Revised Fall 2009 1

BIOPSYCHOSOCIAL INTAKE FORM

Date: _____________ Name: ________________________________________________________________________ First Last M.I. Address _________________________ City: _______________ State:_______ Zip: _________ Telephone (home): _________________ (work): ________________ (cell): ________________ Email ______________________ Indicate preference for messages _______________________ Therapist name: ________________________________________________________________

Caregiver Information (Custodial, if/child/adolescent client) Name __________________________________________ Age _______ Sex _______________ Biological parent ___ Adoptive parent ___ Foster parent ___ Step parent ___ Other __________ Address if another than above _____________________________________________________ Work # ____________________ Home # ____________________ Cell # __________________ Email ______________________ Indicate preference for messages _______________________ Employer ____________________________________ Position __________________________

Additional Caregiver Information (Custodial, if/child/adolescent client) Name __________________________________________ Age _______ Sex _______________ Biological parent ___ Adoptive parent ___ Foster parent ___ Step parent ___ Other __________ Address if another than above _____________________________________________________ Work # ____________________ Home # ____________________ Cell # __________________ Email ______________________ Indicate preference for messages _______________________ Employer ____________________________________ Position __________________________

Caregiver Information (Non-Custodial, if/child/adolescent client) Name __________________________________________ Age _______ Sex _______________ Biological parent ___ Adoptive parent ___ Foster parent ___ Step parent ___ Other __________ Address if another than above _____________________________________________________ Work # ____________________ Home # ____________________ Cell # __________________ Email ______________________ Indicate preference for messages _______________________ Employer ____________________________________ Position __________________________

In Case of Emergency Notification

Name _________________________________ Relation _______________________________ Phone # _______________________________ Other _________________________________ Identifying Information Age: _________ Date of birth: _________ /_________ /_________ Sex: _________

Mara Thornberg

Revised Fall 2009 2

Race: White ______ Black _____ Hispanic _____ Asian _____ Other _____ Who referred you? __________________________________ Religious preference: __________________________________ Education/Employment Information Education completed: years ____ High School ____ Trade School ____College ____ School: ____________________________________________ Grade _____________________ Teacher/Counselor ______________________________ Phone __________________________ Do you have a trade, skill, or profession? Yes ____ No ____ If yes, please specify: _______________________________ Are you currently employed? Yes____ No ____ Full-time ____ Part-time ____ Occupation: _______________________________ Employer: __________________________ How long was your longest full-time job? Years_________________ Months ______________ Have you experienced employment problems in the past 60 days? Yes ____ No ____ How many people depend on you for the majority of their food, shelter, etc.? _______________ Medical/Psychiatric Information Medical Doctor __________________________________ Phone_________________________ Are you currently taking any prescribed medication? Yes ____No ____ If yes, name(s) and dosage of the medication(s): _______________ Who prescribed the medication(s): _________________ How many times in your life have you been hospitalized for medical problems? ___________ If hospitalized, name provider and dates of service: ____________________ Do you have any chronic medical problems which interfere with your life? Yes ____ No ____ Have you been treated for any psychological or emotional problems? Yes ____ No ____ If yes, name provider and dates of service: ___________________________________________ Have you ever experienced: Depression Yes ____ No ____ Anxiety or tension Yes ____ No ____

Hallucinations Yes ____ No____ Difficulty concentrating or remembering Yes ____ No ____ Trouble controlling violent behavior Yes ____ No ____ Serious thoughts of homicide Yes ____ No ____ Serious thoughts of suicide Yes ____ No ____ Attempted suicide Yes ____ No ____ Do you receive benefits for a physical or psychiatric disability? Yes ____ No ____

Drug/Alcohol Information

Revised Fall 2009 3

Have you ever used: Alcohol Yes ____ No ____ If yes, how often ________ Cocaine Yes ____ No ____ If yes, how often ________ Crack Yes ____ No ____ If yes, how often ________ Amphetamines Yes ____ No ____ If yes, how often ________ Marijuana Yes ____ No ____ If yes, how often ________ Inhalants Yes ____ No ____ If yes, how often ________ Heroin Yes ____ No ____ If yes, how often ________ Other _____________ More than one substance per day Yes ____ No ____ Have you ever been treated for alcohol abuse? Yes ____ No ____ Have you ever been treated for drug abuse? Yes ____ No ____ In the past 60 days have you experienced problems related to drug or alcohol use? Yes__ No __ Legal Information Have you been referred to counseling by the criminal justice system? Yes ____ No ____ Are you on probation or parole? Yes ____ No ____ Have you ever been arrested and charged with the following: Shoplifting/vandalism Yes ____ No ____

Parole/probation violations Yes ____ No ____ Drug charges Yes ____ No ____ Driving while intoxicated Yes ____ No ____ Forgery Yes ____ No ____ Robbery Yes ____ No ____ Assault Yes ____ No ____ Rape Yes ____ No ____ Homicide, manslaughter Yes ____ No ____ Contempt of court Yes ____ No ____ Other ______________ Yes ____ No ____

Are you presently awaiting charges, trial, or sentence? Yes ____ No ____ If yes, what for? _________________________________________________ Family/Social Relationships Marital Status:

Married _______ Single _______ Never married ______ Separated ______ Divorced ______ Widowed _________ Remarried ______ (if checked, how many times? ___________)

If married, how many years? __________ Do you have any children? Yes _____ No _____ Usual living arrangements in the past 2 years:

Revised Fall 2009 4

With spouse and children Yes _____ No _____ With spouse alone Yes _____ No _____ With children alone Yes _____ No _____

With parents Yes _____ No _____ With family Yes _____ No _____ With friends Yes _____ No _____ Alone Yes _____ No _____ No stable arrangements Yes _____ No _____

Do you live with someone who has a current drug problem? Yes _____ No _____ Do you live with someone who has a current alcohol problem? Yes _____ No _____ Would you say you had a close, long lasting, personal relationship with any of the following people in your life: Mother Yes _____ No _____ Father Yes _____ No _____

Siblings Yes _____ No _____ Partner Yes _____ No _____ Children Yes _____ No _____ Friends Yes _____ No _____ Coworkers Yes _____ No _____

Have you had significant periods in which you had experienced serious problems getting along with any of the above? Yes _____ No _____ Who __________________________________ Is it important for you to receive counseling for family or social problems? Yes _____ No _____ Presenting Problem What brings you into counseling today? __________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ How long have you been experiencing this problem? __________________________________

Client Informed Consent

This client information form will answer most of your questions about therapy services with Mara Elizabeth Thornberg, Licensed Professional Counselor – Intern (LPC-Intern) under the supervision of Greer Swiatek a Licensed Professional Counselor – Supervisor (LPC-S). If there is anything you do not understand, please feel free to ask at any time during therapy.

Therapeutic Process

Mara’s process in counseling is one of support, curious exploration, current experiencing and challenge as you become aware of experiences that cause impairment in intrapersonal, social, occupational and relational areas of your life. The therapeutic process involves establishing awareness of circumstances in relation to who and how we are, courage to change the things we can, and acceptance of circumstances that we cannot. In addition to seeing clients in the office, Mara provides Equine Assisted Psychotherapy at a nearby ranch. As the client, you have the right to ask Mara questions about her qualifications, background, and orientation. The most important factor in the success of therapy is good communication between the client and the therapist. In some instances, talking about your problems can make you feel worse. If you continue to work on your problem, however, this should improve over time. In addition, not all individuals benefit from therapy or working with a particular therapist. If at any time during therapy you have questions about whether or not treatment is working for you or if you need clarification of our goals, do not hesitate to bring this up in session.

Benefits and Risks

I understand that counseling often has benefits, and counseling may help bring about positive changes in feelings, behaviors, and personal relationships. However, there is no guarantee that the Minor Client will experience these benefits. Counseling also has potential risks. Effective counseling may involve discussing unpleasant events or thoughts, and the Minor Client may feel sadness, guilt, anger, frustration, or other strong emotions. Some people feel that counseling did not help or, in rare situations, made things worse. Therapy may affect the Minor Client’s relationships with family members and friends. I understand that either I or the Minor Client should share any of these concerns with the Minor Client’s counselors. I can stop counseling services for the Minor Client at any time.

Confidentiality

By law and professional ethics, your sessions are strictly confidential. There are a few exceptions to this confidentiality policy: • You give your therapist written permission to communicate with someone about your session and/or about the progress you are making in therapy. • If your therapy records are subpoenaed by the court • If you are the victim or perpetrator of child abuse, neglect or exploitation. Child Protective Services or other appropriate authorities responsible for investigating child

abuse by law must be notified. • If you are a victim or perpetrator of elder or dependent adult abuse, neglect or exploitation, Adult Protective Services or other appropriate authorities responsible for investing elder abuse by law must be notified. • If you threaten to harm yourself or others, the police may be called or other reasonable steps taken to prevent such harm from occurring. • Although your therapist will make every effort to maintain confidentiality in relation to emails and phone calls, it is not guaranteed that information contained in emails and phone calls can be completely secured and kept from being seen by a third party. This includes (512) 661-2895, mthornberg@collaboracare.com and the primary Collaborative Care email address, admin@collaboracare.com. • If online services are provided, they will be issued through Doxy.me, a HIPAA compliant software. Although your therapist will make every effort to maintain confidentiality in relation to online software, it is not guaranteed that information contained in online software can be completely secured and kept from being seen by a third party. This includes therapy services provided online at https://doxy.me/marathornberglpcintern. • Please be aware if you use location-based services, Siri or Google Assistant on your mobile phone, smart watch or head phones you may compromise your privacy while attending session at my office or online. Enabled GPS tracking makes it possible for others to surmise you are a counseling client due to regular check-ins at my office location. Siri and Google Assistant are always listening. Siri is always disabled on all of my professional devices during our sessions. Parents Please Note: Mara request that parents sit in on at least half of intake session. Mara requires that parents provide legal parenting agreement outlining parents’ rights to consent to treatment if parents are divorced or separated. If there is not parental agreement, Mara may request consent to treatment signed by both parents if deemed appropriate for child’s therapy. Mara works with clients of minority age only if their attendance is voluntary. Since therapy can only succeed in a trusting environment, parents are encouraged to respect their child’s confidentiality and privacy. She will keep what your child says confidential except as the conditions specified above may apply. However, parents can be assured that she will encourage children to share critical information and feelings with their parents.

Supervision

You, as the client, understand that you will be provided therapeutic services by a LPC-Intern under the supervision of a LPC-S. The LPC-Intern may receive supervision regarding the therapy services provided to you in both individual, and group supervision sessions. The LPC-S will have access to your files for review, consultation, and training purposes.

Social Media

It is not a part of my practice to search for clients on Google, Facebook, or other searchable sites. If there is content you wish to share from your online life, please bring it into our sessions where we can explore it together. I do not accept friend or contact requests on personal

accounts from current or former clients on any social networking site (Facebook, LinkedIn, etc.). Adding clients as friends on these sites can compromise confidentiality and the therapeutic relationship.

Being Ready for Sessions

Everyone attending sessions must be in good health (i.e. not sick,) and sober, not under the influence of alcohol or drugs that are not prescribed and taken as directed by a physician. Masks will be required for face to face session, a COVID 19 check in and a temperature check. It is fine to bring a drink or snack to sessions.

If anyone presents under the influence of drugs or alcohol the session will be rescheduled, and if needed appropriate authorities notified. If individuals come without closed-toed shoes then the session will be held without horses for that person’s safety

Fees and Cancellations

You are expected to pay for therapy at the beginning of each session. Fees for therapy are based upon the services received and or agreed upon (See the Fee Schedule Form). If at any time you have financial concerns, do not hesitate to discuss them with your therapist. We never want financial problems to be the reason someone does not come for therapy. You must call your therapist 512-661-2895 24 HOURS PRIOR TO THE SCHEDULED APPOINTMENT to reschedule an appointment. Failure to do so will be considered a “No Show” and may be billed for the full session rate for Mara Elizabeth Thornberg, and is due at the time of the next session.

Insurance

Mara Elizabeth Thornberg is not currently accepting insurance for services rendered. Insurance companies will not pay for services provided by LPC-Interns. However, you may request a copy of your account.

No Show

Two (2) “no show” appointments in a row will be assumed that the therapist-client relationship has been terminated and must be re-established for further treatment to continue. This may be an indication that therapy is not optimal or a priority at this time.

After Hours Emergencies

No staff or counselors are available after hours for emergencies. If a client has an after-hour emergency, or needs immediate assistance, you should call 911, your primary care physician or medical group, or go to the nearest emergency room. DO NOT call or email Collaborative Care in the event of an emergency. Collaborative Care is not a crisis center, and the phone and email are only checked during regular business hours.

Court****

If a member of your therapy team is required to testify about your treatment or your child’s treatment, your attorney or you, if you do not have an attorney, will be billed for preparation, record review, travel, parking, and time spent in court.

Terminating Treatment

You have the right to terminate therapy at any time. However, if you decide to terminate your treatment, you will be encouraged to talk with your therapist about the reason for your decision so that sufficient closure to your treatment can be made. In your final session, your progress and ways that you can continue to utilize the skills and knowledge you gained through therapy can be discussed. Any referrals needed will also be discussed at that time.

Ethical Guidelines Therapists are governed by the Code of Ethics of the Texas State Board of Examiners of Professional Counselors. If I have any complaints related to therapy services you are encouraged to take my complaint to Greer Swiatek, LPC-S at 512-595-0244 or gswiatek@collaboracare.com. A consumer who wishes to file a complaint against an individual licensed by the board, may also call 1-800-942-5540, visit: www.dshs.texas.gov/counselor, or write to Texas State Board of Examiners of Professional Counselors Investigations at P.O. Box 141369 Austin TX, 78714-1369.

Consent to Treatment

I have signed this Form at the bottom as the parent or guardian of a minor (the Minor Client) to acknowledge my agreement to the following: I consent for the Minor Client to receive counseling services from Mara Elizabeth Thornberg, LPC-Intern. I understand that services will be provided to me by Licensed Professional Counseling - Intern under the general supervision of Greer Swiatek, LPC-S, CRC, NCC, NLC-C. LPC - Interns may share confidential information about me or my treatment with their supervisors. Both I and the Minor Client are responsible for knowing and following Mara Elizabeth Thornberg’s policies. Copies of the policies and this document have been provided to me. These policies are also available at my request. I have been presented with a copy of Mara Elizabeth Thornberg’s Informed Consent and Privacy policies, detailing how my information might be used and disclosed as permitted under federal and state law. This document is a legal agreement in which I am making binding promises and giving up certain rights.

By signing below, I agree that I have read and I understand this document. Dated this _____ day of _____________, 20___. _____________________________________ ________________________________________ Name of Parent/Guardian Parent/Guardian Signature _____________________________________ ________________________________________ Name of Minor Client Minor Client Signature

CLIENT FEE AGREEMENT Fees are an important issue to anyone receiving professional services. This sheet will explain my fee policy. Under no circumstances do I want the fee be the main reason someone does not come to counseling. 1. Following is the fee schedule for the psychotherapy services of Mara Elizabeth Thornberg, LPC_Intern: o Initial Intake/Assessment (90791) * 50 Minutes $110.00 o Individual Psychotherapy (90837) * 50 Minutes $110.00 o Family Psychotherapy (90847) * 50 Minutes $110.00 o Equine Assisted Psychotherapy * 50 Minutes $200.00 o Court appearances & preparation * 60 Minutes $200.00 o Equine Assisted Psychotherapy *15 Minutes $25.00 o Phone Consultation * 15 minutes $10.00 If you are unable to afford this fee or changes in finances occur, please let me know, and we will see what we can do to reduce the fee or provide adequate resources. Services rendered are not contingent on the amount you pay. o Fee negotiated:_________________ 2. Payment is expected at the time the service is rendered in the form of cash, check or credit card. Make checks payable to “John Abraham” and put counseling on the memo line. A receipt is available upon request. Other payment plans and options may be discussed. 3. A $35 fee on all returned checks will be charged. 4. I do not accept insurance assignments. Insurance companies will not pay for services provided by LPC-Interns. However, you may request a copy of your account. 5. Appointments not cancelled 24 hours in advance are charged at the regularly hour rate and expected at the time of next service. 6. Telephone calls to clients, family members, doctors, therapists, attorneys, or others may be billed at rates proportionate to time spent for the call. 7. If a client or a family member damages equipment, furnishings, property, building, or grounds in or around the office of Greer Swiatek and Mara Elizabeth Thornberg the client is financially responsible for damage and will make prompt restitution. Please sign and date below indicating you understand the fee policy. Thank you. Client Name:___________________________ Signature: _______________________ Date: Guardian Name:_________________________ Signature: _______________________ Date:

AUTHORIZATION TO DISCLOSE PROTECTED HEALTH INFORMATIONDeveloped for Texas Health & Safety Code § 181.154(d)

effective June 2013

Please read this entire form before signing and complete all the sections that apply to your decisions relating to the disclosure of protected health information. Covered entities as that term is defined by HIPAA and Texas Health & Safety Code § 181.001 must obtain a signed authorization from the individual or the individual’s legally authorized representative to electronically disclose that indi-vidual’s protected health information. Authorization is not required for disclosures related to treatment, payment, health care operations, performing certain insurance functions, or as may be otherwise au-thorized by law. Covered entities may use this form or any other form that complies with HIPAA, the Texas Medical Privacy Act, and other applicable laws. Individuals cannot be denied treatment based on a failure to sign this authorization form, and a refusal to sign this form will not affect the payment, enrollment, or eligibility for benefits.

I AUTHORIZE THE FOLLOWING TO DISCLOSE THE INDIVIDUAL’S PROTECTED HEALTH INFORMATION:Person/Organization Name _____________________________________________________Address ____________________________________________________________________City ______________________________________ State ________ Zip Code __________Phone (_______)____________________Fax (_______)_____________________________

WHO CAN RECEIVE AND USE THE HEALTH INFORMATION?Person/Organization Name _____________________________________________________Address ____________________________________________________________________City ______________________________________ State ________ Zip Code __________Phone (_______)____________________Fax (_______)_____________________________

SIGNATURE X__________________________________________________________________________ ________________________ Signature of Individual or Individual’s Legally Authorized Representative DATE

Printed Name of Legally Authorized Representative (if applicable): ____________________________________________________________________If representative, specify relationship to the individual: ¨ Parent of minor ¨ Guardian ¨ Other ________________________________

A minor individual’s signature is required for the release of certain types of information, including for example, the release of information related to cer-tain types of reproductive care, sexually transmitted diseases, and drug, alcohol or substance abuse, and mental health treatment (See, e.g., Tex. Fam. Code § 32.003).

SIGNATURE X__________________________________________________________________________ ________________________ Signature of Minor Individual DATE

NAME OF PATIENT OR INDIVIDUAL

______________________________________________________________Last First Middle

OTHER NAME(S) USED _________________________________________

DATE OF BIRTH Month __________Day __________ Year______________

ADDRESS _____________________________________________________

______________________________________________________________

CITY ____________________________STATE_______ ZIP______________

PHONE (_____)______________ ALT. PHONE (_____)_________________

EMAIL ADDRESS (Optional): ______________________________________

EFFECTIVE TIME PERIOD. This authorization is valid until the earlier of the occurrence of the death of the individual; the individual reach-ing the age of majority; or permission is withdrawn; or the following specific date (optional): Month _________ Day __________ Year _________

RIGHT TO REVOKE: I understand that I can withdraw my permission at any time by giving written notice stating my intent to revoke this au-thorization to the person or organization named under “WHO CAN RECEIVE AND USE THE HEALTH INFORMATION.” I understand that prior actions taken in reliance on this authorization by entities that had permission to access my health information will not be affected.

SIGNATURE AUTHORIZATION: I have read this form and agree to the uses and disclosures of the information as described. I un-derstand that refusing to sign this form does not stop disclosure of health information that has occurred prior to revocation or that is otherwise permitted by law without my specific authorization or permission, including disclosures to covered entities as provid-ed by Texas Health & Safety Code § 181.154(c) and/or 45 C.F.R. § 164.502(a)(1). I understand that information disclosed pursu-ant to this authorization may be subject to re-disclosure by the recipient and may no longer be protected by federal or state privacy laws.

REASON FOR DISCLOSURE (Choose only one option below)

¨ Treatment/Continuing Medical Care¨ Personal Use¨ Billing or Claims¨ Insurance¨ Legal Purposes¨ Disability Determination¨ School ¨ Employment¨ Other ________________________

WHAT INFORMATION CAN BE DISCLOSED? Complete the following by indicating those items that you want disclosed. The signature of a minor patient is required for the release of some of these items. If all health information is to be released, then check only the first box.

¨ All health information ¨ History/Physical Exam ¨ Past/Present Medications ¨ Lab Results¨ Physician’s Orders ¨ Patient Allergies ¨ Operation Reports ¨ Consultation Reports¨ Progress Notes ¨ Discharge Summary ¨ Diagnostic Test Reports ¨ EKG/Cardiology Reports¨ Pathology Reports ¨ Billing Information ¨ Radiology Reports & Images ¨ Other________________

Your initials are required to release the following information:______Mental Health Records (excluding psychotherapy notes) ______Genetic Information (including Genetic Test Results)______Drug, Alcohol, or Substance Abuse Records ______ HIV/AIDS Test Results/Treatment

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Mara Elizabeth Thornberg5910 Courtyard Dr Suite 220

Austin TX 78731512 661-2895 512 382-6268

X

X

IMPORTANT INFORMATION ABOUT THE AUTHORIZATION TO DISCLOSE PROTECTED HEALTH INFORMATIONDeveloped for Texas Health & Safety Code § 181.154(d)

effective June 2013

Definitions - In the form, the terms “treatment,” “healthcare operations,” “psychotherapy notes,” and “protected health informa-tion” are as defined in HIPAA (45 CFR 164.501). “Legally authorized representative” as used in the form includes any person authorized to act on behalf of another individual. (Tex. Occ. Code § 151.002(6); Tex. Health & Safety Code §§ 166.164, 241.151; and Tex. Probate Code § 3(aa)).

Health Information to be Released - If “All Health Information” is selected for release, health information includes, but is not lim-ited to, all records and other information regarding health history, treatment, hospitalization, tests, and outpatient care, and also educational records that may contain health information. As indicated on the form, specific authorization is required for the release of information about certain sensitive conditions, including:

• Mental health records (excluding “psychotherapy notes” as defined in HIPAA at 45 CFR 164.501).• Drug, alcohol, or substance abuse records.• Records or tests relating to HIV/AIDS.• Genetic (inherited) diseases or tests (except as may be prohibited by 45 C.F.R. § 164.502).

Note on Release of Health Records - This form is not required for the permissible disclosure of an individual’s protected health information to the individual or the individual’s legally authorized representative. (45 C.F.R. §§ 164.502(a)(1)(i), 164.524; Tex. Health & Safety Code § 181.102). If requesting a copy of the individual’s health records with this form, state and federal law allows such access, unless such access is determined by the physician or mental health provider to be harmful to the individu-al’s physical, mental or emotional health. (Tex. Health & Safety Code §§ 181.102, 611.0045(b); Tex. Occ. Code § 159.006(a); 45 C.F.R. § 164.502(a)(1)). If a healthcare provider is specified in the “Who Can Receive and Use The Health Information” section of this form, then permission to receive protected health information also includes physicians, other health care providers (such as nurses and medical staff) who are involved in the individual’s medical care at that entity’s facility or that person’s office, and health care providers who are covering or on call for the specified person or organization, and staff members or agents (such as busi-ness associates or qualified services organizations) who carry out activities and purposes permitted by law for that specified cov-ered entity or person. If a covered entity other than a healthcare provider is specified, then permission to receive protected health information also includes that organization’s staff or agents and subcontractors who carry out activities and purposes permitted by this form for that organization. Individuals may be entitled to restrict certain disclosures of protected health information related to services paid for in full by the individual (45 C.F.R. § 164.522(a)(1)(vi)).

Authorizations for Sale or Marketing Purposes - If this authorization is being made for sale or marketing purposes and the cov-ered entity will receive direct or indirect remuneration from a third party in connection with the use or disclosure of the individual’s information for marketing, the authorization must clearly indicate to the individual that such remuneration is involved. (Tex. Health & Safety Code §181.152, .153; 45 C.F.R. § 164.508(a)(3), (4)).

Charges - Some covered entities may charge a retrieval/processing fee and for copies of medical records. (Tex. Health & Safety Code § 241.154).

Right to Receive Copy - The individual and/or the individual’s legally authorized representative has a right to receive a copy of this authorization.

Limitations of this form - This authorization form shall not be used for the disclosure of any health information as it relates to: (1) health benefits plan enrollment and/or related enrollment determinations (45 C.F.R. § 164.508(b)(4)(ii), .508(c)(2)(ii); (2) psychotherapy notes (45 C.F.R. § 164.508(b)(3)(ii); or for research purposes (45 C.F.R. § 164.508(b)(3)(i)).Use of this form does not exempt any entity from compliance with applicable federal or state laws or regulations regarding access, use or disclosure of health informa-tion or other sensitive personal information (e.g., 42 CFR Part 2, restricting use of information pertaining to drug/alcohol abuse and treatment), and does not entitle an entity or its employees, agents or assigns to any limitation of liability for acts or omissions in connection with the access, use, or disclosure of health information obtained through use of the form.

The Attorney General of Texas has adopted a standard Authorization to Disclose Protected Health Information in accordance with Texas Health & Safety Code § 181.154(d). This form is intended for use in complying with the requirements of the Health Insur-ance Portability and Accountability Act and Privacy Standards (HIPAA) and the Texas Medical Privacy Act (Texas Health & Safety Code, Chapter 181). Covered Entities may use this form or any other form that complies with HIPAA, the Texas Medical Privacy Act, and other applicable laws. Covered entities, as that term is defined by HIPAA and Texas Health & Safety Code § 181.001, must obtain a signed authorization from the individual or the individual’s legally authorized representative to electronically disclose that individual’s protected health information. Authorization is not required for disclosures related to treatment, payment, health care operations, performing certain insurance functions, or as may be otherwise authorized by law. (Tex. Health & Safety Code §§ 181.154(b),(c), § 241.153; 45 C.F.R. §§ 164.502(a)(1); 164.506, and 164.508).

The authorization provided by use of the form means that the organization, entity or person authorized can disclose, commu-nicate, or send the named individual’s protected health information to the organization, entity or person identified on the form, including through the use of any electronic means.

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NOTICE OF PRIVACY POLICIES

This notice describes how your medical information may be used and/or disclosed and how you can get access to this information. Please review this document. Your privacy is of the utmost importance to us. The following is our privacy promise to you, our patient. We are committed to preserving, disclosing, and using your protected health information responsibly. Your privacy is a top priority at our practice. This Notice applies to all protected health information (PHI) as defined by federal regulations. Understanding Your Health Record/Information Each time you visit Mara Thornberg, a record of your visit is made. Typically, this record contains your symptoms, examination and test results, diagnoses, treatment, and a plan for future care or treatment. This information, often referred to as your health or medical record, serves as a:

• Basis for planning your care and treatment • Means of communication among the many health professionals who contribute to your care • Legal document describing the care you received • Means by which you or a third-party payer can verify that services billed were actually provided • A source of data for medical research • A source of information for public health officials charged with improving the health of the state and the

nation • A source of data for our planning and marketing • A tool with which we can assess and continually work to improve the care we render and the outcomes we

achieve We wish to help you better understand what is in your record and how your health information will be used and disclosed. By being open with you, we feel this will ensure accuracy, better understanding who, what, when, where, and why others may access your health information, and make more informed decisions when authorizing disclosure to other parties. Your Health Information Rights Please realize that your health record is the physical property of Greer Swiatek, LPC-S over Mara Thornberg, LPC-Intern; however, the information belongs to you. You have the following rights regarding your protected health information (PHI):

• Obtain a paper copy of this notice of informational practices upon request • Inspect and copy your health records as provided for in 45 CFR 164.524 • Amend your health record as provided in 45 CFR 164.524 • Obtain an accounting of disclosures of your health information as provided in 45 CFR 164.524 • Request communications of your health information by alternative means or at alternative locations • Request a restriction on certain uses and disclosures of your information as provided by 45 CFR 164.524 • Revoke your authorization to use or disclose health information except to the extent that action has been

already been taken

Our Responsibilities

• Maintain the privacy of your health information

• Provide you with this notice as to our legal duties and privacy practices with respect to information we collect

and maintain about you

• Abide by the terms of this notice

• Notify you if we are unable to agree to a requested restriction

• Accommodate reasonable requests you may have to communicate health information by alternative means or

at alternative locations.

We reserve the right to change our practices if we feel it is necessary to protect your information. The new provisions

effective for all protected health information (PHI) we maintain will be mailed to you if necessary. Should our

information practices change, we will mail a revised notice to the address you have supplied to us.

We will not use or disclose your health information without your authorization, except as described in this notice. We

will also discontinue to use or disclose your health information after we have received a written revocation of the

authorization according to the procedures included in the authorization. This will not affect discloses made in good faith

of the original authorization.

For More Information or to Report a Problem

If you have questions, and would like additional information, you may contact the practice’s Privacy Officer. If you

believe your privacy rights have been violated, you can file a complaint with the practice’s Privacy Officer or with the

Office for Civil Rights, U.S. Department of Health and Human Services. We will not take any retaliation for filing a

complaint with either the Privacy Officer or the Office for Civil Rights.

Office for Civil Rights

U.S. Department of Health and Human Services

200 Independence Avenue, SW

Room 509F, HHH Building

Washington, DC 20201

Examples of Disclosures for Treatment, Payment and Health Operations

We will use your health information for treatment: Information obtained by a nurse, physician, or other member of

your health care team will be recorded in your record and used to determine the course of treatment that should work

best for you. Your provider will document in your record his or her expectations of the members of your health care

team. Members of your health care team will then record the actions they took and their observations. In that way, the

provider will know how you are responding to treatment.

We will also provide your provider or a subsequent health care provider with copies of various reports that should assist

him or her in treating you if you are referred to a specialist or other healthcare provider or in a situation where you are

released from treatment.

We will use your health information for payment: A bill may be sent to you or a third-party payer. The information on

or accompanying the bill may include information that identifies you, as well as your diagnoses, procedures, and

supplies used.

We will use your health information for regular health operations: Members of the medical staff may use information

in your health record to assess the care and outcomes in your case and others like it. This information will then be used

in an effort to continually improve the quality and effectiveness of the healthcare and service we provide. We may also

use your mailing and contact information to send you notices from time to time to get such important notices to you.

Calls and Messages: We may contact you by phone to confirm your appointment. Messages may be left on answering machines to this effect. In the case of a missed appointment, we may call to make sure everyone is all right and to reschedule the appointment for a later date. Business Associates: There are some services provided in our organization through contacts with business associates. Examples include emergency departments, medical laboratories, etc. When these services are contracted, we may disclose your health information to our business associate so that they can perform the job we have asked them to do and bill you or your third-party payer for services rendered. To protect your health information, however, we require the business associate to appropriately safeguard your information. Notification: We may, with your permission, use or disclose information to notify or assist in notifying a family member, personal representative, or another person responsible for your care, your location, and general condition. Communication with family: Health professionals, using their best judgment, may disclose to a family member, other relative, close personal friend, or any other person you identify, health information relevant to that person’s involvement in your care or payment related to your care. Research: We may disclose information to researchers when their research has been approved by an institutional review board that has reviewed the research proposal and established protocols to ensure the privacy of your health information. Marketing: We may contact you to provide appointment reminders or information about treatment alternatives or other health-related benefits and services that may be of interest to you. Food and Drug Administration (FDA): We may disclose to the FDA health information relative to adverse events with respect to food, supplements, product and product defects, or post marketing surveillance information to enable product recalls, repairs, or replacements. Workers Compensation: We may disclose health information to the extent authorized by and to the extent necessary to comply with laws relating to workers compensation or other similar programs established by law. Public Health: As required by law, we may disclose your health information to public health or legal authorities charged with preventing or controlling disease, injury, or disability. Law Enforcement: We may disclose health information for law enforcement purposes as required by law or in response to a valid subpoena. Federal law makes provision for your health information to be released to an appropriate health oversight agency, public health authority or attorney, provided that a work force member or business associate(s) believes in good faith that we have engaged in unlawful conduct or have otherwise violated professional or clinical standards and are potentially endangering one or more patients, workers, or the public.

HIPAA Overview HIPAA Privacy and Security Regulations:

A Synopsis of the Relevant Mandates of Title II (Administrative Simplification)

Health Insurance Portability and Accountability Act of 1996 Public Law 104-191

In 1996, President Clinton signed the Health Insurance Portability and Accountability Act (HIPAA). This law mandates action that seeks to: 1) ensure continuity of healthcare coverage for individuals changing jobs; 2) impact on the management of health information; 3) simplify the administration of health insurance; and 4) combat waste, fraud, and abuse in health insurance and health care.

Title II: The Security and Privacy Mandates Title II of the HIPAA law (also known as Administrative Simplification) includes requirements for ensuring the security and privacy of individuals’ medical information. The standards aim to maintain the right of individuals to keep private information about themselves. The Department of Health and Human Services is charged with developing the issuing regulations to address these requirements. The final privacy rule was released April 14, 2001; compliance is now required by April 2003. The security rule is being finalized; the released date is expected to be June/July 2001.

Protected Information HIPAA regulations protect medical records and other “individually identifiable health information” (communicated electronically, on paper, or orally) that are created or received by covered health care entities that transmit information electronically.

“Individually identifiable health information…” includes • any information, including demographic information collected from an individual; and • any information that identifies an individual, or could be reasonably believed to identify an individual

HIPAA protects “individually identifiable health information” which… • relates to the past, present, or future physical or mental health condition of an individual, the provision

of health care or the payment for such care • is maintained or transmitted, and is (or has been) in electronic form • is used or disclosed by covered entities

What is the difference between Security and Privacy? Security – relates to the means (process and technology) by which an entity protects the privacy of health information. The goals of security measures are to keep information secured, and decrease the means of tampering, destruction, or inappropriate access. There are four categories of requirements:

• Administrative Procedures – documented, formal practices to protect data • Physical Safeguards – protect data from fire, other natural and environmental hazards, and intrusion • Technical Security Services – protect information and control individual access to information • Technical Security Mechanisms – guard against unauthorized access to data over communications network

Privacy – refers to the individual’s right to keep certain information private, unless that information will be used or disclosed with his or her permission. Privacy topics include:

• Scope of Providers who must Comply • Rights of Individuals • Consent/Authorization Issues/Procedures/Processes • Business Associates Requirements • Organized Health Care Arrangements

Note: there are civil penalties when entities/individuals violate the privacy rule. Security and privacy are very intertwined – security assures privacy.