After reviewing the policies(this is long, but read it all, please!) please begin the intake. There is no feel for the intake, and it is part of the free consultation for both of us to begin the process of seeing if we are an appropriate fit. *You will also find the intake embedded directly into this page at the bottom, with the calendar also available for you to book. Only those who have filled out the survey and who have been accepted in writing as a client may schedule sessions.
THERAPY vs COACHING
For the most part, I am coaching you, using therapeutic strategies from various modalities such as DBT, CBT, Art Therapy, and more, unless you are a trauma client or I am working with you with your team of medical and psychiatric professionals.
By reading this page and
completing the intake survey,
you are agreeing to the terms in full.
THIS NOTICE DESCRIBES HOW YOUR PROTECTED HEALTH INFORMATION (PHI) ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION.
PLEASE REVIEW THIS NOTICE CAREFULLY.
Your health record contains personal information about you and your health. This information about you that may identify you and that relates to your past, present or future physical or mental health or condition and related health care services is referred to as Protected Health Information (“PHI”). This Notice of Privacy Practices describes how we may use and disclose your PHI in accordance with applicable law, including the Health Insurance Portability and Accountability Act (“HIPAA”), regulations promulgated under HIPAA including the HIPAA Privacy and Security Rules, and the Code of Ethics by Oregon Licensed board of Professional Counselors and Therapists. It also describes your rights regarding how you may gain access to and control your PHI.
We are required by law to maintain the privacy of PHI and to provide you with notice of our legal duties and privacy practices with respect to PHI. We are required to abide by the terms of this Notice of Privacy Practices. We reserve the right to change the terms of our Notice of Privacy Practices at any time. Any new Notice of Privacy Practices will be effective for all PHI that we maintain at that time. We will provide you with a copy of the revised Notice of Privacy Practices by posting a copy on our website, sending a copy to you in the mail upon request or providing one to you at your next appointment.
For Treatment. Your PHI may be used and disclosed within our practice (Paiva Psych/Michele Paiva), by those who are involved in your care for the purpose of providing, coordinating, or managing your health care treatment and related services. This includes consultation with clinical supervisors or other treatment team members. We will disclose PHI to any other consultant only with your authorization. If you are working with Michele Paiva, there is no other individual that would have access. If you are working with The Brave Girl, you give Alexandria Kochinsky access. For this reason everything is stated as “we”.
For Payment. For those that this pertains, we may use and disclose PHI so that we can receive payment for the treatment services provided to you. This will only be done with your authorization. Examples of payment-related activities are: making a determination of eligibility or coverage for insurance benefits, processing claims with your insurance company, reviewing services provided to you to determine medical necessity, or undertaking utilization review activities. If it becomes necessary to use collection processes due to lack of payment for services, we will only disclose the minimum amount of PHI necessary for purposes of collection.
For Health Care Operations. We may disclose your PHI to facilitate the efficient and correct operation of our practice. Example: We may provide your PHI to our attorneys, accountants, consultants, and others to make sure that we are in compliance with applicable laws.
Required by Law. Under the law, we must disclose your PHI to you upon your request. In addition, we must make disclosures to the Secretary of the Department of Health and Human Services for the purpose of investigating or determining our compliance with the requirements of the Privacy Rule.
Without Authorization. Following is a list of the categories of uses and disclosures permitted by HIPAA without authorization. Applicable law and ethical standards permit us to disclose information about you without your authorization only in a limited number of situations.
- Child Abuse or Neglect. We may disclose your PHI to a state or local agency that is authorized by law to receive reports of child abuse or neglect.
- Judicial and Administrative Proceedings. We may disclose your PHI pursuant to a subpoena (with your written consent), court order, administrative order or similar process.
- Deceased Patients. We may disclose PHI regarding deceased patients as mandated by state law, or to a family member or friend that was involved in your care or payment for care prior to death, based on your prior consent. A release of information regarding deceased patients may be limited to an executor or administrator of a deceased person’s estate or the person identified as next-of-kin. PHI of persons that have been deceased for more than fifty (50) years is not protected under HIPAA.
- Medical Emergencies. We may use or disclose your PHI in a medical emergency situation to medical personnel only in order to prevent serious harm. Our staff will try to provide you a copy of this notice as soon as reasonably practicable after the resolution of the emergency.
- Family Involvement in Care. We may disclose information to close family members or friends directly involved in your treatment based on your consent or as necessary to prevent serious harm.
- Health Oversight. If required,we may disclose PHI to a health oversight agency for activities authorized by law, such as audits, investigations, and inspections. Oversight agencies seeking this information include government agencies and organizations that provide financial assistance to the program (such as third-party payers based on your prior consent) and peer review organizations performing utilization and quality control.
- Law Enforcement. We may disclose PHI to a law enforcement official as required by law, in compliance with a subpoena (with your written consent), court order, administrative order or similar document, for the purpose of identifying a suspect, material witness or missing person, in connection with the victim of a crime, in connection with a deceased person, in connection with the reporting of a crime in an emergency, or in connection with a crime on the premises.
- Specialized Government Functions. We may review requests from U.S. military command authorities if you have served as a member of the armed forces, authorized officials for national security and intelligence reasons and to the Department of State for medical suitability determinations, and disclose your PHI based on your written consent, mandatory disclosure laws and the need to prevent serious harm.
- Public Health. If required, we may use or disclose your PHI for mandatory public health activities to a public health authority authorized by law to collect or receive such information for the purpose of preventing or controlling disease, injury, or disability, or if directed by a public health authority, to a government agency that is collaborating with that public health authority.
- Public Safety. We may disclose your PHI ifnecessary to prevent or lessen a serious and imminent threat to the health or safety of a person or the public. If information is disclosed to prevent or lessen a serious threat it will be disclosed to a person or persons reasonably able to prevent or lessen the threat, including the target of the threat.
- Verbal Permission. We may also use or disclose your information to family members that are directly involved in your treatment with your verbal permission. in that moment OR via written permission.
- With Authorization. Uses and disclosures not specifically permitted by applicable law will be made only with your written authorization, which may be revoked at any time, except to the extent that we have already made a use or disclosure based upon your authorization. The following uses and disclosures will be made only with your written authorization: (i) most uses and disclosures of psychotherapy notes which are separated from the rest of your medical record; (ii) most uses and disclosures of PHI for marketing purposes, including subsidized treatment communications; (iii) disclosures that constitute a sale of PHI; and (iv) other uses and disclosures not described in this Notice of Privacy Practices.
If you believe your privacy rights have been violated, you may discuss your concerns with your therapist. You may also deliver a written complaint addressed to your therapist and file a complaint to the U.S. Secretary of Health and Human Services.
YOUR RIGHTS REGARDING YOUR PHI
You have the following rights regarding PHI we maintain about you.
- Right of Access to Inspect and Copy. You have the right, which may be restricted only in exceptional circumstances, to inspect and copy PHI that is maintained in a “designated record set”. A designated record set contains mental health/medical and billing records and any other records that are used to make decisions about your care. Your right to inspect and copy PHI will be restricted only in those situations where there is compelling evidence that access would cause serious harm to you or if the information is contained in separately maintained psychotherapy notes. We may charge a reasonable, cost-based fee for copies. If your records are maintained electronically, you may also request an electronic copy of your PHI. You may also request that a copy of your PHI be provided to another person.
- Right to Amend. If you feel that the PHI we have about you is incorrect or incomplete, you may ask us to amend the information although we are not required to agree to the amendment. If we deny your request for amendment, you have the right to file a statement of disagreement with us. We may prepare a rebuttal to your statement and will provide you with a copy.
- Right to an Accounting of Disclosures. You have the right to request an accounting of certain of the disclosures that we make of your PHI. We may charge you a reasonable fee if you request more than one accounting in any 12-month period.
- Right to Request Restrictions. You have the right to request a restriction or limitation on the use or disclosure of your PHI for treatment, payment, or health care operations. We are not required to agree to your request unless the request is to restrict disclosure of PHI to a health plan for purposes of carrying out payment or health care operations, and the PHI pertains to a health care item or service that you paid for out of pocket. In that case, we are required to honor your request for a restriction.
- Right to Request Confidential Communication. You have the right to request that we communicate with you about health matters in a certain way or at a certain location. We will accommodate reasonable requests. We may require information regarding how payment will be handled or specification of an alternative address or other methods of contact as a condition for accommodating your request. We will not ask you for an explanation of why you are making the request.
- Breach Notification. If there is a breach of unsecured PHI concerning you, we may be required to notify you of this breach, including what happened and what you can do to protect yourself.
- Right to a Copy of this Notice. You have the right to a copy of this notice. you may print or screenshot.
We are required to provide you with a copy of our Notice of Privacy Practices, which states how we may use and/or disclose your health information. Please sign this form to acknowledge receipt of the Notice. You may refuse to sign this acknowledgement if you wish. I acknowledge that I have received a copy of Paiva Psychotherapy/Michele Paiva HIPAA Notice of Privacy Practices.
Telehealth Informed Consent Form
I, consent to receive psychological treatment (or coaching) via telehealth with Michele Paiva, to facilitate both my access to professional services and my treatment goals.
I understand that telehealth services may include evaluation, assessment, consultation,
treatment planning, as well as psychological coaching and counseling. Telehealth will occur primarily through interactive audio, video, telephone and/or other audio/visual
communications. I understand I have the following rights with respect to telehealth:
- I have the right to withhold or remove consent at any time without affecting my right to future
care or treatment.
- The laws that protect the confidentiality of my personal information also apply to telehealth. As such, I understand the information released by me during the course of my sessions is confidential. I also understand that the dissemination of any personally identifiable images or information from the telehealth interaction to other entities shall not occur without my written
- I understand that there are risks and consequences from telehealth including, but not limited to, the possibility, despite reasonable efforts, that technology may fail.
- By signing this document, I agree that certain situations including emergencies and crises are inappropriate for audio, video and/or computer-based psychological or psychiatric services. If I am in crisis or I am experiencing a medical or psychiatric emergency, I should immediately call
911 or go to the nearest hospital or crisis facility.
- By signing this document, I understand that emergency situations may include thoughts about hurting or harming myself or others, having uncontrolled psychotic or manic symptoms,experiencing a life threatening or emergency situation, abusing drugs or alcohol or experiencing
other concerns which may present a risk to your safety.
I have read and understand the above information and agree to participate in telehealth services Michele Paiva.
All fees are prepaid, meaning even if you are in a subscription, you are forwarding a fee for the month or sessions in the future.
Payments are not prorated, transferred or refunded, please contract only what you are willing to commit to.
You will be given a schedule. It is up to you to book your sessions and cancel them if need be, within 24 hours, though I realize that emergencies happen. You are responsible for calling or contacting me via phone, zoom, etc, for your sessions. I do not call or contact clients as this may create a confidentiality/privacy concern.
In the case that I may need to change the schedule, I will offer options. If I need to miss sessions long-term, you will be prorated or refunded.
Social Media: I personally feel that social media is anything but private, so I do not have strong social media policies. That being said, it is up to you if you disclose we are connected via coaching or therapy. I will always refer to you as someone I met in one of my meditation classes.
If we see each other in public, I will not acknowledge you with more than a slight smile and nod. This is not to brush you off but to honor your privacy and personal life. If it up to you to acknowledge me and I will take your lead; the go to is that I taught you meditation techniques. I have had clients in the past who have openly stated “hey this is my therapist” and that is fine also. I go with the flow!
I am thankful that you entrust me with your inner feelings and secrets and repay this with support, respect and confidentiality.