The purpose of this document is to allow you, the client, to make an informed decision about your treatment. Please feel free at any time to ask any questions regarding this form. 

Information about your Therapist: The individual therapist who operates this practice is: Dr. Marci Kyle, DSW, LCSW and is licensed in both the state of California and Arizona California License: LCSW-78555 Arizona License: LCSW-15934 

Formal Education and Training: Dr. Kyle holds a doctoral degree in Social Work from the University of Southern California. In addition, Dr. Kyle holds a Master's Degree in Social Work from Washington University in St. Louis.

Experience: Dr. Kyle has had extensive experience working with teens, families, adults, and older adults as well as having worked with diverse populations such as LGBTQ+, veterans, inmates, and the homeless. Dr. Kyle has proficient knowledge in the fields of addiction, emotional distress, crisis management, adolescent issues and aging adults. Dr. Kyle has also received training to assist the transgender community with documentation required for gender affirming surgery and managing gender dysphoria. 

Dr. Kyle has worked in inpatient and outpatient settings, supervising clinical teams throughout her career. Some of her best experiences have been in the prison setting, using therapeutic techniques for inmates in maximum and minimum security units. Dr. Kyle also has a background in medical social work, assisting patients and their families needing organ transplants as well as oncology patients. Dr. Kyle has opened a counseling center in Arizona and California and has worked extensively with teen females as well as adults. 

Dr. Kyle has been trained in numerous therapeutic styles which include Cognitive Behavioral Therapy (CBT),  Dialectical Behavior Therapy (DBT), Mindfulness Therapy, Solution Focused Behavioral Therapy (SFBT), Eye Movement Desensitization Reprocessing (EMDR), Rational Emotive Behavioral Therapy (REBT), Existential Therapy, Gestalt Therapy, Positive Therapy, Trauma Informed Therapy, and many other modalities. Dr. Kyle does not utilize just one modality as she does not believe in cookie cutter types of treatment, rather, she seeks to individualize the therapeutic experience based on your needs, experiences, and goals. 

Psychological Services: Psychotherapy varies depending on the particular goals of each client. It is your therapists'  intention to provide you with therapeutic recommendations based on the information you provide. As a client, you have the right at any time to refuse treatment, ask for clarification of and/or challenge treatment procedures, understand the goals of therapy, seek a second opinion, and/or terminate therapy. Individual and conjoint (marriage/family) sessions are generally on a regular weekly basis and last approximately 45 minutes, unless otherwise indicated. 

Psychotherapy involves both risks and benefits. There are no guarantees about the treatment outcome. 

Risks Involved: Talking about past or traumatic events may cause emotional distress. You may experience uncomfortable feelings such as sadness, guilt, anxiety, and anger. 

Benefits Involved: You may benefit from the act of sharing your experiences with another person. You may experience a feeling of relief, or find that you have a sense of greater self-knowledge as a result. 

Confidentiality: You have the right to privacy, and all information identifying you will remain confidential, as required by the legal/ethical standards set forth by the Arizona Board of Behavioral Health and the California Board of Behavioral Sciences. All communications that occur with your therapist will be maintained in strict confidence unless you provide written permission to release information about your treatment.  

Exceptions to confidentiality include cases in which there is a risk of imminent danger to yourself or another person, elder/dependent adult abuse, or the physical abuse, sexual abuse or neglect of a child. Under these circumstances, your therapist is legally/ethically bound to report this information to the proper authorities.

Data and related records could also be subpoenaed in a court of law. If you participate in marital or family therapy, your therapist will not disclose confidential information about your treatment unless all persons who participated in the treatment with you provide their written authorization to release such information.

It is important that you know that your therapist uses a "no-secrets" policy when conducting conjoint (marriage/family) therapy. This policy means that if you participate in conjoint (marriage/family) therapy, your therapist is permitted to use information obtained in an individual session that you may have had with her, when working with other members of your family. 

Privacy in Child Therapy: 

California Law: For most types of medical care, parents need to give consent and they can get information about their teen's doctor's visits. But under California law, teens can get private care without parent consent for some "confidential" or "sensitive" visits, such as those for: - Birth control - Pregnancy - Sexually transmitted diseases (for ages 12 and older) - Sexual assault services - Mental health counseling (for ages 12 and older) - Alcohol and drug counseling (for ages 12 and older) 

Arizona Law: Clients under the age of 18 years of age who are not emancipated, and their parents, should be aware that the law may allow parents to examine their child's treatment records. 

Please Consider: One of the major purposes of therapy is to create a safe place for a child(ren) to discuss any topic in a healthy manner. Many children (and more often adolescents) will not open up and reveal information if they are aware that the information will be disclosed. Dr. Kyle requests your child's privacy be honored during the course of therapy unless he or she discloses harmful situations at which time you would need to be involved in treatment for us to discuss how to keep your child safe. 

Experience has shown that revealing therapy notes or the content of conversations can harm the trust relationship between therapist and child(ren). No matter how carefully this is explained, the child(ren) can invariably feel betrayed and may no longer choose to be in therapy with the individual who released the information. Sometimes this breach of trust may have an impact on other relationships as well such as the relationship between the parent(s) and the child(ren).

Records: You have the right to a copy of your records or a summary of your records. Requests must be made in writing. You will be charged a nominal fee for photocopies, $1 per page. 

Fees/Cancellation/No Show Policy: Your fees will be determined prior to treatment. All services through The Lotus Counseling Center are through telehealth. There are no in person visits available. The fee for service is $150 for 45 mins. Payment is required at the time services are rendered. Payments may be by debit/credit card.

If you need to cancel an appointment, you are expected to provide notification at least 24 hours prior to your scheduled appointment. If you do not provide at least 24 hour notification in advance, you will be responsible  for the full fee of the missed session. You will be responsible for payment prior to or on the date of your next scheduled appointment. Failure to do so will result in a cancellation of your next session. A "no show" is considered a missed appointment where your therapist does not receive any communication from you. Additionally, if you are more than 15 minutes late to your therapy session, it will be considered a "no show" and you will be responsible for payment of the missed session.

Therapist Availability and Emergencies: You may leave a message for your therapist at any time on her voicemail. If you wish your therapist to return your call, please be sure to leave your name and phone number, along with a brief message concerning the nature of your call. You should be aware that your therapist is generally available to return phone calls within one business day. 

A temporary break in treatment may be necessary when your therapist is ill, on vacation, or has an emergency situation. You will be notified as early as possible. 

 In case of emergency outside my normal business hours please contact:

California:

CalHOPE Warm Line: 1-833-317-4673 

Crisis Text Line: Text "home" to 741741 

National Suicide Prevention Lifeline: 1-800-273-8255 

The nearest emergency room Call 911 for immediate assistance 

Arizona:

Crisis Response Network: 1-800-631-1314 

Crisis Text Line: Text "home" to 741741 

National Suicide Prevention Lifeline: 1-800-273-8255 

The nearest emergency room Call 911 for immediate assistance 

Health Insurance Portability Accountability Act (HIPAA) 

Client Rights & Therapist Duties 

This document contains important information about federal law, the Health Insurance Portability and Accountability Act (HIPAA), that provides privacy protections and patient rights with regard to the use and disclosure of your Protected Health Information (PHI) used for the purpose of treatment, payment, and health care operations. 

HIPAA requires that I provide you with a Notice of Privacy Practices (the Notice) for use and disclosure of PHI for treatment, payment and health care operations. The Notice, explains HIPPA and its application to your PHI in greater detail. The law requires that I obtain your signature acknowledging that I have provided you with this. If you have any questions, it is your right and obligation to ask so I can have a further discussion prior to signing this document. When you sign this document, it will also represent an agreement between us. You may revoke this Agreement in writing at any time. That revocation will be binding unless I have taken action in reliance on it. 

LIMITS ON CONFIDENTIALITY 

The law protects the privacy of all communication between a patient and a therapist. In most situations, I can only release information about your treatment to others if you sign a written authorization form that meets certain legal requirements imposed by HIPAA. There are some situations where I am permitted or required to disclose information without either your consent or authorization. If such a situation arises, I will limit my disclosure to what is necessary. 

Reasons I may have to release your information without authorization: 

1. If you are involved in a court proceeding and a request is made for information concerning your diagnosis and treatment, such information is protected by the psychologist-patient privilege law. I cannot provide any information without your (or your legal representative's) written authorization, or a court order, or if I receive a subpoena of which you have been properly notified and you have failed to inform me that you oppose the subpoena. If you are involved in or contemplating litigation, you should consult with an attorney to determine whether a court would be likely to order me to disclose information. 

2. If a government agency is requesting the information for health oversight activities, within its appropriate legal authority, I may be required to provide it for them. 

3. If a patient files a complaint or lawsuit against me, I may disclose relevant information regarding that patient in order to defend myself. 

4. If a patient files a worker's compensation claim, and I am providing necessary treatment related to that claim, I must, upon appropriate request, submit treatment reports to the appropriate parties, including the patient's employer, the insurance carrier or an authorized qualified rehabilitation provider. 

5. I may disclose the minimum necessary health information to my business associates that perform functions on our behalf or provide us with services if the information is necessary for such functions or services. My business associates sign agreements to protect the privacy of your information and are not allowed to use or disclose any information other than as specified in our contract. 

There are some situations in which I am legally obligated to take actions, which I believe are necessary to attempt to protect others from harm, and I may have to reveal some information about a patient's treatment: 

1. If I know, or have reason to suspect, that a child under 18 has been abused, abandoned, or neglected by a parent, legal custodian, caregiver, or any other person responsible for the child's welfare, the law requires that I file a report with the California or Arizona Abuse Hotline. Once such a report is filed, I may be required to provide additional information. 

2. If I know or have reasonable cause to suspect, that a vulnerable adult has been abused, neglected, or exploited, the law requires that I file a report with the California or Arizona Abuse Hotline. Once such a report is filed, I may be required to provide additional information. 

3. If I believe that there is a clear and immediate probability of physical harm to the patient, to other individuals, or to society, I may be required to disclose information to take protective action, including communicating the information to the potential victim, and/or appropriate family member, and/or the police or to seek hospitalization of the patient. 

CLIENT RIGHTS AND THERAPIST DUTIES 

Use and Disclosure of Protected Health Information:

For Treatment - I use and disclose your health information internally in the course of your treatment. If I wish to provide information outside of our practice for your treatment by another health care provider, I will have you sign an authorization for release of information. Furthermore, an authorization is required for most uses and disclosures of psychotherapy notes. 

For Payment - I may use and disclose your health information to obtain payment for services provided to you as delineated in the Therapy Agreement. 

For Operations - I may use and disclose your health information as part of our internal operations. For example, this could mean a review of records to assure quality. I may also use your information to tell you about services, educational activities, and programs that I feel might be of interest to you.

Patient's Rights: 

Right to Treatment - You have the right to ethical treatment without discrimination regarding race, ethnicity, gender identity, sexual orientation, religion, disability status, age, or any other protected category. 

Right to Confidentiality - You have the right to have your health care information protected. If you pay for a service or health care item out-of-pocket in full, you can ask us not to share that information for the purpose of payment or our operations with your health insurer. I will agree to such unless a law requires us to share that information. 

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. 

Right to Inspect and Copy - You have the right to inspect or obtain a copy (or both) of PHI. Records must be requested in writing and release of information must be completed. Furthermore, there is a copying fee charge of $1.00 per page. Please make your request well in advanced and allow 2 weeks to receive the copies. If I refuse your request for access to your records, you have a right of review, which I will discuss with you upon request. 

Right to Amend - If you believe the information in your records is incorrect and/or missing important information, you can ask us to make certain changes, also known as amending, to your health information. You have to make this request in writing. You must tell us the reasons you want to make these changes, and I will decide if it is and if I refuse to do so, I will tell you why within 60 days. 

Right to a Copy of This Notice - If you received the paperwork electronically, you have a copy in your email. If you completed this paperwork in the office at your first session a copy will be provided to you per your request or at any time. 

Right to an Accounting - You generally have the right to receive an accounting of disclosures of PHI regarding you. On your request, I will discuss with you the details of the accounting process. 

Right to Choose Someone to Act for You - If someone is your legal guardian, that person can exercise your rights and make choices about your health information; I will make sure the person has this authority and can act for you before I take any action. 

Right to Choose - You have the right to decide not to receive services with me. If you wish, I will provide you with names of other qualified professionals. 

Right to Terminate - You have the right to terminate therapeutic services with me at any time without any legal or financial obligations other than those already accrued. I ask that you discuss your decision with me in session before terminating or at least contact me by phone letting me know you are terminating services. 

Right to Release Information with Written Consent - With your written consent, any part of your record can be released to any person or agency you designate. Together, we will discuss whether or not I think releasing the information in question to that person or agency might be harmful to you.

Therapist'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 a revised notice in office during our session. 

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, you may contact me, the State of California or Arizona Department of Health, or the Secretary of the U.S. Department of Health and Human Services. 

YOUR SIGNATURE BELOW INDICATES THAT YOU HAVE READ THIS AGREEMENT AND AGREE TO ITS TERMS AND ALSO SERVES AS AN ACKNOWLEDGEMENT THAT YOU HAVE RECEIVED THE HIPAA NOTICE FORM DESCRIBED ABOVE