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

In order to provide you care, Christine Velasquez (your “Provider”) must collect, create and maintain health information about you, which includes any individually identifiable information that we obtain from you or others that relates to your past, present or future physical or mental health, the health care you have received, or payment for your health care. Your Provider is required by law to maintain the privacy of this information. This Notice of Privacy Practices (this “Notice”) describes how your health information may be used and disclosed, and explains certain rights you have regarding this information. Your Provider is required by law to provide you with this Notice, and will comply with the terms as stated.

How Provider Uses and Discloses Your Health Information:

Your Provider protects your health information from inappropriate use and disclosure, and will use and disclose your health information for only the purposes listed below:

Uses and Disclosures for Treatment, Payment and Health Care Operations. Your Provider may use and disclose your protected health information in order to provide your care or treatment, obtain payment for services provided to you and in order to conduct our health care operations as detailed below.

Treatment and Care Management: We may use and disclose health information about you to facilitate treatment, and coordinate and manage your care with other health care providers.

Payment: We may use and disclose health information about you for our own payment purposes and to assist in the payment activities of other health care providers. Our payment activities include, without limitation, determining your eligibility for benefits and obtaining payment from insurers that may be responsible for providing coverage to you, including Federal and State entities.

Health Care Operations. We may use and disclose health information about you to support health care functions related to treatment and payment, which include, without limitation, care management, quality improvement activities, evaluating our own performance and resolving any complaints or grievances you may have. We may also use and disclose your health information to assist other health care providers in performing health care operations.

Uses and Disclosures Without Your Consent or Authorization:

We may use and disclose your health information without your specific written authorization for the following purposes:

As required by law. We may use and disclose your health information as required by state, federal and local law.

Public health activities: We may disclose your health information to public authorities or other agencies and organizations conducting public health activities, such as preventing or controlling disease, injury or disability, reporting births, deaths, child abuse or neglect, domestic violence, potential problems with products regulated by the Food and Drug Administration or communicable diseases.

Victims of abuse, neglect or domestic violence: We may disclose your health information to an appropriate government agency if we believe you are a victim of abuse, neglect, domestic violence and you agree to the disclosure or the disclosure is required or permitted by law. We will let you know if we disclose your health information for this purpose unless we believe that advising you or your caregiver would place you or another person at risk of serious harm.

Health oversight activities: We may disclose your health information to federal or state health oversight agencies for activities authorized by law such as audits, investigations, inspections and licensing surveys.

Judicial and administrative proceedings: We may disclose your health information in the course of any judicial or administrative proceeding in response to an appropriate order of a court or administrative body.

Law enforcement purposes: We may disclose your health information to a law enforcement agency to respond to a court order, warrant, summons or similar process, to help identify or locate a suspect or missing person, to provide information about a victim of a crime, a death that may be the result of criminal activity, or criminal conduct on our premises, or, in emergency situations, to report a crime, the location of the crime or the victims, or the identity, location or description of the person who committed the crime.

Deceased individuals: We may disclose your health information to a coroner, medical examiner or a funeral director as necessary and as authorized by law.

Organ or tissue donations: We may disclose your health information to organ procurement organizations and similar entities.

For research: We may use or disclose your health information for research purposes. We will use or disclose your health information for research purposes only with the approval of our Institutional Review Board, which must follow a special approval process. When required, we will obtain a written authorization from you prior to using your health information for research.

Health or safety: We may use or disclose your health information to prevent or lessen a threat to the health or safety of you or the general public. We may also disclose your health information to public or private disaster relief organizations such as the Red Cross or other organizations participating in bio-terrorism countermeasures.

Specialized government functions: We may use or disclose your health information to provide assistance for certain types of government activities. If you are a member of the armed forces of the United States or a foreign country, we may disclose your health information to appropriate military authority as is deemed necessary. We may also disclose your health information to federal officials for lawful intelligence or national security activities.

Workers’ compensation: We may use or disclose your health information as permitted by the laws governing the workers’ compensation program or similar programs that provide benefits for work-related injuries or illnesses.

Individuals involved in your care: We may disclose your health information to a family member, other relative or close personal friend assisting you in receiving health care services. If you are available, we will give you an opportunity to object to these disclosures, and we will not make these disclosures if you object. If you are not available, we will determine whether a disclosure to your family or friends is in your best interest, taking into account the circumstances and based upon our professional judgment.

Appointments, Information and Services: We may contact you to provide appointment reminders or information about treatment alternatives or other health-related services that may be of interest to you.

Incidental Uses and Disclosures: Incidental uses and disclosures of your health information sometimes occur and are not considered to be a violation of your rights. Incidental uses and disclosures are by-products of otherwise permitted uses or disclosures which are limited in nature and cannot be reasonably prevented.

Special Treatment of Certain Records: HIV related information, genetic information, alcohol and/or substance abuse records, mental health records related to services provided by a New York Article 31 mental health clinic and other specially protected health information may enjoy certain special confidentiality protections (that are more restrictive than those outlined above) under applicable state and federal law. Any disclosures of these types of records will be subject to these special protections.

Obtaining Your Authorization for Other Uses and Disclosures: Certain uses and disclosures of your health information will be made only with your written authorization, including uses and/or disclosures: (a) of psychotherapy notes (where appropriate); (b) for marketing purposes; and (c) that constitute a sale of health information under the Privacy Rule. Your Provider will not use or disclose your health information for any purpose not specified in this Notice unless we obtain your express written authorization or the authorization of your legally appointed representative. If you give us your authorization, you may revoke it at any time, in which case we will no longer use or disclose your health information for the purpose you authorized, except to the extent we have relied on your authorization to provide your care.

Your Rights Regarding Your Health Information:

You have the following rights regarding your health information:

Right to Inspect or Get a Copy of Your Medical Record. You have the right to inspect or request a copy of health information about you that we maintain. Your request should describe the information you want to review and the format in which you wish to review it. We may refuse to allow you to inspect or obtain copies of this information in certain limited cases. We may charge you a fee of up to $.75 per page for copies or the rate established by the Department of Health. We may also deny a request for access to health information under certain circumstances if there is a potential for harm to yourself or others. If we deny a request for access for this purpose, you have the right to have our denial reviewed in accordance with the requirements of applicable law.

Right to Request Changes to Your Medical Record: You have the right to request changes to any health information we maintain about you if you state a reason why this information is incorrect or incomplete. Your Provider might not agree to make the changes you request. If we do not agree with the requested changes we will notify you in writing and inform you how to have your objection included in our records.

Right to an Accounting of Disclosures: You have the right to receive a list of all disclosures we have made of your health information. The list will not include disclosures made for certain purposes including, without limitation, disclosures for treatment, payment or health care operations or disclosures you authorized in writing. Your request should specify the time period covered by your request, which cannot exceed six years. The first time you request a list of disclosures in any 12-month period, it will be provided at no cost. If you request additional lists within the 12-month period, we may charge you a nominal fee.

Right to Request Restrictions: You have the right to request restrictions on the ways which we use and disclose your health information for treatment, payment and health care operations, or disclose this information to disaster relief organizations or individuals who are involved in your care. We are required to comply with your request if it relates to a disclosure to your health plan regarding health care items or services for which you have paid the bill in full, though in other instances, we may not agree to the restrictions you request.

Right to Request Confidential Communications: You have the right to ask us to send health information to you in a different way or at a different location. Your request for an alternate form of communication should also specify where and/or how we should contact you.

Right to Receive Notification of Breach: You have the right to receive a notification, in the event that there is a breach of your unsecured health information, which requires notification under the Privacy Rule.

Right to Paper Copy of Notice: You have the right to receive a paper copy of this Notice of Privacy Practices at any time.

To make a request as described in any of the above, please contact your Provider.

Right to File Complaints: If you believe your privacy rights have been violated you may file a complaint with your Provider or with the Secretary of the U.S. Department of Health and Human Services. You will not be penalized or retaliated against by your Provider for filing a complaint.

Changes to this Notice: Your Provider may change the terms of this Notice of Privacy Practices at any time. If the terms of the Notice are changed, the new terms will apply to all of your health information, whether created or received by your Provider before or after the date on which the Notice is changed. Any updates to the Notice will be provided to you.

I look forward to working with you and want to offer you some important information about the services that you will receive from me. This consent form will provide a clear framework for our work together and will begin to build our therapeutic relationship. Please feel free to discuss any concerns that arise.

In the following paragraphs I, Christine A. Velasquez, LCSW, am referred to as “Therapist.”

1. Confidentiality: As Client’s therapist, Therapist is legally prohibited from revealing to another person that Client is in therapy with Therapist, nor can Therapist reveal what Client has said to Therapist in any way that identifies Client without Client’s written permission. However, as outline in the Notice of Privacy to be briefly reviewed here, there are instances in which a Client’s right to confidentiality must be set aside, as the Therapist is a mandated reporter and is legally held liable to disclose the Client’s information to the appropriate authorities in the following circumstances:

A. Instances of actual or suspected physical or sexual abuse, emotional cruelty, or neglect of a child or an elder or dependent adult must be reported to the appropriate protective services.

B. If Therapist has a reason to believe that a client poses an unavoidable and imminent danger of violence to another person, Therapist must warn the intended victim, and Therapist must also notify the proper authorities.

C. If you, as a client, reveal a serious intent to harm yourself, Therapist is ethically bound to do what Therapist can to help maintain your safety, which may involve notifying others who may be of assistance.

D. If a judge orders Therapist’s testimony or, in the context of a legal proceeding, you raise your own psychological state as an issue, Therapist might be required to release your confidential information to the court.

In all of the above cases, it is incumbent upon Therapist to release only that information necessary to appropriately carry out Therapist’s responsibilities. Client’s confidentiality still remains an ethical priority. In order to provide the best possible service to Therapist’s clients, Therapist may consult with other licensed professionals from time to time for additional therapeutic perspectives. In these consultations, Therapist will protect Client’s anonymity. Unless Client objects, Therapist will not notify Client of these consultations unless Therapist feels that it is important to our work together.

2. Risks and Benefits of Therapy: Psychotherapy is a process in which Therapist and Client discuss a variety of issues, events, experiences and memories for the purpose of creating positive change so client can experience his/her life more fully. It provides an opportunity to better, and more deeply understand one self, as well as, any problems or difficulties Client may be experiencing.

Participating in therapy may result in a number of benefits to client, including, but not limited to, reduced stress and anxiety, a decrease in negative thoughts and self-sabotaging behaviors, improved interpersonal relationships, increased comfort in social, work, and family settings, increased capacity for intimacy, and increased self-confidence. Such benefits may also require substantial effort on the part of Client, including an active participation in the therapeutic process, honesty, and a willingness to change feelings, thoughts and behaviors. There is no guarantee that therapy will yield any or all of the benefits listed above.

Participating in therapy may also involve some discomfort, including remembering and discussing unpleasant events, feelings and experiences. The process may evoke strong feelings of sadness, anger, fear, etc. There may be times in which Therapist will challenge Client’s perceptions and assumptions, and offer different perspectives. The issues presented by client may result in unintended outcomes, including changes in personal relationships. Client should be aware that any decision on the status of his/her personal relationships is the responsibility of Client.

During the therapeutic process, many clients find that they feel worse before they feel better. This is generally a normal course of events. Personal growth and change may be easy and swift at times, but may also be slow and frustrating. Client should address any concerns he/she has regarding his/her progress in therapy with me.

3. Appointments: Client’s weekly appointment time is reserved for Client. Therapy sessions are normally a 50 minute hour. Clients under the age of 18 must be accompanied by a guardian, who must remain in the waiting area during the session. Cancellations must be made 24 hours in advance; otherwise, Client is responsible for the no show fee of $60 any credit card processing fees . Cancellation notice should be left on Therapist’s voice mail or can be done via text at (510) 305-6480. Therapist will make every effort to reschedule Client during the same week, but cannot guarantee that this will always be possible. Therapist is out of the office on weekends and holidays. Regular attendance is recommended to ensure continuity of services and to enhance the effectiveness of the therapy.

Therapist will notify Client of intended vacation leave two weeks in advance. However, Therapist does reserve the right to cancel session without two weeks notice in cases of emergency. Therapist will provide as much advanced notice as possible.

4. Professional Fees and Payments: For non insurance/private pay Clients, Therapist’s customary fee is $180 per individual or couples/family psychotherapy session. Therapist’s fees may increase over the course of treatment, but only with prior notification of three weeks and consideration of Client’s financial ability to pay and to continue in treatment. Typically, fees will be raised once yearly. Payment is expected at the time of each session, unless we agree otherwise. Should Client wish to bill Client’s insurance company for reimbursement, Therapist will provide Client with a billing statement for that purpose. Please be aware that a diagnosis is required by insurance companies for payment. Therapist will be happy to discuss this matter with Client should Client be interested.

Balances more than 120 days overdue may be subject to collection through the use of a collection agency. However, Therapist will first attempt to make other arrangements with Client as needed. Returned checks will be subject to a 50 fee and remittance of the original check amount with the additional fee will be due immediately in the form of cash or a money order. In general, it is important to discuss with Therapist any issues that arise in connection with our financial arrangements, so that they do not hinder the working relationship.

For client's enrolled in treatment with me via Alma, Alma will confirm your insurance and co-pay costs. It is recommended that you enroll in autopay so as to keep your account in good standing.

5. Telephone Accessibility: Therapist is available via cellular telephone. Therapist does monitor her messages frequently and will make every effort to return Client’s call within 24 hours with the exception of weekends and holidays. If Client is difficult to reach, please inform Therapist of different times when Client will be available. Therapist is unable to provide 24-hour crisis service. Should Client have a true clinical emergency that requires immediate attention or action; Client will need to call 911 or go to the nearest emergency room.

Therapist does not charge for telephone consultations that are less than 10 minutes. Consultations of greater length will be pro-rated based on Client’s hourly fee. Should it become apparent that additional sessions are indicated, Therapist and Client will increase the number of weekly sessions as needed.

6. Termination of Therapy: Therapist reserves the right to terminate therapy at her discretion. Reasons for termination include, but are not limited to, untimely payment of fees, failure to comply with treatment recommendations, conflicts of interest, failure to participate in therapy, Client needs are outside of therapist’s scope of competence or practice, or Client is not making adequate progress in therapy. Client also has the right to terminate therapy at his/her discretion, without any obligation, except for fees already incurred. Upon either party’s decision to terminate therapy, Therapist will generally recommend that Client participate in at least one termination session. These sessions are intended to facilitate a positive termination experience and give both parties an opportunity to reflect on the work that has been done. Therapist also reserves the right to close/terminate treatment if client has made no contact or effort to reschedule after 3 weeks or is anticipated not to be able to participate in therapy for a month or more.

7. Mediation and Arbitration: All disputes arising out of or in relation to this agreement to provide psychotherapy services shall first be referred to mediation, before, and as a pre-condition of, the initiation of arbitration. The mediator shall be a neutral third party chosen by Christine A. Velasquez, LCSW and the client. The cost of such mediation, if any, shall be split equally, unless otherwise agreed. In the event that mediation is unsuccessful, any unresolved controversy related to this agreement should be submitted to and settled by binding arbitration in Los Angeles County, in accordance with the rules of the American Arbitration Association which are in effect at the time the demand for arbitration is filed. By signing this contract you are agreeing to have any issue of medical or psychological malpractice decided by neutral arbitration and you are giving up your right to a jury or court trial. Notwithstanding the foregoing, in the event that your account is overdue (unpaid) and there is no agreement on a payment plan, Christine A. Velasquez, LCSW can use legal means (court, collection agency, etc.) to obtain payment. The prevailing party in arbitration or collection proceeding shall be entitled to recover a reasonable sum as and for collection or attorneys’ fees. In the case of arbitration, the arbitrator will determine that sum.

8. Client Litigation: Therapist will not voluntarily participate in any litigation, or custody dispute in which Client and another individual or entity are parties. Therapist has a policy of not communicating with Client’s attorney and will generally not write or sign letters, reports, declarations, or affidavits to be used in Client’s legal matter. Therapist will generally not provide records or testimony unless compelled to do so. Should Therapist be subpoenaed or ordered by a court of law to appear as a witness in an action involving Client, Client agrees to reimburse therapist for any time spent for preparation, travel, or other time in which therapist has made herself available for such an appearance at Therapist’s usual and customary hourly rate of $180.00.

9. Health Insurance & Confidentiality of Records: Disclosure of confidential information may be required by your health insurance carrier in order to process claims. If you so instruct me, only the minimum necessary information will be communicated to the carrier. Unless authorized by you explicitly the Psychotherapy Notes will not be disclosed to your insurance carrier. I have no control or knowledge over what insurance companies do with the information I submit or who has access to this information. You must be aware that submitting a mental health invoice for reimbursement carries a certain amount of risk to confidentiality, privacy, or to future eligibility to obtain health or life insurance. The risk stems from the fact that mental health information is entered into insurance companies’ computers and will also be reported to the National Medical Data Bank. Accessibility to companies’ computers or to the National Medical Data Bank database is always in question, as computers are inherently vulnerable to break-ins and unauthorized access. Medical data has been reported to have been sold, stolen, or accessed by enforcement agencies; therefore, you are in a vulnerable position.

10. Confidentiality of E-mail, Cell Phone and Fax Communication: It is very important to be aware that e-mail and cell phone communication can be relatively easily accessed by unauthorized people and hence, the privacy and confidentiality of such communication can be compromised. E-mails, in particular, are vulnerable to such unauthorized access due to the fact that servers have unlimited and direct access to all e-mails that go through them. Faxes can easily be sent erroneously to the wrong address. Please notify me if you decide to avoid or limit in any way the use of any or all of the above- mentioned communication devices.

11. Record Keeping: Therapist may take notes during session, and will also produce other notes and records regarding treatment. These notes constitute Therapist’s clinical and business records, which by law, Therapist is required to maintain. Such records are the sole property of Therapist. Therapist will not alter her normal record keeping process at the request of any client. Should Client request a copy of Therapist’s records, such a request must be made in writing. Therapist reserves the right, under California law, to provide Client with a treatment summary in lieu of actual records.

Therapist also reserves the right to refuse to produce a copy of the record under certain circumstances, but may, as requested, provide a copy of the record to another treating health care provider. Therapist will maintain Client’s records for ten years following termination of therapy. However, after ten years, Client’s records will be destroyed in a manner that preserves Client’s confidentiality.

12. Partnership: Finally, Client has the right to expect that Therapist will maintain professional and ethical boundaries by not entering into other personal, financial, or professional relationships with Client, all of which would greatly compromise our work together. Therapy involves a partnership between Therapist and Client. As Client’s therapist, Therapist will contribute knowledge, skills and a willingness to do her best. The determination of success, however, will ultimately depend upon Client’s commitment to Client’s own personal growth and care.

NOTICE TO CLIENTS: The Board of Behavioral Sciences receives and responds to complaints regarding services provided within the scope of practice of licensed clinical social workers and licensed marriage and family therapists. You may contact the board online at www.bbs.ca.gov, or by calling (916) 574-7830.

APPOINTMENTS AND CANCELLATIONS

Please remember to cancel or reschedule 24 hours in advance. You will be responsible for the entire fee if cancellation is less than 24 hours.

The standard meeting time for psychotherapy is 50 minutes. It is up to you, however, to determine the length of time of your sessions. Requests to change the 50-minute session needs to be discussed with the therapist in order for time to be scheduled in advance.

A $50.00 service charge will be charged for any checks returned for any reason for special handling.

Cancellations and re-scheduled session will be subject to a full charge if NOT RECEIVED AT LEAST 24 HOURS IN ADVANCE. This is necessary because a time commitment is made to you and is held exclusively for you. If you are late for a session, you may lose some of that session time.

PROFESSIONAL FEES AND PAYMENT:

Therapist’s customary fee is $180 per individual session. Therapist and Client will discuss and establish our fee at the outset of treatment, and any fee change will be negotiated in good faith. Therapist’s fees may increase over the course of treatment, but only with prior notification of three weeks and consideration of Client’s financial ability to pay and to continue in treatment. Typically, fees will be raised once yearly. Payment is expected at the time of each session, unless we agree otherwise. Should Client wish to bill Client’s insurance company for reimbursement, Therapist will provide Client with a billing statement for that purpose. Please be aware that a diagnosis is required by insurance companies for payment. Therapist will be happy to discuss this matter with Client should Client be interested.

Balances more than 120 days overdue may be subject to collection through the use of a collection agency. However, Therapist will first attempt to make other arrangements with Client as needed. In general, it is important to discuss with Therapist any issues that arise in connection with our financial arrangements, so that they do not hinder the working relationship.

TELEPHONE ACCESSIBILITY If you need to contact me between sessions, please leave a message on my voice mail. I am often not immediately available; however, I will attempt to return your call within 24 hours. Please note that Face- to-face sessions are highly preferable to phone sessions. However, in the event that you are out of town, sick or need additional support, phone sessions are available. If a true emergency situation arises, please call 911 or any local emergency room.

SOCIAL MEDIA AND TELECOMMUNICATION

Due to the importance of your confidentiality and the importance of minimizing dual relationships, I do not accept friend or contact requests from current or former clients on any social networking site (Facebook, LinkedIn, etc). I believe that adding clients as friends or contacts on these sites can compromise your confidentiality and our respective privacy. It may also blur the boundaries of our therapeutic relationship. If you have questions about this, please bring them up when we meet and we can talk more about it.

ELECTRONIC COMMUNICATION

I cannot ensure the confidentiality of any form of communication through electronic media, including text messages. If you prefer to communicate via email or text messaging for issues regarding scheduling or cancellations, I will do so. While I may try to return messages in a timely manner, I cannot guarantee immediate response and request that you do not use these methods of communication to discuss therapeutic content and/or request assistance for emergencies.

Services by electronic means, including but not limited to telephone communication, the Internet, facsimile machines, and e-mail is considered telemedicine by the State of California. Under the California Telemedicine Act of 1996, telemedicine is broadly defined as the use of information technology to deliver medical services and information from one location to another. If you and your therapist chose to use information technology for some or all of your treatment, you need to understand that:

(1) You retain the option to withhold or withdraw consent at any time without affecting the right to future care or treatment or risking the loss or withdrawal of any program benefits to which you would otherwise be entitled.

(2) All existing confidentiality protections are equally applicable.

(3) Your access to all medical information transmitted during a telemedicine consultation is guaranteed, and copies of this information are available for a reasonable fee.

(4) Dissemination of any of your identifiable images or information from the telemedicine interaction to researchers or other entities shall not occur without your consent.

(5) There are potential risks, consequences, and benefits of telemedicine. Potential benefits include, but are not limited to improved communication capabilities, providing convenient access to up-to-date information, consultations, support, reduced costs, improved quality, change in the conditions of practice, improved access to therapy, better continuity of care, and reduction of lost work time and travel

costs. Effective therapy is often facilitated when the therapist gathers within a session or a series of sessions, a multitude of observations, information, and experiences about the client. Therapists may make clinical assessments, diagnosis, and interventions based not only on direct verbal or auditory communications, written reports, and third person consultations, but also from direct visual and olfactory observations, information, and experiences. When using information technology in therapy services, potential risks include, but are not limited to the therapist's inability to make visual and olfactory observations of clinically or therapeutically potentially relevant issues such as: your physical condition including deformities, apparent height and weight, body type, attractiveness relative to social and cultural norms or standards, gait and motor coordination, posture, work speed, any noteworthy mannerism or gestures, physical or medical conditions including bruises or injuries, basic grooming and hygiene including appropriateness of dress, eye contact (including any changes in the previously listed issues), sex, chronological and apparent age, ethnicity, facial and body language, and congruence of language and facial or bodily expression. Potential consequences thus include the therapist not being aware of what he

or she would consider important information, that you may not recognize as significant to present verbally the therapist.

MINORS

If you are a minor, your parents may be legally entitled to some information about your therapy. I will discuss with you and your parents what information is appropriate for them to receive and which issues are more appropriately kept confidential.

TERMINATION

Ending relationships can be difficult. Therefore, it is important to have a termination process in order to achieve some closure. The appropriate length of the termination depends on the length and intensity of the treatment. I may terminate treatment after appropriate discussion with you and a termination process if I determine that the psychotherapy is not being effectively used or if you are in default on payment. I will not terminate the therapeutic relationship without first discussing and exploring the reasons and purpose of terminating. If therapy is terminated for any reason or you request another therapist, I will provide you with a list of qualified psychotherapists to treat you. You may also choose someone on your own or from another referral source.

Should you fail to schedule an appointment for three consecutive weeks, unless other arrangements have been made in advance, for legal and ethical reasons, I must consider the professional relationship discontinued.