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Terms and Policy

INFORMED CONSENT & OFFICE POLICIES

Welcome to my psychotherapy practice. This document contains important information about my professional services and business policies. This form provides you (client) with information that is additional to that detailed in the Notice of Privacy Practices. Please read it carefully and identify any questions you may have to discuss. Please initial each paragraph in the space provided indicating that you have read and understood the content of that paragraph. When you sign this document, it will represent an agreement between us.

THE PURPOSE OF THERAPY: The purpose of therapy is to support and/or create positive change so the client can experience life more fully. It provides an opportunity to better, and more deeply, understand oneself, as well as any problems or difficulties such as abandonment issues or sadness due to divorce one may be experiencing.

THE PROCESS OF THERAPY: Psychotherapy is a process in which the therapist and the client discuss a variety of issues, events, experiences and memories for the purpose of creating positive change so the client can experience life more fully. It provides an opportunity to better, and more deeply, understand oneself, as well as any problems or difficulties one may be experiencing. Progress and success may vary depending upon the particular problems or issues being addressed, as well as many other factors. Participation in therapy can result in a number of benefits to the client, including, but not limited to, reduced stress and anxiety, a decrease in negative thoughts and self-sabotaging behaviors, improvement in interpersonal relationships, increased comfort in social, work and family settings, increased capacity for intimacy, increased self-confidence as well as resolution of the specific concerns that led you to seek therapy. Psychotherapy requires your very active involvement, honesty, and openness in order to change. As your therapist, I will ask for your feedback and views on your therapy, your progress, and other aspects of the therapy process. Although therapy typically has a positive outcome, there is no guarantee that therapy will yield all or any of the benefits listed above.

Participating in therapy may also involve some risk or discomfort, including remembering or talking about painful memories, unpleasant events, feelings, and/or thoughts. The process may evoke feelings of sadness, anger, fear, shame, anxiety, depression, etc. At times, I may challenge some of your assumptions and/or perceptions and propose different ways of looking at, thinking about, or handling situations that can cause you to feel upset, angry, depressed, challenged, or disappointed. Attempting to resolve issues that brought you to therapy, such as personal or interpersonal relationships, may result in changes that were not originally intended. Psychotherapy may result in decisions about changing perceptions, beliefs, behaviors, employment, substances use, schooling, housing, or relationships. Sometimes, a decision that is positive for one family member can be viewed negatively by another family member. Personal growth and change may be easy and swift at times, but it may also be slow and even frustrating. I will strive to help make your therapeutic experience as productive as possible.

CONFIDENTIALITY: All information disclosed within sessions and the written records pertaining to those sessions are confidential and may not be revealed to anyone without your (client's) written permission, except where disclosure is required by law. Most of the provisions explaining when the law requires disclosure were described to you in the Notice of Privacy Practices that you received with this form.

When disclosure is required by law: Some of the circumstances where disclosure is required by law are: when there is a reasonable suspicion of child, dependent or elder, physical or sexual abuse and/or neglect; and where a client presents a danger to self, to others: or is gravely disabled (see also Notice of Privacy Practices form)

When disclosure may be required: Disclosure may be required pursuant to a legal proceeding. If you place your mental status at issue in litigation initiated by you, the defendant may have the right to obtain the psychotherapy records and/or testimony by your therapist. In couple and family therapy, or when different family members are seen individually, confidentiality and privilege do not apply between the couple or among family members. Your therapist will not release

records to any outside party unless they are authorized to do so by all adult family members who were part of the treatment.

Confidentiality of Records & Health Insurance: Pursuant to HIPPA, your clinical file contains two types of information, 1 Protected Health Information (PHI) and a Designated Record Set. The Designated Record Set refers to information in your health record/file that can identify you. The PHI is your clinical record which includes information about your reasons for seeking therapy, a description how your problem impacts your life, your diagnosis, your treatment goals. Your medical, social and psychological history, your treatment history and treatment records that I receive from other providers, reports of professional consultations, your billing records, and reports that have been sent to anyone including your insurance carrier.

I keep a set of progress notes. These notes are for my use and are designed to assist me in tracking your treatment and providing you with the best treatment. While progress notes vary from client to client, they can include the contents of our conversations, my analysis of our conversations and how they impact on therapy.

Your health insurance carrier may require disclosure of confidential information when using your PPO coverage, or other third party payer, to process the claims. Only the minimum necessary information will be communicated to the carrier. Unless authorized by you explicitly, the progress notes will not and cannot be disclosed to your insurance carrier. Your therapist has no control or knowledge over what insurance companies do with the information they submit or who has access to this information. Be aware that submitting a mental health invoice for reimbursement carries a certain amount of risk to confidentiality, privacy, or future eligibility to obtain health or life insurance. The risk stems from the fact that mental health information, including a diagnosis, is entered into insurance companies' computers and will also be reported to the Congress-approved National Medical Data Bank. Any computer or database is subject to unauthorized access.

Client files and records are securely stored. I practice in the same office with another mental health professional. I do not share Protected Health Information with the other professional in my office. All mental Health professionals are bound by the same rules of confidentiality. Client files are kept for seven years after the case is completed or until a child reaches the age of 21 if the child received treatment. After the records have been stored for the scheduled amount of time, the records will be disposed of with a HIPPA compliance service. In the event of my death or my inability to authorize the release of your records, Lauren Molnar, MC, LPC will be authorized to retrieve and release the records with appropriate authorizations. She can be reached at 1536 East Maryland Ave, Phoenix, AZ 85014 323-536-2187. A request by client for his/her records must be in writing and will be released within 30 days of request.

Confidentiality of E-mail, cell phone, and faxes communication: It is very important to be aware that e-mail and cell phone communication can be relatively easily accessed by unauthorized people and hence, the privacy and confidentiality of such communication can be compromised. E-mails, in particular, are vulnerable to such unauthorized access due to the fact that servers have unlimited and direct access to all e- mails that go through them. Faxes can be sent erroneously to the wrong address. Please notify me at the beginning of treatment if you decide to avoid or limit in any way the use of any or all of the above- mentioned communication devices. Please do not use e-mail or faxes for emergencies.

CONSULTATION: At times I find it helpful to consult with other professionals regarding a client and/or case; however, the client's name or other identifying information is never mentioned. The client's identity remains completely anonymous, and confidentiality is fully maintained. This is done to provide you with the best care possible.

DISCUSSION OF TREATMENT PLAN: Together we will develop an individualized treatment plan that outlines the primary issues you want to address, identifies treatment objectives and goals and potential outcomes. Treatment plans will be reviewed and revised if needed at least once annually. If you have any unanswered questions about the course of your therapy, the possible risks, or about the treatment plan, please ask for further explanation. You also have the right to ask about other treatments for your condition and their risks and benefits as well as referral for those services if needed or wanted. During the course of therapy, I am likely to draw on various psychological approaches according, in part, to the problem that is being treated and the assessment of what will best benefit you. Sometimes more than one approach can be helpful in dealing with a certain situation. These approaches may include, but are not limited to: cognitive-behavioral, systems/family of origin, developmental (adult/child/family), psychodynamic, somatic experiencing, behavioral, existential, biblio- therapy, or psycho-educational and use of the Daring Way Model. A separate consent will be offered for Somatic Experiencing.

CLOSURE/TERMINATION: You have the right to end therapy at any time. Ideally, this happens when the goals of therapy have been met. A closure session is recommended to review your accomplishments and to discuss supports available to maintain your growth. If you voluntarily withdraw or refuse treatment there can be consequences to your mental or physical health (i.e. your condition may worsen, you may become suicidal). Any such concerns will be discussed with you. Or if at any point during therapy, I believe I am not being effective in helping you reach your therapeutic goals, I am obliged to discuss it with you and, if appropriate, to terminate treatment. In both such cases, I would give you a number of referrals that may be of help to you. If you request it and authorize it in writing, I will talk to the new psychotherapist of your choice in order to help with the transition. If at any time you want another professional's opinion or wish to consult with another therapist, I will assist you in finding someone qualified, and with your written consent will provide him or her with the essential information needed.

DUAL RELATIONSHIPS: A dual relationship exists when you have some type of relationship with your therapist outside the clinical setting. This may include civic and philanthropic groups, religious communities, sports leagues, etc. Appropriate dual relationships are not unethical. Therapy never involves sexual or any other dual relationship that can be exploitative in nature, or impairs your therapist's objectivity, clinical judgment, and/or therapeutic effectiveness. I will discuss with you the potential difficulties that may be involved in dual relationships and will discontinue the dual relationship if it interferes with the effectiveness of the therapeutic process.

TELEPHONE & EMERGENCY PROCEDURES: Due to my work schedule, I am often not immediately available by telephone. If you need to contact me between sessions, please leave a message on my voice mail. I will typically respond to messages within 24 hours. In case of medical emergency, or when there is immediate danger or potential for harm, please call 911. Or, if you have an emotional emergency, please call the Banner Helpline at (602) 254-4357 or the EMPACT Crisis Hotline at (480) 784-1500.

APPOINTMENTS, FEES & PAYMENTS: I reserve 50 minutes for each appointment with a client unless otherwise discussed with client. If you are unable to keep a scheduled appointment, please notify me as soon as possible. Late cancellations make it difficult to offer the appointment time to someone else. Therefore, missed appointments and cancellations made less than one full business day (24 hours) in advance of the scheduled appointment will result in you being charged in full for your reserved appointment time. Payment is expected at the time of service, unless other arrangements have been agreed upon. The cost of therapy services is your responsibility. The standard fee for a 50-minute initial intake assessment, an individual, conjoint or family counseling session is $160.00. Longer extended sessions, telephone conversations over 15 minutes, report writing and reading, attendance at meetings with other professionals you have authorized and time spent performing other services you have requested of me etc. will be charged at the same rate, unless indicated and agreed upon otherwise. Unpaid services or balances past due over 90 days may be referred to a collection agency. If a matter goes to collection some confidential information such as your name and address will be disclosed to the collection company.

INSURANCE POLICY: I am not a contracted provider of your insurance or managed care provider. I am considered an out-of-network provider with your insurance company. If you have a Preferred Provider Plan (PPO), I will provide you with a statement (known as a superbill) which you may submit to your insurance or managed care provider to seek reimbursement of fees already paid.

LITIGATION LIMITATION: Due to the nature of the therapeutic process and the fact that it often involves making a full disclosure with regard to many matters which may be of a confidential nature, it is agreed that, should there be legal proceedings (such as, but not limited to divorce and custody disputes, injuries, lawsuits, etc.), neither you nor your attorney(s), nor anyone else acting on your behalf will call on Maria-Victoria Munoz to testify in court or at any other proceeding, nor will a disclosure of the psychotherapy records be requested unless otherwise agreed upon.


MEDIATION & ARBITRATION: All disputes arising out of, or in relation to, this agreement to provide psychotherapy services shall first be referred to mediation, before, and as a pre-condition of, the initiation of arbitration. The mediator shall be a neutral third party chosen by agreement of Maria-Victoria Munoz and the client(s). The cost of such mediation, if any, shall be split equally, unless otherwise agreed upon. In the event that mediation is unsuccessful, any unresolved controversy related to this agreement should be submitted to and settled by binding arbitration in Arizona in accordance with the rules of the American Arbitration Association which are in effect at the time the demand for arbitration is filed. Notwithstanding the foregoing, in the event that your account is overdue (unpaid) and there is no agreement on a payment plan, Maria-Victoria Munoz can use legal means (court, collection agency, etc.) to obtain payment. The prevailing party in arbitration or collection proceedings shall be entitled to recover a reasonable sum as and for attorney's fees. In the case of arbitration, the arbitrator will determine that sum.


I have read the above Informed Consent for Psychotherapy Services & Office Policies carefully; I understand them and agree to comply with them.

( Type Full Name )
Somatic Experiencing Consent
When appropriate, and according to my clinical judgment, I will use Somatic Experiencing (SE) in our work together. SE is a short-term naturalistic approach to the resolution and healing of trauma developed by Dr. Peter Levine and is supported by research. It is based upon the observation that wild prey animals, though threatened routinely, are rarely traumatized. Animals in the wild utilize innate mechanisms to regulate and discharge the high levels of energy arousal associated with defensive survival behaviors. These mechanisms provide animals with built-in “immunity” to trauma that enables them to return to normal in the aftermath of highly “charged” life-threatening experiences.

- SE employs awareness of body sensation to help people “renegotiate” and heal rather than re-live or re-enact trauma.

- SE’s guidance of the bodily “felt sense,” allows the highly aroused survival energies to be safely experienced and gradually discharged.

- SE “titrates” experience (breaks down into small, incremental steps), rather than evoking catharsis-which can overwhelm the regulatory mechanisms of the organism.

For more information about SE please note the following references:

Levine, P. and Frederick, A. (1997). Waking the Tiger: Healing Trauma: The Innate Capacity to Transform Overwhelming Experiences. Berkeley, CA: North Atlantic Books.

Kline, M. and Levine, P. (2007). Trauma Through A Child’s Eyes: Awakening the Ordinary Miracle of Healing. Berkeley, CA: North Atlantic Books.

For further references and information online about Se go to: http://www.traumahealing.com

SE can result in a number of benefits to you, such as relief of traumatic stress symptoms, increased resiliency, and resourcefulness. Like any other treatment it may also have unintended negative “side effects.” It is important that you are aware that there are other forms of body-oriented and somatic psychotherapy. The United States Association of Body Psychotherapy (www.usabp.org) is a good source of information about other modalities. Obviously, there are also many non-somatic focused forms of psychotherapy and counseling that you can choose from.

As with all therapy, it is your responsibility to tell me when you are uncomfortable with any parts of treatment. If you have any questions about SE or other treatments, please ask and I will do my best to answer your questions in full. You have the right to refuse or terminate treatment at all times, or to refuse techniques or interventions I may propose or employ. I have read the above informed consent, understand, and agree to it.
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HEALTH INFORMATION PORTABILITY & ACCOUNTABILITY ACT (HIPPAA)
This Notice Describes How Medical Information About You May Be Used And Disclosed, And How You Can Get Access To This Information. Please Review It Carefully.

It is your therapist’s legal duty to safeguard your Protected Health Information (PHI). By law your therapist is required to ensure that your PHI is kept private. The PHI constitutes information created or noted by your therapist that can be used to identify you. It contains data about your past, present, or future health or condition, the provision of health care services to you, or the payment for such health care. Your therapist is required to provide you with this Notice about her privacy procedures. This Notice must explain when, why, and how your therapist would use and/or disclose your PHI. Use of PHI means when your therapist shares, applies, utilizes, examines, or analyzes information within the practice; PHI is disclosed when your therapist releases, transfers, gives, or otherwise reveals it to a third party outside the practice. With some exceptions, your therapist may not use or disclose more of your PHI than is necessary to accomplish the purpose for which the use or disclosure is made; however, your therapist is always legally required to follow Arizona law and the privacy practices described in this Notice.

Please note that your therapist reserves the right to change the terms of this Notice and the privacy policies at any time. Any changes will apply to PHI already on file with your therapist. Before your therapist makes any important changes to the policies, they will immediately change this Notice and post a new copy of it in the office. You may also request a copy of this Notice from your therapist, or you can view a copy of it in the office.

How Your Therapist Will Use And Disclose Your PHI
Your therapist will use and disclose your PHI for many different reasons. Most of the uses or disclosures will require your prior written authorization; others, however, will not. Below you will find the different categories of your therapist’s uses and disclosures, with some examples.

Uses and Disclosures Related to Treatment, Payment, or Health Care Operations That Do Not Require Your Prior Written Consent:
1. When disclosure is required by federal, state, or local law; judicial, board, or administrative proceedings; or law enforcement. Your therapist may make a disclosure to the appropriate officials when the law requires them to report information to courts, government agencies, law enforcement personnel, and/or in an administrative proceeding. This includes search warrants and court orders for release of records. If you, or anyone else, places your mental condition as part of any litigation (such as divorce, custody, or personal injury), your therapist may be compelled to release your PHI.
2. Disclosure is compelled or permitted when you are in such mental or emotional condition as to be dangerous to yourself and if your therapist determines that disclosure is necessary to prevent potential harm. For example, suicidal or serious self-destructive behavior.
3. Disclosure is mandated by the Arizona Child Abuse and Neglect Reporting Law. For example, if your therapist has a reasonable suspicion of child abuse or neglect.
4. Disclosure is mandated by the Arizona Elder/Dependent Adult Abuse Reporting Law. For example, if your therapist has a reasonable suspicion of elder abuse or dependent adult abuse.
5. Disclosure is mandated when you tell your therapist of a serious/imminent threat of physical violence by you against a reasonably identifiable victim or victims. Also, confidentiality does not apply to disclosure of crimes planned for the future. This applies to interests of national security, such as protecting the President of the United States, or assisting with intelligence operations to prevent future terror activities.
6. When disclosure is required to obtain payment for treatment. Your therapist might send PHI to your insurance company, health plan, or other third party payer in order to receive payment for services your therapist provided to you. Your therapist may also provide your PHI to business associates, such as billing associates, such as billing companies or others that process health care claims for the office.
7. Appointment reminders and health-related benefits or services. Your therapist may use PHI to provide appointment reminders. Your therapist may use PHI to give you information about alternative treatment options, or other health care services or benefits your therapist offers.
8. When disclosure is otherwise specifically required by law.

Other Uses And Disclosures Require Your Prior Written Authorization. For situations not described above, your therapist will require written authorization before disclosing any of your PHI. This includes communication with family members or other health care providers. Even if you signed an authorization to disclose your PHI, you may later revoke that authorization, in writing, to stop any future disclosures.

What Rights You Have Regarding Your PHI:

The Right to See and Get Copies of Your PHI. In general, you have the right to see your PHI that is in your therapist’s possession, or to get copies of it; however, you must request it in writing. You will receive a response from your therapist within 5 days of receiving your written request. Under certain circumstances, your therapist may deny your request. If they do, your therapist will give you, in writing, the reasons for the denial. You have the right to have the denial reviewed. If you ask for copies of your PHI, you will not be charged more than $.25 per page. Your therapist may see fit to provide you with a summary or explanation of the PHI, but only if you agree to it, as well as the cost, in advance.

The Right to Request Limits on Uses and Disclosures of Your PHI. You have the right to ask that your therapist limit how your therapist uses and discloses your PHI. You do not have the right to limit the uses and disclosures that they are legally required to make.

The Right to Choose How Your PHI is Sent to You. It is your right to ask that your PHI be sent to you at an alternate address (for example, sending information to your work address rather than your home address), or by an alternate method (for example, via e-mail instead of by regular mail).

The Right to a List of the Disclosures Your Therapist Has Made. You are entitled to a list of disclosures of your PHI that your therapist has made after April 15, 2003. The list will not include uses or disclosures made before April 15, 2003. After April 15, 2003, disclosure records will be held for six years.

The Right to Amend Your PHI. If you believe that there is some error in your PHI or that important information has been omitted, it is your right to request that your therapist correct the existing information or add the missing information. Your request must be made in writing. Your therapist may deny your request, in writing, if your therapist finds that the PHI is: (a) correct and complete, (b) forbidden to be disclosed, (c) not part of their records, or (d) written by someone other than your therapist. Your therapist’s denial must be in writing and must state the reasons for the denial. You have the right to file a written statement objecting to the denial. You have the right to ask that your request and the denial be attached to any future disclosures of your PHI. When approved, your therapist will advise others who need to know about the change to your PHI.

The Right to Get a Copy of This Notice. You have the right to get this notice by e-mail or paper hard copy.

How To Complain About Your Therapist’s Privacy Practices:
If, in your opinion, your therapist may have violated your privacy rights, or if you object to a decision your therapist made about access to your PHI, you are entitled to file a complaint with your therapist, or, if applicable, their clinical supervisor. You may also send a written complaint to the Secretary of the Department of Health and Human Services at 200 Independence Avenue S.W. Washington, D.C. 20201. If you file a complaint about privacy practices, your therapist will take no retaliatory action against you.

If you have any questions about this notice or my health information privacy policies please ask.

This Notice Is In Effect From April 14, 2003.

I acknowledge the terms of this notice and the privacy practices of this office.
( Type Full Name )