Child Abuse

If your counselor has reasonable cause to believe a child known to him/her in his/her professional capacity may be an abused child or a neglected child, your counselor must report this belief in accordance with the Abused and Neglected Child Reporting Act.

Adult and Domestic Abuse

If your counselor has reason to believe that an individual (who is protected by state law) has been abused, neglected, or financially exploited, he/she must report this belief in accordance with the Illinois Elder Abuse and Neglect Act.

Serious Threat to Health or Safety

If your counselor believed that you present an imminent, serious risk of physical or mental injury or death to yourself, he/she may make disclosures he/she considers necessary to protect you from harm. If you communicate to your counselor a specific threat of imminent harm against another individual or if he/she believes that there is clear, imminent risk of physical or mental injury being inflicted against another individual, he/she may make disclosures that he/she believes are necessary to protect that individual from harm.

1.

Tell your counselor if you do not understand this authorization, and he/she will explain it to you.

2.

You have the right to revoke or cancel this authorization at any time, except: to the extent that information has already been released based on the authorization this authorization was obtained as a condition of obtaining insurance coverage for services. *to revoke or cancel this authorization, you must submit your request in writing to your counselor and your insurance company, if applicable.

3.

You may refuse to sign this authorization. If you refuse to sign this authorization, your provider has the right to decide not to treat you or accept you as a client in their practice.

4.

Once the information about you leaves this office according to the terms of this authorization, this office has no control over how it will be used by the recipient. You need to be aware that at that point your information may no longer be protected by HIPAA.

5.

If this office initiated this authorization, you MUST receive a copy of the signed authorization.

1.

HIPAA provides special protections to certain medical records known as “Psychotherapy Notes.” All Psychotherapy Notes recorded on any medium (i.e. paper, electronic) by a mental health professional (such as a psychologist, psychiatrist, or counselor) must be kept by the author and filed separately from the rest of the client’s medical records to maintain a higher standard of protection.

2.

“Psychotherapy Notes” are defined under HIPAA as notes recorded by a health care provider who is a mental health professional documenting or analyzing the contents of conversation during a private counseling session or a group, joint, or family counseling session and that are separate from the rest of the individual’s medical records.

3.

Excluded from the “Psychotherapy Notes” definition are the following:

• medication prescription and monitoring

4.

In order for a medical provider to release “Psychotherapy Notes” to a third party, the client who is the subject of the Psychotherapy Notes must sign this authorization to specifically allow for the release of Psychotherapy Notes. Such authorization must be separate from an authorization to release other medical records.