Notice of Privacy Practices

Informed Consent

Counseling Agreement

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 privacy protections and patient rights about the use and disclosure of your Protected Health Information (PHI) for the purposes of treatment, payment, and health care operations. When you sign this document, it will also represent an agreement between us. We can discuss any questions you have now or at any time in the future.

Counseling is a relationship between people that works in part because of clearly defined rights and responsibilities held by each person. As a client in counseling, you have certain rights and responsibilities that are important for you to understand. Legal limitations to those rights exist that you should be aware of. I, as your counselor, have corresponding responsibilities to you. These rights and responsibilities are described in the following sections.

The Counseling Process

You have taken a very positive step by deciding to seek counseling. The outcome of such counseling depends largely on your willingness to engage in this process, which may, at times, result in considerable discomfort. You have identified a need for change in yourself or your family system and changing established habits and emotional reactions to situations can be difficult. I cannot promise that your behavior or circumstance will change. I can promise to support you and assist you in achieving your goals, as well as to help you clarify what it is that you want for yourself and/or your family.
If you are unhappy with progress in counseling, I hope you will will talk with me or office management so that I or we can respond to your concerns. Such comments will be taken seriously and handled with care and respect. You may also request that you are referred to another counselor and are free to end counseling at any time. You have the right to considerate, safe, affirming, and respectful care, without discrimination as to race, ethnicity, color, gender, sexual orientation, age, religion, national origin, or source of payment. You have the right to ask questions about any aspect of counseling and about my specific training and/or experience.

Goals of Counseling

We will collaborate to find the treatment goals that work to improve your circumstances. We will identify presenting concerns, treatment goals, family treatment goals, therapeutic interventions, and expected outcomes. The counselor may make recommendations on how to reach treatment goals, but you decide the direction you want to go in counseling.

Risks/Benefits of Counseling

Counseling is an intensely personal process which can bring unpleasant memories or emotions to the surface. The counselor can give no guarantee that counseling will work for you. Clients can sometimes make improvements only to go backwards after time. Progress may happen slowly. Counseling requires a very active effort on your part. In order to be most successful, you will have to work on things we discuss outside of sessions.
Many benefits to counseling are present as well. Counseling may be able to help you develop effective coping skills, make behavioral changes, reduce symptoms of mental health conditions, improve the quality of your life, and many other possible advantages.


Appointments will ordinarily be approximately 50-60 minutes for individual sessions and 90 minutes for couples sessions, once per week at a time we agree on, although some sessions may be more or less frequent as needed. The time scheduled for your appointment is assigned to you and you alone. If you need to cancel or reschedule a session, I ask that you provide me with 24 hours’ notice. If you miss a session without canceling, or cancel with less than 24 hours’ notice, you may be required to pay for the session (unless we both agree that you were unable to attend due to circumstances beyond your control). It is important to note that insurance companies do not provide reimbursement for cancelled sessions; thus, you will be responsible for the cancellation fee. If you no show two consecutive sessions, your services may be suspended. If you no show three sessions within a three-month span of time, your services may be suspended as well. In addition, you are responsible for coming to your session on time; if you are fifteen or more minutes late, your appointment may be cancelled for that day. If you are less than fifteen minutes late, your appointment will still need to end on time.

Release of Information

If billing through insurance, your clinical records will be released to your insurance company. I may also discuss your care with a guardian (if applicable) and emergency contact. If you wish to have information released to another individual or organization, you will be required to sign a release of information form before such information will be released.


Your counselor will make every effort to keep your personal information private. The counseling session content and all relevant materials to the client’s treatment will be held confidential unless the client requests in writing to have all or portions of such content released to a specifically named person/persons. Some limitations to confidentiality are present to which you need to be aware. Limitations of client held privilege of confidentiality exist and are itemized below:
1. If a client threatens or attempts to die by suicide or otherwise conducts him/her/their self in a manner in which a substantial risk of incurring serious bodily to harm to self exists.
2. If a client threatens grave bodily harm or death to another person.
3. If the counselor has a reasonable suspicion that a client or other named victim is the perpetrator, observer of, or actual survivor of physical abuse, emotional abuse, sexual abuse, or neglect of children under the age of 18 years or an elderly person.
4. If a court of law issues a legitimate subpoena for information stated on the subpoena.
5. If a client is in counseling or being treated by order of a court of law, or if information is obtained for the purpose of rendering an expert’s report to an attorney.
Occasionally I may need to consult with other professionals (or in some cases professional supervisor) in their areas of expertise in order to provide the best treatment for you. Information about you may be shared in this context without using your name or other identifying information.
If we see each other accidentally outside of counseling sessions, I will not acknowledge you first. Your right to privacy and confidentiality is of the utmost importance to me, and I do not wish to jeopardize your right to privacy. However, if you acknowledge me first, I will be more than happy to speak with you, but feel it appropriate not to engage in any lengthy discussions in public.

Confidentiality and Technology

Some clients may choose to use technology in their counseling sessions. This includes but is not limited to online counseling via telecounseling, telephone, email, or text message. Due to the nature of using technology in counseling, the possibility always exists that unauthorized persons may attempt to discover your personal information. While I will take every precaution to safeguard your information by having a BAA for email correspondence and telecounseling sessions, I cannot guarantee that unauthorized access to electronic communications could not occur.

Please be advised to take precautions with regard to authorized and unauthorized access to any technology used in counseling sessions or to supplement counseling sessions. For safety reasons, I do not encourage text messages or lengthy personal emails. Any written or verbal correspondence will be entered into your clinician records.
Be aware of any friends, family members, significant others, or co-workers who may have access to your computer, phone, or other technology used in your counseling sessions. Before coming to the counseling office, you are invited to maintain your own personal safety if needed by taking precautions such as disabling your GPS signal on your mobile devices (while letting trusted, safe parties know your location).

Clinical Records

I will keep clinical records of your counseling sessions, intake, correspondences, releases of information, treatment plans, insurance information, and any other pertinent information required for your treatment. These records are kept to ensure a direction to your sessions and continuity in service. They will not be shared except with respect to the limits to confidentiality and other reasons stated in the release of information section above. Should the client wish to have their records released, they are required to sign a release of information which specifies what information is to be released and to whom. Records will be kept for at least 7 years but may be kept for longer. Records will be kept either electronically or in a paper file and stored in a locked cabinet in the counselor’s office.

Professional Fees

You are responsible for paying at the time of your session unless prior arrangements have been made. Payment must be made by cash, check, Visa, MasterCard, Discover, American Express, or PayPal. If you refuse to pay your debt, I reserve the right to use an attorney or collection agency to secure payment.If you anticipate becoming involved in a court case, I recommend that we discuss this fully before you waive your right to confidentiality. If your case requires my participation, you will be expected to pay for the professional time required. In the case a client damages property belonging to the counselor, the client is responsible for the cost of said property. To receive sliding scale fees, you must present proof of income through recent pay stubs or tax forms. If your financial situation changes during the course of treatment, you are required to inform me and present proof of income through recent pay stubs or tax forms. Therapeutic contact outside of session has a fee of one dollar a minute or one dollar per 200 words of text. Fees are subject to change at the counselor’s discretion.
In the case a client damages property belonging to the counselor, the client is responsible for the cost of said property.

Fees for Legal Proceedings

If you anticipate becoming involved in a court case, I recommend that we discuss this fully before you waive your right to confidentiality. If your case requires my participation, you will be expected to pay for the professional time required.
An authorized release of information is also necessary should you become involved in any legal proceedings that require your counselor’s participation. If this does occur, you will be expected to pay for the professional time even if called to testify by another party. Going to court is expensive in both time and money, therefore clients are strongly discouraged from having their counselor subpoenaed. Remember, your counselor’s testimony will be to the facts of the case and his/her professional opinion and may or may not be in your favor. However, should you choose to have your attorney subpoena your counselor, on the day your counselor receives the subpoena, you will be charged anon-refundable $1500 retainer fee. This fee is non-refundable even if the case does not go to court.If the case does go to court, the following fees apply and must be paid in full by the end of the court day. If they are not paid by the end of the court day, all fees are doubled.

1. Preparation time (including submission of records): $225/hour (no less than one hour)
2. Phone calls or emails with your attorney, the attorney’s office personnel, or the court: $225/hour (one hour will be charged for each contact regardless of time actually spent)
3. Depositions: $250/hour (no less than one hour)
4. Time required to give testimony (this includes wait time prior to the hearing and will be charged whether testimony is given or not): $350/hour
5. Mileage: $.40/mile (travel to and from will be charged)
6. Any expenses such as parking, meals, accommodations, or snacks/drinks
7. All attorney fees and costs incurred by the counselor as a result of the legal action.
8. Time away from office due to depositions/testimony: $225/hour (no less than one hour)
9. Time away from other employment that the counselor must take time off for: $225/hour
10. Filing a document with the court: $100
If a subpoena or notice to meet with an attorney(s) is received without a 48-hour notice, there will be an additional $250 “express” charge. If the case is reset with less than 2 business days’ notice, you will be charged an additional $500 which is non-refundable. Finally, all fees are doubled if the counselor had scheduled plans to go out of town.


Your safety is very important to me. For this reason, please inform me if you have a change of address or a change occurs for your emergency contact. If we decide to create a safety plan together, please keep a copy and give copies to your caregiver(s) or other appropriate parties.

Contacting Me

I am often not immediately available by telephone or email. I do not answer my phone or answer my email when I am with clients or otherwise unavailable. At these times, you may leave a message on my confidential voicemail or email and I will get back to you as soon as possible, but it may take a day or two for non-urgent matters. If you need to reschedule or cancel an appointment, please call the Director of Operations. If you feel you cannot wait for a return call or email and it is an emergency situation, go to your local hospital or call 911.


Notice of Privacy Practices

Avail Services, LLC (“Avail Services”) is required by law to maintain the privacy of your health information and to provide you with notice of its legal duties and privacy practices with respect to your health information. If you have questions about any part of this Notice or if you want more information about the privacy practices at Avail Services, please contact the Director of Operations at (205) 575-8216 or at 2127 14th Avenue South, Birmingham, Alabama 35205.

Understanding Your Medical Record/Health Information

Each time you visit a healthcare provider, a record of your visit is made. Typically, this record contains your symptoms, assessment, diagnosis, treatment plan, and treatment recommendations. These records may also disclose or reveal that you are a recipient of public welfare benefits. This Protected Health Information (PHI), often referred to as your medical record, serves as a basis for planning your treatment, a means to communicate between service providers involved in your care, as a legal document describing your care and services, and verification for you and/or a third party payer that the services billed were provided to you. It can also be used as a source of data to assure that we are continuously monitoring the quality of services and measuring outcomes. Understanding what is in your medical record and how, when and why we use the information helps you make informed decisions when authorizing disclosure to others. Your health information will not be disclosed without your authorization unless required or allowed by State and Federal laws, rules or regulations.

Our Responsibilities

Avail Services must protect and secure health information that we have created or received about your past, present, or future health condition, health care we provide to you, or payment for your health care. We are only allowed to use and disclose protected health information in the manner described in this Notice. This Notice is posted on our website and we will provide you a paper copy of this Notice upon your request.

How Avail Services May Use or Disclose Your Health Information

The following categories describe ways that Avail Services may use or disclose your health information. Any use or disclosure of your health information will be limited to the minimum information necessary to carry out the purpose of the use or disclosure. For each category of uses and disclosures, we will explain what we mean and present some examples. Not every use or disclosure in a category will be listed. However, all the ways we are permitted to use and disclose information will fall within one of the categories. Note that we can only use or disclose alcohol and drug abuse records with your consent or as specifically permitted under federal law. These exceptions are listed on the next page.

Payment Functions

We may use or disclose health information about you to determine eligibility for plan benefits, obtain premiums, facilitate payment for the treatment and services you receive from health care providers, determine plan responsibility for benefits, and to coordinate benefits. Health information may be shared with other government programs such as Medicare, Medicaid, Allkids, or private insurance to manage your medical necessity of health care services, determine whether a particular treatment is experimental or investigative, or determine whether a treatment is covered under your plan.

Healthcare Operations

We may use and disclose health information about you to carry out necessary managed care/insurance-related activities. For example, such activities may include premium rating and other activities relating to plan coverage; conducting quality assessment and improvement activities such as handling and investigating complaints; submitting claims for stop-loss coverage; conducting or arranging for medical review, legal services, audit services, and fraud and abuse detection programs; and business planning, management and general administration.


Avail Services is a provider of mental healthcare which includes maintaining clinical records that regard areas of treatment which may include session content, symptoms, assessments, diagnosis, treatment plans, treatment recommendations, and other information regarding your mental healthcare treatment. Sometimes referrals are made by Avail Services for a assessments, coordinating appropriate and effective care, treatment and services or setting up an appointment with other behavioral health and health care providers. We may also share your health information with emergency treatment providers when you need emergency services. We may also communicate and share information with other behavioral health service Providers who have Contracts with Avail Services or governmental entities with whom we have Business Associate Agreements. These include hospitals, licensed facilities, licensed practitioners, community-based service providers, and governmental entities such as local jails and schools. When these services are contracted, we may disclose your health information to our contractors so that they can provide you services and bill you or your third‐party payer for services rendered. We require the contractor to appropriately safeguard your information. We are required to give you an opportunity to object before we are allowed to share your PHI with another HIPAA Covered Entity such as your Primary Care Physician or another type of physical health type provider. If you wish to object to us sharing your PHI with these types of providers, then there is a form you must sign that will be kept on file and we are required by law to honor your request.

Required by Law

Avail Services may use and disclose your health information as required by law. Some examples where we are required by law to share limited information include but are not limited to: PHI related to your care/treatment with your next of kin, family member, or another person that is involved in your care; with organizations such as the Red Cross during an emergency; to report certain type of wounds or other physical injuries; and to the extent necessary to fulfill responsibilities when a consumer is examined or committed for inpatient treatment.

Public Health

Your health information may be reported to a public health authority or other appropriate government authority authorized by law to collect or receive information for purposes related to: preventing or controlling disease, injury or disability; reporting to the Food and Drug Administration problems with products and reactions to medications, and reporting disease or infection exposure.

Health Oversight Activities

We may disclose your health information to health, regulatory and/or oversight agencies during the course of audits, investigations, inspections, licensure, and other proceedings related to oversight of the healthcare system. For example, health information may be reviewed by investigators, auditors, accountants or lawyers who make certain that we comply with various laws; or to audit your file to make sure that no information about you was given to someone in a way that violated this Notice.

Judicial and Administrative Proceedings

We may disclose your health information in response to a subpoena or court order in the course of any administrative or judicial proceeding, in the course of any administrative or judicial proceeding required by law (such as a licensure action), for payment purposes (such as a collection action), or for purposes of litigation that relates to health care operations where Avail Services is a party to the proceeding.

Public Safety/Law Enforcement

We may disclose your health information to appropriate persons in order to prevent or lessen a serious or imminent danger or threat to the health or safety of a particular person or the general public or when there is a likelihood of the commission of a felony or violent misdemeanor.

National Security

We may disclose your health information for military, prisoner, and national security.

Worker’s Compensation

We may disclose your health information as necessary to comply with worker’s compensation or similar laws.


We may contact you to give you information about health-related benefits and services that may be of interest to you. If we receive compensation from a third party for providing you with information about other products or services (other than drug refill reminders or generic drug availability), we will obtain your authorization to share information with this third party.

Disclosures to Plan Sponsors
We may disclose your health information to the sponsor of your group health plan, for purposes of administering benefits under the plan. If you have a group health plan, your employer is the plan sponsor.


Under certain circumstances, and only after a special approval process, we may use and disclose your health information to help conduct research.

Applicability of More Stringent State Laws
Some of the uses and disclosures described in this notice may be limited in certain cases by applicable State laws or rules that are more stringent than Federal laws or regulations, including disclosures related to mental health and substance abuse, intellectual/developmental disabilities, alcohol and other drug abuse (AODA), and HIV testing.

Use and Disclosure of Health Information Without your Authorization
Federal laws require or allow that we share your health information, including alcohol and drug abuse records, with others in specific situations in which you do not have to give consent, authorize or have the opportunity to agree or object to the use and disclosure. Prior to disclosing your health information under one of these exceptions, we will evaluate each request to ensure that only necessary information will be disclosed. These situations include, but are not limited to the following:
To a county Department of Social Services or law enforcement to report abuse, neglect or domestic violence; or
To respond to a court order or subpoena; or
To qualified personnel for research, audit, and program evaluation; or
To a health care provider who is providing emergency medical services; or
To appropriate authorities if we learn that you might seriously harm another person or property (including Avail Services) in the future or that you intend to commit a crime of violence or that you intend to self-harm; or
For the purpose of internal communications, as outlined above; or
To qualified service organization agencies when appropriate. (These agencies must agree to abide by the Federal law.)

When Avail Services May Not Use or Disclose Your Protected Health Information
Except as described in this Notice, Avail Services will not use or disclose your health information without written authorization from you. If you do authorize us to use or disclose your health information for another purpose, you may revoke your authorization in writing at any time. If you revoke your authorization, we will no longer be able to use or disclose health information about you for the reasons covered by your written authorization, though we will be unable to take back any disclosures we have already made with your permission.
Your authorization is necessary for most uses and disclosures of psychotherapy notes.
Your authorization is necessary for any disclosures of health information in which the health plan receives compensation.
Your authorization is necessary for most uses and disclosures of alcohol and drug abuse records (exceptions are listed above).

Statement of Your Health Information Rights
Although your health information is the physical property of Avail Services, the information belongs to you. You have the right to request, in writing, certain uses and disclosures of your health information.

Right to Request Restrictions
You have the right to request a restriction on certain uses and disclosures of your health information. We are not required to agree to the restrictions that you request. If you would like to make a request for restrictions, you must submit your request in writing to the Director of Operations at the address listed below. We will let you know if we can comply with the restriction or not.

Right to Request Confidential Communications
You have the right to receive your health information through a reasonable alternative means or at an alternate location. To request confidential communications, you must submit your request in writing to the Director of Operations at the address listed below. We are not required to agree to your request.

Right to Inspect and Copy
You have the right to inspect and receive an electronic or paper copy of your health information that may be used to make decisions about your plan benefits. To inspect and copy information, you must submit your request in writing to the Director of Operations at the address listed below. If you request a copy of the information, we may charge you a reasonable fee to cover expenses associated with your request. There are certain situations where we will be unable to grant your request to review records.

Right to Request Amendment
You have a right to request that we amend your health information that you believe is incorrect or incomplete. We are not required to change your health information and if your request is denied, we will provide you with information about our denial and how you can appeal the denial. To request an amendment, you must make your request in writing to the Director of Operations at the address listed below. You must also provide a reason for your request.

Right to an Accounting of Disclosures
You have the right to receive a list or accounting of disclosures of your health information made by us in the past six years, except that we do not have to account for disclosures made for purposes of payment functions, healthcare operations of treatment, or made by you. To request this accounting of disclosures, you must submit your request in writing to the Director of Operations at the address listed below. We will provide one list or accounting per 12 month period free of charge; we may charge you for additional lists or accountings. We will inform you of the cost and you may choose to withdraw or modify your request before any costs are incurred. There are certain exceptions that apply.

Right to a Copy
You have a right to receive an electronic copy of this Notice at any time. To obtain a paper copy of this Notice, send your written request to the Director of Operations at 2127 14th Avenue South, Birmingham, Alabama 35205.

Right to be Notified of a Breach
You have the right to be notified in the event that we (or one of our contracted counselors) discover a breach of your unsecured protected health information. Notice of any such breach will be made in accordance with federal requirements.
If you would like to have a more detailed explanation of these rights or if you would like to exercise one or more of these rights, contact the Director of Operations at 2127 14th Avenue South, Birmingham, Alabama 35205 or by calling (205) 575-8216.

Changes to This Notice and Distribution
Avail Services reserves the right to amend this Notice of Privacy Practices at any time in the future and to make the new Notice provisions effective for all health information that it maintains. As your health plan, we will provide a copy of our notice upon your enrollment in the plan and will remind you at least every three years where to find our notice and how to obtain a copy of the notice if you would like to receive one. If we have more than one Notice of Privacy Practices, we will provide you with the Notice that pertains to you. The notice is provided and pertains to the named Medicaid beneficiary or other individual enrolled in the plan.
As a health plan that maintains a website describing our customer service and benefits, we also post to our website the most recent Notice of Privacy Practices which will describe how your health information may be used and disclosed as well as the rights you have to your health information. If our Notice has a material change, we will post information regarding this change to the website for you to review. In addition, following the date of the material change, we will include a description of the change that occurred and information on how to obtain a copy of the revised Notice in any annual mailing required by 42 CFR Part 438.

Complaints about this Notice of Privacy practices or about how we handle your health information should be directed to the Director of Operations at 2127 14th Avenue South, Birmingham, Alabama 35205 or by calling (205) 575-8216. Avail Services will not retaliate against you in any way for filing a complaint. All complaints to Avail Services must be submitted in writing. If you believe your privacy rights have been violated, you may file a complaint with the Secretary of the Department of Health and Human Services at or call (800) 368-1019.