Notice of Privacy Practices

THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFROMATION.
PLEASE REVIEW IT CAREFULLY

Our Commitment to your privacy
Bridges of Hope Counseling is dedicated to maintaining the privacy of your personal health information as part of providing professional care. We are also required by law to keep your information private, according to what is known as HIPAA. The laws are complicated, but we must give you this important information as part of the laws regulating counseling. If you would like to discuss more information than what is found in this shorter document please see Jeremy Spence, Privacy Officer, to obtain more information and ask specific questions or problems.

We will use the information about your health which we get from you or from others mainly to provide you with treatment, to arrange payment for our services, and for other business activities which are called, in the law, health care operations. After you have read this NPP we will ask you to sign a Consent Form to let us use and share your information. If you do NOT consent and sign this form, we cannot treat you. If we or you want to use or disclose (send, share, release) your information for any other purposes we will discuss this with you and ask you to sign an Authorization Form to allow this to happen.

Of course we will keep your health information private but there are some times when the laws require us to use or share it. For example:
- When there is a serious threat to your health and safety or to the health and safety of another individual or the public. We will only share information with a person or organization who is able to help prevent or reduce the threat.
- Some lawsuits and legal or court proceedings.
- If a law enforcement official requires to do so.
- For Workers Compensation and similar benefit programs.
- There are other situation like these but which do not happen very often.


Your rights regarding your health information
1. You can ask us to communication with you about your health and related issues in a particular way or at a certain place which is more private for you. For example, you can ask us to call you at home, and not at a work to schedule or cancel an appointment. We will try our best to do as you ask.
2. You have the right to ask us to limit what we tell people involved in your care or the payment for your care, such as family members and friends.
3. You have the right to look at the health information we have about you such as your medical and billing records. You can even get a copy of these records but we may charge you. Contact Jeremy Spence MS LLPC (MI), LPC (OH), (Privacy Officer) to arrange how to see your records. See Below.
4. If you believe the information in your records is incorrect or missing important information, you can ask us to make some kinds of changes (called amending) to your health information. You have to make this request in writing and send it to our Privacy Officer. You must tell us the reasons you want to make the changes requested.
5. You have the right to a copy of this notice. If we change the NPP we will post the new version in our office and you can always get a copy of the NPP from your counselor or the Privacy Officer.
6. You have the right to file a complaint if you believe your privacy rights have been violated. You can file a complaint with our Privacy Officer and with the Secretary of the Department of Health and Human Services. All complaints must be in writing. Filing a complain will not change the health care we provide to you in any way.

If you have any questions regarding this notice or our health information privacy policies, please contact our Privacy Officer who is Mr. Jeremy Spence and he can be reached at 937-951-0550 or by email at Jeremy@bridgesofhopecounseling.com. The effective date of this notice is 9/1/2015.

You may also have other rights, which are granted to you by the laws of Ohio, and these may be the same or different from the rights described above. I will be happy to discuss these situations with you now or as they arise.


Jeremy Spence MS LPC (OH), 
Privacy Officer

Consent to use and disclose your health information


This form is an agreement between you, _________________________ and Jeremy Spence, LPC. When we use the word "you" below, it will mean your child, relative, or other person if you have written his or her name here _______________________. When we examine, diagnose, treat or refer you we will be collecting what the law calls Protected Health Information (PHI) about you. We need to use this information her to decide on what treatment is best for you and to provide treatment to you. We may also share this information with others who provide treatment to you or need tit to arrange payment for your treatment or for other business or government functions. By signing this form you are agreeing to let us use your information here and send to others. The Notice of Privacy Practices explains in more detail your rights and how we can use and share your information. Please read this before you sign this Consent form.

If you do not sign this consent form agreeing to what is in our Notice of Privacy Practices we cannot treat you.

In the future we may change how we use and share your information and so may change our Notice of Privacy Practices. If we do change it, you can get a copy by calling us at 937-951-0550. If you are concerned about some of your information, you have the right to ask us to not use or share some of your information for treatment, payment or administrative purposes. You will have to tell us what you want in writing. Although we will try to respect your wishes, we are not required to agree to those limitations. However, if we do agree, we promise to comply with your wishes unless a future agreement is reached. After you have signed this consent, you have the right to revoke it (by writing a letter telling us you no longer consent) and we will comply with your wishes about using or sharing your information from that time on but we may already have used or shared some of your information and cannot change that.

INFORMED CONSENT

Welcome! I want you to know that I look forward to getting to know you and working with you as we begin our therapeutic work together.  This document contains important information regarding my policies and processes. These are important things for you to be aware of as we work together. You are invited to ask me any question you have about these policies or about the counseling process.

Today's appointment will take approximately 50-90 minutes.  I realize that starting counseling is a major decision and you may have many questions.  This document is intended to inform you of my policies, State and Federal Laws and your rights.  If you have other questions or concerns, please ask and I will try my best to give you all the information you need. The market rate for a 50 minute session for me is $100.  By signing this form, you are agreeing this rate is what you will pay unless you make arrangements with me prior to counseling.  I do work on a sliding fee scale so we can discuss what you are able to pay for sessions.

In addition to provided face-to-face, Jeremy is able to provide counseling via internet, using to residents of Ohio If this is the format you, and I agree to, you understand that though online counseling is HIPAA compliant that because of the nature of the internet it is not the same as a session in person.  Jeremy is a Board Certified TeleMental Health (BC-TMH) Provider.

Phone calls are not to be considered confidential due to cell phone reception and the technology.  Though you may text necessary updates pertaining to making or cancelling a session please note this is not HIPAA compliant.  By using phone or text messaging you are acknowledging the risk of using such technology.

Jeremy's license number as a professional clinical counselor is, E.2303853.  You  may verify the status of the license at www.csmft.ohio.gov. This information is required by the Counselor, Social Worker, and Marriage and Family Therapist Board, which regulates the practices of professional counseling, social work, and marriage and family therapy in this state.  You may contact the state CSWMFT Board with complaints or concerns: Counselor, Social Worker and Marriage & Family Therapist Board 77 South High Street, 24th Floor, Room 2468, Columbus, Ohio 43215-6171; (614) 466-0912. 

About Jeremy:

Jeremy Spence LPCC has earned a Bachelor of Arts Degree in Bible from Cedarville University and has completed his Master of Science in Mental Health Counseling from Capella University. He has over 15 years experience working with adolescents, their families, and other individuals in a faith based environment.  Jeremy practices standard client directed and cognitive therapy (reality therapy) for most conditions.  Jeremy does not impose any religious values on his clients and integration occurs at client request. Treatment practices, philosophy and plan limitations and risks will be discussed with you today.  Along with the above experiences and information Jeremy is able to conduct counseling through technology as he has obtained extra credentialing and competency on how best to use technology to serve clients.

CONFIDENTIALITY AND EMERGENCY SITUATIONS:Your verbal communication and clinical records are strictly confidential except for:  a) information you and/or you child or children report about physical or sexual abuse or neglect; then, by Ohio State Law, I am obligated to report this to the applicable Child Protection agency, b) where you sign a release of information to have specific information shared, and c) if you provide information that informs me that you are in danger of harming yourself or others d) information necessary for case supervision or consultation and e) or when required by law.  If an emergency situation for which the client or their guardian feels immediate attention is necessary, the client or guardian understands that they are to contact the emergency services in the community(911) for those services. I will follow those emergency services with standard counseling and support to the client or the client's family.  There may be times when supervision is obtained, help with a case and if a diagnosis is necessary or beneficial, but then only necessary information will be shared with the supervisor.

No Secrets Policy:

Please note that with couples and family therapy the couple and/or the family is the client, not the individuals. As a result, I practice a "no secrets" policy when conducting marital/couples/family therapy. This means that confidentiality does not apply between the couple or among family members when one member of the treatment unit requests an individual session or contacts me outside of the therapy session to share a secret. When in couples or family treatment, an individual session may be scheduled on occasion to assist in the overall treatment and when mutually agreed upon. Please understand that any information given in the individual sessions will not be held in secret in couples or family therapy. I will encourage the person holding the secret to share the secret in the following session(s) and will support the client in doing so. I also reserve the right to share or disclose information revealed by one partner or family member in an individual session to the other partner or family members as I deem appropriate or necessary to support the treatment unit's overall treatment progress and goals. If you are seeking couples or family therapy, each member of the treatment unit needs to read and sign this agreement.

Contact Between sessions:

I am available to take a brief 10 minute phone call or answer a short email regarding your therapy appointment times or therapy homework 1 time between therapy sessions, and no more than one time per month without the client incurring a fee. If the client feels that more contact is needed between sessions I am willing to discuss the possibility of increasing the weekly sessions or scheduling a paid phone appointment temporarily if I feel that it supports the client's therapy. If frequent non-crisis contact continues between sessions, it will be important to talk about referring out for a higher level of care than once a week therapy can provide.

I also make it a policy to not have clients as social media "friends".  Please know the request will be denied.

Emergency contact:

For emergency only situations, I will make every effort to return the call or email within 24 hours. I ask that if the client is facing a life threatening emergency that they call 911 immediately. There will be a regular session fee for emergency phone calls and sessions that are in excess of 10 minutes, or more than 1 time per month.  I reserve the right to not charge at my discretion.

Fee Schedule:

Below is the market rate for my services.  I can work on a sliding fee scale with the listed amounts being the starting point for decisions made.  No one will be turned away due to inability to pay the stated fees.  Please discuss any issues you have with these fees with me prior to treatment.

Initial meeting (60-90 Minutes): $125; 50 Minute session: $100; Group Sessions (90-120 minutes) $50-100 per session; Report Preparation: $100 per hour; Court depositions and/or court appearances: $125 per hour.