Informed Consent for Telephone Therapy Session Services for:
Dr. Sadie Sheafe, Ph.D., LCSW (disclosure page)


YOU MUST ACCEPT THE FOLLOWING TERMS AND CONDITIONS TO CONTINUE


What is HIPAA

Which stands for the American Health Insurance Portability and Accountability Act of 1996, is a set of rules to be followed by doctors, hospitals and other health care providers.  HIPAA took effect on April 14, 2006.  HIPAA helps ensure that all medical records, medical billing, and patient accounts meet certain consistent standards with regard to documentation, handling and privacy.

In addition, HIPAA requires that all patients be able access their own medical records, correct errors or omissions, and be informed how personal information is shared used.  Other provisions involve notification of privacy procedures to the patient.  HIPAA provisions that have led in many cases to extensive overhauling with regard to medical records and billing systems.




TERMS AND CONDITIONS
I certify that:

1. I am over 18 years of age.
2. I am not and have not been told that I need to be under the care of a physician for a major mental or emotional     illness.
3. I am not receiving individual counseling or psychotherapy with another practitioner.
4. I am not at present feeling suicidal or homicidal.
5. I accept full responsibility for informing my counselor immediately if I believe I am becoming seriously     depressed, or I am having thoughts of injuring myself or another person. I understand that she may contact     local emergency services if she feels my state of mind poses a danger to myself or others.

I understand that:

1. The records and notes from my communications will be kept confidential except where Dr. Sadie Sheafe, Ph.D     is legally required to release them.
2. My personal information will be kept confidential.
3. My therapist will make every effort to return e-mails within 72 hours of receipt.
4. I am responsible for payment in advance for all services.
5. I have read all the information listed here and by clicking the ‘I ACCEPT’ button below, I agree to all of the     above.

NOTE: I Understand that it is necessary to have an assessment prior to conducting my telephone counseling session. Do you accept? No Yes