PRIVACY NOTICE
This document governs the privacy notice of our website laurafedericotherapy.com. Laura Federico, licensed psychotherapist operating out of the USA and Switzerland, has created this site and is committed to protecting your privacy. Our privacy notice tells you what data we may collect from you, how we collect it, how we protect it, how we may share it, and how you can access and change it. This privacy notice also explains your legal rights to your personal data. Please read our policy carefully before deciding to use our website.
YOUR RIGHTS
When using our website and submitting personal data to us, you may have certain rights under the General Data Protection Regulation (GDPR) and other laws. Depending on the legal basis for processing your personal data, you may have some or all of the following rights:
The right to be informed
You have the right to be informed about the personal data we collect from you, and how we process it.
The right of access
You have the right to get confirmation that your personal data is being processed and have the ability to access your personal data.
The right to rectification
You have the right to have your personal data corrected if it is inaccurate or incomplete.
The right to erasure (right to be forgotten)
You have the right to request the removal or deletion of your personal data if there is no compelling reason for us to continue processing it.
The right to restrict processing
You have a right to ‘block’ or restrict the processing of your personal data. When your personal data is restricted, we are permitted to store your data, but not to process it further.
The right to data portability
You have the right to request and get your personal data that you provided to us and use it for your own purposes. We will provide your data to you within 30 days of your request. To request your personal data, please contact us using the information at the top of this privacy notice.
The right to object
You have the right to object to us processing your personal data for the following reasons:
Processing was based on legitimate interests or the performance of a task in the public interest/exercise of official authority (including profiling);
Direct marketing (including profiling); and
Processing for purposes of scientific/historical research and statistics.
Rights in relation to automated decision-making and profiling.
Automated individual decision-making and profiling
You will have the right not to be subject to a decision based solely on automated processing, including profiling, which produces legal effects concerning you or similarly significantly affects you.
Filing a complaint with authorities
You have the right to file a complaint with supervisory authorities if your information has not been processed in compliance with the General Data Protection Regulation. If the supervisory authorities fail to address your complaint properly, you may have the right to a judicial remedy.
For details about your rights under the law, click here.
INFORMATION WE COLLECT
Generally, you control the amount and type of information that you provide to us when using our website. Our legal basis for collecting and processing your data is based on consent when you sign up to our bimonthly affirmations, or submit an online form requesting a consultation or more information regarding services.
Our Legal Basis for Collecting and Processing Personal Data
Our legal basis for collecting and processing your data when you sign up for our bimonthly affirmations or submit an online form through our website opt-in forms is based on consent.
What Happens If You Don’t Give Us Your Data:
If you do not provide us with enough information, we may not be able to provide you with all our products and services. However, you can access and use some parts of our website without giving us your data.
We Collect Your Personal Data in the Following Ways:
Automatic Information
We automatically receive information from your web browser or mobile device. This information includes the name of the website from which you entered our website, if any, as well as the name of the website you’ll visit when you leave our website. This information also includes the IP address of your computer/the proxy server you use to access the Internet, your Internet service provider’s name, your web browser type, the type of mobile device, your computer operating system, and data about your browsing activity when using our website. We use all this information to analyze trends among our users to help improve our website.
When Entering and Using Our Website
When you enter and use our website and agree to accept cookies, some of these cookies may contain your data.
When you Submit an Online Form
When you sign up to our bimonthly affirmations we collect your email address. When you fill out a contact form or schedule a consultation we collect your first and last name, your email address and any additional information you choose to share.
When Engaging in Therapy
We work with reputable companies to deliver confidential, convenient remote therapy. Our online office is provided through CounSol, who contracts with Stripe, the payment gateway, to facilitate safe and secure payments. These companies may have their own terms of service, privacy policies, and other practices which are different from ours. It’s important to carefully review the policies as specified below.
GOOD FAITH ESTIMATE
You have the right to receive a “Good Faith Estimate” explaining how much your medical care will cost.
Under the law, health care providers need to give patients who don’t have insurance or who are not using insurance an estimate of the bill for medical items and services.
You have the right to receive a Good Faith Estimate for the total expected cost of any non-emergency items or services. This includes related costs like medical tests, prescription drugs, equipment, and hospital fees.
Make sure your health care provider gives you a Good Faith Estimate in writing at least 1 business day before your medical service or item. You can also ask your healthcare provider, and any other provider you choose, for a Good Faith Estimate before you schedule an item or service.
If you receive a bill that is at least $400 more than your Good Faith Estimate, you can dispute the bill.
Make sure to save a copy or picture of your Good Faith Estimate. For questions or more information about your right to a Good Faith Estimate, visit www.cms.gov/nosurprises or call 800-985-3059.
COUNSOL
CounSol has designed a state of the art service to protect the privacy of all counselors and clients. CounSol has implemented all the required components to make the site HIPAA compliant and more. CounSol's number one priority is making sure counselors’ information is safe and secure.
Servers housed in Tier-IV data center with SSAE16, HITRUST, ISO 27001 & PCI 2.0 compliance
PCI (Payment Card Industry) standards applied to our internal systems and software
All traffic is required to use SSL (Secure Socket Layer) with 256-bit encryption
Unique login for all users
Logging of all user activity
256-bit encryption of all sensitive data
No sensitive information is sent via email, only notifications to login will be sent
Data backed up hourly using 256-bit encryption
To learn more, read the CounSol Privacy Policy here:
https://counsol.com/site/legal/privacy/
STRIPE
We use Stripe.com as our payment gateway, to learn more, please refer to their Privacy Policy here:
SQUARESPACE
Our website is hosted on Squarespace. Your data is stored through Squarespace’s data storage, databases and the general Squarespace application.
To learn more, read the Squarespace Terms of Service here or Privacy Statement here:
http://www.squarespace.com/terms-of-service/
http://www.squarespace.com/privacy/
MAILCHIMP
If you consent to bimonthly affirmations, you will receive emails through MailChimp. Your email is stored securely. To learn more, read the MailChimp Privacy Policy here:
https://mailchimp.com/legal/privacy/
COOKIES
Our website uses cookies. A cookie is a small piece of data or a text file that is downloaded to your computer or mobile device when you access certain websites. Cookies may contain text that can be read by the web server that delivered the cookie to you. The text contained in the cookie generally consists of a sequence of letters and numbers that uniquely identifies your computer or mobile device; it may contain other information as well.
By agreeing to accept our use of cookies, you are giving us, and third parties we partner with, permission to place, store, and access some or all the cookies described below on your computer.
Strictly Necessary Cookies
These cookies are necessary for proper functioning of the website, such as displaying content, logging in, validating your session, responding to your request for services, and other functions. Most web browsers can be set to disable the use of cookies. However, if you disable these cookies, you may not be able to access features on our website correctly or at all.
Performance Cookies
These cookies collect information about the use of the website, such as pages visited, traffic sources, users’ interests, content management, and other website measurements.
Functional Cookies
These cookies enable the website to remember a user’s choices – such as their language, user name, and other personal choices – while using the website. They can also be used to deliver services, such as letting a user make a blog post, listen to audio, or watch videos on the website.
Media Cookies
These cookies can be used to improve a website’s performance and provide special features and content. They can be placed by third parties who provide services to us or by our company.
Advertising or Targeting Cookies
These cookies are usually placed and used by advertising companies to develop a profile of your browsing interests and serve advertisements on other websites that are related to your interests. You will see less advertising if you disable these cookies.
Session Cookies
These cookies allow websites to link the actions of a user during a browser session. They may be used for a variety of purposes, such as remembering what a user has put in their shopping cart as they browse a website. Session cookies also permit users to be recognized as they navigate a website so that any item or page changes they make are remembered from page to page. Session cookies expire after a browser session; thus, they are not stored long term.
Persistent Cookies
These cookies are stored on a user’s device in between browser sessions, which allows the user’s preferences or actions across a site (or, in some cases, across different sites) to be remembered. Persistent cookies may be used for a variety of purposes, including remembering users’ choices and preferences when using a website or to target advertising to them.
We may also use cookies for:
• Identifying the areas of our website that you have visited
• Our website analytics
• Allowing you to post comments
• Allowing you to share content with social networks
Most web browsers can be set to disable the use of cookies. However, if you disable cookies, you may not be able to access features on our website correctly or at all.
Google Analytics Privacy Notice
Our website uses Google Analytics to collect information about the use of our website. Google Analytics collects information from users such as age, gender, interests, demographics, how often they visit our website, what pages they visit, and what other websites they have used before coming to our website. We use the information we get from Google Analytics to analyze traffic. Google Analytics collects only the IP address assigned to you on the date you visit our website, not your name or other identifying information. We do not combine the information collected using Google Analytics with personal data. Although Google Analytics plants a permanent cookie on your web browser to identify you as a unique user the next time you visit our website, the cookie cannot be used by anyone but Google. Google also uses specific identifiers to help collect information about the use of our website. For more information on how Google collects and processes your data, visit https://www.google.com/policies/privacy/partners/
You can prevent Google Analytics from using your information by opting out at this link: https://tools.google.com/dlpage/gaoptout
Squarespace Cookies
You can find more details on the exact cookies that this Squarespace website uses in this article. This website is configured to disable Analytics and Performance Cookies unless you click on Continue on the Cookie Notice.
THIRD-PARTY SERVICES
In general, the third-party providers used by us will only collect, use and disclose your information to the extent necessary to allow them to perform the services they provide to us.
However, certain third-party service providers, such as payment gateways and other payment transaction processors, have their own privacy policies in respect to the information we are required to provide to them for your purchase-related transactions.
For these providers, we recommend that you read their privacy policies so you can understand the manner in which your personal information will be handled by these providers.
In particular, remember that certain providers may be located in or have facilities that are located a different jurisdiction than either you or us. So if you elect to proceed with a transaction that involves the services of a third-party service provider, then your information may become subject to the laws of the jurisdiction(s) in which that service provider or its facilities are located.
As an example, if you are located in Canada and your transaction is processed by a payment gateway located in the United States, then your personal information used in completing that transaction may be subject to disclosure under United States legislation, including the Patriot Act.
Once you leave our shop’s website or are redirected to a third-party website or application, you are no longer governed by this Privacy Notice.
HOW YOUR INFORMATION IS USED
We use the information we receive from you to:
Send you a bimonthly affirmation via email
Provide our products and services you have requested or purchased from us
Communicate via email to organize a consultation as requested by you
Communications and Emails
When we communicate with you about our website, we will use the email address you provided.
Sharing Information With Affiliates and Other Third Parties
We do not sell or rent your data to third parties for marketing purposes.
We may provide your information to any successor in interest in the event of a merger, divestiture, restructuring, reorganization, dissolution, or other sale or transfer of some or all of our assets and/or business.
We may disclose information when legally compelled to do so, in other words, when we, in good faith, believe that the law requires it or for the protection of our legal rights or when compelled by a court or other governmental entity to do so.
RETAINING AND DESTROYING YOUR DATA
We retain information that we collect from you only for as long as we need it for legal, business, or tax purposes. Your information may be retained in electronic form, paper form, or a combination of both. When your information is no longer needed, we will destroy, delete, or erase it.
UPDATING YOUR DATA
You can update your data using services found on our website. If no such services exist, you can contact us using the contact information found at the top of this privacy notice and we will help you. However, we may keep your data as needed to enforce our agreements and to comply with any legal obligations.
REVOKING YOUR CONSENT TO USE DATA
You have the right to revoke your consent for us to use your data at any time. Such an optout will not affect disclosures otherwise permitted by law including but not limited to: (i) disclosures to affiliates and business partners, (ii) disclosures to third-party service providers that provide certain services for our business, such as credit card processing, computer system services, shipping, data management services, (iii) disclosures to third parties as necessary to fulfill your requests, (iv) disclosures to governmental agencies or law enforcement departments, or as otherwise required to be made under applicable law, (v) previously completed disclosures to third parties, or (vi) disclosures to third parties in connection with subsequent contests or promotions you may choose to enter, or third-party offers you may choose to accept. If you want to revoke your consent for us to use your data, send us an email with your request to: laurafedericotherapy@gmail.com
DO NOT TRACK SETTINGS
Some web browsers have settings that enable you to request that our website not track your movement within our website. Our website does not obey such settings when transmitted to and detected by our website. You can turn off tracking features and other security settings in your browser by referring to your browser’s user manual.
LINKS TO OTHER WEBSITES
Our website may contain links to other websites. These websites are not under our control and are not subject to our privacy notice. These websites will likely have their own privacy notices. We have no responsibility for these websites and we provide links to these websites solely for your convenience. You acknowledge that your use of and access to these websites are solely at your risk. It is your responsibility to check the privacy notices of these websites to see how they treat your data.
PROTECTING CHILDREN'S PRIVACY
Even though our website is not designed for use by anyone under the age of 16, we realize that a child under the age of 16 may attempt to access our website. We do not knowingly collect data from children under the age of 16. If you are a parent or guardian and believe that your child is using our website, please contact us. Before we remove any information, we may ask for proof of identification to prevent malicious removal of account information. If we discover that a child is accessing our website, we will delete that child's information within a reasonable period of time. You acknowledge that we do not verify the age of our users nor do we have any liability to do so.
EMAIL POLICY
You can always opt out of receiving further email correspondence from us or our affiliates. We will not sell, rent, or trade your email address to any unaffiliated third party without your permission.
SECURITY POLICY
We have built our website using industry-standard security measures and authentication tools to protect the security of your data. We and the third parties who provide services for us, also maintain technical and physical safeguards to protect your data. When we collect your credit card information through our website, we will encrypt it before it travels over the Internet using industry-standard technology for conducting secure online transactions. Unfortunately, we cannot guarantee against the loss or misuse of your data or secure data transmission over the Internet because of its nature.
We strongly urge you to protect any password you may have for our website and to not share it with anyone. You should always log out of our website when you finish using it, especially if you are sharing or using a computer in a public place.
USE OF CREDIT CARD
You may have to provide a credit card to purchase sessions. We use third-party billing services and have no control over these services. We use our commercially reasonable efforts to make sure your credit card number is kept strictly confidential by using only third-party billing services that use industry-standard encryption technology to protect your credit card number from unauthorized use. However, you understand and agree that we are in no way responsible for any misuse of your credit card number.
TRANSFERRING DATA FROM THE EU
Data that we collect from you may be stored, processed, and transferred between any of the countries in which we operate, specifically the United States. The European Union has not found the United States and some other countries to have an adequate level of protection of data under Article 45 of the GDPR. Our company relies on derogations for specific situations as defined in Article 49 of the GDPR. For European Union customers and users, with your consent, your data may be transferred outside the European Union to the United States. We will use your data to provide the goods, services, and/or information you request from us to perform a contract with you or to satisfy a legitimate interest of our company in a manner that does not outweigh your freedoms and rights. Wherever we transfer, process or store your data, we will take reasonable steps to protect it. We will use the information we collect from you in accordance with our privacy notice. By using our website, services, or products, you agree to the transfers of your data described within this section.
CHANGES TO OUR PRIVACY NOTICE
We reserve the right to change this privacy notice at any time. If our company decides to change this privacy notice, we will post those changes on our website so that our users and customers are always aware of what information we collect, use, and disclose. If at any time we decide to disclose or use your data in a method different from that specified at the time it was collected, we will provide advance notice by email (sent to the email address on file in your account). Otherwise we will use and disclose our users’ and customers’ data in agreement with the privacy notice in effect when the information was collected. In all cases, your continued use of our website, services, and products after any change to this privacy notice will constitute your acceptance of such change.
QUESTIONS AND CONTACT
Any questions please contact Laura at laurafedericotherapy@gmail.com, or mail to
LF Therapy
223 Bedford Ave
PMB #744
Brooklyn, NY 11211
LAURA FEDERICO, MS, LCSW
POLICIES + CLIENT SERVICE AGREEMENT
As a Licensed Clinical Social Worker, I am governed by various laws and regulations and by the code of ethics of my profession. The ethics code requires that I make you aware of my specific practice policies and procedures, how these policies and procedures may affect you, and your rights as a client. I welcome any questions you may have about this document and will address them during your intake appointment. I am registered and licensed in New York State and Iowa and am located in Iowa at this time.
CONFIDENTIALITY OF DISTANCE SUPPORT
The laws that protect the privacy and confidentiality of sensitive information, which may include both the United States Health Insurance Portability and Accountability Act, the Swiss Federal Act on Data Protection, and other applicable federal, state and international laws, also apply to distance support. I contract with a HIPAA-compliant office platform, CounSol, which allows us to communicate through secure and safe written messaging, video and instant message sessions, and keeps sensitive information protected.
We conduct our clinical communication through our CounSol online office, allowing for safe and secure support.
There are risks from teletherapy, including, but not limited to, the possibility, despite reasonable efforts on my part, that: the transmission of sensitive information could be disrupted or distorted by technical failures; the transmission of sensitive information could be interrupted by unauthorized persons; and/or the electronic storage of sensitive information could be accessed by unauthorized persons. You agree that I am not responsible for disruptions or interruptions to our communications.
I ask that you determine who has access to your computer and electronic information prior to our sessions. This would include family members, co-workers, supervisors and friends. I encourage you to only communicate through a computer that you know is safe, i.e. wherein confidentiality can be ensured. Be sure to fully exit all online teletherapy sessions and emails. I encourage you to find a location for our sessions with proper lighting, limited audio and visual distractions, and a sound barrier to prevent others overhearing the session.
If you choose to email me from your personal email account, please limit the contents to basic issues such as cancellation or change in contact information. I will not respond to clinical concerns via regular email. If you want to send personal or clinical information by email then you will need to communicate with me using encrypted and secure messages via CounSol. You are responsible for information security on your computer or device. If you decide to keep copies of our confidential clinical correspondence on your computer or device, it is your responsibility to keep that information secure.
There is the possibility of an interruption in service due to technical difficulties or poor visual quality. In the event that this happens, I will re-initiate the session. If reconnection is not possible, then we will message to reschedule. Please note that CounSol has state of the art HIPAA-compliant security, including:
Servers housed in Tier-IV data center with SSAE16, HITRUST, ISO 27001 & PCI 2.0 compliance
PCI (Payment Card Industry) standards applied to our internal systems and software
All traffic is required to use SSL (Secure Socket Layer) with 256-bit encryption
Unique login for all users
Logging of all user activity
256-bit encryption of all sensitive data
No sensitive information is sent via email, only notifications to login will be sent
Data backed up hourly using 256-bit encryption
Please note that CounSol is located in the United States and that your personal data may be processed in the United States, Switzerland and the European Union, and you agree to such processing. In addition, CounSol uses software tags known as "cookies" within certain functions of its web sites to remember its visitors' preferences and to maximize the performance of the site and the individual's experience. Access to certain functionality may not be available to individuals that do not give their consent to the data processing carried out through cookies or whose browsers are set to reject all cookies.
Teletherapy may not be as complete as face-to-face support. I will tell you if I believe you would be better served by face-to-face services and will refer you to a practitioner who can provide such services if necessary. I do not provide emergency or crisis services within my practice, and will refer you to appropriate services if it seems distance support is not clinically appropriate for you at this time.
PROFESSIONAL RECORDS
The laws and standards of my profession require that I keep Protected Health Information (PHI) about you in your clinical record. Your clinical record may contain information such as a diagnosis, intake information, consent to treatment, treatment plan, phone and email contact, and treatment notes. Treatment notes are brief summaries of our individual sessions outlining important issues, facts, or any treatment recommendations discussed. Except in unusual circumstances that involve danger to yourself and/or others or where information has been supplied to me confidentially by others, you may request in writing to examine and/or receive a copy of your clinical record. These are professional records that can be misinterpreted and/or upsetting to untrained readers. For this reason, I strongly recommend that you review them in my presence or upon your written consent, have them sent to another mental health professional to review with you. For more information regarding how I can use and disclose your PHI, please refer to my Notice of Privacy Practices.
FEES + PAYMENT FOR SERVICES
My current fee for a standard teletherapy session of 45 minutes is $250, for an extended 60-minute session the fee is $325. My current fee for sex therapy consultation is $300 for a 50-minute session. My current fee for couples is $300 per 50-minute session. While I no longer offer payment packages, the last offered full fee monthly teletherapy plan is $800. This includes 4 standard sessions of 45 minutes as well as written communication between sessions pertaining to client care plan. This package will be paid in full at the beginning of one's billing month, and expires 30 days later. Messaging between sessions is often a service utilized as part of your treatment plan - the scope of written communication is determined by me after careful consideration of best client care. If a true hardship exists, I will take such matters into consideration. I reserve about 20% of my practice for reduced-rate, sliding scale and pro-bono clients. If finances prohibit us from continuing to work together, I will do my best to direct you towards a referral better suited to your needs. Fees are to be paid at time of service through my confidential website. You will be notified in advance in writing if any changes in fees are to be made. Please discuss with me if circumstances prohibit you from paying your bill on a monthly or weekly basis. I am unable to accumulate balances; if your account is more than 60 days past-due and suitable arrangements for payment have not been agreed upon, I have the option of suspending or discontinuing your treatment. If you carry an unpaid balance after the time of service, the card you have on file will automatically be run to pay your outstanding fees. I do not participate in any US or European insurance plans at this time.
CONTACT BETWEEN SESSIONS
I do not provide emergency services within my practice. A crisis resource for 24/7 mental health support is the National Suicide Prevention Hotline 800-273-8255 (24/7) Online chat: https://suicidepreventionlifeline.org/chat/ (24/7). In the event of a life or limb-threatening emergency, always call 911 or go to the nearest emergency room. To contact me between sessions, I ask that you utilize CounSol's safe and secure messaging platform. I check these messages every 24 hours and will respond accordingly. In the instance I will be unavailable for an extended period of time, I will provide you with a referral in advance.
SESSIONS + CANCELLATION
All sessions will be made in advance by appointment. Other than for true emergencies, it is expected that you will attend your scheduled session. If canceling is necessary, I require a minimum of 24 hours notice; if notice is given under 24 hours, I will charge you my normal fee of $250 per 45-minute session, $325 per extended 60-minute or relationship session, and $300 for a 50-minute sex therapy consultation. If you have a monthly plan, your missed session will be rolled into your monthly fee, and will not be deducted from the overall package cost. I try to accommodate requests to reschedule when conflicts arise, though it must be within the same week of your appointment time and is subject to my availability.
ENDING SERVICES
You have the right to end services at any time. Should you decide between sessions to withdraw from services, I request that you attend one additional teletherapy session to discuss a supportive transition with me.
COUPLES AND RELATIONSHIP SESSIONS
Boundaries: Because the relationship is the main focus of couples and relationship therapy both partners of a couple must be present for the couples session to start. It is often not in the best interest of the couple to distribute time unevenly between partners or to have unplanned meetings with only one partner present. If one partner is late in arriving or does not show for the appointment, I reserve the right to delay the start of the session or to cancel the session if necessary.
No secrets: As a couples therapist who IS entrusted with information from both partners in a relationship, I have a policy of "No Secrets", which means that I cannot promise to protect secrets of either partner from the other person, especially if the secret is harmful or destructive to the process of the therapy itself or undermines the agreed-upon intention of the therapy.
Confidentiality: When you attend sessions with a psychotherapist, the information you share is protected by strict confidentiality laws enforced both by the licensing board governing my license and state law. Without your written consent and permission, I cannot reveal whether or not you are a client of mine and cannot discuss any information from our sessions with a third party. The following are exceptions to this rule: If one of you poses an imminent danger to yourself, your partner, or a third person, I am allowed to disclose information to law enforcement personnel or hospital staff to keep you safe and coordinate care. If you talk about events that lead me to believe that a child under the age of 18 or an elderly or disabled person is at risk of emotional, physical, or sexual abuse, neglect, or exploitation, I am required by law to make a report to New York or Iowa Family or Adult Protective Services. If you disclose sexual misconduct by a previous therapist I am required to make a report to their licensing board. If a judge in a court of law orders me to release information or if I need to respond to a lawfully issued subpoena. If I need to cooperate with legal actions against a mental health professional by a licensing board.
The couple and relationship is the client: When you attend couples therapy sessions, you as a couple are considered to be "the client" and your mental health records therefore belong to both of you. This means that except in the circumstances above, I will need written consent from both of you in order to disclose any information from your record to a third party.
Couples and relationship treatment involves 1. Assessment: This process includes an interview with the couple, followed by individual interviews with each partner. Couples also complete online questionnaires which provide comprehensive data on the relationship's strengths and challenges. Feedback on the results of the assessment is provided, and the recommended areas for intervention are discussed. This phase yields a scientifically-based, personalized treatment plan from which interventions are selected. 2. Therapeutic Intervention: In this phase, structured interventions that are designed to strengthen friendship, intimacy, and conflict management are introduced and practiced in each session. Couples learn to replace negative conflict patterns with positive interactions and to repair past hurts, and begin to create shared meaning and purpose in their relationship. The therapy ends once couples have reduced the behaviors that predict a split and are able to effectively use conflict management tools without the therapist.
What to expect: Couples and relationship therapy is a process of identifying interaction and communication patterns that are negatively impacting the friendship, intimacy, and fulfillment of needs of any partners in a relationship. Each partner will be expected to honestly examine their own interaction and communication styles, identify and express their own feelings, and make an attempt at experimenting with alternative methods of communicating and interacting. Each partner will be helped to further clarify their own values and their own level of commitment to the relationship, and the outcome of the therapy may be increased satisfaction with the partnership or increased clarity about the decision to part ways.
Limitations to couples therapy: Couples Therapy has been shown to have benefits for couples. It often leads to a significant reduction of feelings of distress, resolution of specific problems, and a stronger relationship. In many cases, it has moved couples from thinking of ending their relationship to recommitting to it in new ways. However, it is important that you also understand the risks involved. You will be asked to address areas of difficulty in your relationship. As a result, you and/or your partner may experience uncomfortable feelings like sadness, guilt, anxiety, anger, loneliness, and helplessness. Your therapy may also involve recalling unpleasant aspects of your history together and/or individually. Difficulties between the two of you may become temporarily amplified. Additionally, difficulties with people important to you may also occur, family secrets may be disclosed, and despite our best efforts, therapy may not work out well. Deliberate dishonesty or deceit, unwillingness to introspect and take responsibility for one's actions, or lack of interest and motivation to engage in the couples' therapy process by one or both partners will undermine the therapy. Thus, we can make no guarantees about how the therapy process will be for you specifically or what the outcome will be for your relationship. In addition, couples therapy is not advisable in the following situations: If there is active alcohol and/or drug addiction on the part of either or both partners, from either partner's perspective If there is serious violence in your relationship, threats by one or both partners that serious violence might occur, or fear of such serious violence on the part of one or both partners If either partner currently has an untreated major mental illness. This does not include past, successfully treated psychotic episodes. If there is an undisclosed, current affair that you are not willing to disclose (such secrets predict marital therapy failure) If either partner is currently experiencing suicidal or homicidal thoughts, or has a history of serious harm inflicted on him/herself or another person. Couple and relationship therapy will only be effective in cases where both partners put in a good faith effort to work on their problems and their relationship. Deliberate dishonesty or deceit, unwillingness to introspect and take responsibility for one's actions, or lack of interest and motivation to engage in the couples therapy process by one or both partners will undermine the therapy.
GOVERNING LAW
You agree that this Agreement, the rights, and obligations hereunder, and any claims or disputes remaining thereto, including, but not limited to, disputes regarding fees and/or malpractice or other tortious or contractual claims, shall be governed by and construed in accordance with the laws of the State of New York without regard to its rules with respect to conflicts of laws. I further understand that in the event of litigation arising from a dispute, the federal and state courts located in the County of New York, State of New York (where I am licensed), and the courts and regulatory agencies and bodies therein, shall serve as the venue for all legal disputes. By entering into the Agreement, you consent to the courts of the State of New York having personal jurisdiction over me for all disputes arising in connection with this Agreement.
I agree to the terms and conditions contained in this Client Services Agreement. I agree to pay for each scheduled therapy session for the fee established with Laura Federico, MS, LCSW. I understand that I am financially responsible for paying for all scheduled sessions. I agree to provide updated credit card information to be kept on file to cover the cost of scheduled sessions that I did not show up for or that I did not cancel with at least 24 hours advance notice. I accept that any missed appointments or late cancellations will result in my credit card being charged the regular fee amount for individual sessions as outlined in this Client Services Agreement. Any unpaid balance will be charged on my registered credit card at the end of every billing month.
INFORMED CONSENT FOR DISTANCE SUPPORT
I hereby consent to participating in distance support via the internet (hereinafter referred to as "teletherapy")
I understand that by entering into this agreement (hereafter the "Agreement"), the terms and conditions of which I have reviewed in depth, I provide my informed consent to Laura Federico (hereafter the "Treating Therapist") such that I will participate in teletherapy with the treating therapist in accordance with the terms of this Agreement.
I understand that "teletherapy" allows my treating therapist to consult, treat, transfer sensitive data, and educate using interactive audio, video, or data communication regarding my treatment.
I understand that I have the following rights under this Agreement: I have a right to confidentiality with teletherapy under the same laws that protect the confidentiality of my sensitive information for in- person psychotherapy. Any information disclosed by me during the course of my therapy, therefore, is generally confidential.
There are, by law, exceptions to confidentiality, including mandatory reporting of child, elder, and dependent adult abuse and any threats of violence I may make towards a reasonably identifiable person. I also understand that if I am in such mental or emotional condition to be a danger to myself or others, my treating therapist has the right to break confidentiality in attempts to prevent the threatened danger.
I understand that while psychotherapeutic treatment of all kinds has been found to be effective in treating a wide range of mental disorders, personal, and relational issues, there is no guarantee that all treatment of all clients will be effective. Thus I understand that while I may benefit from teletherapy, results cannot be guaranteed or assured.
I further understand that there are risks unique and specific to teletherapy, including, but not limited to, the possibility that our therapy sessions or other communication by my treating therapist to others regarding my treatment could be disrupted or distorted by technical failures or could be interrupted or could be accessed by unauthorized persons. In addition, I understand that teletherapy treatment is different from in-person therapy and that teletherapy may not be as complete as face-to-face support. If my treating therapist believes I would be better served by another form of psychotherapeutic services, such as in-person treatment, I will be referred to a therapist in my geographic area that can provide such services.
I understand that I have a right to access my medical information and copies of medical records in accordance with applicable law.
I have the right to withhold or withdraw consent at any time without affecting my right to future care or treatment and without risking the loss or withdrawal of any benefits to which I would otherwise be entitled.
Governing Law. I understand that the Treating Therapist is licensed to practice therapy in the State of New York, United States of America. As such, I understand that this Agreement, the rights and obligations hereunder, and any claims or disputes remaining thereto, including, but not limited to, disputes regarding fees and/or malpractice or other tortious or contractual claims, shall be governed by and construed in accordance with the laws of the State of New York without regard to its rules with respect to conflicts of law. I further understand that in the event of litigation arising from a dispute with the Treating Therapist, the federal and state courts located in the County of New York, State of New York, where the Treating Therapist is licensed, and the courts and regulatory agencies and bodies therein, shall serve as the venue for all legal disputes. By entering into the Agreement, I thus consent to the courts of the State of New York having personal jurisdiction over me for all disputes arising in connection with this Agreement.
I have read and understand the information provided above. I have the right to discuss any and all of this information with my treating therapist and to have any questions I may have regarding my treatment answered to my satisfaction.
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 INFORMATION. PLEASE REVIEW IT CAREFULLY.
I am required by law to maintain the privacy of your protected health information and to provide you with this Notice of Privacy Practices (“Notice”) of my legal duties and privacy practices with respect to your protected health information.
The Health Insurance Portability and Accountability Act (HIPAA) is a federal law that provides privacy protection with regard to the use and disclosure of your clinical records (also known as your Protected Health Information or PHI) for the purposes of treatment, payment, and health care operations. This describes the ways in which I may use and disclose your PHI. It also describes your rights and my legal obligations with respect to your PHI.
I reserve the right to change the privacy policies and practices described in this Notice. Unless I notify you by mail of changes, I am required to abide by the terms in this Notice.
EXPLANATION OF USES AND DISCLOSURES:
1. For treatment: I may use and disclose your PHI to provide you with treatment and related services. For example, in order to provide the best possible clinical care for my clients, I may seek professional consultation, such as with your physician. Any other professional with whom I discuss clinical information with is also legally bound to keep the information confidential.
2. For Payment: I may use and disclose your PHI to bill and receive payment for the treatment and services I provide. For example, I may inform your insurance company upon your request to obtain the appropriate approvals and/or to confirm coverage for your treatment.
3. For Health Care Operations: I may also use and disclose your PHI as necessary to operate my practice. For example, I may use and disclose your PHI:
• To review and improve the quality of care you receive;
• To my lawyers, consultants, accountants, and other business associates, including, without limitation, my telecommunications provider (currently, CounSol) to allow me to communicate through written messaging, video and instant message sessions;
• To organizations that evaluate, certify or license me;
• If I sell my practice or merge with another health care entity; and
• To send you appointment reminders.
4. Treatment of Couples: In the treatment of couples, both clients must consent to the release of treatment records. When consent is not given, records will only be released with a court order.
5. Treatment of Minors: Clients under 18 years of age who are not emancipated should be aware that the law may allow both parents the right to examine their treatment records. Privacy in psychotherapy is very important to the success of treatment and I will likely ask parents to respect the need for confidentiality in their child’s therapy relationship. Under most circumstances, some parental involvement in a child’s treatment is essential to successful therapy outcomes. When children are age 12 or older, I will request that an agreement be made between my client and parent(s) to share general information about treatment progress and compliance with scheduled appointments. Other communication about what is shared in session between the child and me will require the child’s authorization. An exception to this agreement would be if I feel that the child may be in danger or is a danger to someone else, in which case, parents will be notified of the concern. I will do my best to discuss these kinds of concerns with the child beforehand if this type of disclosure to a parent becomes necessary.
6. Uses and Disclosures Requiring Authorization: With some limited exceptions, I need to obtain your authorization before releasing your Psychotherapy Notes—notes I have made about your conversations during a counseling session, which may be kept separate from the rest of your record. These notes are given a greater degree of protection than other PHI. You may revoke all such authorizations at any time, provided each revocation is in writing. You may not revoke an authorization to the extent that (1) I have already released information based on that authorization; or (2) if the authorization was obtained as a condition of obtaining insurance coverage, and the law provides the insurer the right to contest the claim under the policy.
I MAY ALSO USE AND DISCLOSE YOUR PHI WITHOUT YOUR AUTHORIZATION IN LIMITED SITUATIONS.
The following are situations in which I may use or disclose your PHI without your written authorization or an opportunity for you to agree or object, as described below.
- As Required by Law: I may disclose your PHI when required to do so by federal, state or local law or other judicial or administrative proceedings.
- Emergencies: If a client threatens to harm herself/himself, I may be obligated to seek hospitalization for her/him, or to contact family members or others who can provide protection. In addition, if a client communicates an immediate threat of serious physical harm to an identifiable victim, I may be required to take protective actions. These actions may include notifying the potential victim, contacting the police, or seeking hospitalization for the patient.
- Individuals Involved in Your Care or Payment for Your Care: Unless you object, I may disclose PHI about you to a family member, relative, close personal friend or any other person you identify, including clergy, who is involved in your care. These disclosures are limited to information relevant to the person’s involvement in your care or in payment for your care.
- Reporting Victims of Abuse or Neglect: In the event that a client discloses information that provides evidence of current abuse including neglect of a minor child, or a disabled or elderly adult, the law requires that I report this to the appropriate state agency.
- Health Oversight Activities: When authorized by law, I may disclose your PHI to a health oversight agency for activities, such as audits, investigations, inspections, licensure actions or other legal proceedings. A health oversight agency is a state or federal agency that oversees the health care system.
- Judicial and Administrative Proceedings: If a client files a complaint or lawsuit against me, I may disclose relevant information regarding that client in order to defend myself. In addition, I may disclose your PHI in response to a court or an administrative order. In certain circumstances, I also may disclose PHI in response to a subpoena, a discovery request, or any other lawful process by another party involved in the action. I will make a reasonable effort to inform you about the request.
- Law Enforcement: I may disclose your PHI for certain law enforcement purposes, such as: reports required by law; identifying or locating a suspect or missing person, material witness or fugitive; and answering certain requests for information concerning crimes, about the victim of crimes.
- Military and Veterans: If you are a member of the armed forces, I may use and disclose your PHI as required by military command authorities. I may also disclose your PHI to the appropriate foreign military authority if you are a member of a foreign military.
- National Security and Intelligence Activities: I may disclose PHI to authorized federal officials conducting national security, counterintelligence, and intelligence activities authorized by law. I may also disclose your PHI to authorized federal officials, as needed, to provide protection to the President of the United States, other authorized persons, foreign heads of states or to conduct certain special investigations.
- Workers’ Compensation: If I am providing treatment for conditions directly related to worker’s compensation claim, I may have to submit such records, upon appropriate request, to the Chairman of the Worker’s Compensation Board on such forms and at such times as the Chairman may require.
YOUR RIGHTS
You have the following rights regarding your PHI that I maintain:
1. The Right to Access Your PHI: Except under limited circumstances, and upon written request, you have the right to inspect and obtain a copy of your PHI. Under current New York law, I may charge you no more than 75 cents per page, plus first-class postage, if I make a copy of your medical record. To inspect and request a copy of your PHI, you should submit your written request to me. I must respond to your request within 30 days, by either supplying the records or sending a written notification of denial. If you are denied access to your PHI, in some cases you will have the right to request a review of this denial. The review will be performed by a licensed health care professional designated by me, who did not participate in the original decision to deny access.
2. The Right to Request Restrictions: You have the right to request a restriction on the way I use or disclose your PHI for treatment, payment or health care operations. You also have the right to request restrictions on the PHI that I disclose about you to a family member, friend or other person involved in your care or the payment of your care. If you wish to request such a restriction, you should submit your written request to me. You must tell me what information you want restricted, to whom you want the information restricted, and whether you want to limit my use, disclosure or both.
Generally, I am not required to agree to such a restriction. If I do agree to the restriction, I will honor that restriction except as needed to provide you with emergency treatment.
I am required to honor your requested restriction that I withhold PHI from your insurance plan, subject to you paying for the services you do not wish disclosed, and other specific details. If you wish to request such a restriction, please let me know immediately. I will provide you with additional details on how to obtain this restriction. Be advised, Medicaid may not allow you to make this request.
3. The Right to Request Confidential Communications: You have the right to request that I communicate with you concerning your health matters in a certain manner or at a certain location. For example, you can request that I contact you only at a certain phone number or a specific address. You should submit your written request for confidential communications to me. You must tell me how and where you want to be contacted. I will accommodate your reasonable requests, but may deny the request if you are unable to provide me with appropriate methods of contacting you.
4. The Right to Request an Amendment: You have the right to request that I amend medical or billing records, or other PHI maintained by me, for as long as the information is kept by me. Your request must be made in writing and must explain the reasons for the requested amendment. I may deny your request for amendment if the information: was not created by me (unless you prove the creator of the information is no longer available to amend the record); is not part of the records maintained by me; in my opinion, is information that is accurate and complete; and is information to which you do not have a right of access.
I must respond to your request within 60 days of receiving the request. If I agree to the amendment, I will notify you and amend the relevant portions of your medical record. I will also make a reasonable effort to inform business associates and other individuals known to me, or identified by you, as having the PHI being amended.
If I deny your request for amendment, I will give you a written denial notice, including the reasons for the denial and explain to you that you have the right to submit a written statement disagreeing with the denial. Your statement of disagreement will be attached to your medical record. If you should submit a statement of disagreement, I have the right to insert a rebuttal statement into the medical record. I will provide you with a copy of the rebuttal statement. If you do not wish to submit a statement of disagreement, you may request that a copy of the amendment request and a copy of my denial be included with all future disclosures.
Should I deny your request for an amendment, you have the right to pursue a complaint process by contacting the Secretary of Health and Human Services to lodge your complaint.
If you wish to request an amendment, you should submit the request to me in writing.
5. The Right to An Accounting of Disclosures: You have the right to request an accounting of certain disclosures of your PHI. You may request an accounting of disclosures made up to six (6) years before the date of your request. An accounting is a listing of disclosures made by me or by others on my behalf, but does not include: disclosures made for treatment, payment and health care operations; disclosures made directly to you, that you authorized, or those which are made to individuals involved in your care; disclosure made to correctional institutions or law enforcement official about an inmate in custody; disclosure made for national security or intelligence purposes; disclosure of a limited data set; or an incidental disclosure.
You must submit your request for an accounting of disclosures to me in writing. You must state the time period for which you would like the accounting. I must respond to you 60 days after receipt of your request. The accounting will include the disclosure date, the name, address (if known) of the person or entity that received the information, a brief description of the information disclosed, and a brief statement of the purpose of the disclosure. If you request a listing of disclosures more than once within a 12-month period, I will charge you a reasonable fee for the accounting. The first accounting, within a 12-month period, is provided to you at no charge.
6. The Right to a Paper Copy of This Notice: You have the right to obtain a paper copy of this Notice, even if you have agreed to receive this Notice electronically. You may request a copy of this Notice at any time by contacting my office in writing or by phone.
7. Right to Be Notified of a Breach of Unsecured PHI. You have the right to be notified in the event there is a breach of your unsecured PHI. While I never expect this to happen, if it does, I will contact you (usually by mailing a letter, but I might also call you) to explain what happened, and provide you with additional details and I will let you know that who you can call at my office for more information.
8. Right to request restrictions as a self-pay patient. You have the right to restrict certain disclosures of health information to a health plan if you pay for a service in full and out of pocket. If you choose to restrict any information under this circumstance, you must submit your request in writing to laurafedericotherapy@gmail.com.
COMPLAINTS
If you believe I have violated your privacy rights, or you disagree with a decision I made about access to your records, you have the right to file a complaint in writing with me and/or with the Secretary of Health and Human Services at 200 Independence Avenue, S.W. Washington, D.C. 20201 or by calling (202) 619-0257. You may also contact the New York Professional Misconduct Enforcement System at 1-800-442-8106 or conduct@mail.nysed.gov. I will not retaliate against you for filing a complaint.
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