Common use of Contact Clause in Contracts

Contact. If needed, you can leave your psychologist a message at 720.324.8781. When you leave a message, include your telephone number, even if you think your psychologist already has it, and best times to reach you. Every effort is made to return calls in a timely manner. In the rare circumstance that a message is missed or accidentally deleted, and you do not hear back from us within one business day, please leave a second message. If we are unavailable for an extended time, such as on vacation, we will inform you of the contact information for the therapist on-call during our absence. If you are in an emergency situation and cannot wait for us to return your call, contact your family physician or the nearest emergency room and ask for the psychologist or psychiatrist on call. Highlands Behavioral Health offers 24-hour emergency behavioral health and may be contacted by calling 000.000.0000. Enrich Relationship Center of Colorado, formerly Xxxxxx Psychology, Inc., is not a crisis facility. Do not contact us by email in an emergency, as we may not receive the information quickly. Unless you indicate otherwise, your signature on this form communicates permission for your psychologist to communicate with you through phone calls, voicemails, and text and email messages, including a termination letter that will be sent to the email address(es) on file. If you would like to limit such communication, please clearly inform your psychologist of your wishes. SOCIAL MEDIA POLICY In order to maintain your confidentiality and our respective privacy, we do not interact with current or former clients on social networking websites. We do not accept friend or contact requests from current or former clients on any social networking site, including Twitter, Facebook, LinkedIn, etc. We will not solicit testimonials, ratings or grades from clients on websites or through any means. We will not respond to testimonials, ratings or grades on websites, whether positive or negative, in order to maintain your confidentiality. Our hope is that you will bring concerns about our work together to the therapy session so we can address them directly. Please do not contact us through text messages or emails regarding clinical issues. These are not secure means of communication, and there is the possibility that we will not get the message in a timely manner, or that communication will be misinterpreted. If you need to contact your psychologist between sessions, please call 000.000.0000. Text messages and emails are only to be used for scheduling or changing or canceling appointments. LIMITS ON CONFIDENTIALITY The law protects the privacy of all communications between a client and a psychologist. In most situations, we can only release information about your treatment to others if you sign an authorization form that meets certain legal requirements imposed by HIPAA. There are other situations that require only your written, advance consent. Your signature on this Agreement provides consent for those activities, as follows: We may occasionally find it helpful to consult other health and mental health professionals about a case. During a consultation, every effort is made to avoid revealing the identity of a client. The other professionals are also legally bound to keep the information confidential. If you don’t object, we will not tell you about these consultations unless we feel that it is important to our work together. We will note all consultations in your clinical record (which is called “PHI” in the Colorado Notice - Notice of Psychologist’s Policies and Practices to Protect the Privacy of Your Health Information below). You should be aware that we employ administrative staff. In most cases, we need to share protected information with these individuals for administrative purposes, such as billing and quality assurance. All the mental health professionals are bound by the same rules of confidentiality. All staff members have been given training about protecting your privacy and have agreed not to release any information outside of the practice without permission. Disclosures required by health insurers or to collect overdue fees are discussed elsewhere in this Agreement. If a client threatens to harm himself/herself, we may be obligated to seek hospitalization for him/her, or to contact family members or others who can help provide protection. There are some situations when we are permitted or required to disclose information without either your consent or authorization: If a client is involved in a court proceeding and a request is made for information concerning professional services, such information is protected by the psychologist-client privilege law. We cannot provide any information without a client’s written authorization or a court order. If a client is involved in or contemplating litigation, they should consult with their attorney to determine whether the court would be likely to order us to disclose information. If a government agency is requesting the information for health oversight activities, we are required to provide it to them. If a client files a complaint or lawsuit against us, we may disclose relevant information regarding that client in order to defend ourselves. If a client files a worker’s compensation claim, we are required to submit a report to the Workers’ Compensation Division. There are some situations in which we are legally obligated to take actions which we believe are necessary to attempt to protect others from harm and, in so doing, we may have to reveal information about a client’s treatment. These situations are unusual in our practice and, if such a situation arises, we will make every effort to fully discuss it with you before taking any action and will limit our disclosure to what is necessary: If we have reasonable cause to know or suspect that a child has been subjected to abuse or neglect or if we have observed a child being subjected to circumstances or conditions which would reasonably result in abuse or neglect, the law requires that we file a report with the appropriate governmental agency. Once such a report is filed, we may be required to provide additional information. If we have reasonable cause to believe that an at-risk adult has been or is at imminent risk of being mistreated, self-neglected, or financially exploited, the law requires that we file a report with the appropriate governmental agency. Once such a report is filed, we may be required to provide additional information. If a client communicates a serious threat of imminent physical violence against a specific person or persons, we must make an effort to notify such person and/or an appropriate law enforcement agency and/or take other appropriate action, including seeking hospitalization of the client. While this written summary of exceptions to confidentiality should prove helpful in informing you about potential problems, it is important that we discuss any questions or concerns that you may have now or in the future. The laws governing confidentiality can be quite complex, and we are not attorneys. In situations where specific advice is required, formal legal consultation may be needed. PROFESSIONAL RECORDS The laws and standards of our profession require that we keep Protected Health Information about you in your clinical record. Except in unusual circumstances that involve danger to yourself and others, or where information has been supplied to us confidentially by others, you may examine and/or receive a copy of your clinical record, if you request it in writing. Because these are professional records, they can be misinterpreted and/or upsetting to untrained readers. For this reason, we recommend that you initially review them in our presence or have them forwarded to another mental health professional to discuss the contents. In most situations, we are allowed to charge a copying fee of $1.00 per page (and for certain other expenses). If we refuse your request for access to your records, you have a right of review, which we will discuss with you upon request. For those receiving relationship/couples therapy, the written consent of all people involved in the treatment is necessary to release any clinical information. All records will be created and maintained in accordance with the Colorado Revised Statutes and may not be maintained after the required seven-year period (commencing on the date of termination of psychological services or the date of last contact, whichever is later). CLIENT RIGHTS HIPAA provides you with several new or expanded rights with regard to your clinical record and disclosures of protected health information. These rights include requesting that we amend your record; requesting restrictions on what information from your clinical record is disclosed to others; requesting an accounting of most disclosures of protected health information that you have neither consented to nor authorized; determining the location to which protected information disclosures are sent; having any complaints you make about our policies and procedures recorded in your records; and, the right to a paper copy of this Agreement, the Notice, and our privacy policies and procedures. We are happy to discuss any of these rights with you. MINORS & PARENTS Clients under 13 years of age who are not emancipated and their parents should be aware that the law may allow parents to examine their child’s treatment record, unless we decide that such access is likely to injure the child. Because privacy in psychotherapy is often crucial to successful progress, particularly with teenagers, it is our policy to request an agreement from parents that they consent to give up their access to their child’s records. If they agree, during treatment we will provide them only with general information about the progress of the child’s treatment, and their attendance at scheduled sessions. Upon request, we will also provide parents with a summary of their child’s treatment when it is complete. Any other communication will require the child’s authorization, unless we feel that the child is in danger or is a danger to someone else, in which case we will notify the parents of our concern. To the extent possible, before giving parents any information we will discuss the matter with the child and do our best to handle any objections they may have. COLORADO NOTICE Notice of Psychologists’ Policies and Practices to Protect the Privacy of Your Health Information THIS NOTICE DESCRIBES HOW PSYCHOLOGICAL AND MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY.

Contact. If needed, you can leave your psychologist therapist a message at 720.324.8781. When you leave a message, include your telephone number, even if you think your psychologist therapist already has it, and best times to reach you. Every effort is made to return calls in a timely manner. In the rare circumstance that a message is missed or accidentally deleted, and you do not hear back from us within one business day, please leave a second message. If we are unavailable for an extended time, such as on vacation, we will inform you of the contact information for the therapist on-call during our absence. If you are in an emergency situation and cannot wait for us to return your call, contact your family physician or the nearest emergency room and ask for the psychologist therapist or psychiatrist on call. Highlands Behavioral Health offers 24-hour emergency behavioral health and may be contacted by calling 000.000.0000. Enrich Relationship Center of Colorado, formerly Xxxxxx Psychology, Inc., is not a crisis facility. Do not contact us by email in an emergency, as we may not receive the information quickly. We are dedicated to the best in clinical care. Unless you communicate with your therapist your wish not to participate, you will receive periodic surveys to ascertain your satisfaction with your interactions and therapy at Enrich Relationship Center of Colorado. Unless you indicate otherwise, your signature on this form communicates permission for your psychologist therapist to communicate with you through phone calls, voicemails, and text and email messages, including therapy satisfaction surveys and a termination letter correspondence that will be sent to the email address(es) on file. If you would like to limit such communication, please clearly inform your psychologist of your wishes. SOCIAL MEDIA POLICY In order to maintain your confidentiality and our respective privacy, we do not interact with current or former clients on social networking websites. We do not accept friend or contact requests from current or former clients on any social networking site, including Twitter, Facebook, LinkedIn, etc. We will not solicit testimonials, ratings ratings, or grades from clients on websites or through any means. We will not respond to testimonials, ratings ratings, or grades on websites, whether positive or negative, in order to maintain your confidentiality. Our hope is that you will bring concerns about our work together to the therapy session so we can address them directly. Please do not contact us through text messages or emails regarding clinical issues. These are not secure means of communication, and there is the possibility that we will not get the message in a timely manner, or that communication will be misinterpreted. If you need to contact your psychologist therapist between sessions, please call 000.000.0000. Text messages and emails are only to be used for scheduling or changing or canceling appointments. Any and all posts, opinions, comments, or interactions your therapist has on their professional social media accounts are entirely their own and not necessarily representative of Enrich Relationship Center of Colorado. LIMITS ON CONFIDENTIALITY The law protects the privacy of all communications between a client and a psychologisttherapist. In most situations, we can only release information about your treatment to others if you sign an authorization form that meets certain legal requirements imposed by HIPAA. There are other situations that require only your written, advance consent. Your signature on this Agreement provides consent for those activities, as follows: We may occasionally find it helpful to consult other health and mental health professionals about a case. During a consultation, every effort is made to avoid revealing the identity of a client. The other professionals are also legally bound to keep the information confidential. If you don’t object, we will not tell you about these consultations unless we feel that it is important to our work together. We will note all consultations in your clinical record (which is called “PHI” in the Colorado Notice - Notice of PsychologistTherapist’s Policies and Practices to Protect the Privacy of Your Health Information below). You should be aware that we employ administrative staff. In most cases, we need to share protected information with these individuals for administrative purposes, such as billing and quality assurance. All the mental health professionals are bound by the same rules of confidentiality. All staff members have been given training about protecting your privacy and have agreed not to release any information outside of the practice without permission. Disclosures required by health insurers or to collect overdue fees are discussed elsewhere in this Agreement. If a client threatens to harm himself/herselfthemselves, we may be obligated to seek hospitalization for him/herthem, or to contact family members or others who can help provide protection. There are some situations when we are permitted or required to disclose information without either your consent or authorization: If a client is involved in a court proceeding and a request is made for information concerning professional services, such information is protected by the psychologisttherapist-client privilege law. We cannot provide any information without a client’s written authorization or a court order. If a client is involved in or contemplating litigation, they should consult with their attorney to determine whether the court would be likely to order us to disclose information. If a government agency is requesting the information for health oversight activities, we are required to provide it to them. If a client files a complaint or lawsuit against us, we may disclose relevant information regarding that client in order to defend ourselves. If a client files a worker’s compensation claim, we are required to submit a report to the Workers’ Compensation Division. There are some situations in which we are legally obligated to take actions which we believe are necessary to attempt to protect others from harm and, in so doing, we may have to reveal information about a client’s treatment. These situations are unusual in our practice and, if such a situation arises, we will make every effort to fully discuss it with you before taking any action and will limit our disclosure to what is necessary: If we have reasonable cause to know or suspect that a child has been subjected to abuse or neglect or if we have observed a child being subjected to circumstances or conditions which would reasonably result in abuse or neglect, the law requires that we file a report with the appropriate governmental agency. This may include a report of a child being a witness to intimate partner violence/domestic violence. Once such a report is filed, we may be required to provide additional information. If we have reasonable cause to believe that an at-risk adult has been or is at imminent risk of being mistreated, self-neglected, or financially exploited, the law requires that we file a report with the appropriate governmental agency. Once such a report is filed, we may be required to provide additional information. If a client communicates a serious threat of imminent physical violence against a specific person or persons, we must make an effort to notify such person and/or an appropriate law enforcement agency and/or take other appropriate action, including seeking hospitalization of the client. While this written summary of exceptions to confidentiality should prove helpful in informing you about potential problems, it is important that we discuss any questions or concerns that you may have now or in the future. The laws governing confidentiality can be quite complex, and we are not attorneys. In situations where specific advice is required, formal legal consultation may be needed. PROFESSIONAL RECORDS The laws and standards of our profession require that we keep Protected Health Information about you in your clinical record. Except in unusual circumstances that involve danger to yourself and others, or where information has been supplied to us confidentially by others, you may examine and/or receive a copy of your clinical record, if you request it in writing. Because these are professional records, they can be misinterpreted and/or upsetting to untrained readers. For this reason, we recommend that you initially review them in our presence or have them forwarded to another mental health professional to discuss the contents. In most situations, we are allowed to charge a copying fee of $1.00 per page (and for certain other expenses). If we refuse your request for access to your records, you have a right of review, which we will discuss with you upon request. For those receiving relationship/couples therapy, the written consent of all people involved in the treatment is necessary to release any clinical information. All records will be created and maintained in accordance with the Colorado Revised Statutes and may not be maintained after the required seven-year period (commencing on the date of termination of psychological services or the date of last contact, whichever is later). CLIENT RIGHTS HIPAA provides you with several new or expanded rights with regard to your clinical record and disclosures of protected health information. These rights include requesting that we amend your record; requesting restrictions on what information from your clinical record is disclosed to others; requesting an accounting of most disclosures of protected health information that you have neither consented to nor authorized; determining the location to which protected information disclosures are sent; having any complaints you make about our policies and procedures recorded in your records; and, the right to a paper copy of this Agreement, the Notice, and our privacy policies and procedures. We are happy to discuss any of these rights with you. MINORS & PARENTS Clients under 13 years of age who are not emancipated emancipated, and their parents should be aware that the law may allow parents to examine their child’s treatment record, unless we decide that such access is likely to injure the child. Because privacy in psychotherapy is often crucial to successful progress, particularly with teenagers, it is our policy to request an agreement from parents that they consent to give up their access to their child’s records. If they agree, during treatment we will provide them only with general information about the progress of the child’s treatment, and their attendance at scheduled sessions. Upon request, we will also provide parents with a summary of their child’s treatment when it is complete. Any other communication will require the child’s authorization, unless we feel that the child is in danger or is a danger to someone else, in which case we will notify the parents of our concern. To the extent possible, before giving parents any information we will discuss the matter with the child and do our best to handle any objections they may have. COLORADO NOTICE Notice of PsychologistsTherapists’ Policies and Practices to Protect the Privacy of Your Health Information THIS NOTICE DESCRIBES HOW PSYCHOLOGICAL AND MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY.

Contact. If needed, you can leave your psychologist a message at 720.324.8781. When you leave a message, include your telephone number, even if you think your psychologist already has it, and best times to reach you. Every effort is made to return calls in a timely manner. In the rare circumstance that a message is missed or accidentally deleted, and you do not hear back from us within one business day, please leave a second message. If we are unavailable for an extended time, such as on vacation, we will inform you of the contact information for the therapist on-call during our absence. If you are in an emergency situation and cannot wait for us to return your call, contact your family physician or the nearest emergency room and ask for the psychologist or psychiatrist on call. Highlands Behavioral Health offers 24-hour emergency behavioral health and may be contacted by calling 000.000.0000. Enrich Relationship Center of Colorado, formerly Xxxxxx Psychology, Inc., is not a crisis facility. Do not contact us by email in an emergency, as we may not receive the information quickly. Unless you indicate otherwise, your signature on this form communicates permission for your psychologist to communicate with you through phone calls, voicemails, and text and email messages, including a termination letter that will be sent to the email address(es) on file. If you would like to limit such communication, please clearly inform your psychologist of your wishes. SOCIAL MEDIA POLICY In order to maintain your confidentiality and our respective privacy, we do not interact with current or former clients on social networking websites. We do not accept friend or contact requests from current or former clients on any social networking site, including Twitter, Facebook, LinkedIn, etc. We will not solicit testimonials, ratings or grades from clients on websites or through any means. We will not respond to testimonials, ratings or grades on websites, whether positive or negative, in order to maintain your confidentiality. Our hope is that you will bring concerns about our work together to the therapy session so we can address them directly. Please do not contact us through text messages or emails regarding clinical issues. These are not secure means of communication, and there is the possibility that we will not get the message in a timely manner, or that communication will be misinterpreted. If you need to contact your psychologist between sessions, please call 000.000.0000. Text messages and emails are only to be used for scheduling or changing or canceling appointments. Social Media Disclosure: In addition to being a therapist, Xx. Xxxxx also is an author, public speaker, and mental health advocate. As such, you may encounter her writing, talks, or social media posts outside of the office. If you feel uncomfortable about any encounter, please bring it to her attention so it can be discussed. You are under no obligation to seek Xx. Xxxxx’x work outside of session. However, if you are interested, you are welcome to follow her professional Facebook and Instagram pages, as they are open to the public: Xx. Xxxxxxxx Xxxxx (Facebook) and @adhd_doc (Instagram). Please note that you will not be followed back to protect your privacy, and Xx. Xxxxx will not reveal that she knows you personally or works with you therapeutically. Xx. Xxxxx does not respond to personal messages on social media platforms. Keep in mind that at times she posts photos on her professional pages that relate to day-to-day life, paired with a message, meaningful quote, or comment. These sorts of posts are brief and infrequent, but you may see photos of her dogs or husband, or an event she attended. For some people, this is uncomfortable and triggering due to the nature of the work. For others, this is interesting or minor. Please take a moment to think through how you may feel looking through such posts before following Xx. Xxxxx. You are more than welcome to unfollow her if at any time you find that knowing more about her outside of the professional setting is unhelpful or for any other reason. Please don’t hesitate to raise these sorts of concerns in session. Speaking Events Disclosure: You are also welcomed to attend any of Xx. Xxxxx’x speaking events, in person or digitally. If Xx. Xxxxx recognizes you in the audience or you ask a question, confidentiality applies. You are welcome to approach Xx. Xxxxx to say hello if paths are crossed in public, but Xx. Xxxxx will not make the first approach, in order to protect confidentiality. Even if you say hello, Xx. Xxxxx will not indicate how she knows you or allude in any way to therapy. Blogging/Writing Disclosure: Please know that if any case vignettes or stories are used in Xx. Xxxxx’x writing or speaking, they are not taken directly from work with an individual client. Xxxxxx, Xx. Xxxxx uses characters who are composites of a myriad of clients and other people known to her or with whom she has worked over the years. Any possibly identifying information is concealed in such composites. LIMITS ON CONFIDENTIALITY The law protects the privacy of all communications between a client and a psychologist. In most situations, we can only release information about your treatment to others if you sign an authorization form that meets certain legal requirements imposed by HIPAA. There are other situations that require only your written, advance consent. Your signature on this Agreement provides consent for those activities, as follows: We may occasionally find it helpful to consult other health and mental health professionals about a case. During a consultation, every effort is made to avoid revealing the identity of a client. The other professionals are also legally bound to keep the information confidential. If you don’t object, we will not tell you about these consultations unless we feel that it is important to our work together. We will note all consultations in your clinical record (which is called “PHI” in the Colorado Notice - Notice of Psychologist’s Policies and Practices to Protect the Privacy of Your Health Information below). You should be aware that we employ administrative staff. In most cases, we need to share protected information with these individuals for administrative purposes, such as billing and quality assurance. All the mental health professionals are bound by the same rules of confidentiality. All staff members have been given training about protecting your privacy and have agreed not to release any information outside of the practice without permission. Disclosures required by health insurers or to collect overdue fees are discussed elsewhere in this Agreement. If a client threatens to harm himself/herself, we may be obligated to seek hospitalization for him/her, or to contact family members or others who can help provide protection. There are some situations when we are permitted or required to disclose information without either your consent or authorization: If a client is involved in a court proceeding and a request is made for information concerning professional services, such information is protected by the psychologist-client privilege law. We cannot provide any information without a client’s written authorization or a court order. If a client is involved in or contemplating litigation, they should consult with their attorney to determine whether the court would be likely to order us to disclose information. If a government agency is requesting the information for health oversight activities, we are required to provide it to them. If a client files a complaint or lawsuit against us, we may disclose relevant information regarding that client in order to defend ourselves. If a client files a worker’s compensation claim, we are required to submit a report to the Workers’ Compensation Division. There are some situations in which we are legally obligated to take actions which we believe are necessary to attempt to protect others from harm and, in so doing, we may have to reveal information about a client’s treatment. These situations are unusual in our practice and, if such a situation arises, we will make every effort to fully discuss it with you before taking any action and will limit our disclosure to what is necessary: If we have reasonable cause to know or suspect that a child has been subjected to abuse or neglect or if we have observed a child being subjected to circumstances or conditions which would reasonably result in abuse or neglect, the law requires that we file a report with the appropriate governmental agency. Once such a report is filed, we may be required to provide additional information. If we have reasonable cause to believe that an at-risk adult has been or is at imminent risk of being mistreated, self-neglected, or financially exploited, the law requires that we file a report with the appropriate governmental agency. Once such a report is filed, we may be required to provide additional information. If a client communicates a serious threat of imminent physical violence against a specific person or persons, we must make an effort to notify such person and/or an appropriate law enforcement agency and/or take other appropriate action, including seeking hospitalization of the client. While this written summary of exceptions to confidentiality should prove helpful in informing you about potential problems, it is important that we discuss any questions or concerns that you may have now or in the future. The laws governing confidentiality can be quite complex, and we are not attorneys. In situations where specific advice is required, formal legal consultation may be needed. PROFESSIONAL RECORDS The laws and standards of our profession require that we keep Protected Health Information about you in your clinical record. Except in unusual circumstances that involve danger to yourself and others, or where information has been supplied to us confidentially by others, you may examine and/or receive a copy of your clinical record, if you request it in writing. Because these are professional records, they can be misinterpreted and/or upsetting to untrained readers. For this reason, we recommend that you initially review them in our presence or have them forwarded to another mental health professional to discuss the contents. In most situations, we are allowed to charge a copying fee of $1.00 per page (and for certain other expenses). If we refuse your request for access to your records, you have a right of review, which we will discuss with you upon request. For those receiving relationship/couples therapy, the written consent of all people involved in the treatment is necessary to release any clinical information. All records will be created and maintained in accordance with the Colorado Revised Statutes and may not be maintained after the required seven-year period (commencing on the date of termination of psychological services or the date of last contact, whichever is later). CLIENT RIGHTS HIPAA provides you with several new or expanded rights with regard to your clinical record and disclosures of protected health information. These rights include requesting that we amend your record; requesting restrictions on what information from your clinical record is disclosed to others; requesting an accounting of most disclosures of protected health information that you have neither consented to nor authorized; determining the location to which protected information disclosures are sent; having any complaints you make about our policies and procedures recorded in your records; and, the right to a paper copy of this Agreement, the Notice, and our privacy policies and procedures. We are happy to discuss any of these rights with you. MINORS & PARENTS Clients under 13 years of age who are not emancipated and their parents should be aware that the law may allow parents to examine their child’s treatment record, unless we decide that such access is likely to injure the child. Because privacy in psychotherapy is often crucial to successful progress, particularly with teenagers, it is our policy to request an agreement from parents that they consent to give up their access to their child’s records. If they agree, during treatment we will provide them only with general information about the progress of the child’s treatment, and their attendance at scheduled sessions. Upon request, we will also provide parents with a summary of their child’s treatment when it is complete. Any other communication will require the child’s authorization, unless we feel that the child is in danger or is a danger to someone else, in which case we will notify the parents of our concern. To the extent possible, before giving parents any information we will discuss the matter with the child and do our best to handle any objections they may have. COLORADO NOTICE Notice of Psychologists’ Policies and Practices to Protect the Privacy of Your Health Information THIS NOTICE DESCRIBES HOW PSYCHOLOGICAL AND MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY.

Contact. If needed, you can leave your psychologist a message at 720.324.8781. When you leave a message, include your telephone number, even if you think your psychologist already has it, and best times to reach you. Every effort is made to return calls in a timely manner. In the rare circumstance that a message is missed or accidentally deleted, and you do not hear back from us within one business day, please leave a second message. If we are unavailable for an extended time, such as on vacation, we will inform you of the contact information for the therapist on-call during our absence. If you are in an emergency situation and cannot wait for us to return your call, contact your family physician or the nearest emergency room and ask for the psychologist or psychiatrist on call. Highlands Behavioral Health offers 24-hour emergency behavioral health and may be contacted by calling 000.000.0000. Enrich Relationship Center of Colorado, formerly Xxxxxx Psychology, Inc., is not a crisis facility. Do not contact us by email in an emergency, as we may not receive the information quickly. Unless you indicate otherwise, your signature on this form communicates permission for your psychologist to communicate with you through phone calls, voicemails, and text and email messages, including a termination letter that will be sent to the email address(es) on file. If you would like to limit such communication, please clearly inform your psychologist of your wishes. SOCIAL MEDIA POLICY In order to maintain your confidentiality and our respective privacy, we do not interact with current or former clients on social networking websites. We do not accept friend or contact requests from current or former clients on any social networking site, including Twitter, Facebook, LinkedIn, etc. We will not solicit testimonials, ratings or grades from clients on websites or through any means. We will not respond to testimonials, ratings or grades on websites, whether positive or negative, in order to maintain your confidentiality. Our hope is that you will bring concerns about our work together to the therapy session so we can address them directly. Please do not contact us through text messages or emails regarding clinical issues. These are not secure means of communication, and there is the possibility that we will not get the message in a timely manner, or that communication will be misinterpreted. If you need to contact your psychologist between sessions, please call 000.000.0000. Text messages and emails are only to be used for scheduling or changing or canceling appointments. Social Media Disclosure: In addition to being a therapist, Xx. Xxxxx also is an author, public speaker, and mental health advocate. As such, you may encounter her writing, talks, or social media posts outside of the office. If you feel uncomfortable about any encounter, please bring it to her attention so it can be discussed. You are under no obligation to seek Xx. Xxxxx’x work outside of session. However, if you are interested, you are welcome to follow her professional Facebook and Instagram pages, as they are open to the public: Xx. Xxxxxxxx Xxxxx (Facebook) and @adhd_doc (Instagram). Please note that you will not be followed back to protect your privacy, and Xx. Xxxxx will not reveal that she knows you personally or works with you therapeutically. Xx. Xxxxx does not respond to personal messages on social media platforms. Keep in mind that at times she posts photos on her professional pages that relate to day-to-day life, paired with a message, meaningful quote, or comment. These sorts of posts are brief and infrequent, but you may see photos of her dogs or husband, or an event she attended. For some people, this is uncomfortable and triggering due to the nature of the work. For others, this is interesting or minor. Please take a moment to think through how you may feel looking through such posts before following Xx. Xxxxx. You are more than welcome to unfollow her if at any time you find that knowing more about her outside of the professional setting is unhelpful or for any other reason. Please don’t hesitate to raise these sorts of concerns in session. Speaking Events Disclosure: You are also welcomed to attend any of Xx. Xxxxx’x speaking events, in person or digitally. If Xx. Xxxxx recognizes you in the audience or you ask a question, confidentiality applies. You are welcome to approach Xx. Xxxxx to say hello if paths are crossed in public, but Xx. Xxxxx will not make the first approach, in order to protect confidentiality. Even if you say hello, Xx. Xxxxx will not indicate how she knows you or allude in any way to therapy. Blogging/Writing Disclosure: Please know that if any case vignettes or stories are used in Xx. Xxxxx’x writing or speaking, they are not taken directly from work with an individual client. Xxxxxx, Xx. Xxxxx uses characters who are composites of a myriad of clients and other people known to her or with whom she has worked over the years. Any possibly identifying information is concealed in such composites. LIMITS ON CONFIDENTIALITY The law protects the privacy of all communications between a client and a psychologist. In most situations, we can only release information about your treatment to others if you sign an authorization form that meets certain legal requirements imposed by HIPAA. There are other situations that require only your written, advance consent. Your signature on this Agreement provides consent for those activities, as follows: We may occasionally find it helpful to consult other health and mental health professionals about a case. During a consultation, every effort is made to avoid revealing the identity of a client. The other professionals are also legally bound to keep the information confidential. If you don’t object, we will not tell you about these consultations unless we feel that it is important to our work together. We will note all consultations in your clinical record (which is called “PHI” in the Colorado Notice - Notice of Psychologist’s Policies and Practices to Protect the Privacy of Your Health Information below). You should be aware that we employ administrative staff. In most cases, we need to share protected information with these individuals for administrative purposes, such as billing and quality assurance. All the mental health professionals are bound by the same rules of confidentiality. All staff members have been given training about protecting your privacy and have agreed not to release any information outside of the practice without permission. Disclosures required by health insurers or to collect overdue fees are discussed elsewhere in this Agreement. If a client threatens to harm himself/herself, we may be obligated to seek hospitalization for him/her, or to contact family members or others who can help provide protection. There are some situations when we are permitted or required to disclose information without either your consent or authorization: • If a client is involved in a court proceeding and a request is made for information concerning professional services, such information is protected by the psychologist-client privilege law. We cannot provide any information without a client’s written authorization or a court order. If a client is involved in or contemplating litigation, they should consult with their attorney to determine whether the court would be likely to order us to disclose information. • If a government agency is requesting the information for health oversight activities, we are required to provide it to them. • If a client files a complaint or lawsuit against us, we may disclose relevant information regarding that client in order to defend ourselves. • If a client files a worker’s compensation claim, we are required to submit a report to the Workers’ Compensation Division. There are some situations in which we are legally obligated to take actions which we believe are necessary to attempt to protect others from harm and, in so doing, we may have to reveal information about a client’s treatment. These situations are unusual in our practice and, if such a situation arises, we will make every effort to fully discuss it with you before taking any action and will limit our disclosure to what is necessary: • If we have reasonable cause to know or suspect that a child has been subjected to abuse or neglect or if we have observed a child being subjected to circumstances or conditions which would reasonably result in abuse or neglect, the law requires that we file a report with the appropriate governmental agency. Once such a report is filed, we may be required to provide additional information. • If we have reasonable cause to believe that an at-risk adult has been or is at imminent risk of being mistreated, self-self- neglected, or financially exploited, the law requires that we file a report with the appropriate governmental agency. Once such a report is filed, we may be required to provide additional information. • If a client communicates a serious threat of imminent physical violence against a specific person or persons, we must make an effort to notify such person and/or an appropriate law enforcement agency and/or take other appropriate action, including seeking hospitalization of the client. While this written summary of exceptions to confidentiality should prove helpful in informing you about potential problems, it is important that we discuss any questions or concerns that you may have now or in the future. The laws governing confidentiality can be quite complex, and we are not attorneys. In situations where specific advice is required, formal legal consultation may be needed. PROFESSIONAL RECORDS The laws and standards of our profession require that we keep Protected Health Information about you in your clinical record. Except in unusual circumstances that involve danger to yourself and others, or where information has been supplied to us confidentially by others, you may examine and/or receive a copy of your clinical record, if you request it in writing. Because these are professional records, they can be misinterpreted and/or upsetting to untrained readers. For this reason, we recommend that you initially review them in our presence or have them forwarded to another mental health professional to discuss the contents. In most situations, we are allowed to charge a copying fee of $1.00 per page (and for certain other expenses). If we refuse your request for access to your records, you have a right of review, which we will discuss with you upon request. For those receiving relationship/couples therapy, the written consent of all people involved in the treatment is necessary to release any clinical information. All records will be created and maintained in accordance with the Colorado Revised Statutes and may not be maintained after the required seven-year period (commencing on the date of termination of psychological services or the date of last contact, whichever is later). CLIENT RIGHTS HIPAA provides you with several new or expanded rights with regard to your clinical record and disclosures of protected health information. These rights include requesting that we amend your record; requesting restrictions on what information from your clinical record is disclosed to others; requesting an accounting of most disclosures of protected health information that you have neither consented to nor authorized; determining the location to which protected information disclosures are sent; having any complaints you make about our policies and procedures recorded in your records; and, the right to a paper copy of this Agreement, the Notice, and our privacy policies and procedures. We are happy to discuss any of these rights with you. MINORS & PARENTS Clients under 13 years of age who are not emancipated and their parents should be aware that the law may allow parents to examine their child’s treatment record, unless we decide that such access is likely to injure the child. Because privacy in psychotherapy is often crucial to successful progress, particularly with teenagers, it is our policy to request an agreement from parents that they consent to give up their access to their child’s records. If they agree, during treatment we will provide them only with general information about the progress of the child’s treatment, and their attendance at scheduled sessions. Upon request, we will also provide parents with a summary of their child’s treatment when it is complete. Any other communication will require the child’s authorization, unless we feel that the child is in danger or is a danger to someone else, in which case we will notify the parents of our concern. To the extent possible, before giving parents any information we will discuss the matter with the child and do our best to handle any objections they may have. COLORADO NOTICE Notice of Psychologists’ Policies and Practices to Protect the Privacy of Your Health Information THIS NOTICE DESCRIBES HOW PSYCHOLOGICAL AND MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY.

Contact. If needed, you can leave your psychologist a message at 720.324.8781. When you leave a message, include your telephone number, even if you think your psychologist already has it, and best times to reach you. Every effort is made to return calls in a timely manner. In the rare circumstance that a message is missed or accidentally deleted, and you do not hear back from us within one business day, please leave a second message. If we are unavailable for an extended time, such as on vacation, we will inform you of the contact information for the therapist on-call during our absence. If you are in an emergency situation and cannot wait for us to return your call, contact your family physician or the nearest emergency room and ask for the psychologist or psychiatrist on call. Highlands Behavioral Health offers 24-hour emergency behavioral health and may be contacted by calling 000.000.0000. Enrich Relationship Center of Colorado, formerly Xxxxxx Psychology, Inc., is not a crisis facility. Do not contact us by email in an emergency, as we may not receive the information quickly. Unless you indicate otherwise, your signature on this form communicates permission for your psychologist to communicate with you through phone calls, voicemails, and text and email messages, including a termination letter that will be sent to the email address(es) on file. If you would like to limit such communication, please clearly inform your psychologist of your wishes. SOCIAL MEDIA POLICY In order to maintain your confidentiality and our respective privacy, we do not interact with current or former clients on social networking websites. We do not accept friend or contact requests from current or former clients on any social networking site, including Twitter, Facebook, LinkedIn, etc. We will not solicit testimonials, ratings or grades from clients on websites or through any means. We will not respond to testimonials, ratings or grades on websites, whether positive or negative, in order to maintain your confidentiality. Our hope is that you will bring concerns about our work together to the therapy session so we can address them directly. Please do not contact us through text messages or emails regarding clinical issues. These are not secure means of communication, and there is the possibility that we will not get the message in a timely manner, or that communication will be misinterpreted. If you need to contact your psychologist between sessions, please call 000.000.0000. Text messages and emails are only to be used for scheduling or changing or canceling appointments. LIMITS ON CONFIDENTIALITY The law protects the privacy of all communications between a client and a psychologist. In most situations, we can only release information about your treatment to others if you sign an authorization form that meets certain legal requirements imposed by HIPAA. There are other situations that require only your written, advance consent. Your signature on this Agreement provides consent for those activities, as follows: We may occasionally find it helpful to consult other health and mental health professionals about a case. During a consultation, every effort is made to avoid revealing the identity of a client. The other professionals are also legally bound to keep the information confidential. If you don’t object, we will not tell you about these consultations unless we feel that it is important to our work together. We will note all consultations in your clinical record (which is called “PHI” in the Colorado Notice - Notice of Psychologist’s Policies and Practices to Protect the Privacy of Your Health Information below). You should be aware that we employ administrative staff. In most cases, we need to share protected information with these individuals for administrative purposes, such as billing and quality assurance. All the mental health professionals are bound by the same rules of confidentiality. All staff members have been given training about protecting your privacy and have agreed not to release any information outside of the practice without permission. Disclosures required by health insurers or to collect overdue fees are discussed elsewhere in this Agreement. If a client threatens to harm himself/herself, we may be obligated to seek hospitalization for him/her, or to contact family members or others who can help provide protection. There are some situations when we are permitted or required to disclose information without either your consent or authorization: • If a client is involved in a court proceeding and a request is made for information concerning professional services, such information is protected by the psychologist-client privilege law. We cannot provide any information without a client’s written authorization or a court order. If a client is involved in or contemplating litigation, they should consult with their attorney to determine whether the court would be likely to order us to disclose information. • If a government agency is requesting the information for health oversight activities, we are required to provide it to them. • If a client files a complaint or lawsuit against us, we may disclose relevant information regarding that client in order to defend ourselves. • If a client files a worker’s compensation claim, we are required to submit a report to the Workers’ Compensation Division. There are some situations in which we are legally obligated to take actions which we believe are necessary to attempt to protect others from harm and, in so doing, we may have to reveal information about a client’s treatment. These situations are unusual in our practice and, if such a situation arises, we will make every effort to fully discuss it with you before taking any action and will limit our disclosure to what is necessary: • If we have reasonable cause to know or suspect that a child has been subjected to abuse or neglect or if we have observed a child being subjected to circumstances or conditions which would reasonably result in abuse or neglect, the law requires that we file a report with the appropriate governmental agency. Once such a report is filed, we may be required to provide additional information. • If we have reasonable cause to believe that an at-risk adult has been or is at imminent risk of being mistreated, self-self- neglected, or financially exploited, the law requires that we file a report with the appropriate governmental agency. Once such a report is filed, we may be required to provide additional information. • If a client communicates a serious threat of imminent physical violence against a specific person or persons, we must make an effort to notify such person and/or an appropriate law enforcement agency and/or take other appropriate action, including seeking hospitalization of the client. While this written summary of exceptions to confidentiality should prove helpful in informing you about potential problems, it is important that we discuss any questions or concerns that you may have now or in the future. The laws governing confidentiality can be quite complex, and we are not attorneys. In situations where specific advice is required, formal legal consultation may be needed. PROFESSIONAL RECORDS The laws and standards of our profession require that we keep Protected Health Information about you in your clinical record. Except in unusual circumstances that involve danger to yourself and others, or where information has been supplied to us confidentially by others, you may examine and/or receive a copy of your clinical record, if you request it in writing. Because these are professional records, they can be misinterpreted and/or upsetting to untrained readers. For this reason, we recommend that you initially review them in our presence or have them forwarded to another mental health professional to discuss the contents. In most situations, we are allowed to charge a copying fee of $1.00 per page (and for certain other expenses). If we refuse your request for access to your records, you have a right of review, which we will discuss with you upon request. For those receiving relationship/couples therapy, the written consent of all people involved in the treatment is necessary to release any clinical information. All records will be created and maintained in accordance with the Colorado Revised Statutes and may not be maintained after the required seven-year period (commencing on the date of termination of psychological services or the date of last contact, whichever is later). CLIENT RIGHTS HIPAA provides you with several new or expanded rights with regard to your clinical record and disclosures of protected health information. These rights include requesting that we amend your record; requesting restrictions on what information from your clinical record is disclosed to others; requesting an accounting of most disclosures of protected health information that you have neither consented to nor authorized; determining the location to which protected information disclosures are sent; having any complaints you make about our policies and procedures recorded in your records; and, the right to a paper copy of this Agreement, the Notice, and our privacy policies and procedures. We are happy to discuss any of these rights with you. MINORS & PARENTS Clients under 13 years of age who are not emancipated and their parents should be aware that the law may allow parents to examine their child’s treatment record, unless we decide that such access is likely to injure the child. Because privacy in psychotherapy is often crucial to successful progress, particularly with teenagers, it is our policy to request an agreement from parents that they consent to give up their access to their child’s records. If they agree, during treatment we will provide them only with general information about the progress of the child’s treatment, and their attendance at scheduled sessions. Upon request, we will also provide parents with a summary of their child’s treatment when it is complete. Any other communication will require the child’s authorization, unless we feel that the child is in danger or is a danger to someone else, in which case we will notify the parents of our concern. To the extent possible, before giving parents any information we will discuss the matter with the child and do our best to handle any objections they may have. COLORADO NOTICE Notice of Psychologists’ Policies and Practices to Protect the Privacy of Your Health Information THIS NOTICE DESCRIBES HOW PSYCHOLOGICAL AND MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY.

Contact. If needed, you can leave your psychologist a message at 720.324.8781. When you leave a message, include your telephone number, even if you think your psychologist already has it, and best times to reach you. Every effort is made to return calls in a timely manner. In the rare circumstance that a message is missed or accidentally deleted, and you do not hear back from us within one business day, please leave a second message. If we are unavailable for an extended time, such as on vacation, we will inform you of the contact information for the therapist on-call during our absence. If you are in an emergency situation and cannot wait for us to return your call, contact your family physician or the nearest emergency room and ask for the psychologist or psychiatrist on call. Highlands Behavioral Health offers 24-hour emergency behavioral health and may be contacted by calling 000.000.0000. Enrich Relationship Center of Colorado, formerly Xxxxxx Psychology, Inc., is not a crisis facility. Do not contact us by email in an emergency, as we may not receive the information quickly. We are dedicated to the best in clinical care. Unless you communicate with your provider your wish not to participate, you will receive periodic surveys to ascertain your satisfaction with your interactions and therapy at Enrich Relationship Center. Unless you indicate otherwise, your signature on this form communicates permission for your psychologist to communicate with you through phone calls, voicemails, and text and email messages, including therapy satisfaction surveys and a termination letter correspondence that will be sent to the email address(es) on file. If you would like to limit such communication, please clearly inform your psychologist of your wishes. SOCIAL MEDIA POLICY In order to maintain your confidentiality and our respective privacy, we do not interact with current or former clients on social networking websites. We do not accept friend or contact requests from current or former clients on any social networking site, including Twitter, Facebook, LinkedIn, etc. We will not solicit testimonials, ratings or grades from clients on websites or through any means. We will not respond to testimonials, ratings or grades on websites, whether positive or negative, in order to maintain your confidentiality. Our hope is that you will bring concerns about our work together to the therapy session so we can address them directly. Please do not contact us through text messages or emails regarding clinical issues. These are not secure means of communication, and there is the possibility that we will not get the message in a timely manner, or that communication will be misinterpreted. If you need to contact your psychologist between sessions, please call 000.000.0000. Text messages and emails are only to be used for scheduling or changing or canceling appointments. Any and all posts, opinions, comments, or interactions your therapist has on their professional social media accounts are entirely their own and not necessarily representative of Enrich Relationship Center of Colorado. LIMITS ON CONFIDENTIALITY The law protects the privacy of all communications between a client and a psychologist. In most situations, we can only release information about your treatment to others if you sign an authorization form that meets certain legal requirements imposed by HIPAA. There are other situations that require only your written, advance consent. Your signature on this Agreement provides consent for those activities, as follows: We may occasionally find it helpful to consult other health and mental health professionals about a case. During a consultation, every effort is made to avoid revealing the identity of a client. The other professionals are also legally bound to keep the information confidential. If you don’t object, we will not tell you about these consultations unless we feel that it is important to our work together. We will note all consultations in your clinical record (which is called “PHI” in the Colorado Notice - Notice of Psychologist’s Policies and Practices to Protect the Privacy of Your Health Information below). You should be aware that we employ administrative staff. In most cases, we need to share protected information with these individuals for administrative purposes, such as billing and quality assurance. All the mental health professionals are bound by the same rules of confidentiality. All staff members have been given training about protecting your privacy and have agreed not to release any information outside of the practice without permission. Disclosures required by health insurers or to collect overdue fees are discussed elsewhere in this Agreement. If a client threatens to harm himself/herselfthemselves, we may be obligated to seek hospitalization for him/herthem, or to contact family members or others who can help provide protection. There are some situations when we are permitted or required to disclose information without either your consent or authorization: If a client is involved in a court proceeding and a request is made for information concerning professional services, such information is protected by the psychologist-client privilege law. We cannot provide any information without a client’s written authorization or a court order. If a client is involved in or contemplating litigation, they should consult with their attorney to determine whether the court would be likely to order us to disclose information. If a government agency is requesting the information for health oversight activities, we are required to provide it to them. If a client files a complaint or lawsuit against us, we may disclose relevant information regarding that client in order to defend ourselves. If a client files a worker’s compensation claim, we are required to submit a report to the Workers’ Compensation Division. There are some situations in which we are legally obligated to take actions which we believe are necessary to attempt to protect others from harm and, in so doing, we may have to reveal information about a client’s treatment. These situations are unusual in our practice and, if such a situation arises, we will make every effort to fully discuss it with you before taking any action and will limit our disclosure to what is necessary: If we have reasonable cause to know or suspect that a child has been subjected to abuse or neglect or if we have observed a child being subjected to circumstances or conditions which would reasonably result in abuse or neglect, the law requires that we file a report with the appropriate governmental agency. This may include a report of a child being a witness to intimate partner violence/domestic violence. Once such a report is filed, we may be required to provide additional information. If we have reasonable cause to believe that an at-risk adult has been or is at imminent risk of being mistreated, self-neglected, or financially exploited, the law requires that we file a report with the appropriate governmental agency. Once such a report is filed, we may be required to provide additional information. If a client communicates a serious threat of imminent physical violence against a specific person or persons, we must make an effort to notify such person and/or an appropriate law enforcement agency and/or take other appropriate action, including seeking hospitalization of the client. While this written summary of exceptions to confidentiality should prove helpful in informing you about potential problems, it is important that we discuss any questions or concerns that you may have now or in the future. The laws governing confidentiality can be quite complex, and we are not attorneys. In situations where specific advice is required, formal legal consultation may be needed. PROFESSIONAL RECORDS The laws and standards of our profession require that we keep Protected Health Information about you in your clinical record. Except in unusual circumstances that involve danger to yourself and others, or where information has been supplied to us confidentially by others, you may examine and/or receive a copy of your clinical record, if you request it in writing. Because these are professional records, they can be misinterpreted and/or upsetting to untrained readers. For this reason, we recommend that you initially review them in our presence or have them forwarded to another mental health professional to discuss the contents. In most situations, we are allowed to charge a copying fee of $1.00 per page (and for certain other expenses). If we refuse your request for access to your records, you have a right of review, which we will discuss with you upon request. For those receiving relationship/couples therapy, the written consent of all people involved in the treatment is necessary to release any clinical information. All records will be created and maintained in accordance with the Colorado Revised Statutes and may not be maintained after the required seven-year period (commencing on the date of termination of psychological services or the date of last contact, whichever is later). CLIENT RIGHTS HIPAA provides you with several new or expanded rights with regard to your clinical record and disclosures of protected health information. These rights include requesting that we amend your record; requesting restrictions on what information from your clinical record is disclosed to others; requesting an accounting of most disclosures of protected health information that you have neither consented to nor authorized; determining the location to which protected information disclosures are sent; having any complaints you make about our policies and procedures recorded in your records; and, the right to a paper copy of this Agreement, the Notice, and our privacy policies and procedures. We are happy to discuss any of these rights with you. MINORS & PARENTS Clients under 13 years of age who are not emancipated and their parents should be aware that the law may allow parents to examine their child’s treatment record, unless we decide that such access is likely to injure the child. Because privacy in psychotherapy is often crucial to successful progress, particularly with teenagers, it is our policy to request an agreement from parents that they consent to give up their access to their child’s records. If they agree, during treatment we will provide them only with general information about the progress of the child’s treatment, and their attendance at scheduled sessions. Upon request, we will also provide parents with a summary of their child’s treatment when it is complete. Any other communication will require the child’s authorization, unless we feel that the child is in danger or is a danger to someone else, in which case we will notify the parents of our concern. To the extent possible, before giving parents any information we will discuss the matter with the child and do our best to handle any objections they may have. COLORADO NOTICE Notice of Psychologists’ Policies and Practices to Protect the Privacy of Your Health Information THIS NOTICE DESCRIBES HOW PSYCHOLOGICAL AND MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY.

Contact. If needed, you can leave your psychologist a message at 720.324.8781. When you leave a message, include your telephone number, even if you think your psychologist already has it, and best times to reach you. Every effort is made to return calls in a timely manner. In the rare circumstance that a message is missed or accidentally deleted, and you do not hear back from us within one business day, please leave a second message. If we are unavailable for an extended time, such as on vacation, we will inform you of the contact information for the therapist on-call during our absence. If you are in an emergency situation and cannot wait for us to return your call, contact your family physician or the nearest emergency room and ask for the psychologist or psychiatrist on call. Highlands Behavioral Health offers 24-hour emergency behavioral health and may be contacted by calling 000.000.0000. Enrich Relationship Center of Colorado, formerly Xxxxxx Psychology, Inc., is not a crisis facility. Do not contact us by email in an emergency, as we may not receive the information quickly. Unless you indicate otherwise, your signature on this form communicates permission for your psychologist to communicate with you through phone calls, voicemails, and text and email messages, including a termination letter that will be sent to the email address(es) on file. If you would like to limit such communication, please clearly inform your psychologist of your wishes. SOCIAL MEDIA POLICY In order to maintain your confidentiality and our respective privacy, we do not interact with current or former clients on social networking websites. We do not accept friend or contact requests from current or former clients on any social networking site, including Twitter, Facebook, LinkedIn, etc. We will not solicit testimonials, ratings or grades from clients on websites or through any means. We will not respond to testimonials, ratings or grades on websites, whether positive or negative, in order to maintain your confidentiality. Our hope is that you will bring concerns about our work together to the therapy session so we can address them directly. Please do not contact us through text messages or emails regarding clinical issues. These are not secure means of communication, and there is the possibility that we will not get the message in a timely manner, or that communication will be misinterpreted. If you need to contact your psychologist between sessions, please call 000.000.0000. Text messages and emails are only to be used for scheduling or changing or canceling appointments. LIMITS ON CONFIDENTIALITY The law protects the privacy of all communications between a client and a psychologist. In most situations, we can only release information about your treatment to others if you sign an authorization form that meets certain legal requirements imposed by HIPAA. There are other situations that require only your written, advance consent. Your signature on this Agreement provides consent for those activities, as follows: We may occasionally find it helpful to consult other health and mental health professionals about a case. During a consultation, every effort is made to avoid revealing the identity of a client. The other professionals are also legally bound to keep the information confidential. If you don’t object, we will not tell you about these consultations unless we feel that it is important to our work together. We will note all consultations in your clinical record (which is called “PHI” in the Colorado Notice - Notice of Psychologist’s Policies and Practices to Protect the Privacy of Your Health Information below). You should be aware that we employ administrative staff. In most cases, we need to share protected information with these individuals for administrative purposes, such as billing and quality assurance. All the mental health professionals are bound by the same rules of confidentiality. All staff members have been given training about protecting your privacy and have agreed not to release any information outside of the practice without permission. Disclosures required by health insurers or to collect overdue fees are discussed elsewhere in this Agreement. If a client threatens to harm himself/herself, we may be obligated to seek hospitalization for him/her, or to contact family members or others who can help provide protection. There are some situations when we are permitted or required to disclose information without either your consent or authorization: • If a client is involved in a court proceeding and a request is made for information concerning professional services, such information is protected by the psychologist-client privilege law. We cannot provide any information without a client’s written authorization or a court order. If a client is involved in or contemplating litigation, they should consult with their attorney to determine whether the court would be likely to order us to disclose information. • If a government agency is requesting the information for health oversight activities, we are required to provide it to them. • If a client files a complaint or lawsuit against us, we may disclose relevant information regarding that client in order to defend ourselves. • If a client files a worker’s compensation claim, we are required to submit a report to the Workers’ Compensation Division. There are some situations in which we are legally obligated to take actions which we believe are necessary to attempt to protect others from harm and, in so doing, we may have to reveal information about a client’s treatment. These situations are unusual in our practice and, if such a situation arises, we will make every effort to fully discuss it with you before taking any action and will limit our disclosure to what is necessary: • If we have reasonable cause to know or suspect that a child has been subjected to abuse or neglect or if we have observed a child being subjected to circumstances or conditions which would reasonably result in abuse or neglect, the law requires that we file a report with the appropriate governmental agency. Once such a report is filed, we may be required to provide additional information. • If we have reasonable cause to believe that an at-risk adult has been or is at imminent risk of being mistreated, self-self- neglected, or financially exploited, the law requires that we file a report with the appropriate governmental agency. Once such a report is filed, we may be required to provide additional information. • If a client communicates a serious threat of imminent physical violence against a specific person or persons, we must make an effort to notify such person and/or an appropriate law enforcement agency and/or take other appropriate action, including seeking hospitalization of the client. While this written summary of exceptions to confidentiality should prove helpful in informing you about potential problems, it is important that we discuss any questions or concerns that you may have now or in the future. The laws governing confidentiality can be quite complex, and we are not attorneys. In situations where specific advice is required, formal legal consultation may be needed. PROFESSIONAL RECORDS The laws and standards of our profession require that we keep Protected Health Information about you in your clinical record. Except in unusual circumstances that involve danger to yourself and others, or where information has been supplied to us confidentially by others, you may examine and/or receive a copy of your clinical record, if you request it in writing. Because these are professional records, they can be misinterpreted and/or upsetting to untrained readers. For this reason, we recommend that you initially review them in our presence or have them forwarded to another mental health professional to discuss the contents. In most situations, we are allowed to charge a copying fee of $1.00 per page (and for certain other expenses). If we refuse your request for access to your records, you have a right of review, which we will discuss with you upon request. For those receiving relationship/couples therapy, the written consent of all people involved in the treatment is necessary to release any clinical information. All records will be created and maintained in accordance with the Colorado Revised Statutes and may not be maintained after the required seven-year period (commencing on the date of termination of psychological services or the date of last contact, whichever is later). CLIENT RIGHTS HIPAA provides you with several new or expanded rights with regard to your clinical record and disclosures of protected health information. These rights include requesting that we amend your record; requesting restrictions on what information from your clinical record is disclosed to others; requesting an accounting of most disclosures of protected health information that you have neither consented to nor authorized; determining the location to which protected information disclosures are sent; having any complaints you make about our policies and procedures recorded in your records; and, the right to a paper copy of this Agreement, the Notice, and our privacy policies and procedures. We are happy to discuss any of these rights with you. MINORS & PARENTS Clients under 13 years of age who are not emancipated and their parents should be aware that the law may allow parents to examine their child’s treatment record, unless we decide that such access is likely to injure the child. Because privacy in psychotherapy is often crucial to successful progress, particularly with teenagers, it is our policy to request an agreement from parents that they consent to give up their access to their child’s records. If they agree, during treatment we will provide them only with general information about the progress of the child’s treatment, and their attendance at scheduled sessions. Upon request, we will also provide parents with a summary of their child’s treatment when it is complete. Any other communication will require the child’s authorization, unless we feel that the child is in danger or is a danger to someone else, in which case we will notify the parents of our concern. To the extent possible, before giving parents any information we will discuss the matter with the child and do our best to handle any objections they may have. COLORADO NOTICE Notice of Psychologists’ Policies and Practices to Protect the Privacy of Your Health Information THIS NOTICE DESCRIBES HOW PSYCHOLOGICAL AND MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY.

Contact. If needed, you can leave your psychologist a message at 720.324.8781. When you leave a message, include your telephone number, even if you think your psychologist already has it, and best times to reach you. Every effort is made to return calls in a timely manner. In the rare circumstance that a message is missed or accidentally deleted, and you do not hear back from us within one business day, please leave a second message. If we are unavailable for an extended time, such as on vacation, we will inform you of the contact information for the therapist on-call during our absence. If you are in an emergency situation and cannot wait for us to return your call, contact your family physician or the nearest emergency room and ask for the psychologist or psychiatrist on call. Highlands Behavioral Health offers 24-hour emergency behavioral health and may be contacted by calling 000.000.0000. Enrich Relationship Center of Colorado, formerly Xxxxxx Psychology, Inc., is not a crisis facility. Do not contact us by email in an emergency, as we may not receive the information quickly. Unless you indicate otherwise, your signature on this form communicates permission for your psychologist to communicate with you through phone calls, voicemails, and text and email messages, including a termination letter that will be sent to the email address(es) on file. If you would like to limit such communication, please clearly inform your psychologist of your wishes. SOCIAL MEDIA POLICY In order to maintain your confidentiality and our respective privacy, we do not interact with current or former clients on social networking websites. We do not accept friend or contact requests from current or former clients on any social networking site, including Twitter, Facebook, LinkedIn, etc. We will not solicit testimonials, ratings or grades from clients on websites or through any means. We will not respond to testimonials, ratings or grades on websites, whether positive or negative, in order to maintain your confidentiality. Our hope is that you will bring concerns about our work together to the therapy session so we can address them directly. Please do not contact us through text messages or emails regarding clinical issues. These are not secure means of communication, and there is the possibility that we will not get the message in a timely manner, or that communication will be misinterpreted. If you need to contact your psychologist between sessions, please call 000.000.0000. Text messages and emails are only to be used for scheduling or changing or canceling appointments. LIMITS ON CONFIDENTIALITY The law protects the privacy of all communications between a client and a psychologist. In most situations, we can only release information about your treatment to others if you sign an authorization form that meets certain legal requirements imposed by HIPAA. There are other situations that require only your written, advance consent. Your signature on this Agreement provides consent for those activities, as follows: We may occasionally find it helpful to consult other health and mental health professionals about a case. During a consultation, every effort is made to avoid revealing the identity of a client. The other professionals are also legally bound to keep the information confidential. If you don’t object, we will not tell you about these consultations unless we feel that it is important to our work together. We will note all consultations in your clinical record (which is called “PHI” in the Colorado Notice - Notice of Psychologist’s Policies and Practices to Protect the Privacy of Your Health Information below). You should be aware that we employ administrative staff. In most cases, we need to share protected information with these individuals for administrative purposes, such as billing and quality assurance. All the mental health professionals are bound by the same rules of confidentiality. All staff members have been given training about protecting your privacy and have agreed not to release any information outside of the practice without permission. Disclosures required by health insurers or to collect overdue fees are discussed elsewhere in this Agreement. If a client threatens to harm himself/herself, we may be obligated to seek hospitalization for him/her, or to contact family members or others who can help provide protection. There are some situations when we are permitted or required to disclose information without either your consent or authorization: • If a client is involved in a court proceeding and a request is made for information concerning professional services, such information is protected by the psychologist-client privilege law. We cannot provide any information without a client’s written authorization or a court order. If a client is involved in or contemplating litigation, they should consult with their attorney to determine whether the court would be likely to order us to disclose information. • If a government agency is requesting the information for health oversight activities, we are required to provide it to them. • If a client files a complaint or lawsuit against us, we may disclose relevant information regarding that client in order to defend ourselves. • If a client files a worker’s compensation claim, we are required to submit a report to the Workers’ Compensation Division. There are some situations in which we are legally obligated to take actions which we believe are necessary to attempt to protect others from harm and, in so doing, we may have to reveal information about a client’s treatment. These situations are unusual in our practice and, if such a situation arises, we will make every effort to fully discuss it with you before taking any action and will limit our disclosure to what is necessary: • If we have reasonable cause to know or suspect that a child has been subjected to abuse or neglect or if we have observed a child being subjected to circumstances or conditions which would reasonably result in abuse or neglect, the law requires that we file a report with the appropriate governmental agency. Once such a report is filed, we may be required to provide additional information. • If we have reasonable cause to believe that an at-risk adult has been or is at imminent risk of being mistreated, self-neglected, or financially exploited, the law requires that we file a report with the appropriate governmental agency. Once such a report is filed, we may be required to provide additional information. • If a client communicates a serious threat of imminent physical violence against a specific person or persons, we must make an effort to notify such person and/or an appropriate law enforcement agency and/or take other appropriate action, including seeking hospitalization of the client. While this written summary of exceptions to confidentiality should prove helpful in informing you about potential problems, it is important that we discuss any questions or concerns that you may have now or in the future. The laws governing confidentiality can be quite complex, and we are not attorneys. In situations where specific advice is required, formal legal consultation may be needed. PROFESSIONAL RECORDS The laws and standards of our profession require that we keep Protected Health Information about you in your clinical record. Except in unusual circumstances that involve danger to yourself and others, or where information has been supplied to us confidentially by others, you may examine and/or receive a copy of your clinical record, if you request it in writing. Because these are professional records, they can be misinterpreted and/or upsetting to untrained readers. For this reason, we recommend that you initially review them in our presence or have them forwarded to another mental health professional to discuss the contents. In most situations, we are allowed to charge a copying fee of $1.00 per page (and for certain other expenses). If we refuse your request for access to your records, you have a right of review, which we will discuss with you upon request. For those receiving relationship/couples therapy, the written consent of all people involved in the treatment is necessary to release any clinical information. All records will be created and maintained in accordance with the Colorado Revised Statutes and may not be maintained after the required seven-year period (commencing on the date of termination of psychological services or the date of last contact, whichever is later). CLIENT RIGHTS HIPAA provides you with several new or expanded rights with regard to your clinical record and disclosures of protected health information. These rights include requesting that we amend your record; requesting restrictions on what information from your clinical record is disclosed to others; requesting an accounting of most disclosures of protected health information that you have neither consented to nor authorized; determining the location to which protected information disclosures are sent; having any complaints you make about our policies and procedures recorded in your records; and, the right to a paper copy of this Agreement, the Notice, and our privacy policies and procedures. We are happy to discuss any of these rights with you. MINORS & PARENTS Clients under 13 years of age who are not emancipated and their parents should be aware that the law may allow parents to examine their child’s treatment record, unless we decide that such access is likely to injure the child. Because privacy in psychotherapy is often crucial to successful progress, particularly with teenagers, it is our policy to request an agreement from parents that they consent to give up their access to their child’s records. If they agree, during treatment we will provide them only with general information about the progress of the child’s treatment, and their attendance at scheduled sessions. Upon request, we will also provide parents with a summary of their child’s treatment when it is complete. Any other communication will require the child’s authorization, unless we feel that the child is in danger or is a danger to someone else, in which case we will notify the parents of our concern. To the extent possible, before giving parents any information we will discuss the matter with the child and do our best to handle any objections they may have. COLORADO NOTICE Notice of Psychologists’ Policies and Practices to Protect the Privacy of Your Health Information THIS NOTICE DESCRIBES HOW PSYCHOLOGICAL AND MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY.

Contact. If needed, you can leave your psychologist a message at 720.324.8781. When you leave a message, include your telephone number, even if you think your psychologist already has it, and best times to reach you. Every effort effort is made to return calls in a timely manner. In the rare circumstance that a message is missed or accidentally deleted, and you do not hear back from us within one business day, please leave a second message. If we are unavailable for an extended time, such as on vacation, we will inform you of the contact information for the therapist on-call during our absence. If you are in an emergency situation and cannot wait for us to return your call, contact your family physician or the nearest emergency room and ask for the psychologist or psychiatrist on call. Highlands Behavioral Health offers offers 24-hour emergency behavioral health and may be contacted by calling 000.000.0000. Enrich Relationship Center of Colorado, formerly Xxxxxx Psychology, Inc., is not a crisis facility. Do not contact us by email in an emergency, as we may not receive the information quickly. Unless you indicate otherwise, your signature on this form communicates permission for your psychologist to communicate with you through phone calls, voicemails, and text and email messages, including a termination letter leJer that will be sent to the email address(es) on filefile. If you would like to limit such communication, please clearly inform your psychologist of your wishes. SOCIAL MEDIA POLICY In order to maintain your confidentiality confidentiality and our respective privacy, we do not interact with current or former clients on social networking websites. We do not accept friend or contact requests from current or former clients on any social networking site, including Twitter, Facebook, LinkedIn, etc. We will not solicit testimonials, ratings or grades from clients on websites or through any means. We will not respond to testimonials, ratings or grades on websites, whether positive or negative, in order to maintain your confidentialityconfidentiality. Our hope is that you will bring concerns about our work together to the therapy session so we can address them directly. Please do not contact us through text messages or emails regarding clinical issues. These are not secure means of communication, and there is the possibility that we will not get the message in a timely manner, or that communication will be misinterpreted. If you need to contact your psychologist between sessions, please call 000.000.0000. Text messages and emails are only to be used for scheduling or changing or canceling appointments. LIMITS ON CONFIDENTIALITY The law protects the privacy of all communications between a client and a psychologist. In most situations, we can only release information about your treatment to others if you sign an authorization form that meets certain legal requirements imposed by HIPAA. There are other situations that require only your written, advance consent. Your signature on this Agreement provides consent for those activities, as follows: We may occasionally find find it helpful to consult other health and mental health professionals about a case. During a consultation, every effort effort is made to avoid revealing the identity of a client. The other professionals are also legally bound to keep the information confidentialconfidential. If you don’t object, we will not tell you about these consultations unless we feel that it is important to our work together. We will note all consultations in your clinical record (which is called “PHI” in the Colorado Notice - Notice of Psychologist’s Policies and Practices to Protect the Privacy of Your Health Information below). You should be aware that we employ administrative staff. staff. In most cases, we need to share protected information with these individuals for administrative purposes, such as billing and quality assurance. All the mental health professionals are bound by the same rules of confidentialityconfidentiality. All staff staff members have been given training about protecting your privacy and have agreed not to release any information outside of the practice without permission. Disclosures required by health insurers or to collect overdue fees are discussed elsewhere in this Agreement. If a client threatens to harm himself/herself, we may be obligated to seek hospitalization for him/her, or to contact family members or others who can help provide protection. There are some situations when we are permitted permiJed or required to disclose information without either your consent or authorization: • If a client is involved in a court proceeding and a request is made for information concerning professional services, such information is protected by the psychologist-client privilege law. We cannot provide any information without a client’s written authorization or a court order. If a client is involved in or contemplating litigation, they should consult with their attorney to determine whether the court would be likely to order us to disclose information. • If a government agency is requesting the information for health oversight activities, we are required to provide it to them. • If a client files files a complaint or lawsuit against us, we may disclose relevant information regarding that client in order to defend ourselves. • If a client files files a worker’s compensation claim, we are required to submit a report to the Workers’ Compensation Division. There are some situations in which we are legally obligated to take actions which we believe are necessary to attempt to protect others from harm and, in so doing, we may have to reveal information about a client’s treatment. These situations are unusual in our practice and, if such a situation arises, we will make every effort effort to fully discuss it with you before taking any action and will limit our disclosure to what is necessary: • If we have reasonable cause to know or suspect that a child has been subjected to abuse or neglect or if we have observed a child being subjected to circumstances or conditions which would reasonably result in abuse or neglect, the law requires that we file file a report with the appropriate governmental agency. Once such a report is filedfiled, we may be required to provide additional information. • If we have reasonable cause to believe that an at-risk adult has been or is at imminent risk of being mistreated, self-self- neglected, or financially financially exploited, the law requires that we file file a report with the appropriate governmental agency. Once such a report is filedfiled, we may be required to provide additional information. • If a client communicates a serious threat of imminent physical violence against a specific specific person or persons, we must make an effort effort to notify such person and/or an appropriate law enforcement agency and/or take other appropriate action, including seeking hospitalization of the client. While this written summary of exceptions to confidentiality confidentiality should prove helpful in informing you about potential problems, it is important that we discuss any questions or concerns that you may have now or in the future. The laws governing confidentiality confidentiality can be quite complex, and we are not attorneys. In situations where specific specific advice is required, formal legal consultation may be needed. PROFESSIONAL RECORDS The laws and standards of our profession require that we keep Protected Health Information about you in your clinical record. Except in unusual circumstances that involve danger to yourself and others, or where information has been supplied to us confidentially confidentially by others, you may examine and/or receive a copy of your clinical record, if you request it in writing. Because these are professional records, they can be misinterpreted and/or upsetting to untrained readers. For this reason, we recommend that you initially review them in our presence or have them forwarded to another mental health professional to discuss the contents. In most situations, we are allowed to charge a copying fee of $1.00 per page (and for certain other expenses). If we refuse your request for access to your records, you have a right of review, which we will discuss with you upon request. For those receiving relationship/couples therapy, the written wriJen consent of all people involved in the treatment is necessary to release any clinical information. All records will be created and maintained in accordance with the Colorado Revised Statutes and may not be maintained after aaer the required seven-year period (commencing on the date of termination of psychological services or the date of last contact, whichever is later). CLIENT RIGHTS HIPAA provides you with several new or expanded rights with regard to your clinical record and disclosures of protected health information. These rights include requesting that we amend your record; requesting restrictions on what information from your clinical record is disclosed to others; requesting an accounting of most disclosures of protected health information that you have neither consented to nor authorized; determining the location to which protected information disclosures are sent; having any complaints you make about our policies and procedures recorded in your records; and, the right to a paper copy of this Agreement, the Notice, and our privacy policies and procedures. We are happy to discuss any of these rights with you. MINORS & PARENTS Clients under 13 years of age who are not emancipated and their parents should be aware that the law may allow parents to examine their child’s treatment record, unless we decide that such access is likely to injure the child. Because privacy in psychotherapy is often oaen crucial to successful progress, particularly with teenagers, it is our policy to request an agreement from parents that they consent to give up their access to their child’s records. If they agree, during treatment we will provide them only with general information about the progress of the child’s treatment, and their attendance at scheduled sessions. Upon request, we will also provide parents with a summary of their child’s treatment when it is complete. Any other communication will require the child’s authorization, unless we feel that the child is in danger or is a danger to someone else, in which case we will notify the parents of our concern. To the extent possible, before giving parents any information we will discuss the matter with the child and do our best to handle any objections they may have. COLORADO NOTICE Notice of Psychologists’ Policies and Practices to Protect the Privacy of Your Health Information THIS NOTICE DESCRIBES HOW PSYCHOLOGICAL AND MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY.

Contact. If needed, you can leave your psychologist therapist a message at 720.324.8781. When you leave a message, include your telephone number, even if you think your psychologist therapist already has it, and best times to reach you. Every effort is made to return calls in a timely manner. In the rare circumstance that a message is missed or accidentally deleted, and you do not hear back from us within one business day, please leave a second message. If we are unavailable for an extended time, such as on vacation, we will inform you of the contact information for the therapist on-call during our absence. If you are in an emergency situation and cannot wait for us to return your call, contact your family physician or the nearest emergency room and ask for the psychologist therapist or psychiatrist on call. Highlands Behavioral Health offers 24-hour emergency behavioral health and may be contacted by calling 000.000.0000. Enrich Relationship Center of Colorado, formerly Xxxxxx Psychology, Inc., is not a crisis facility. Do not contact us by email in an emergency, as we may not receive the information quickly. Unless you indicate otherwise, your signature on this form communicates permission for your psychologist therapist to communicate with you through phone calls, voicemails, and text and email messages, including a termination letter that will be sent to the email address(es) on file. If you would like to limit such communication, please clearly inform your psychologist therapist of your wishes. SOCIAL MEDIA POLICY In order to maintain your confidentiality and our respective privacy, we do not interact with current or former clients on social networking websites. We do not accept friend or contact requests from current or former clients on any social networking site, including Twitter, Facebook, LinkedIn, etc. We will not solicit testimonials, ratings or grades from clients on websites or through any means. We will not respond to testimonials, ratings or grades on websites, whether positive or negative, in order to maintain your confidentiality. Our hope is that you will bring concerns about our work together to the therapy session so we can address them directly. Please do not contact us through text messages or emails regarding clinical issues. These are not secure means of communication, and there is the possibility that we will not get the message in a timely manner, or that communication will be misinterpreted. If you need to contact your psychologist therapist between sessions, please call 000.000.0000. Text messages and emails are only to be used for scheduling or changing or canceling appointments. LIMITS ON CONFIDENTIALITY The law protects the privacy of all communications between a client and a psychologisttherapist. In most situations, we can only release information about your treatment to others if you sign an authorization form that meets certain legal requirements imposed by HIPAA. There are other situations that require only your written, advance consent. Your signature on this Agreement provides consent for those activities, as follows: We may occasionally find it helpful to consult other health and mental health professionals about a case. During a consultation, every effort is made to avoid revealing the identity of a client. The other professionals are also legally bound to keep the information confidential. If you don’t object, we will not tell you about these consultations unless we feel that it is important to our work together. We will note all consultations in your clinical record (which is called “PHI” in the Colorado Notice - Notice of PsychologistTherapist’s Policies and Practices to Protect the Privacy of Your Health Information below). You should be aware that we employ administrative staff. In most cases, we need to share protected information with these individuals for administrative purposes, such as billing and quality assurance. All the mental health professionals are bound by the same rules of confidentiality. All staff members have been given training about protecting your privacy and have agreed not to release any information outside of the practice without permission. Disclosures required by health insurers or to collect overdue fees are discussed elsewhere in this Agreement. If a client threatens to harm himself/herself, we may be obligated to seek hospitalization for him/her, or to contact family members or others who can help provide protection. There are some situations when we are permitted or required to disclose information without either your consent or authorization: If a client is involved in a court proceeding and a request is made for information concerning professional services, such information is protected by the psychologisttherapist-client privilege law. We cannot provide any information without a client’s written authorization or a court order. If a client is involved in or contemplating litigation, they should consult with their attorney to determine whether the court would be likely to order us to disclose information. If a government agency is requesting the information for health oversight activities, we are required to provide it to them. If a client files a complaint or lawsuit against us, we may disclose relevant information regarding that client in order to defend ourselves. If a client files a worker’s compensation claim, we are required to submit a report to the Workers’ Compensation Division. There are some situations in which we are legally obligated to take actions which we believe are necessary to attempt to protect others from harm and, in so doing, we may have to reveal information about a client’s treatment. These situations are unusual in our practice and, if such a situation arises, we will make every effort to fully discuss it with you before taking any action and will limit our disclosure to what is necessary: If we have reasonable cause to know or suspect that a child has been subjected to abuse or neglect or if we have observed a child being subjected to circumstances or conditions which would reasonably result in abuse or neglect, the law requires that we file a report with the appropriate governmental agency. Once such a report is filed, we may be required to provide additional information. If we have reasonable cause to believe that an at-risk adult has been or is at imminent risk of being mistreated, self-neglected, or financially exploited, the law requires that we file a report with the appropriate governmental agency. Once such a report is filed, we may be required to provide additional information. If a client communicates a serious threat of imminent physical violence against a specific person or persons, we must make an effort to notify such person and/or an appropriate law enforcement agency and/or take other appropriate action, including seeking hospitalization of the client. While this written summary of exceptions to confidentiality should prove helpful in informing you about potential problems, it is important that we discuss any questions or concerns that you may have now or in the future. The laws governing confidentiality can be quite complex, and we are not attorneys. In situations where specific advice is required, formal legal consultation may be needed. PROFESSIONAL RECORDS The laws and standards of our profession require that we keep Protected Health Information about you in your clinical record. Except in unusual circumstances that involve danger to yourself and others, or where information has been supplied to us confidentially by others, you may examine and/or receive a copy of your clinical record, if you request it in writing. Because these are professional records, they can be misinterpreted and/or upsetting to untrained readers. For this reason, we recommend that you initially review them in our presence or have them forwarded to another mental health professional to discuss the contents. In most situations, we are allowed to charge a copying fee of $1.00 per page (and for certain other expenses). If we refuse your request for access to your records, you have a right of review, which we will discuss with you upon request. For those receiving relationship/couples therapy, the written consent of all people involved in the treatment is necessary to release any clinical information. All records will be created and maintained in accordance with the Colorado Revised Statutes and may not be maintained after the required seven-year period (commencing on the date of termination of psychological services or the date of last contact, whichever is later). CLIENT RIGHTS HIPAA provides you with several new or expanded rights with regard to your clinical record and disclosures of protected health information. These rights include requesting that we amend your record; requesting restrictions on what information from your clinical record is disclosed to others; requesting an accounting of most disclosures of protected health information that you have neither consented to nor authorized; determining the location to which protected information disclosures are sent; having any complaints you make about our policies and procedures recorded in your records; and, the right to a paper copy of this Agreement, the Notice, and our privacy policies and procedures. We are happy to discuss any of these rights with you. MINORS & PARENTS Clients under 13 years of age who are not emancipated and their parents should be aware that the law may allow parents to examine their child’s treatment record, unless we decide that such access is likely to injure the child. Because privacy in psychotherapy is often crucial to successful progress, particularly with teenagers, it is our policy to request an agreement from parents that they consent to give up their access to their child’s records. If they agree, during treatment we will provide them only with general information about the progress of the child’s treatment, and their attendance at scheduled sessions. Upon request, we will also provide parents with a summary of their child’s treatment when it is complete. Any other communication will require the child’s authorization, unless we feel that the child is in danger or is a danger to someone else, in which case we will notify the parents of our concern. To the extent possible, before giving parents any information we will discuss the matter with the child and do our best to handle any objections they may have. COLORADO NOTICE Notice of PsychologistsTherapists’ Policies and Practices to Protect the Privacy of Your Health Information THIS NOTICE DESCRIBES HOW PSYCHOLOGICAL AND MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY.

Contact. If needed, you can leave your psychologist a message at 720.324.8781. When you leave a message, include your telephone number, even if you think your psychologist already has it, and best times to reach you. Every effort is made to return calls in a timely manner. In the rare circumstance that a message is missed or accidentally deleted, and you do not hear back from us within one business day, please leave a second message. If we are unavailable for an extended time, such as on vacation, we will inform you of the contact information for the therapist on-call during our absence. If you are in an emergency situation and cannot wait for us to return your call, contact your family physician or the nearest emergency room and ask for the psychologist or psychiatrist on call. Highlands Behavioral Health offers 24-hour emergency behavioral health and may be contacted by calling 000.000.0000. Enrich Relationship Center of Colorado, formerly Xxxxxx Psychology, Inc., is not a crisis facility. Do not contact us by email in an emergency, as we may not receive the information quickly. Unless you indicate otherwise, your signature on this form communicates permission for your psychologist to communicate with you through phone calls, voicemails, and text and email messages, including a termination letter that will be sent to the email address(es) on file. If you would like to limit such communication, please clearly inform your psychologist of your wishes. SOCIAL MEDIA POLICY In order to maintain your confidentiality and our respective privacy, we do not interact with current or former clients on social networking websites. We do not accept friend or contact requests from current or former clients on any social networking site, including Twitter, Facebook, LinkedIn, etc. We will not solicit testimonials, ratings or grades from clients on websites or through any means. We will not respond to testimonials, ratings or grades on websites, whether positive or negative, in order to maintain your confidentiality. Our hope is that you will bring concerns about our work together to the therapy session so we can address them directly. Please do not contact us through text messages or emails regarding clinical issues. These are not secure means of communication, and there is the possibility that we will not get the message in a timely manner, or that communication will be misinterpreted. If you need to contact your psychologist between sessions, please call 000.000.0000. Text messages and emails are only to be used for scheduling or changing or canceling appointments. LIMITS ON CONFIDENTIALITY The law protects the privacy of all communications between a client and a psychologist. In most situations, we can only release information about your treatment to others if you sign an authorization form that meets certain legal requirements imposed by HIPAA. There are other situations that require only your written, advance consent. Your signature on this Agreement provides consent for those activities, as follows: We may occasionally find it helpful to consult other health and mental health professionals about a case. During a consultation, every effort is made to avoid revealing the identity of a client. The other professionals are also legally bound to keep the information confidential. If you don’t object, we will not tell you about these consultations unless we feel that it is important to our work together. We will note all consultations in your clinical record (which is called “PHI” in the Colorado Notice - Notice of Psychologist’s Policies and Practices to Protect the Privacy of Your Health Information below). You should be aware that we employ administrative staff. In most cases, we need to share protected information with these individuals for administrative purposes, such as billing and quality assurance. All the mental health professionals are bound by the same rules of confidentiality. All staff members have been given training about protecting your privacy and have agreed not to release any information outside of the practice without permission. Disclosures required by health insurers or to collect overdue fees are discussed elsewhere in this Agreement. If a client threatens to harm himself/herself, we may be obligated to seek hospitalization for him/her, or to contact family members or others who can help provide protection. There are some situations when we are permitted or required to disclose information without either your consent or authorization: If a client is involved in a court proceeding and a request is made for information concerning professional services, such information is protected by the psychologist-client privilege law. We cannot provide any information without a client’s written authorization or a court order. If a client is involved in or contemplating litigation, they should consult with their attorney to determine whether the court would be likely to order us to disclose information. If a government agency is requesting the information for health oversight activities, we are required to provide it to them. If a client files a complaint or lawsuit against us, we may disclose relevant information regarding that client in order to defend ourselves. If a client files a worker’s compensation claim, we are required to submit a report to the Workers’ Compensation Division. There are some situations in which we are legally obligated to take actions which we believe are necessary to attempt to protect others from harm and, in so doing, we may have to reveal information about a client’s treatment. These situations are unusual in our practice and, if such a situation arises, we will make every effort to fully discuss it with you before taking any action and will limit our disclosure to what is necessary: If we have reasonable cause to know or suspect that a child has been subjected to abuse or neglect or if we have observed a child being subjected to circumstances or conditions which would reasonably result in abuse or neglect, the law requires that we file a report with the appropriate governmental agency. Once such a report is filed, we may be required to provide additional information. If we have reasonable cause to believe that an at-risk adult has been or is at imminent risk of being mistreated, self-neglected, or financially exploited, the law requires that we file a report with the appropriate governmental agency. Once such a report is filed, we may be required to provide additional information. If a client communicates a serious threat of imminent physical violence against a specific person or persons, we must make an effort to notify such person and/or an appropriate law enforcement agency and/or take other appropriate action, including seeking hospitalization of the client. While this written summary of exceptions to confidentiality should prove helpful in informing you about potential problems, it is important that we discuss any questions or concerns that you may have now or in the future. The laws governing confidentiality can be quite complex, and we are not attorneys. In situations where specific advice is required, formal legal consultation may be needed. PROFESSIONAL RECORDS The laws and standards of our profession require that we keep Protected Health Information about you in your clinical record. Except in unusual circumstances that involve danger to yourself and others, or where information has been supplied to us confidentially by others, you may examine and/or receive a copy of your clinical record, if you request it in writing. Because these are professional records, they can be misinterpreted and/or upsetting to untrained readers. For this reason, we recommend that you initially review them in our presence or have them forwarded to another mental health professional to discuss the contents. In most situations, we are allowed to charge a copying fee of $1.00 per page (and for certain other expenses). If we refuse your request for access to your records, you have a right of review, which we will discuss with you upon request. For those receiving relationship/couples therapy, the written consent of all people involved in the treatment is necessary to release any clinical information. All records will be created and maintained in accordance with the Colorado Revised Statutes and may not be maintained after the required seven-year period (commencing on the date of termination of psychological services or the date of last contact, whichever is later). CLIENT RIGHTS HIPAA provides you with several new or expanded rights with regard to your clinical record and disclosures of protected health information. These rights include requesting that we amend your record; requesting restrictions on what information from your clinical record is disclosed to others; requesting an accounting of most disclosures of protected health information that you have neither consented to nor authorized; determining the location to which protected information disclosures are sent; having any complaints you make about our policies and procedures recorded in your records; and, the right to a paper copy of this Agreement, the Notice, and our privacy policies and procedures. We are happy to discuss any of these rights with you. MINORS & PARENTS Clients under 13 years of age who are not emancipated and their parents should be aware that the law may allow parents to examine their child’s treatment record, unless we decide that such access is likely to injure the child. Because privacy in psychotherapy is often crucial to successful progress, particularly with teenagers, it is our policy to request an agreement from parents that they consent to give up their access to their child’s records. If they agree, during treatment we will provide them only with general information about the progress of the child’s treatment, and their attendance at scheduled sessions. Upon request, we will also provide parents with a summary of their child’s treatment when it is complete. Any other communication will require the child’s authorization, unless we feel that the child is in danger or is a danger to someone else, in which case we will notify the parents of our concern. To the extent possible, before giving parents any information we will discuss the matter with the child and do our best to handle any objections they may have. COLORADO NOTICE Notice of Psychologists’ Policies and Practices to Protect the Privacy of Your Health Information THIS NOTICE DESCRIBES HOW PSYCHOLOGICAL AND MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY.