Notification of Supervision Status

This notice is to inform you that Bunny Sumner Young, MA, QMHP is currently receiving supervision to become a Licensed Professional Counselor.

I provide individual and/or group supervision in accordance to the Regulations Governing the Practice of Professional Counseling by the Virginia Board of Counseling.

Supervisee is a Qualified Mental Health Professional based on the regulations of the Department of Behavioral Health and Developmental Services and a Resident in Counseling approved by the Virginia Board of Counseling.

Should you have any questions or concerns regarding the services please feel free to contact me at:

Clinical Supervisor:

Name: Adina Silvestri, EdD, LPC

Address:
8100 Three Chopt Rd. Ste. 148
Richmond, VA, 23229
Telephone: 804-536-9143

Outpatient Services Agreement

Welcome to my practice. This document contains important information about my professional services and business
policies. It also contains summary information about the Health Insurance Portability and Accountability Act (HIPAA), a
federal law that provides new privacy protections and new patient rights with regard to the use and disclosure of your
Protected Health Information (PHI) used for the purposes of treatment, payment, and health care operations. HIPAA
requires that I provide you with a HIPAA Privacy Practices Form that explains HIPAA and its application to your personal health information in greater detail. The law requires that I obtain your signature acknowledging that I have provided you with this information at the end of our first session. Although these documents are long and complex, it is very important that you read them all before our next session. Please note any questions that you might have so that we can discuss them further. After reading this outpatient services agreement, your signature indicates a binding agreement between us. You may revoke this Agreement in writing at any time.

Counseling Services
Counseling is not easily described in general statements. It varies depending on the personality of both the therapist and the client and the particular problems that the client brings. There are a number of different approaches that can be utilized to address the problems you hope to address. In order for therapy to be most successful, you will be asked to work on things we talk about both during our sessions and at home.

Therapy has both benefits and risks. Risks sometimes include experiencing uncomfortable feelings such as sadness, guilt, anxiety, anger, and frustration as well as sometimes discussing unpleasant aspects of your life. Therapy has also been shown to have positive benefits for those undertake it. It often leads to significant reduction of feelings of distress, better relationships, and resolutions of specific problems. There are no guarantees that this will happen but it is the goal of the therapy process.

During our first session, I will be asking you questions about what brings you in, what your goals are, and information about your past & current history. I usually take notes during this initial session (but not in later sessions) so that I can prepare an intake summary and begin working with you on establishing treatment goals. By the end of this initial session, I will be able to offer you some impressions of what our work might include if you decide to continue.

You should evaluate this information along with your own assessment about whether you feel comfortable working with me. Therapy involves a large commitment of time, money, and energy, so you should be very careful about the therapist that you select. If you have questions about my procedures, please ask me whenever they arise. If your doubts persist, I will be happy to help you to secure an appropriate consultation with another mental health professional.

Meetings/Missed Session Fee
If we do decide to continue to meet for therapy sessions, I will schedule sessions as your needs require. Once each
appointment time has been scheduled, you are expected to pay a missed session fee unless you provide 24- hour advance notice of cancellation. Missed sessions cannot be billed under insurance.


Professional Fees
I accept a varying list of insurances. If I do not take your insurance, I will discuss payment options with you during our initial phone contact. In either case, you will be made aware of approximately what type of fee or insurance co-pay will be charged for each session. Generally, I charge a fee equal to the amount of your co-pay-fee if 24-hour notice of cancellation is not provided. Other professional services such as report writing, SSD reports, attendance at meetings with other professionals (that you have requested & authorized), or preparation of records or treatment summaries may incur a fee for my time.

Occasionally, clients, either during therapy or after, are in legal situations where our work together may be considered relevant. If I am called to court to testify, I will ask that you assume financial responsibility for my preparation time as well as court & legal fees that may be incurred (even if I am compelled to testify by another party). See attached Payment Policies for a complete list of charges.

Billing & Payment
I will expect you to pay for each session by cash, check or credit card at the beginning of each meeting, unless we have agreed otherwise or unless your insurance coverage pays for the session in full. I do not routinely bill for sessions. Payment schedules for other professional services will be agreed to at the time these services are requested. In circumstances of financial hardship, I may be willing to negotiate a fee adjustment or installment payment plan.

If your account becomes more than 60 days in arrears and suitable arrangements for payment have not been agreed to, I have the options of: 1) adding an additional fee for late payment, 2) using a collection agency, or 3) using legal means to secure payment. If such legal action is necessary, the costs of bringing that proceeding will be included in the claim. I will inform you prior to sending your information (usually name, nature of services provided and amount due) to another source.

Insurance Reimbursement
If you have a health insurance policy, I will facilitate your receipt of the benefits to which you are entitled including filling out forms and speaking with insurance representatives. You will be held responsible for full payment of our agreed upon fee should your insurance company deny benefits or should your coverage lapse. Therefore, it is very important that you find out exactly what benefits your insurance policy covers. Read your plan carefully and call your provider if you have questions.

Many insurance plans require advance authorization before they will provide reimbursement for my services. These plans often are oriented toward a short-term model and provide only a certain amount of sessions per year. Many insurance companies may only authorize a few sessions at a time and I will need to periodically call them to authorize additional sessions.

When I call to authorize treatment or continue our sessions, I will provide them with the minimum amount of information
needed, usually including a diagnosis, goals for treatment, and a brief summary of your current functioning. It is possible, but very rare, that they would require a copy of my clinical record. This information will become part of insurance company files and is likely to be computerized. All insurance companies claim to keep such information confidential, but once it is in their hands, I have no control over what they do with it. In some cases, they may share the information with a national medical information data bank. By signing this Agreement, you agree that I can provide requested information to your insurance carrier.

If you request it, I will provide you with a copy of any report that I am asked to submit. I make it my policy to inform you
along the way of where we stand with your insurance company and what kind of information they have requested. Should your insurance coverage end for some reason, we can discuss an out-of-pocket session fee. You can always choose to select this option and have the right to pay for my services yourself to avoid the complexities of the insurance industry.

Contacting Me
I am only in the office on specific days. Since this is the case, I am often not immediately available by telephone. To reach me, call (804) 536-9143. Leave a message in my confidential voicemail. Leave your name, phone number, and how I can reach you. Remove any call blocking devices until I return the call. I usually check my voice mail 1-2 times per day during the business week. I will make every effort to return your call the same day or early the following business day. If we have difficulty reaching each other, please leave times when I can reach you and alternative phone numbers.

If you are experiencing a clinical emergency call me directly. If I am available, I will call you back as soon as possible. If you are in crisis and cannot reach me or wait for me to return your call, you should call your family physician, psychiatrist, or Crisis Services (a 24-hour crisis hot-line with counselors that can insure your safety or talk to you about the crisis).

If I know that I will be out of town for an extended period of time, I will have another counselor designated to be on-call for me in crisis situations. If you feel that you might potentially utilize these crises options, please let me know during our session so that we can develop a comprehensive crisis plan.

Professional Records
Both the legal and professional standards of my job require that I keep Protected Health Information about you in your
Clinical Record. Except in situations where you are a danger to yourself (or others) or where others have supplied information to me confidentially, you may examine and/or receive a copy of your Clinical Record. This request must be made in writing. Because they are professional records, they can be misinterpreted or upsetting to lay readers. If you wish to see your records, I recommend that you review them in my presence so that we can discuss the contents. If you would like me to copy your records for you, I will charge a copying fee of one dollar per page.

Patient Rights
Please see attached HIPAA Privacy Practices Form for a listing of your rights.

Minors & Parents
State law gives children of any age the right to independently consent to and receive mental health treatment without parental consent if they request it and if it is determined that such services are necessary and requiring parental consent would have a detrimental effect on the course of the child’s treatment. Even where parental consent is given, children over the age of 12 have a right to control access to their treatment records. If you are age 13 or older, I will request an agreement from your parents that they consent to allow me to maintain your confidentiality. If they agree, I will provide them only with general information about our work together unless I feel that there is a high risk that you will seriously harm yourself, harm another, or are in an abusive situation. In these situations, I will notify them of my concerns about your safety. If they request it, I will provide them with a summary of your treatment when it is complete. Before giving them any information, I will discuss the matter with you (if possible), and will do the best I can to resolve any objections you may have about what I am prepared to discuss with your parents.

Couples
If you are coming for couple’s therapy, be advised that I do keep your records together. Should any given situation require that I submit records to a third party, both members of the couple will need to give permission for mutual information to be released. I will make every effort to discuss the material to be released with you prior to taking action on any request.

Confidentiality
I take the matter of confidentiality quite seriously. The confidentiality of all communications between a client and a counselor is protected by law and I can only release information about our work together with others if you sign a written Authorization form that meets certain legal requirements imposed by HIPAA. There are some situations that require only your advance consent. Your signature on this Agreement provides consent for the following activities:

• Occasionally, I may consult with other professionals about strategies or resources that may benefit you. I make every effort to avoid revealing the identity of my clients and often change identifying information in my description. The consultant is, of course, also legally bound to keep the information confidential. Unless you object, I will not tell you about these consultations unless I feel it is important to our work together. I will note all consultations in your Clinical Record.

• You should be aware that a secretary at my office might have access to your name or phone number if I need to reach you. All mental health professionals are bound by the same rules of confidentiality. All therapists and staff at this location have agreed not to release any client information unless specifically instructed to by the
appropriate mental health professional.

There are some situations where I am permitted or required to disclose information without either your consent or authorization:

♦ In most legal situations, you have the right to decline permission for me to release any information about your treatment. In some circumstances (like child custody proceedings and situations where your emotional health is relevant), a judge may require my testimony if he/she determines that resolution of the issues demands it. As I am not trained in testifying in legal situations, I may not be the right therapist to help you in a court case. Please notify me if you have reason to believe that our work together might be relevant in current or future legal proceedings.

♦ Legally, I am required to take action to protect others from harm even if it means revealing some information about a
client’s treatment. If I believe that a child, elderly person, or disabled person is being abused, I must report this to the
appropriate state agency.

♦ If I believe that a client is threatening serious bodily harm to another, I am required to take protective actions that may
include: notifying the potential victim, calling the police, or seeking appropriate hospitalization. If a client threatens to
harm him/herself, I am required to seek hospitalization for the client or to contact family members or others who can
help provide protection.

♦ If a government agency is requesting the information for health oversight activities, I may be required to provide the
requested information. Examples include: public health authorities, coroner or medical examiner, military/veteran’s affairs agencies, law enforcement, or for national security purposes.

♦ If a client files a complaint or lawsuit against me, I may disclose relevant information regarding that client to defend
myself.

♦ Worker’s compensation cases may require records to be submitted to the Chairman of the Worker’s Compensation Board.

These situations are quite rare in my practice. Should such a situation occur, I do make every effort to discuss with you my intended actions prior to making any disclosures.

I have read and understand the above information. My signature indicates that I agree to abide by
the terms of this Agreement during our professional relationship.

HIPAA PRIVACY PRACTICES NOTICE FORM
Notice of Policies and Practices to Protect the Privacy of Your Health Information

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

I. Uses and Disclosures for Treatment, Payment, and Health Care Operations
I may use or disclose your protected health information (PHI), for treatment, payment, and health care operations purposes with your consent. To help clarify these terms, here are some definitions:
• “PHI” refers to information in your health record that could identify you.

• “Treatment, Payment and Health Care Operations”

–Treatment is when I provide, coordinate or manage your health care and other services related to your health care. An example of treatment would be when I consult with another health care provider, such as your family physician or another counselor.

-Payment is when I obtain reimbursement for your healthcare. Examples of payment are when I
disclose your PHI to your health insurer to obtain reimbursement for your health care or to determine eligibility or coverage.

-Health Care Operations are activities that relate to the performance and operation of my practice. Examples of health care operations are quality assessment and improvement activities, business-related matters such as audits and administrative services, and case management and care coordination.

• “Use” applies only to activities within my [office, clinic, practice group, etc.] such as sharing, employing, applying, utilizing, examining, and analyzing information that identifies you.

• “Disclosure” applies to activities outside of my [office, clinic, practice group, etc.], such as releasing, transferring,or providing access to information about you to other parties.

II. Uses and Disclosures Requiring Authorization
I may use or disclose PHI for purposes outside of treatment, payment, and health care operations when your appropriate authorization is obtained. An “authorization” is written permission above and beyond the general consent that permits only specific disclosures.

In those instances when I am asked for information for purposes outside of treatment, payment and health care operations,I will obtain an authorization from you before releasing this information. I will also need to obtain an authorization before releasing your psychotherapy notes. “Psychotherapy notes” are notes I have made about our conversation during a private, group, joint, or family counseling session. These notes are given a greater degree of protection than PHI. I will need authorization.

You may revoke all such authorizations (of PHI or psychotherapy notes) at any time, provided each revocation is in writing. You may not revoke an authorization to the extent that (1) I have relied 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.

In these cases, I may not share information unless you give me permission: 1) Marketing purposes 2) Most sharing of psychotherapy notes 3) Share information with your family, friends, or others involved in your case 4) Share information in a disaster relief case.

III.Uses and Disclosures with Neither Consent nor Authorization
I may use or disclose PHI without your consent or authorization in the following circumstances:

• Child Abuse: If, in my professional capacity, a child comes before me which I have reasonable cause to suspect is an abused or maltreated child, or I have reasonable cause to suspect a child is abused or such abuse or maltreatment to the statewide central register of child abuse and maltreatment, or the maltreated where the parent, guardian, custodian other person legally responsible for such child comes before me in my professional or official capacityand states from personal knowledge facts, conditions or circumstances which, if correct, would render the child an abused or maltreated child, I must report local child protective services agency.

• Health Oversight: If there is an inquiry or complaint about my professional conduct to the Commission On Rehabilitation Counselor Certification, I must furnish to the Commission, your confidential mental health records relevant to this inquiry.

Judicial or Administrative Proceedings: If you are involved in a court proceeding and a request is made for information about the professional services that I have provided you and/or the records thereof, such information is privileged under state law, and I must not release this information without your written authorization,or a court order. This privilege does not apply when you are being evaluated for a third party or where the evaluation is court ordered. I must inform you in advance if this is the case.

• Serious Threat to Health or Safety: I may disclose your confidential information to protect you or others from a serious threat of harm by you.

• Worker’s Compensation: If you file a worker’s compensation claim,and Iam treating you for the issues involved with that complaint, then I must furnish to the chairman of the Worker’s Compensation Board records, which contain information regarding your psychological condition and treatment.

• Health Research: I may disclose your information for health research.


IV. Patient’s Rights and Counselor’s Duties
Patient’s Rights:
• Right to Request Restrictions – You have the right to request restrictions on certain uses and disclosures of protected health information about you. However, I am not required to agree to a restriction you request.

• Right to Receive Confidential Communications by Alternative Means and at Alternative Locations – You have the right to request and receive confidential communications of PHI by alternative means and at alternative locations. (For example, you may not want a family member to know that you are seeing me. upon your request, I will send your bills to another address.)

• Right to Inspect and Copy – You have the right to inspect or obtain a copy (or both) of PHI and psychotherapy notes in my mental health and billing records used to make decisions about you for as long as the PHI is maintained in the record. I may deny your access to PHI under certain circumstances, but in some cases, you may have this decision reviewed. On your request, I will discuss with you the details of the request and denial process.

• Right to Amend – You have the right to request an amendment of PHI for as long as the PHI is maintained in the record. I may deny your request. On your request, I will discuss with you the details of the amendment process.

• Right to an Accounting – You generally have the right to receive an accounting of disclosures of PHI for which you have neither provided consent nor authorization (as described in Section III of this Notice). On your request, I will discuss with you the details of the accounting process.


• Right to a Paper Copy – You have the right to obtain a paper copy of the notice from me upon request, even if you have agreed to receive the notice electronically.

Counselor’s Duties:
• I am required by law to maintain the privacy of PHI and to provide you with a notice of my legal duties and privacy practices with respect to PHI.
• I reserve the right to change the privacy policies and practices described in this notice. Unless I notify you of such changes, however, I am required to abide by the terms currently in effect.
• If I revise my policies and procedures, I will provide you with an updated copy if you are still in therapy with me. If we have ended therapy, you may request an updated copy to be sent to you by mail.

V. Complaints
If you are concerned that I have violated your privacy rights, or you disagree with a decision I made about access to your records, please speak with me about your concerns. If you do not feel comfortable doing this, you may call the LPC licensing board in your area.

VI. Effective Date, Restrictions and Changes to Privacy Policy
This policy is in effect on September 20, 2013. I reserve the right to change the terms of this notice and to make the new notice provisions effective for all PHI that I maintain. I will provide you with a revised notice by providing you with a paper copy at our next session from the date of revision. If you are no longer in therapy, I will provide a revised notice only at your written request.

Under the Health Insurance Portability and Accountability Act of 1996 (HIPAA), you have certain rights regarding the use and disclosure of your protected health information. By checking the box below, you are acknowledging that you have received a copy of HIPPA Notice of Privacy Practices.

List of Charges

Psychotherapy: 60 Minutes ………...$100.00 Group Therapy……….............variable
Initial Diagnostic Evaluation………...$125.00 Consultations (per hour) $100.00
Psychotherapy: 45 Minutes ………... $75.00 Court Appearance………...see below
Employee Assistance Programs…….By Contract Letters to courts, attorneys, schools
Resident Fees………………………………$60.00 etc…………………………………$50.00

Payment Policies

1. Insurance companies do not reimburse for missed appointments. Therefore, there will
Be a $100.00 charge for missed appointments unless Adina Silvestri is notified at least 24 hours prior to the appointment. This charge will be waived in the event of an emergency or illness. A cancelled appointment will not be accepted via text message as it will not be received. There is also a $25.00 returned check fee for checks written with insufficient funds. If chart files need to be copied, there is a fee of $1.00 per page plus mailing costs.

2. If consultation with the legal system is requested or required as a result of services
Provided to you or your child, you will assume the expenses associated with the time Involved. Court appearance cost includes travel, preparation, and total time spent at the courthouse. It also includes time lost at the office if the court hearing is canceled on short notice, Court appearances are charged at a minimum of $500.00 which includes the first 3 hours of time. There is an additional charge of $150.00 per hour when more than 3 hours of time is required. The fee of $500.00 is due fourteen (14) days in advance of the court date. For contact with others involved in legal proceedings (e.g. attorneys, CASA workers, guardians ad litem, social services, court appointed evaluators, judges) the cost is $100.00 per hour, billed by the quarter hour. Brief contact with those involved in legal proceedings will not result in a charge.

3. Most insurance companies will reimburse a percentage of the cost of services. We will file your insurance claims as a courtesy to you. Please be aware, however, that you, not the insurance company, are ultimately responsible for payment of all charges. By agreeing to these Payment Policies, you agree to be responsible for paying for all services provided. Please have your insurance card available on your first visit to verify coverage. Unless other arrangements are made, your co-pays (and deductible, if applicable) should be made at the time of each visit.

I HAVE READ THIS FORM EXPLAINING PAYMENT POLICIES AND AGREE TO ABIDE BY THESE CONIDITONS OUTLINED.

List of Charges

Psychotherapy: 60 Minutes ………...$125.00 Group Therapy……….............variable
Initial Diagnostic Evaluation………...$150.00 Consultations (per hour).......$125.00
Psychotherapy: 45 Minutes ………...$100.00 Court Appearance………..........see below
Employee Assistance Programs…….By Contract Letters to courts, attorneys, schools
Resident Fees………………………………..$60.00 etc…………………………………$50.00

Payment Policies

1. Insurance companies do not reimburse for missed appointments. Therefore, there will Be a $125.00 charge for missed appointments unless Adina Silvestri is notified at least 24 hours prior to the appointment. This charge will be waived in the event of an emergency or illness. A cancelled appointment will not be accepted via text message as it will not be received. There is also a $25.00 returned check fee for checks written with insufficient funds. If chart files need to be copied, there is a fee of $1.00 per page plus mailing costs.

2. If consultation with the legal system is requested or required as a result of services
Provided to you or your child, you will assume the expenses associated with the time Involved. Court appearance cost includes travel, preparation, and total time spent at the courthouse. It also includes time lost at the office if the court hearing is canceled on short notice, Court appearances are charged at a minimum of $500.00 which includes the first 3 hours of time. There is an additional charge of $150.00 per hour when more than 3 hours of time is required. The fee of $500.00 is due fourteen (14) days in advance of the court date. For contact with others involved in legal proceedings (e.g. attorneys, CASA workers, guardians ad litem, social services, court appointed evaluators, judges) the cost is $125.00 per hour, billed by the quarter hour. Brief contact with those involved in legal proceedings will not result in a charge.

3. Most insurance companies will reimburse a percentage of the cost of services. We will file your insurance claims as a courtesy to you. Please be aware, however, that you, not the insurance company, are ultimately responsible for payment of all charges. By agreeing to these Payment Policies, you agree to be responsible for paying for all services provided. Please have your insurance card available on your first visit to verify coverage. Unless other arrangements are made, your co-pays (and deductible, if applicable) should be made at the time of each visit.

I HAVE READ THIS FORM EXPLAINING PAYMENT POLICIES AND AGREE TO ABIDE BY THESE CONDITIONS OUTLINED.