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Eastfield Counseling Services
3737 Motley Drive
Mesquite, TX 75150

Informormed Consent and Notice of Privacy Practices


This agreement contains information about your rights as a client of Eastfield Counseling Services (ECS), how health information about you may be used and disclosed, and how you can gain access to this information. privacy and client’s rights. as required by law. Please review it carefully. The law requires that we obtain your signature acknowledging that you were provided this information. Your signature represents a revocable Agreement between you, the client, and ECS. A written revocation will be binding on ECS unless ECS has taken action in reliance on it.

  1. Psychotherapy Services: The nature of psychotherapy varies depending on the personalities of the therapist and the client. In order for the therapy to be successful, you will have to work on things talked about both during sessions and at home. Psychotherapy can have benefits and risks. Since therapy often involves discussing unpleasant aspects of your life, you may experience uncomfortable feelings. However, benefits of therapy include improvements in relationships, solutions to specific problems, and significant reductions in feelings of distress. There are no guarantees of what you will experience. Your therapist will evaluate your needs and offer treatment recommendations. You can discuss any questions you may have. If you have persistent doubts, your therapist will help you get a second opinion.
  2. Meetings: Psychotherapy sessions consist of one 45 to 50 minute session. Once a session is scheduled, you will be expected to give 24 hour advanced notice of cancellation if you are unable to meet at your appointed time. Should you miss two consecutive appointments without calling, you will be placed on a waiting list to see a therapist. Your therapist will work to accommodate you subject to the availability of open appointment times.
  3. Contacting Your Therapist:
  4. You may leave a confidential voicemail to your therapist at 972-860-7371. ECS will attempt to return your call on the same day, excluding after business hours, weekends, and holidays. If you are unable to reach your therapist and cannot wait for a return call, contact your family physician, Emergency Medical Services (911), or the nearest hospital emergency room.
  5. Uses and Disclosures for Treatment, Payment, and Health Care Operations: Eastfield Counseling Services may use or disclose your Protected Health Information (PHI), for treatment, payment, and health care operations purposes with your consent. To help clarify these terms, here are some definitions:
    1. “PHI” refers to information in your health record that could identify you (e.g. your name, student ID number, date of birth, etc.).
    2. “Treatment, payment, and health care operations”
      1. Treatment is when your doctor or therapist provides, coordinates, or manages your health care and other services related to your health care. An example of treatment would be when your doctor or therapist consults with another health care provider, such as your family physician or another psychologist, psychiatrist, or counselor.
      2. Payment is when your doctor or therapist obtains reimbursement for your health care. Examples of payment are when Eastfield Counseling Services discloses your PHI to your health insurer to obtain reimbursement for your health care or to determine eligibility of coverage. Eastfield Counseling Services does not charge any fee for counseling services for currently enrolled students. Therefore, payment will not be sought from the currently enrolled student or her/his insurer.
      3. Health care operations are activities that relate to the performance and operations of Eastfield Counseling Services. Examples of health care operations are quality assessment and improvement activities, business-related matters such as audits and administrative services, case management, and care coordination.
    3. “Use” applies to activities within Eastfield Counseling Services such as sharing, employing, applying, utilizing, and analyzing information that identifies you.
    4. “Disclosure” applies to activities outside of Eastfield Counseling Services, such as releasing, transferring, or providing access to information about you to other parties.
  6. Uses and Disclosures Requiring Authorization: Your therapist may use or disclose PHI for purposes outside of treatment, payment, and health care operations when your appropriate authorization is obtained. An “authorization is written permission above and beyond the general consent that permits only specific disclosures. In those instances when your therapist is asked for information for purposes outside of treatment, payment, and health care operations, your therapist will obtain an authorization from you before releasing this information. Your therapist will also need to obtain an authorization from you before releasing your Clinical record and Psychotherapy Notes (see Section IV). You may revoke all such authorizations (of PHI or Psychotherapy Notes) at any time, provided each revocation is in writing. You may not revoke an authorization to the extent that
    1. Your therapist has relied on that authorization; or
    2. If the authorization was obtained as a condition of obtaining insurance coverage, and the law provides the insurer the right to contest the claim under the policy.
  7. Uses and Disclosures with Neither Consent nor Authorization: Your therapist may use or disclose PHI without your consent or authorization in the following circumstances:
    1. Child and Adult Abuse: If your therapist has cause to believe that a child has been, or may be abused or neglected (including physical injury, substantial threat of harm, mental or emotional injury, or any kind of sexual contact or conduct), or that a child is a victim of sexual offence, or that an elderly or disabled person is in a state of abuse, neglect, or exploitation a report of such must be made to the appropriate governmental agency. Your therapist may then be required to provide additional information
    2. Health Oversight: If a complaint is filed against your therapist with the Texas State Board of Examiners of Professional Counselors, they have the authority to subpoena confidential mental health information from your therapist relevant to the complaint.
    3. Judicial or Administrative Proceedings: If you are involved in a court proceeding and a request is made for information about your diagnosis and treatment and the records thereof, such information is privileged under state law, and your therapist will not release information, without your written authorization from you or your personal or legally appointed representative, or a court order. The privilege does not apply when you are being evaluated for a third party or where the evaluation is court ordered. You will be informed in advance if this is the case.
    4. Serious Threat to Health or Safety: If your therapist determines that there is a probability of imminent physical injury by you to yourself or others, or there is a probability of immediate mental or emotional injury to yourself or others, your therapist may disclose relevant confidential mental health information to medical or law enforcement personnel or by securing hospitalization of the client. If such a situation arises, your therapist will make an effort to discuss it with you before taking any action and will limit disclosure what is necessary.
    5. Workers’ Compensation: If you file a workers’ compensation claim, your therapist may disclose records relating to your diagnosis and treatment to your employer’s insurance carrier.
    6. CARE Team: The Campus Assessment, Response, and Evaluation (CARE) Team is a behavioral intervention team comprised of college professionals who assist in protecting the health, safety and welfare of the students and members of the college community. If your behavior has been reported to the CARE Team, information from your counseling sessions and Professional Record MAY be shared with the CARE Team, if sharing of said information is considered to be in your best interest and/or the best interest of the community, as determined by the judgment of the Director of Counseling Services.
  8. Professional Records: PHI about you is kept in two sets of records, 1. your Clinical Record; and 2. Psychotherapy Notes. Your Clinical Record includes information about your reasons for seeking therapy, your diagnosis, goals, interventions, behavior changes, homework assignments, medications, treatment plan, medications, progress, medical and social history, treatment history, any past treatment records from received from other providers, reports of professional consultations, and reports that have been sent to anyone, including reports to insurance carriers. Psychotherapy Notes assist your therapist in providing treatment. Psychotherapy Notes are notes your therapist has made about your conversation during a private, group, joint, or family counseling session, which your therapist has kept separate from the rest of your Clinical Record. These notes are given a greater degree of protection than PHI. Typically, you may examine and/or receive a copy of your Clinical Record and Psychotherapy Notes unless your therapist determines that release would be harmful to your physical, mental, or emotional health.
  9. Client’s Rights and Therapist’s Duties
    1. Client’s Rights:
      1. Right to request restriction: You have the right to request restrictions on certain uses and disclosures of PHI about you. However, your therapist is not required to agree to a restriction you request.
      2. Right to Receive Confidential Communications by Alternative Means and at Alternative Locations: You have the right to request and receive confidential communications of PHI by alternative means and at alternative locations. For example, you may not want a family member to know that you are seeing a therapist at Eastfield Counseling Services. Upon your request, Eastfield Counseling Services will send your correspondence to another address.
      3. Right to Inspect and Copy: You have the right to inspect or obtain a copy (or both) of PHI and psychotherapy notes in the mental health records used to make decisions about you for as long as PHI is maintained in the record. Your therapist may deny your access to PHI under certain circumstances, but in most cases you may have this decision reviewed. On your request, your therapist will discuss with you the details of the request and denial process.
      4. Right to Amend: You have the right to request an amendment of PHI for as long as the PHI is maintained in the record. Your therapist may deny your request. At your request, your therapist will discuss with you the details of the amendment process.
      5. Right to an Accounting: You generally have the right to receive an accounting of disclosures of PHI for which you have neither provided consent nor authorization (as described in Section III of this Notice).
      6. Right to a Paper Copy of this Notice: You have the right to obtain a paper copy of this Notice from Eastfield Counseling Services upon request, even if you have agree to receive the Notice Electronically.
    2. Therapist’s Duties
        1. Your therapist is required by law to maintain the privacy of PHI and to provide you with a Notice of the legal duties and privacy practices with respect to PHI.
        2. Eastfield Counseling Services reserves the right to change the privacy policies and practices described in this Notice. Unless you are notified of such changes, however, your therapist is required to abide by the terms currently in effect.
        3. If Eastfield Counseling Services revised these policies and procedures, you will be notified that changes have been made.
  10. Complaints: If you are concerned that your therapist has violated your privacy rights, or you disagree with a decision made about access to your records, you may contact the Director of Eastfield Counseling Services for further information. You may also send a written complaint to the Secretary of the U.S. Department of Health and Human Services, 200 Independence Avenue, S.W., Washington, D.C. 20201, Telephone: 202-619-0257, Toll Free: 1-877-696-6775.
  11. Effective Date, Restrictions, and Changes to Privacy Policy: This Notice is effective January 1, 2012. Eastfield Counseling Services reserves the right to change the terms of this Notice and to make the new Notice provisions effective for all PHI that Eastfield Counseling Services maintains. If Eastfield Counseling Services revises these policies and procedures, you will be notified that changes have been made in person, by telephone, by mail, or by email.

I have read and understand the above Client Services Agreement and Notice of Privacy Practices for Use and Disclosure of Private Health Information. I consent to participate in the services offered to me by my therapist. I understand that I may stop counseling service at any time.

By typing my name above, I confirm: I have read this Notice of Informed Consent and Privacy Practices. I understand how Eastfield Counseling Services secures my Protected Health Information.