Shannon follows the American Counseling Association (ACA) Code of Ethics and Health Insurance Portability and Accountability Act (HIPAA) to ensure that her clients’ information is kept secure and safe, and that clients receive highly professional mental health services.
HIPAA Notice of Privacy Practices (preview)
Effective Date: August 25, 2026
THIS NOTICE DESCRIBES HOW HEALTH INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY.
Plain-Language Summary
I am required by law to protect your health information (called “protected health information” or PHI). I use and share your information only as needed to provide treatment, receive payment, run my practice, or when the law requires it. You have rights regarding your information, including the right to see it, request corrections, and ask for limits on how it is used. The full details are below.
I. My Commitment to Your Privacy
I understand that your health information is personal. I create a record of the care you receive so I can provide quality services and meet legal requirements. This notice applies to all records I generate about your care. I am required by law to:
- Keep your protected health information private.
- Give you this notice of my legal duties and privacy practices.
- Follow the terms of the notice that is currently in effect.
I may change this notice. Any changes will apply to all information I already have about you. The new notice will be available upon request, in my office, and on my website.
II. How I May Use and Disclose Your Health Information
For Treatment, Payment, or Health Care Operations
Federal rules allow me to use or disclose your PHI without your written authorization for these purposes. Examples include:
- Coordinating your care or consulting with another provider.
- Billing and collecting payment.
- Running my practice (quality improvement, training, etc.).
Disclosures for treatment are not limited to the “minimum necessary” standard because full information is often needed for good care.
Lawsuits and Disputes
I may disclose information in response to a court or administrative order. I may also respond to a subpoena or other lawful process, but only after efforts have been made to notify you or obtain a protective order, when required.
III. Uses and Disclosures That Require Your Authorization
- Psychotherapy Notes: I keep psychotherapy notes as defined by HIPAA. I will not use or disclose them without your authorization except for my own treatment of you, training/supervision, defending myself in legal proceedings you bring, certain government investigations, or as otherwise required by law.
- Marketing: I will not use or disclose your PHI for marketing purposes.
- Sale of PHI: I will not sell your PHI.
IV. Uses and Disclosures That Do Not Require Your Authorization
Subject to legal limits, I may use or disclose your PHI without authorization for:
- Reporting required by state or federal law (including suspected child, elder, or dependent adult abuse).
- Preventing or reducing a serious threat to health or safety.
- Health oversight activities (audits, investigations).
- Judicial and administrative proceedings.
- Law enforcement purposes.
- Coroners or medical examiners.
- Research (under specific conditions).
- Specialized government functions.
- Workers’ compensation.
- Appointment reminders and information about treatment alternatives or health-related benefits and services I offer.
V. Uses and Disclosures That Give You the Opportunity to Object
I may share relevant information with a family member, friend, or other person you identify as involved in your care or payment for your care, unless you object. In emergencies, I may share information and give you the chance to object later.
VI. Your Rights Regarding Your Protected Health Information
You have the right to:
- Request limits on how I use or disclose your PHI for treatment, payment, or operations. I am not required to agree if it would affect your care.
- Request restrictions on disclosures to health plans for services you paid for entirely out-of-pocket.
- Choose how I contact you (for example, a specific phone number or address). I will accommodate reasonable requests.
- See and get a copy of your PHI (except psychotherapy notes). I will respond within 30 days and may charge a reasonable cost-based fee.
- Get a list of certain disclosures I have made (an “accounting of disclosures”) for the past six years. The first request in a 12-month period is free; additional requests may have a fee.
- Request that I correct or update your PHI if you believe it is incorrect or incomplete. I may deny the request but will explain why in writing within 60 days.
- Receive a paper or electronic copy of this Notice.
Acknowledgement of Receipt of Notice of Privacy Practices
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 CLICKING ON THE CHECKBOX BELOW I AM AGREEING THAT I HAVE READ, UNDERSTOOD AND AGREE TO THE ITEMS CONTAINED IN THIS DOCUMENT.
Informed Consent, Practice Policies and Telehealth Services
Please read this document carefully. It explains how we will work together, the limits of confidentiality, practice policies, and important information about telehealth. By checking the box at the end, you acknowledge that you have read, understand, and agree to these terms.
1. The Therapeutic Relationship and Process
Therapy is a collaborative process. You have taken a positive step by seeking support. The outcome depends largely on your willingness to engage. Therapy can bring up strong feelings (anger, sadness, anxiety, etc.) as we explore patterns and experiences. There are no guarantees of specific results. I will support you, work to understand you, and help you clarify what you want for yourself.
Sessions are typically 35–45 minutes. Longer sessions may be arranged in advance and may incur additional fees.
2. Confidentiality and Its Limits
What you share in therapy is confidential. I will not release information about you without your written permission, except in the following situations required by law or professional ethics:
- If you threaten or attempt suicide or pose a substantial risk of serious harm to yourself.
- If you threaten serious harm or death to another identifiable person.
- Suspected abuse or neglect of a child under 18, an elderly person, or a dependent adult.
- If a court issues a valid subpoena or order.
- If therapy is court-ordered or information is needed for an expert report.
I may consult with other professionals for clinical guidance. In those cases, I will not use your name or identifying details unless you give permission.
If we see each other in public, I will not acknowledge you first in order to protect your privacy. If you greet me, I will respond briefly.
Recording of sessions by any means (video, audio, phone, etc.) is strictly prohibited. I do not consent to being recorded. Recording may result in termination of services.
3. Practice Policies
Appointments and Cancellations
Please cancel or reschedule at least 24 hours in advance.
- No-show (missed appointment with no notice): You are responsible for the full session fee.
- Late cancellation/reschedule (less than 24 hours’ notice): $25 fee.
These policies exist because the time is reserved exclusively for you.
Contact Between Sessions
Leave a voicemail or send a message for non-urgent matters. I will attempt to return calls/messages within 24 hours (often sooner on business days). For true emergencies, call 911 or go to the nearest emergency room. I do not provide 24-hour emergency coverage.
Electronic Communication
Email and text are acceptable for scheduling and logistical matters only. I cannot guarantee the confidentiality of electronic communication. Do not use email or text for clinical content or emergencies.
Social Media
I do not accept friend or contact requests from current or former clients on social networking sites. This protects your confidentiality and maintains clear professional boundaries.
Minors
If the client is a minor, parents/guardians may have legal rights to certain information. We will discuss appropriate boundaries of confidentiality together.
4. Telehealth (Telemental Health) Services
Telehealth means providing therapy using secure video and audio technology.
Your Rights:
- The same confidentiality protections that apply to in-person therapy also apply to telehealth.
- You may withdraw consent for telehealth at any time without affecting your right to future care.
- You have the right to request in-person sessions if they become available and clinically appropriate.
Benefits include greater convenience, reduced travel, and continued access to care.
Risks include possible technical difficulties, temporary interruption of the connection, or (despite encryption and reasonable safeguards) unauthorized access. I use secure, encrypted platforms.
I cannot make the same visual and other observations possible in an in-person setting. If I determine that telehealth is no longer appropriate for your needs, we will discuss alternatives, including referral.
Telehealth Emergency Procedures
Because we are not in the same physical location:
- At the start of every session you agree to tell me the address where you are located.
- You will provide an Emergency Contact Person (ECP) whom I may contact only in a life-threatening emergency.
- You will identify the nearest preferred hospital and police department to your usual location.
If you are in crisis, experiencing suicidal or homicidal thoughts, or need a higher level of care that cannot be managed remotely, I may determine that telehealth is not appropriate and will help you access local emergency resources (911, crisis line, or emergency room).
Emergency Contact Person (ECP). We may fill this out at the start of the initial session:
Name: ___________
Phone: ___________
Preferred Hospital: ___________
Phone: ___________
Preferred Police Department: ___________
Phone: ___________
5. Termination
Ending therapy is an important part of the process. I will not terminate services without discussing it with you first (except in cases of non-payment, safety concerns, or if therapy is not being used effectively). If we end, I will provide appropriate referrals when possible.
If you do not schedule an appointment for three consecutive weeks and we have not made other arrangements, I will consider the professional relationship discontinued.
6. Acknowledgment and Consent
I have read and understand this Informed Consent for Psychotherapy, Practice Policies, and Telehealth Services document. I have had the opportunity to ask questions. I voluntarily consent to psychotherapy services (including telehealth when used) under the terms described above.
I understand the limits of confidentiality, the cancellation policy, the risks and benefits of telehealth, and the emergency procedures.
BY CHECKING THE BOX BELOW / SIGNING, I AGREE THAT I HAVE READ, UNDERSTOOD, AND AGREE TO THE TERMS IN THIS DOCUMENT.
No Surprises Act – Good Faith Agreement
You have the right to receive a Good Faith Estimate of what your services may cost.
