agree to this policy and its terms:

__________________________________   Date: ________________


__________________________________   Date: ________________

This privacy statement

This privacy statement is based on an original template created by distributed by

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