I. COMMITMENT TO YOUR PRIVACY: TAMARA ASHLEY, LPC and GOAT & SNOWFLAKE, LLC are dedicated to maintaining the privacy of your protected health information (PHI). PHI is information that may identify you and that relates to your past, present or future physical or mental health condition and related health care services either in paper or electronic format. This Notice of Privacy Practices (“Notice”) is required by law to provide you with the legal duties and the privacy practices that GOAT & SNOWFLAKE, LLC maintains concerning your PHI. It also describes how medical and mental health information may be used and disclosed, as well as your rights regarding your PHI. Please read carefully and discuss any questions or concerns with your therapist.

II. LEGAL DUTY TO SAFEGUARD YOUR PHI: By federal and state law, GOAT & SNOWFLAKE, LLC is required to ensure that your PHI is kept private. This Notice explains when, why, and how GOAT & SNOWFLAKE, LLC would use and/or disclose your PHI. Use of PHI means when GOAT & SNOWFLAKE, LLC shares, applies, utilizes, examines, or analyzes information within its practice; PHI is disclosed when GOAT & SNOWFLAKE, LLC releases, transfers, gives, or otherwise reveals it to a third party outside of GOAT & SNOWFLAKE, LLC. With some exceptions, GOAT & SNOWFLAKE, LLC may not use or disclose more of your PHI than is necessary to accomplish the purpose for which the use or disclosure is made; however, GOAT & SNOWFLAKE, LLC is always legally required to follow the privacy practices described in this Notice.

III. CHANGES TO THIS NOTICE: The terms of this notice apply to all records containing your PHI that are created or retained by GOAT & SNOWFLAKE, LLC Please note that GOAT & SNOWFLAKE, LLC reserves the right to revise or amend this Notice of Privacy Practices. Any revision or amendment will be effective for all of your records that GOAT & SNOWFLAKE, LLC has created or maintained in the past and for any of your records that GOAT & SNOWFLAKE, LLC may create or maintain in the future. GOAT & SNOWFLAKE, LLC will have a copy of the current Notice in the office in a visible location at all times, and you may request a copy of the most current Notice at any time. The date of the latest revision will always be listed at the end of GOAT & SNOWFLAKE, LLC’S Notice of Privacy Practices.

IV. HOW GOAT & SNOWFLAKE, LLC MAY USE AND DISCLOSE YOUR PHI: GOAT & SNOWFLAKE, LLC will not use or disclose your PHI without your written authorization, except as described in this Notice or as described in the “Information, Authorization and Consent to Treatment” document. Below you will find the different categories of possible uses and disclosures with some examples.
1. For Treatment: GOAT & SNOWFLAKE, LLC may disclose your PHI to physicians, psychiatrists, psychologists, and other licensed health care providers who provide you with health care services or are; otherwise involved in your care. Example: If you are also seeing a psychiatrist for medication management, GOAT & SNOWFLAKE, LLC may disclose your PHI to her/him in order to coordinate your care. Except for in an emergency, GOAT & SNOWFLAKE, LLC will always ask for your authorization in writing prior to any such consultation.
2. For Health Care Operations: GOAT & SNOWFLAKE, LLC may disclose your PHI to facilitate the efficient and correct operation of its practice, improve your care, and contact you when necessary. Example: We use health information about you to manage your treatment and services.
3. To Obtain Payment for Treatment: GOAT & SNOWFLAKE, LLC may use and disclose your PHI to bill and collect payment for the treatment and services GOAT & SNOWFLAKE, LLC provided to you. Example: GOAT & SNOWFLAKE, LLC might send your PHI to your insurance company or managed health care plan in order to get payment for the health care services that have been provided to you. GOAT & SNOWFLAKE, LLC could also provide your PHI to billing companies, claims processing companies, and others that process health care claims for GOAT & SNOWFLAKE, LLC’s office if either you or your insurance carrier are not able to stay current with your account. In this latter instance, GOAT & SNOWFLAKE, LLC will always do its best to reconcile this with you first prior to involving any outside agency.
4. Employees and Business Associates: There may be instances where services are provided to GOAT & SNOWFLAKE, LLC by an employee or through contracts with third-party “business associates.” Whenever an employee or business associate arrangement involves the use or disclosure of your PHI, GOAT & SNOWFLAKE, LLC will have a written contract that requires the employee or business associate to maintain the same high standards of safeguarding your privacy that is required of GOAT & SNOWFLAKE, LLC.
Note: This state and Federal law provides additional protection for certain types of health information, including alcohol or drug abuse, mental health and AIDS/HIV, and may limit whether and how GOAT & SNOWFLAKE, LLC may disclose information about you to others.

V. USE AND DISCLOSURE OF YOUR PHI IN CERTAIN SPECIAL CIRCUMSTANCES – GOAT & SNOWFLAKE, LLC may use and/or disclose your PHI without your consent or authorization for the following reasons:
1. Law Enforcement: Subject to certain conditions, GOAT & SNOWFLAKE, LLC may disclose your PHI when required by federal, state, or local law; judicial, board, or administrative proceedings; or, law enforcement. Example: GOAT & SNOWFLAKE, LLC may make a disclosure to the appropriate officials when a law requires GOAT & SNOWFLAKE, LLC to report information to government agencies, law enforcement personnel and/or in an administrative proceeding.
2. Lawsuits and Disputes: GOAT & SNOWFLAKE, LLC may disclose information about you to respond to a court or administrative order or a search warrant. GOAT & SNOWFLAKE, LLC may also disclose information if an arbitrator or arbitration panel compels disclosure, when arbitration is lawfully requested by either party, pursuant to subpoena duces tectum (e.g., a subpoena for mental health records) or any other provision authorizing disclosure in a proceeding before an arbitrator or arbitration panel. GOAT & SNOWFLAKE, LLC will only do this if efforts have been made to tell you about the request and you have been provided an opportunity to object or to obtain an appropriate court order protecting the information requested.
3. Public Health Risks: GOAT & SNOWFLAKE, LLC may disclose your PHI to public health or legal authorities charged with preventing or controlling disease, injury, disability, to report births and deaths, and to notify persons who may have been exposed to a disease or at risk for getting or spreading a disease or condition.
4. Food and Drug Administration (FDA): GOAT & SNOWFLAKE, LLC may disclose to the FDA, or persons under the jurisdiction of the FDA, PHI relative to adverse events with respect to drugs, foods, supplements, products and product defects, or post marketing surveillance information to enable product recalls, repairs, or replacement.
5. Serious Threat to Health or Safety: GOAT & SNOWFLAKE, LLC may disclose your PHI if you are in such mental or emotional condition as to be dangerous to yourself or the person or property of others, and if GOAT & SNOWFLAKE, LLC determines in good faith that disclosure is necessary to prevent the threatened danger. Under these circumstances, GOAT & SNOWFLAKE, LLC may provide PHI to law enforcement personnel or other persons able to prevent or mitigate such a serious threat to the health or safety of a person or the public.
6. Minors: If you are a minor (under 18 years of age), GOAT & SNOWFLAKE, LLC may be compelled to release certain types of information to your parents or guardian in accordance with applicable law.
7. Abuse and Neglect: GOAT & SNOWFLAKE, LLC may disclose PHI if mandated by Georgia child, elder, or dependent adult abuse and neglect reporting laws. Example: If GOAT & SNOWFLAKE, LLC has a reasonable suspicion of child abuse or neglect, GOAT & SNOWFLAKE, LLC will report this to the Georgia Department of Child and Family Services.
8. Coroners, Medical Examiners, and Funeral Directors: GOAT & SNOWFLAKE, LLC may release PHI about you to a coroner or medical examiner. This may be necessary, for example, to identify a deceased person, determine the cause of death or other duties as authorized by law. GOAT & SNOWFLAKE, LLC may also disclose PHI to funeral directors, consistent with applicable law, to carry out their duties.
9. Communications with Family, Friends, or Others: GOAT & SNOWFLAKE, LLC may release your PHI to the person you named in your Durable Power of Attorney for Health Care (if you have one), to a friend or family member who is your personal representative (i.e., empowered under state or other law to make health-related decisions for you), or any other person you identify, relevant to that person’s involvement in your care or payment related to your care. In addition, GOAT & SNOWFLAKE, LLC may disclose your PHI to an entity assisting in disaster relief efforts so that your family can be notified about your condition.
10. Military and Veterans: If you are a member of the armed forces, GOAT & SNOWFLAKE, LLC may release PHI about you as required by military command authorities. GOAT & SNOWFLAKE, LLC may also release PHI about foreign military personnel to the appropriate military authority.
11. National Security, Protective Services for the President, and Intelligence Activities: GOAT & SNOWFLAKE, LLC may release PHI about you to authorized federal officials so they may provide protection to the President, other authorized persons, or foreign heads of state, to conduct special investigations for intelligence, counterintelligence, and other national activities authorized by law.
12. Correctional Institutions: If you are or become an inmate of a correctional institution, GOAT & SNOWFLAKE, LLC may disclose PHI to the institution or its agents when necessary for your health or the health and safety of others
13. For Research Purposes: In certain limited circumstances, GOAT & SNOWFLAKE, LLC may use information you have provided for medical/psychological research, but only with your written authorization. The only circumstance where written authorization would not be required would be if the information you have provided could be completely disguised in such a manner that you could not be identified, directly or through any identifiers linked to you. The research would also need to be approved by an institutional review board that has examined the research proposal and ascertained that the established protocols have been met to ensure the privacy of your information.
14. For Workers' Compensation Purposes:
GOAT & SNOWFLAKE, LLC may provide PHI in order to comply with Workers' Compensation or similar programs established by law.
15. Appointment Reminders: GOAT & SNOWFLAKE, LLC is permitted to contact you, without your prior authorization, to provide appointment reminders or information about alternative or other health-related benefits and services that you may need or that may be of interest to you.
16. Health Oversight Activities: GOAT & SNOWFLAKE, LLC may disclose health information to a health oversight agency for activities such as audits, investigations, inspections, or licensure of facilities. These activities are necessary for the government to monitor the health care system, government programs and compliance with laws. Example: When compelled by U.S. Secretary of Health and Human Services to investigate or assess GOAT & SNOWFLAKE, LLC’s compliance with HIPAA regulations.
17. If Disclosure is Otherwise Specifically Required by Law.
18. In the Following Cases, GOAT & SNOWFLAKE, LLC Will Never Share Your Information Unless You Give us Written Permission: Marketing purposes, sale of your information, most sharing of psychotherapy notes, and fundraising. If we contact you for fundraising efforts, you can tell us not to contact you again.

VI. Other Uses and Disclosures Require Your Prior Written Authorization: In any other situation not covered by this notice, GOAT & SNOWFLAKE, LLC will ask for your written authorization before using or disclosing medical information about you. If you chose to authorize use or disclosure, you can later revoke that authorization by notifying GOAT & SNOWFLAKE, LLC in writing of your decision. You understand that GOAT & SNOWFLAKE, LLC is unable to take back any disclosures it has already made with your permission, GOAT & SNOWFLAKE, LLC will continue to comply with laws that require certain disclosures, and GOAT & SNOWFLAKE, LLC is required to retain records of the care that its therapists have provided to you.

VII. RIGHTS YOU HAVE REGARDING YOUR PHI:
1. The Right to See and Get Copies of Your PHI either in paper or electronic format: In general, you have the right to see your PHI that is in GOAT & SNOWFLAKE, LLC’s possession, or to get copies of it; however, you must request it in writing. If GOAT & SNOWFLAKE, LLC does not have your PHI, but knows who does, you will be advised how you can get it. You will receive a response from GOAT & SNOWFLAKE, LLC within 30 days of receiving your written request. Under certain circumstances, GOAT & SNOWFLAKE, LLC may feel it must deny your request, but if it does, GOAT & SNOWFLAKE, LLC will give you, in writing, the reasons for the denial. GOAT & SNOWFLAKE, LLC will also explain your right to have its denial reviewed. If you ask for copies of your PHI, you will be charged a reasonable fee per page and the fees associated with supplies and postage. GOAT & SNOWFLAKE, LLC may see fit to provide you with a summary or explanation of the PHI, but only if you agree to it, as well as to the cost, in advance.
2. The Right to Request Limits on Uses and Disclosures of Your PHI: You have the right to ask that GOAT & SNOWFLAKE, LLC limit how it uses and discloses your PHI. While GOAT & SNOWFLAKE, LLC will consider your request, it is not legally bound to agree. If GOAT & SNOWFLAKE, LLC does agree to your request, it will put those limits in writing and abide by them except in emergency situations. 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. You do not have the right to limit the uses and disclosures that GOAT & SNOWFLAKE, LLC is legally required or permitted to make.
3. The Right to Choose How GOAT & SNOWFLAKE, LLC Sends Your PHI to You: It is your right to ask that your PHI be sent to you at an alternate address (for example, sending information to your work address rather than your home address) or by an alternate method (for example, via email instead of by regular mail). GOAT & SNOWFLAKE, LLC is obliged to agree to your request providing that it can give you the PHI, in the format you requested, without undue inconvenience.
4. The Right to Get a List of the Disclosures. You are entitled to a list of disclosures of your PHI that GOAT & SNOWFLAKE, LLC has made. The list will not include uses or disclosures to which you have specifically authorized (i.e., those for treatment, payment, or health care operations, sent directly to you, or to your family; neither will the list include disclosures made for national security purposes, or to corrections or law enforcement personnel. The request must be in writing and state the time period desired for the accounting, which must be less than a 6-year period and starting after April 14, 2003.
GOAT & SNOWFLAKE, LLC will respond to your request for an accounting of disclosures within 60 days of receiving your request. The list will include the date of the disclosure, the recipient of the disclosure (including address, if known), a description of the information disclosed, and the reason for the disclosure. GOAT & SNOWFLAKE, LLC will provide the list to you at no cost, unless you make more than one request in the same year, in which case it will charge you a reasonable sum based on a set fee for each additional request.
5. The Right to Choose Someone to Act for You: If you have given someone medical power of attorney or if someone is your legal guardian, that person can exercise your rights and make choices about your health information. We will make sure the person has this authority and can act for you before we take any action.
6. The Right to Amend Your PHI: If you believe that there is some error in your PHI or that important information has been omitted, it is your right to request that GOAT & SNOWFLAKE, LLC correct the existing information or add the missing information. Your request and the reason for the request must be made in writing. You will receive a response within 60 days of GOAT & SNOWFLAKE, LLC’s receipt of your request. GOAT & SNOWFLAKE, LLC may deny your request, in writing, if it finds that the PHI is: (a) correct and complete, (b) forbidden to be disclosed, (c) not part of its records, or (d) written by someone other than GOAT & SNOWFLAKE, LLC. Denial must be in writing and must state the reasons for the denial. It must also explain your right to file a written statement objecting to the denial. If you do not file a written objection, you still have the right to ask that your request and GOAT & SNOWFLAKE, LLC’s denial will be attached to any future disclosures of your PHI. If GOAT & SNOWFLAKE, LLC approves your request, it will make the change(s) to your PHI. Additionally, GOAT & SNOWFLAKE, LLC will tell you that the changes have been made and will advise all others who need to know about the change(s) to your PHI.
6. The Right to Get This Notice by Email: You have the right to get this notice by email. You have the right to request a paper copy of it as well.
7. Submit all Written Requests: Submit to GOAT & SNOWFLAKE, LLC, at the address listed on top of page one of this document.

VIII. COMPLAINTS: If you are concerned your privacy rights may have been violated, or if you object to a decision GOAT & SNOWFLAKE, LLC made about access to your PHI, you are entitled to file a complaint. You may also send a written complaint to the Secretary of the Department of Health and Human Services Office of Civil Rights. GOAT & SNOWFLAKE, LLC will provide you with the address. Under no circumstances will you be penalized or retaliated against for filing a complaint.
Please discuss any questions or concerns with your therapist. Your signature on the “Information, Authorization, and Consent to Treatment” (provided to you separately) indicates that you have read and understood this document.

IX. GOAT & SNOWFLAKE, LLC’S Responsibilities: We are required by law to maintain the privacy and security of your PHI. We will let you know promptly if a breach occurs that may have compromised the privacy or security of your information. We must follow the duties and privacy practices described in this notice and give you a copy of it. We will not use or share your information other than as described here unless you tell us we can in writing. If you tell us we can, you may change your mind at any time. Let us know in writing if you change your mind.
Date of Last Revision: 02/01/15

I am very pleased that you have selected me to be your therapist, and I am sincerely looking forward to assisting you. This document is designed to inform you about what you can expect from me regarding confidentiality, emergencies, and several other details regarding your treatment. Although providing this document is part of an ethical obligation to my profession, more importantly, it is part of my commitment to you to keep you fully informed of every part of your therapeutic experience. Please know that your relationship with me is a collaborative one, and I welcome any questions, comments, or suggestions regarding your course of therapy at any time.

Background Information

The following information regarding my educational background and experience as a therapist is an ethical requirement of my profession. If you have any questions, please feel free to ask.

Masters in Professional Counseling (M.S.)

Licensed Professional Counselor (LPC)

Nationally Certified Counselor (NCC)

Certified Rapid Resolution Therapy Specialist (CRRTS)

Theoretical Views & Client Participation

Therapy will be most successful when you participate actively in the process, and communicate with openness and honesty. This means giving me honest feedback so that we can tailor your treatment effectively. This also means avoiding any mind-altering substances like alcohol or non-prescription drugs for at least eight hours prior to your therapy sessions. 

Some of my clients need only a few sessions of Rapid Resolution Therapy to achieve their goals, whereas others may benefit from therapy over a longer period of time--if that's the case, I may refer you to someone with the appropriate skills. If It is my intention to assist you as effectively and as quickly as possible, so that you are empowered and moving ahead with more clarity, peace, and energy in your life. I don't believe in creating dependency or prolonging therapy if the therapeutic intervention does not seem to be helping. If this is the case, I will direct you to other resources that will be of assistance to you. Your personal development is my number one priority.

As a client, you are in complete control, and you may end your relationship with me at any point. I encourage you to let me know if you feel that transferring to another therapist is necessary at any time. My goal is to facilitate healing and growth, and I am very committed to helping you in whatever way seems to produce maximum benefit.

Confidentiality & Records

Your communications with me will become part of a clinical record of treatment, and it is referred to as Protected Health Information (PHI). Your PHI will be stored electronically through an encrypted, HIPAA compliant cloud-based practice management system, "CounSol". Additionally, I will always keep everything you say to me completely confidential, with the following exceptions: (1) you direct me to tell someone else and you sign a "Release of Information" form; (2) I determine that you are a danger to yourself or to others; (3) you report information about the abuse of a child, an elderly person, or a disabled individual who may require protection; or (4) I am ordered by a judge to disclose information. In the latter case, my license does provide me with the ability to uphold what is legally termed "privileged communication." Privileged communication is your right as a client to have a confidential relationship with a therapist. This state has a very good track record in respecting this legal right. If for some unusual reason a judge were to order the disclosure of your private information, this order can be appealed. I cannot guarantee that the appeal will be sustained, but I will do everything in my power to keep what you say confidential.

Structure and Cost of Sessions

I will provide Rapid Resolution Therapy for a fee of $500 for one 2.5-3 hour session, or $750 for a series of three 90 minute sessions, unless otherwise negotiated.

I agree to provide subsequent sessions for the fee of $170 for a 55-60 minute session, or $250 for an 90 minute session, unless otherwise negotiated.

Telephone calls that exceed 15 minutes in duration will be billed at the rate of $3/minute, or $170 for a planned 55-60 minute session.

Cancellation Policy

In the event that you are unable to keep an appointment, please notify me by phone or text at least 24 hours in advance.  If it's the day of an extended RRT session and you are feeling unwell, please let me know as soon as you can so that we can reschedule.  I want to use our session time to best advantage, and will not charge a late cancellation fee the first time it happens.

Payment

The fee for each session will be due at the time of the session unless otherwise agreed. It is my policy to keep an authorized credit card on file to be used for all professional services rendered, including late cancellations. This prevents you from having a past-due balance, and it keeps our therapeutic relationship free of financial tension.  For payment, you may use any credit or debit card with a Visa, MasterCard, American Express or Discover logo. With the exception note above, if you miss or cancel a session with less than 24 hours notice, you will be charged for the full session fee. 

Some of my clients are able get partial reimbursement from their insurance companies for care by out-of-network providers. Insurance companies have many rules and requirements specific to certain plans, and require that I provide them with a diagnosis. It is your responsibility to find out your insurance company's policies and to file for insurance reimbursement. I will be glad to provide you with a statement for your insurance company and to assist you with any questions you may have in this area.  Please note that insurance companies do not reimburse for missed sessions.

Communication Response Time

My practice is considered to be an outpatient facility, and I am set up to accommodate individuals who are reasonably safe and resourceful.  I will typically return phone calls and texts within 24-48 hours, and I may not be available to reply on weekends and holidays. If at any time this does not feel like sufficient support, please inform me, and we can discuss additional resources or transfer your case to a therapist or clinic with 24-hour availability.  

In Case of an Emergency

If you have a mental health emergency, I encourage you not to wait for a call or message back from me, but to do one or more of the following:

- Call Behavioral Health Link/Georgia Crisis and Access Line: 800-715-4225

- Call Ridgeview Institute at 770-434-4567

- Call Peachford Hospital at 770-454-5589

-Call Lifeline at (800) 273-8255 (National Crisis Line)

- Call 911

- Go to your nearest emergency room.

Professional Relationship

Psychotherapy is a professional service I will provide to you. Because of the nature of therapy, your relationship with me has to be different from most relationships. It may differ in how long it lasts, the objectives, or the topics discussed. It must also be limited to only the relationship of therapist and client. If you and I were to interact in any other ways, we would then have a "dual relationship," which could prove to be harmful to you in the long run and is, therefore, unethical in the mental health profession. Dual relationships can set up conflicts between the therapist's interests and the client's interests, and then the client's (your) interests might not be put first. In order to offer all of my clients the best care, my judgment needs to be unselfish and purely focused on your needs. This is why your relationship with me must remain professional in nature.

Additionally, there are important differences between therapy and friendship. Friends may see your position only from their personal viewpoints and experiences. Friends may want to find quick and easy solutions to your problems so that they can feel helpful. These short-term solutions may not be in your long-term best interest. Friends do not usually follow up on their advice to see whether it was useful. They may need to have you do what they advise. A therapist offers you choices and helps you choose what is best for you. A therapist helps you learn how to solve problems better and make better decisions. A therapist's responses to your situation are based on tested theories and methods of change.

You should also know that therapists are required to keep the identity of their clients confidential. As much as I would like to, for your confidentiality I will not address you in public unless you speak to me first. I also must decline any invitation to attend gatherings with your family or friends. Lastly, when your therapy is completed, I will not be able to be a friend to you like your other friends. In sum, it is my duty to always maintain a professional role. Please note that these guidelines are not meant to be discourteous in any way, they are strictly for your long-term protection.

Statement Regarding Ethics, Client Welfare & Safety

I assure you that my services will be rendered in a professional manner consistent with the ethical standards of the American Counseling Association. If at any time you feel that I am not performing in an ethical or professional manner, I ask that you please let me know immediately. If we are unable to resolve your concern, I will provide you with information to contact the professional licensing board that governs my profession.

Due to the very nature of psychotherapy, as much as I would like to guarantee specific results regarding your therapeutic goals, I am unable to do so. However, with your participation, we will work to achieve the best possible results for you. Please also be aware that changes made in therapy may affect other people in your life. For example, an increase in your assertiveness may not always be welcomed by others. It is my intention to help you manage changes in your interpersonal relationships as they arise, but it is important for you to be aware of this possibility nonetheless.

Additionally, at times people find that they feel somewhat worse when they first start therapy before they begin to feel better. This may occur as you begin discussing certain sensitive areas of your life. However, a topic usually isn't sensitive unless it needs attention. Therefore, discovering the discomfort is actually a success. Once you and I are able to target your specific treatment needs and the particular modalities that work the best for you, help is generally on the way.

Our Agreement to Enter into a Therapeutic Relationship

Please sign your name below indicating that you have read and understand the contents of this "Information, Authorization and Consent to Treatment" form. Your signature also indicates that you agree to the policies of your relationship with me, and you are authorizing me to begin treatment with you.

I am sincerely looking forward to facilitating you on your journey toward healing and growth. If you have any questions about any part of this document, please ask.