These are rights for all clients receiving services from Equilibrium Counseling Services.

 Equilibrium, LLC DAB Equilibrium Counseling Services provides non-emergency psychotherapeutic services by scheduled appointment. If your counselor believes your psychotherapeutic issues are above their level of competence or outside their scope of practice, they are legally required to refer, terminate, or consult.

• You consent to evaluation and mental health treatment for yourself (or your child). You are aware care & treatment is not an exact science & acknowledge no guarantees have been made to you as to the result of treatment.

• You are entitled to receive information regarding the methods of therapy, techniques used, duration of therapy (if known) & fee structure. You are encouraged to participate in decisions regarding your treatment. Please ask at any time you have questions.

• You have the right to be treated with dignity and respect.

• You are welcome to seek a second opinion from another therapist or terminate therapy at any time.

• It is asked if you choose to terminate services to please let your therapist know.

• In a professional relationship, sexual intimacy between a therapist & a client is never appropriate. If sexual intimacy occurs, it should be reported to the State Grievance Board.

• Generally speaking, the information provided by & to a client during therapy sessions (including but not limited to personal information) is legally confidential, an LPC/ LMFT/ LPCC/ LMFTC cannot be forced to disclose the information without client’s consent. Information disclosed is privileged communication & cannot be disclosed in any court of competent jurisdiction in the State of Colorado without the consent of the person to whom the testimony sought relates.

• You have the right to receive copies of treatment records and your service plan and to ask for your records to be changed if you believe them to be inaccurate or incomplete. Requests will be filled in approximately one week. Please be aware text messages and emails are part of the medical record.

• Others requesting copies of records must have a signed Release of Information, or have a legal exception listed by Colorado statutes (see section 43-219, C.R.S. in particular) and must address additional goals. i.e.. subpoenas, audits, and coordinated care.

• There may be times when your counselor may need to consult with another professional about issues raised in therapy. Your confidentially is still protected during consultation by your counselor & the professional consulted. Signing this disclosure gives permission for your therapist to consult as needed to provide professional services to you as a client.

The following specifies your rights about this authorization under the Health Insurance Portability and Accountability Act of 1996, as amended from time to time (“HIPAA”).

• Tell your counselor if you do not understand this authorization & it will be explained it to you.

• You have the right to revoke or cancel this authorization at any time, except:

• to the extent information has already been shared based on this authorization;
• this authorization was obtained as a condition of obtaining insurance coverage.

To revoke or cancel this authorization, you must submit your request in writing at the following address:

330 N LINCOLN AVE SUITE 108

LOVELAND CO, 80537

You may refuse to sign this authorization. Your refusal to sign will not affect your ability to obtain treatment or payment or your eligibility for benefits.

• Once Protected Health Information about you leaves this office according to the terms of this authorization, this office has no control over how it will be used by the recipient. You need to be aware at that point your information may no longer be protected by HIPAA.

• Various electronic means of communication may be used to treat and/or coordinate treatment. Electronic communication may include, but is not limited to; Simple Practice, cellular phone calls, voice mails, text messages, e-mails, etc. This office’s technological systems support the highest security certificate available. However, no electronic system is 100% guaranteed secure. By signing this form, you acknowledge that you understand the inherent risks associated with electronic communications and release this office from any liability or damages if a breach were to occur.

• Equilibrium, LLC does share billing information with Simple Practice, as they provide insurance billing services for Equilibrium. Your health information is still protected by both Equilibrium and Simple Practice.

•. Your copy of this authorization will be available in your client portal or you may ask for a physical copy.

• Special Instructions for completing this authorization for the use and disclosure of Psychotherapy Notes. HIPAA provides special protections to certain medical records known as “Psychotherapy Notes.” All Psychotherapy Notes recorded on any medium <i.e., paper, electronic> by a mental health professional must be kept by the author and filed separate from the rest of the client’s medical records to maintain a higher standard of protection. Excluded from the “Psychotherapy Notes” definition is the following:

progress to date.

counseling session start and stop times

the modalities and frequencies of treatment furnished

the results of clinical tests

any summary of diagnosis

functional status

treatment plans

symptoms

prognosis