Summit Counseling is a private psychotherapy practice licensed by the state of Wisconsin. The following information is provided so that you understand your rights as a client and Summit Counseling’s rights and obligations to you as your provider. Services are provided in accordance with the American Counseling Association’s Code (ACA) of ethics. A copy of the 2014 ACA Code of Ethics may be found at https://www.counseling.org/doc...
Federal and state laws require Summit Counseling to maintain the privacy of your health information. These laws also required Summit Counseling to give you this Notice about privacy practices, legal obligations, fees for services and your rights concerning your health information ("Protected Health Information" or "PHI"). Summit Counseling follows the privacy practices that are described in this Notice (which may be amended from time to time).The law protects the relationship between a client and a psychotherapist, and information cannot be disclosed without written permission. There are exceptions and these are described below.
Treatment
You will be asked to sign the Client Rights and Informed Consent for Treatment form, By signing this form you are giving consent to the therapist and Summit Counseling to share information with all persons mandated or permitted by law. This includes; the agency that referred you, the managed care company, Medicaid, and/or insurance carrier responsible for your health services and payment for your health services. You are also releasing and holding harmless the therapist and Summit Counseling for any departure from your right of confidentiality that may result. Informed consent is given for the duration of 12 months, at which time it will be updated if treatment is ongoing. You have the right to withdraw informed consent, in writing, at any time.
Required by Law
- Suspected child abuse or dependent adult or elder abuse, which therapists are required by law to immediately report to the appropriate authorities
- If a client is threatening serious bodily harm to another person or persons, your therapist must notify the police and inform the intended victim(s).
- If a client intends to harm himself or herself, Your therapist will make every effort to enlist your cooperation in ensuring their safety. If you do not cooperate, your therapist will take further measures without your permission and which are provided to your therapist by law to ensure your safety.
- If you are involved in the sexual assault of a child or disclose a sexual relationship with any individual unable to give consent as defined by the laws of Wisconsin, your therapist is required to notify police. For additional information about the Wisconsin law, please go to the following website: https://www.ageofconsent.net/states/wisconsin.
Your Individual Rights
Uses and Disclosures Requiring Your Written Authorization
Psychotherapy Notes - Notes recorded by your therapist documenting the contents of a counseling session with you. These notes will be used only by your therapist and will not otherwise be used or disclosed without your written authorization.
Marketing Communications: - Summit Counseling will not use your health information for marketing communications.
Other Uses and Disclosures - Uses and disclosures other than those described above will only be made with your written authorization. For example, you will need to sign an authorization form before Summit Counseling can send PHI to your life insurance company, to a school, or to your attorney. You may revoke any such authorization at any time.
Disclosures Not Requiring Your Written Authorization
Under certain circumstances your records can be subpoenaed by a court of law. Summit Counseling will have no option other than to comply with the requirements of the subpoena.
Right to Inspect and Copy
You may request access to your therapy record and billing records maintained by Summit Counseling in order to inspect and request copies of the records. All requests for access must be made in writing. Under limited circumstances access to your records may be denied. A fee for the costs of copying and sending records requested will be applied. If you are a parent or legal guardian of a minor, please note that certain portions of the minor's record may not be accessible to you. For more information, you may go to https://www.dhs.wisconsin.gov/... to view the publication State of Wisconsin, Rights of Children and Adolescents In Outpatient Mental Health Treatment.
Public Contacts, Gifts and Social Media
It is extremely important to me to protect your privacy rights as a client. Therefore, outside of the office setting therapists will restrict relationships with clients. Should you see your therapist in a public place, he/she will not acknowledge you. This is so you won’t feel the need to explain who your therapist is to friends or family. Therapists will not accept social invitations to parties, graduations or other similar events. You pay Summit Counseling a reasonable fee for services; therefore therapists do not accept gifts. Referrals to Summit Counseling are however always appreciated.
Electronic Communications
Increasingly, interpersonal communication includes activities such as texting, email and social networking on sites like Linked-In and Facebook. Summit Counseling therapists will not participate in social networking with clients on these sites. It is recognized however, that voicemail, email and text messaging may be the best form of communication between you and your therapist. It is further understood that these forms of communication potentially include dropped calls or texts and privacy breaches due to hacking. It is generally accepted that users of these forms of communication accept these types of risk.
Where appropriate, client communications will be through HushMail an encrypted email service.
Emergency Contacts
As a free-standing, private out-patient clinic, Summit Counseling LLC is designed to provide therapeutic services to clients assumed to be autonomous and self-responsible. If you are in a crisis or have expectations for after-hours care, you may discuss this need with your therapist so coping strategies can be developed. If necessary, a referral that will better meet your therapeutic needs will be made. In an emergency, always call 911 or go to your nearest Emergency Room for assistance.
2023 Fees for Service
Fees listed below are subject to change without notice. Payment is due at the time of service. Payments may be made in the office or on the Summit Counseling website as you prefer. Please provide as much notice as possible for any cancellations. Failed appointments without 24- hour notice may be charged.
1 - Consultations with client’s lawyers, GAL or other involved parties.
2 - Provided for established clients only after 5 visits. Letters will be descriptive, not interpretive or predictive.
3 - Clients may view their records at no cost.
4 - A retainer of $1000 is due in advance. If a subpoena or notice to meet attorney(s) is received without a minimum of 48-hour notice there will be an additional $250 “express” charge. If the case is reset with less than 3 business day notice, then the client will be charged $500 (in addition to the retainer of $1000).
Billing Disclosure Requirements
Beginning January 1, 2022, psychologists and other health care providers are required by law to give uninsured and self-pay patients a good faith estimate of costs for services that they offer, when scheduling care or when the patient requests an estimate.
EFFECTIVE DATE AND CHANGES TO THIS NOTICE: This Notice is effective on April 20, 2022. The terms of this Notice may change at any time. The new Notice terms will be effective for all PHI being maintained, including any information created or received prior to issuing the new Notice. Revised notices will be posted on the Summit Counseling website at www.SummitCounseling.us.