Privacy Policy

HIPAA Policy & Privacy and Sharing of Information

I authorize the clinic and its associated health professionals to collect my personal and medical information as documented above. In addition, I authorize the clinic and its associated health professionals to communicate with my family doctor and/or referring doctor as deemed necessary for my treatment. I also understand that my personal and medical information is confidential and will only be disclosed to third parties with my permission.

I understand that all information shared with Kelli Czarnick is confidential and will only be released with my documented consent. Documented verbal consent for limited release of information may be necessary in special circumstances.

I understand that there are specific and limited exceptions to this confidentiality, including: ⬥ When there is known risk of imminent danger to a person, all licensed mental health providers are legally and ethically bound to take reasonable and necessary steps to help prevent such danger; ⬥ When there is knowledge or suspicion that a vulnerable person (child, individual with developmental disabilities, or elder) is being sexually, emotionally, or physically abused, neglected, or is at risk of such harm, all licensed mental health providers are legally required to inform the proper authorities; ⬥ When a valid court order is issued for medical records, all licensed mental health providers are bound by law to comply with such requests.

Minors and individuals who are unable to consent for their own treatment maintain a right to confidentiality due to the nature of the therapeutic process. Parents and/or guardians are not automatically afforded the right to treatment records, regardless of the client’s age or legal status.