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As a client of AV Counseling LLC, you have the right to expect your constitutional, human, and civil rights

to be protected. If at any time you feel these rights are being violated, please discuss this matter with your therapist.

1. You have the right to receive services regardless of race, sex, religion, sexual orientation, or disability.

2. You have the right to submit grievances, recommendations, and opinions regarding your treatment

without fear of reprisal.

3. You have the right to receive individualized treatment. You are encouraged to participate in the

planning of your treatment.

4. You have the right to exercise your civil rights.

5. You have the right to give performed consent to treatment.

6. You have the right to expect confidentiality.

7. You have the right to be treated in a competent, compassionate, dignified, and respectful manner at all


8. If you feel that any of these rights have been denied or violated, you are encouraged to discuss this with

your therapist or may ask for another (practice-associated) therapist to assist. You also have the right

to file a grievance with the Kentucky Board of Social Work and/or the Kentucky Board of Marriage

and Family Therapists.


Confidentiality is your right as a client. The code of ethics for therapists, as well as state and

federal laws, ensure that the information that the client shares in the context of therapy will not be disclosed to anyone else without expressed, written permission, unless one of the following applies:

1. By filing an insurance claim, you must qualify for a Mental Health Disorder Diagnosis, and you will be giving your insurance carrier the right to inquire about you and your protected health information.

Some insurance providers only request the diagnosis and dates of sessions, but managed care insurances (HMO’s) may request much more information to determine the appropriateness and need for treatment

and reimbursement. The therapist may be asked by clerical or professional staff employed by the insurance company for details about history, symptoms, therapeutic goals, therapeutic progress, etc. Unless the therapist furnishes this information, you may be denied benefits. The insurance may request

to have access to your records or may request to discuss the treatment in detail with a panel of other professionals. You should know that the therapist has no control over the information once it is supplied to the insurance carrier. If this is a concern, you may want to consider private pay.

2. The abuse reporting laws in Kentucky require that anyone with knowledge of actual or suspected abuse should report it to the Child Protective Services (CPS). Abuse may include, but is not limited to, physical, sexual, or emotional abuse, neglect, abandonment of a child or (dependent) adult or spouse,

and exposure to drug use.

3. If you enter into a legal proceeding in which you raise the issue of mental status (for instance a worker’s compensation claim, a sanity hearing, raising “mental distress” as a result of an accident or injury), then the therapist may be ordered by the court to testify about matters discussed in confidence regardless of

your consent.

4. If the therapist has reason to believe that you are likely to inflict bodily harm on someone else, a therapist is, by law, obligated to attempt to learn and to protect the intended victim(s).

5. If you are in imminent danger of harming yourself, the therapist is required to intervene; which may range from informing and requesting a relative or friend to look after you or arranging an involuntary hospitalization for a three day observation and stabilization period.

6. If some additional expertise is needed to render the best service, a consult with another professional may be made. In this event, no personal identifying data will be given and you will remain anonymous.

7. If you bring a malpractice action against a therapist, the therapist is permitted to reveal facts about the treatment.

8. In order to do couple’s therapy, the therapist may request you to waive the rights of confidentiality.


Unless parental rights have been limited or removed by the court, both parents have a right to be informed about the treatment of their child. However, children also have a need to develop trust in their therapist and may need a certain degree of security and privacy. Therefore, parents may be requested to limit inquiries about the details of the treatment and may be asked to trust that the therapist will bring to the parent’s attention matters that are important for the parent(s) to know. Children who are 18 or older, or children who have been emancipated have the right to complete confidentiality.


Individual and family sessions are scheduled for 53 minutes. If you arrive late for a session we will end 53 minutes after your session was scheduled to begin. In the rare occasion I am late for an appointment, I will make my best efforts to notify you of this in advance. If we begin late due to this circumstance, we will still be together for 53 - 55 minutes.


Clients are responsible for submitting full payment to their therapist at the time of their scheduled treatment session, prior to services being rendered. If you are using your health insurance, a claim will be filed with your insurance company for each treatment session. Your assigned co-payment should be paid in full at the time of the scheduled service, prior to services being rendered. By signing this document you agree to AV Counseling LLC charging your credit card for your session and maintaining credit card information on file in your secured medical record for payment of services and fees. In the event your health insurance company denies a claim or services are first subject to a deductible, you are financially responsible for the contracted fees and deductibles and your credit card can be charged. Therapists require a 24-hour notification to cancel appointments you schedule. If you fail to give 24-hour notification to cancel or miss a session you have scheduled, you will be charged $65 dollars for the reserved time. If at any time you choose to pay with a check for services received and that check is returned for any reason, you will be charged $30 for a returned check fee.

For clients opting to use mental health benefits through their insurance company for payment of services, please be aware that your therapist is required to bill these services in accordance with time guidelines outlined by your insurance company. If you are more than 10 minutes late for your scheduled appointment, your therapist may be required to reschedule your appointment due to these billing guidelines. In this event, you will be responsible for the $65 late cancellation fee.


For questions about payments or request for a payment plan please contact: for more information. Disputed charges through banks and credit card companies will result in appointment dates, names and other limited information being shared with a third-party.


A therapist’s role is to facilitate a safe and supportive therapeutic environment in which clients can share personal information and work on problems. The importance of having a therapeutic alliance that establishes the therapist’s full commitment to safety and confidentiality is the fundamental basis for positive outcomes. Involving a therapist in a legal proceeding as an expert witness undermines the ability for the therapist to preserve and protect privacy and the sanctity of the therapeutic process. Therefore your therapist does not participate in legal proceedings concurrent with the therapeutic process. If you choose to seek a subpoena or another party does so in order to compel your therapist’s testimony, therapeutic services may be terminated, left to the discretion of the therapist and an hourly rate of $350 will be charged from door to door for the time spent traveling to and from the courthouse as well as for the time spent at the courthouse. Additionally, a pro-rated rate of the aforementioned fee may be charged by the therapist for their time-spent preparing letters and/or documentation for court if requested by the client.


Communication with your therapist outside of sessions via cell phone, text messaging, or emails is subject to the privacy policies of the cell phone service provider or email service provider. If you provide your therapist with your cell phone number and/or email address, you are giving consent for your therapist to communicate with you via these options with an understanding of the potential risks to privacy. However, your therapist will do their best to maintain confidentiality at all times.


Each therapist at AV Counseling LLC has an individual phone number that will be shared with you upon intake. This phone number should be utilized for regular office hours needs and for after hours emergencies. If your therapist is away on vacation, they will have a qualified professional covering for them respond to any

emergency needs.


It is understood that active treatment with your therapist is goal oriented. Upon achievement of your goals, you and your therapist will discuss completing treatment. In the event that you elect to no longer actively pursue therapy, it is the policy of AV Counseling LLC that your treatment status will be considered inactive. This is identified by either communicating this to your therapist or not scheduling/attending a session for a period of 90 days without communication of this to your therapist.


Should you require additional services, or if you are inactive in treatment and need support, the following

resources are available to you.

24-Hour Crisis and Information Center Line: (502) 589-4313 or 1-800-221-0446

TDD-(502) 589-4259 or 1-877-589-4259

Contact Local Police: Call 911

Depression/Suicide Prevention: Text LOU to 741741

If your loved one is mentally ill or psychotic and exhibiting symptoms that concern you, and is a danger to

themselves or others, call 911 and ask for a CIT (Crisis Intervention Team) Officer.

Suicide Prevention Lifeline: (800) 273-TALK or (800) SUICIDE

NAMI Information Line: (800) 950-NAMI



I understand that health information about you and your health care is personal. I am committed to protecting health information about you. I create a record of the care and services you receive from me. I 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 mental health care practice. This notice will tell you about the ways in which I may use and disclose health information about you. I also describe your rights to the health information I keep about you, and describe certain obligations I have regarding the use and disclosure of your health information. I am 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.
• I can change the terms of this Notice, and such changes will apply to all information I have about you. The new Notice will be available upon request, in my office, and on my website.


The following categories describe different ways that I use and disclose health information. For each category of uses or disclosures I will explain what I mean and try to give some examples. Not every use or disclosure in a category will be listed. However, all of the ways I am permitted to use and disclose information will fall within one of the categories.

For Treatment Payment, or Health Care Operations: 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. I 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, I may disclose health information in response to a court or administrative order. I 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.



  1. Psychotherapy Notes. I 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 my use in treating you.
    b. For my use in training or supervising mental health practitioners to help them improve their skills in group, joint, family, or individual counseling or therapy.
    c. For my use in defending myself in legal proceedings instituted by you.
    d. For use by the Secretary of Health and Human Services to investigate my compliance with HIPAA.
    e. Required by law and the use or disclosure is limited to the requirements of such law.
    f. Required by law for certain health oversight activities pertaining to the originator of the psychotherapy notes.
    g. Required by a coroner who is performing duties authorized by law.
    h. Required to help avert a serious threat to the health and safety of others.

  2. Marketing Purposes. As a psychotherapist, I will not use or disclose your PHI for marketing purposes.

  3. Sale of PHI. As a psychotherapist, I will not sell your PHI in the regular course of my business.



Subject to certain limitations in the law, I 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.

  4. For judicial and administrative proceedings, including responding to a court or administrative order, although my 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 my preference is to obtain an Authorization from you, I may provide your PHI in order to comply with workers' compensation laws.

  10. Appointment reminders and health related benefits or services. I may use and disclose your PHI to contact you to remind you that you have an appointment with me. I may also use and disclose your PHI to tell you about treatment alternatives, or other health care services or benefits that I offer.



  1. Disclosures to family, friends, or others. I may provide your PHI to a family member, friend, or other person that you indicate is involved in your care or the payment for your health care, unless you object in whole or in part. The opportunity to consent may be obtained retroactively in emergency situations.



  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, payment, or health care operations purposes. I am not required to agree to your request, and I may say “no” if I believe it would affect your health care.

  2. The Right to Request Restrictions for Out-of-Pocket Expenses Paid for In Full. You have the right to request restrictions on disclosures of your PHI to health plans for payment or health care operations purposes if the PHI pertains solely to a health care item or a health care service that you have paid for out-of-pocket in full.

  3. The Right to Choose How I 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 I will agree to all reasonable requests.

  4. The Right to See and Get Copies of Your PHI. Other than “psychotherapy notes,” you have the right to get an electronic or paper copy of your medical record and other information that I have about you. I will provide you with a copy of your record, or a summary of it, if you agree to receive a summary, within 30 days of receiving your written request, and I may charge a reasonable, cost based fee for doing so.

  5. The Right to Get a List of the Disclosures I Have Made. You have the right to request a list of instances in which I have disclosed your PHI for purposes other than treatment, payment, or health care operations, or for which you provided me with an Authorization. I will respond to your request for an accounting of disclosures within 60 days of receiving your request. The list I will give you will include disclosures made in the last six years unless you request a shorter time. I will provide the list to you at no charge, but if you make more than one request in the same year, I will charge you a reasonable cost based fee for each additional request.

  6. 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. I may say “no” to your request, but I will tell you why in writing within 60 days of receiving your request.

  7. 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.



This notice went into effect on February 1, 2021

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 checking the box below, you are acknowledging that you have received a copy of HIPPA Notice of Privacy Practices.




Informed Consent for Psychotherapy

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 together. Feel free to discuss any of this with me. 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 Therapeutic Process
You have taken a very positive step by deciding to seek therapy. The outcome of your treatment depends largely on your willingness to engage in this process, which may, at times, result in considerable discomfort. Remembering unpleasant events and becoming aware of feelings attached to those events can bring on strong feelings of anger, depression, anxiety, etc. There are no miracle cures. I cannot promise that your behavior or circumstance will change. I can promise to support you and do my very best to understand you and repeating patterns, as well as to help you clarify what it is that you want for yourself.

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 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 I 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, I will not acknowledge you first. Your right to privacy and confidentiality is of the utmost importance to me, and I do not wish to jeopardize your privacy. However, if you acknowledge me first, I 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.

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