This notice describes how medical information about you may be used and disclosed and how you can get access to it. Please review carefully.

Your medical records are used to provide treatment, bill and receive payments, and conduct healthcare operations. Examples of these activities include but not limited to review of treatment records to ensure appropriate care, electronic or mail delivery of billing for treatment to you or other authorized payers, appointment reminder telephone calls, and records review to ensure completeness and quality of care. Use and disclosure of medical records is limited to the internal used outlined above except required by law or authorized by the patient or legal

Federal and State laws require abuse, neglect, domestic violence and threats to be reported to social services or other protective agencies. If such reports are made they will be disclosed to you or your legal representative unless disclosure increases risk of further

Disclosed information will be limited to the minimum necessary. You may request an account for any uses or disclosures other than those described in Sections 1 and Sections 2.

You, or your legal representative, may request your records to be disclosed to yourself or any other entity. Your request must be made in writing, clearly identify the person authorized to request the release, specify the information you want disclosed, the name and address of the entity you want the information released to, purpose and the expiration date of the authorization. Any authorization provided may be revoked in writing at anytime. Psychotherapy notes are part of your medical records. We have 30 days to respond to a disclosure request and 60 days if the records is stored off site.

You may request corrections to your records.

A request for disclosure may be denied under the following circumstances: disclosure would likely endanger the life or physical safety of you or another person, requested information references other persons, except another healthcare provider, or if released to a legal representative would likely result in harm.

If a request for disclosure is denied for reasons outlined in Section 6, you or your legal representative may request review of the denial. A review will be conducted by another licensed healthcare provider appointed by the original reviewer, who was not involved in the original decision to deny access. A review will be concluded within 30 days.

You may request that we restrict uses and disclosures outlined in Section 1. However, we are not required to agree to the restrictions. If an agreement is made to restrict use or disclosure, we will be bound by such restriction until revoked by you or your legal representative orally or in writing except when disclosure is required by law or in an emergency. We may also revoke such restrictions but information gathered while required by law or in an emergency. We may also revoke such restrictions but information gathered while the restriction was in place will remain restricted by such an agreement.

I HAVE READ AND UNDERSTOOD THIS PRIVACY NOTICE AND MY RIGHTS CONCERNING USE AND DISCLOSURE OF PROTECTED HEATLH CARE INFORMATION.

I understand the following:

COUNSELING SERVICES: provided by Center Peace Couples and Family Therapy,LLC whose counselors have earned Master's Degree, or higher, in the field of counseling from an accredited graduate program and who have been licensed by the state of Florida as a Mental Health Counselor and/or Marriage and Family Therapist.

EMERGENCY SERVICES: I understand that the counselor is not providing emergency services. If I become emotionally distressed or in danger of hurting myself or someone else, I will call 911 for assistance. I understand that Center Peace Couple and Family Therapy does not offer an on call service at this time.

CONTACTING Therapist: I am often not immediately available by telephone and I probably will not answer the phone when I am with a patient. I do not have specified call-in hours. When I am unavailable, you may leave me a message on my confidential voice mail, which I monitor frequently. I will make every effort to return your call on the same day you make it, with the exception of weekends and holidays, unless you specify that it's an emergency. If you are difficult to reach, please inform me of sometimes when you will be available. If you are unable to reach me and feel that you can't wait for me to return your call, contact your family physician or the nearest emergency room and ask for the psychologist or psychiatrist on call. If I will be unavailable for an extended time, I will provide you with the name of a colleague to contact, if necessary.

PROFESSIONAL RECORDS: The laws and standards of my profession require that I keep treatment records. You are entitled to receive a copy of your records, or I can prepare a summary for you instead. Because these are professional records, they can be misinterpreted and/or upsetting to untrained readers. If you wish to see your records, I recommend that you review them in my presence so that we can discuss the contents. Patients will be charged an appropriate fee for any professional time spent in responding to information requests.

PARTICIPATION: I know of no reason that I should not undertake this therapy and I agree to participate fully and voluntarily. Regular attendance will produce maximum results. Due to the counseling process, I may experience emotional strains, feel worse during treatment, and make life changes that could be distressing.

TREATMENT TERMINATION: If at any time during the course of your treatment I determine I cannot continue, I will terminate treatment and explain why this is necessary. Ideally, therapy ends when we agree your treatment goals have been achieved. Additional conditions of termination include: You have the right to stop treatment at any time. If you make this choice, referrals to other therapists will be provided and you will be asked to attend a final 'termination' session. Professional ethics mandate that treatment continues only if it is reasonably clear you are receiving benefit. If you are meeting with another therapist, you must first terminate treatment with that therapist before I can begin providing services. If you remain in therapy with someone else and this becomes apparent after we begin, I am ethically required to terminate your treatment. Other legal or ethical circumstances may arise and compel me to terminate treatment. In these cases, appropriate referral(s) will be offered. Also, I do not diagnose, treat, or advise on problems outside the recognized boundaries of my competencies. Other situations that warrant termination include: regularly becoming enraged or threatening during session; bringing a weapon onto the premises; persistent drug abuse; arriving under the influence of drugs or alcohol; disclosing illegal intentions or actions.

Your signature below indicates that you have read the information in Informed Consent document and agree to abide by its terms during our professional relationship. You need only print this last page together with the other requested forms.

The purpose of the secured Video policy is to educate you on the use of secured video as a medium to provide you with therapy. It is important to realize that only face-to-face can provide the upmost care.

Center Peace Couple and Family Therapy will use Secured Video for psychotherapy services or when access to the office is not possible. 

Your personal portal uses secured encryption for all communications. 

Center Peace Couple and Family Therapy does not have any control over whether or not this protection for confidentiality is working as it is supposed to. 

You are responsible to read and agree to all of  Your personal portal rules, regulations, and limitations. 

You must be aware of your surroundings when using Secured Video for coaching/teletherapy.  This means that you must be accountable for a safe and confidential location when using. Your counselor cannot provide you with a confidential location other than at the counselor's office.

You will log into your assigned personal portal or Zoom at the time of your appointment.  You must make arrangements to have no distractions or interruptions during your session.

You will not hold Center Peace Couple and Family Therapy or your counselor responsible for any technical issues or other issues beyond the counselor's control resulting in breach of confidentiality. 

You cannot use secured video as a method to contact your counselor in case of an emergency. You must use other means of communication that is arranged by your counselor.

Your counselor is licensed in the state of Florida to practice counseling, if you reside outside of the State, you must understand the parameters relating to you receiving services and that you are receiving coaching services.

Your signature below indicates that you have read the information in this document and agree to abide by its terms during our professional relationship. 

I understand that I will be charged a LATE CANCELLATION fee of $130 or $150 if I fail to give at least 24-hour notice prior to cancelling my appointment.

2. I understand that I will be charged a NO-SHOW fee of $$130 or $150 if I fail to show for my appointment.

3. I understand that these charges are an out of pocket expense and that my insurance carrier will not cover these charges.

4. I understand that the therapy session will last 50 minutes. I understand that if I am late to the appointment, I will still have to end the session at the allotted time. By signing this, I am agreeing to the above stated terms and stipulations regarding the services I receive from this therapist.

5. If your medical insurance coverage provides mental health counseling benefits, we want to help you receive your maximum allowable benefits, however, its your responsibility to pay for services at the time of services and then work with your insurance company for any reimbursement. We will provide a superbill for reimbursement.

6. I understand that if I am using insurance for payment, I will be billed through Alma. If I cancel my appointment without a 24hr notice I will be charged a 50.00 cancellation fee.