Client Intake Form

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Office Policies

I understand that I will be charged for sessions not cancelled at least 24 hours before my scheduled appointment.
I understand that I will be invoiced if I have not pre-paid on the website. I am responsible for payment within 30 days.
My signature below indicates that I have received the abridged HIPAA Notice of Privacy Practices below for Cristina Young, LCSW and that an unabridged notice is available to me upon request.

HIPAA PRIVACY

THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY. Commitment to your privacy: My practice is dedicated to maintaining the privacy of your personal health information as part of providing professional care. I am also required by law to keep your information private. These laws are complicated, but I must give you this important information. This is a shorter version of the full, legally required notice of privacy practices. How I use and disclose your protected health information with your consent: I will use the information I collect about you mainly to provide you with treatment, to arrange payment for our services, and for some other business activities that are called, in the law, health care operations. After you have read this notice, I will ask you to sign a consent form to let me use and share your information in these ways. If you do not consent and sign this form, I cannot treat you. If I want to use or send, share, or release your information for other purposes, I will discuss this with you and ask you to sign an authorization form to allow this. Disclosing your health information without your consent: There are some times when the laws require me to use or share your information: 1. When there is a serious threat to you or another’s health and safety or to the public, I will only share information with persons who are able to help prevent or reduce the threat. 2. When I am required to do so by lawsuits and other legal or court proceedings. 3. If a law enforcement official requires me to do so. 4. For workers’ compensation and similar benefit programs. There are some other rare situations. They are described in the longer version of the notice of privacy practices. Your rights regarding your health information: 1. You can ask me to communicate with you in a particular way or at a certain place that is more private for you. For example, you can ask me to call you at home, and not at work, to schedule or cancel an appointment. I will try my best to do as you ask. 2. You can ask me 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 I have about you, such as your medical and billing records. You can get a copy of these records, but there may be a charge for it. 4. If you believe that the information in your records is incorrect or missing something important, you can ask me to make additions to your records to correct the situation. You have to make this request in writing. You must also tell me the reasons you want to make the changes. 5. You have the right to a copy of this notice. If I change this notice, you can get a copy of it from me then. 6. You have the right to file a complaint if you believe your privacy rights have been violated. You can file a complaint with the Secretary of the U.S. Department of Health and Human Services. All complaints must be in writing. Filing a complaint will not change the health care I provide to you in any way. Also, you may have other rights that are granted to you by the laws of our state, and these may be the same as or different from the rights described above. I will be happy to discuss these situations with you now or as they arise. If you have any questions regarding this notice or health information privacy policies, please let me know.