NOTICE AND DISCLOSURE OF PRIVACY PRACTICES, POLICIES AND CLIENT AGREEMENT

Welcome. It is an honor for me to meet you and to be included in your journey into evaluating what has brought you to therapy. The following document is an explanation of services and an agreement between us that is required by state and federal law. This agreement explains my theoretical approach, the ethics and standards of my practice, as well as your rights and the terms and conditions that apply to therapeutic relationships. I welcome the opportunity to discuss any questions or concerns you may have regarding this agreement or my services.

My Training and Approach to Therapy
My educational background began with a Bachelors degree in Psychology from Georgia State University then a Masters degree in Clinical Social Work from Florida State University. Prior to beginning my work in private practice, I worked in a Southeastern regional adult cancer treatment center, pediatric oncology treatment center, family court system, domestic violence and sexual violence victim advocacy counseling center, and an outpatient counseling center. I am a Georgia Licensed Clinical Social Worker. I have been trained in individual therapy, family therapy, couples therapy, crisis intervention, group counseling, and many other theoretical approaches. I adhere to the National Association of Social Work Code of Ethics. I also answer to the ethical and professional standards of the Georgia State Composite Board for PC, MFT, and MSWs.

As a clinician, I utilize evidence based practice for each theory I may utilize in therapy depending on your goals and concerns. I will orient therapy under the person centered humanistic theory approach coupled with the strengths based treatment model in order to highlight the ways in which your previous thoughts and behaviors have worked for you. For people experiencing grief, loss, or bereavement I utilize Worden's tasks of mourning. I utilize mindfulness a component of gestalt theory with people addressing anxiety and depression symptoms. For all relationship concerns I utilize the Gottman couple therapy and Acceptance and commitment Therapy. For some clients I will utilize Ellis' active directive rational emotive behavior therapy (a type of cognitive behavioral therapy), where I will maintain an active role utilizing lots of homework assignments. When working with teens I incorporate art, including but not limited to poetry, music, and Michael White's narrative therapy. Depending on the presenting concern, I may also draw from Berne's transactional analysis, Myers-Briggs type indicator, Beck's cognitive theory, structural family therapy, or Yalom's group therapy. As part of your counseling journey, you may gain better coping skills, relationship skills, and/or discover a greater sense of hope and self-awareness. It is my pleasure to share in this journey with you.

Confidentiality
All of our communications and the documents in your client file are confidential, exceptions are as follows:

You Authorize Release of Information - I will not talk to any third party (friends, family members, business associates, health care providers, attorneys, or any other parties) about your work with me unless you sign a Release of Information form authorizing the terms of that professional communication.

Seeing you in Public Settings & Social Media - Confidentiality also extends to situations where I may see you in a public place (restaurant, store, business event, office building, etc.) I am required to keep your identity as my client private. I will not address you in public unless you speak to me first. If I am with other people, I will not introduce you to them to further protect your privacy as a client. Similarly, I will decline invitations to connect on any and all social networking websites.

Consultation - In keeping with generally accepted standards of practice for therapists, I frequently discuss client cases with other therapists. The purpose of these discussions is to enhance the quality of the services you receive from me, by drawing on the perspective of others. In consultation discussions, we protect the identity of the client and we follow the confidentiality codes of our profession.

By law, there are exceptions to confidentiality. As a licensed mental health counselor, I am required to break confidentiality if you share with me information that falls under any of the following situations:

Harm to Others - I must comply with "duty to warn" standards depending on the state in which you reside- which state I must report to law enforcement officials any direct and specific threats to physically harm another person. This only applies to threats that represent an imminent danger to the other party.

Harm to Self - Any situations where there is a clear indication of your intent to commit suicide or physically harm your body in a manner that puts your life at risk.

Harm to Child, Elderly or Disabled - Any situations of suspected sexual, physical or emotional abuse or neglect by an adult to a minor or any situations of suspected harm to an elderly person or disabled person.

Or if:

You are currently in litigation, or become involved in litigation during treatment, you may be asked to disclose information regarding your therapy as part of that process. Although I will request your consent to release information, I can be legally obligated by subpoena or court order to turn over my records and testify.

You choose to submit claims to your insurance company. The insurance company will require information regarding your treatment with me including identifying information and a psychiatric diagnosis code. You have the right to know the diagnosis that I use in any communication with your insurance company or other third-party payer or agency.

Communication

Typically, it will not be necessary for us to communicate between therapy sessions. Therapy is best when it is conducted face-to-face. It is easy to misinterpret or misunderstand someone when reading an email. Email is not confidential and it is not in your best interest to be sharing your thoughts and feelings with me by email or text message. If you feel that you are able to express yourself more clearly in writing, I have an online confidential journal that will be available to you. PLEASE do not communicate about life threatening medical or psychiatric situations through email, text or the online journal. Call 911 or go directly to your nearest emergency room. I ask that when you we are speaking by phone, you keep our conversation brief (less than 10 minutes), unless we have scheduled a phone therapy session. If you are canceling or rescheduling an appointment, I prefer that be done by email.

Emergencies
I do not provide emergency services, and I cannot be available at all times. Medical and psychiatric emergencies are life threatening events that require prompt medical treatment- call 911 or go to directly to your nearest emergency care center.

If you need immediate emotional support or feel you are at risk of harming yourself or someone else, or feel you are having some other type of mental health emergency you may call Georgia's Department of Behavioral Health and Developmental Disabilities 24Hr Crisis Hotline at 800-715-4225, Ridgeview Institute at 770-434-4567 or Peachford Hospital at 770-455-3200.

Session Fees and Payments
The industry standard definition for a therapy hour is a 50-minute session. This time frame allows the therapist to have time between hourly sessions to write session notes and have a short break before the next client. I collect payment and schedule your next appointment at the end of our 50 minutes of talking. Sometimes we will schedule longer sessions based on the work we are doing and your schedule and preferences. You agree to pay the session fee in full at the end of each session, either with cash, check, credit card or debit card. My standard fee is $150 per 55 minute session, although it may be adjusted on a sliding scale, if previously agreed upon. The sliding scale is dependent upon gross household income and family size. The fee you will be charged is discussed and set during our first session. A $20.00 fee per check will be charged for returned checks. Telephone calls- no charge for the first 10 minutes, after that standard session rates apply. Standard session rates apply for time spent outside of session on email, legal matters, or other client related business beyond 10 minutes per week. Missed appointments, or sessions cancelled less than 24 hours in advance will be charged the FULL SESSION FEE for the length of session scheduled.

Insurance
Should you attempt to use your health insurance to cover my services, there are a few things you should know. I do not accept insurance, but some insurance companies will partially or fully cover my services. Some will not. If this is a concern for you, please check with your insurance company regarding your eligibility for benefits. I cannot guarantee that your treatment with me will be covered.

Insurance companies require a client be assigned a mental health disorder diagnosis code in order to be reimbursed for counseling services, this diagnosis becomes part of your permanent health record. If you would like to use your insurance, I will provide you a "super bill" that you may submit for reimbursement. I do not call or correspond with your insurance company, or provide additional paperwork. You will still be responsible for payment in full at the end of each session, and your insurance company will reimburse you directly.

Termination of Therapy
As the client, you are in control of your therapy. You begin this relationship voluntarily and you may end your relationship with me at any point. I encourage you to initiate ending your therapy once you have achieved your desired outcomes. When you decide to end therapy, you agree to have an open discussion about your progress and reasons for ending therapy. It is customary and in your best interest to have at least one final session with me to provide you with a healthy closure to this relationship. If during the course of our work together, I believe I am not the best fit for your needs or that you no longer need or are benefiting from this relationship, I will let you know and facilitate a healthy transition. I will also assist you in transitioning to another therapist or resource if that is what you determine is in your best interest. If it has been 90 days since your last session and I have not heard from you or we had not previously discussed this break in your work, I will close your file with the understanding that you are welcome to contact me at anytime in the future to give me an update or schedule an appointment.

Quality of Service

If you feel I have behaved in an unprofessional or unethical manner, please advise me so that the problem can be clarified and resolved. If you feel that this does not resolve the issue, you may contact one or both of the following:
Georgia State Dept of Licensing Committee on Ethics and Professional Practices
237 Coliseum Drive "K" Street, N.W., Suite 407
Macon, GA 31217 Washington, DC 20006
478-207-1670 202 429-1825

Agreement
By signing below, you indicate that you have read, understood and agree to the terms and conditions outlined in the Informed Consent document provided by Hanna Rodgers, LCSW. Your signature also indicates that you have had the opportunity to ask questions and/or discuss any concerns with me, understand and agree to the description of confidentiality and its exceptions as stated above and consent to counseling under the terms described above.

A. Permissible Uses and Disclosures Without Written Authorization

I may use and disclose Protected Health Information without written authorization, excluding Psychotherapy Notes, for certain purposes as described below.

1.Treatment: I may use and disclose PHI in order to provide treatment to clients.

2.Payment: I may use or disclose PHI so that services are appropriately billed to, and payment is collected from, health plans.

3.Health Care Operations: I may use and disclose PHI in connection with health care operations, including quality improvement activities, training programs, accreditation, certification, licensing or credentialing activities.

4.Required or Permitted by Law: I may use or disclose PHI when I am required or permitted to do so by law. For example, I may disclose PHI to appropriate authorities if I reasonably believe that a client is a possible victim of abuse, neglect, or domestic violence or the possible victim of other crimes. In addition, I may disclose PHI to the extent necessary to avert a serious threat to the health or safety of a client or the health or safety of others. Other disclosures permitted or required by law include the following: disclosures for public health activities; health oversight activities including disclosures to state or federal agencies authorized to access PHI; disclosures to judicial and law enforcement officials in response to a court order or other lawful process; disclosures for research when approved by an institutional review board; and disclosures to military or national security agencies, coroners, medical examiners, and correctional institutions or otherwise as authorized by law.

5. Records of Disclosure: Records of disclosure of PHI without client authorization will be maintained in the case record as required by HIPAA standards.

Records of disclosure will include:
- A description of the information to be disclosed;
- Who (individual or organization) is making the request;
- Expiration date of the request;
- A statement that the individual has the right to revoke the request;
- A statement that information may be subject to re-disclosure by the receiving party;
- Signature of the client or their representative and date;
- If signed by a representative, a description of their authority to make the disclosure.

Records of disclosure will be maintained for at least six years from the last date of sessions.
B. Uses and Disclosures Requiring Written Authorization

1.Psychotherapy Notes: Notes documenting the contents of a counseling session ("Psychotherapy Notes") will not be used or disclosed without written client authorization.

2.Marketing Communications: I will not use health information for marketing communications without written authorization.

3.Other Uses and Disclosures: Uses and disclosures other than those described in Section A above will only be made with written client authorization. Clients may revoke such authorizations at any time.

My signature below indicates that I understand and I have received a copy of this information.