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Terms and Policy

Hippa, Consent & Helpful Information


Welcome to Kaleidoscope Family Therapy Family Therapy. We are very pleased that you selected us for your therapy, and we sincerely look forward to assisting you. This document is designed to inform you about what you can expect from your therapist, policies regarding confidentiality and emergencies, and several other details regarding your treatment here at Kaleidoscope Family Therapy. Although providing this document is part of an ethical obligation to our profession, more importantly, it is part of our commitment to you to keep you fully informed of every part of your therapeutic experience. Please know that your relationship with your therapist is a collaborative one, and we welcome any questions, comments, or suggestions regarding the course of therapy at any time.


It is our belief that as people become more aware of their thoughts and behaviors, they are more capable of finding a sense of peace and contentment in their lives. However, self-awareness and self-acceptance are goals that may take a long time to achieve. Some clients need only a few sessions to achieve these goals, whereas others may require months or even years of therapy. Since treatment goals vary from client to client and progress is related to the client's willingness to change, we cannot guarantee results within a given period of time. As a client or client's parent, you are in control and you may end the relationship with your therapist at any point. In order for therapy to be most successful, it is important for your child to take an active role. This means working on the things he/she and his/her therapist talk about both during and between sessions. Generally, the more one invests in therapy, the greater the return. It is our intention to empower your child in his/her growth process to the degree that he/she is capable of facing life's challenges in the future without the help of a therapist. We do not believe in creating dependency or prolonging therapy if it is no longer beneficial to your family. Your personal development is our number one priority.


Your communications with the therapist will become part of a clinical record of treatment, and it is referred to as Protected

Health Information (PHI). Your PHI will be kept in an encrypted  and password protected electronic health record that only your therapist has access to.  

It is filed under your first name and last initial to protect your confidentiality to the fullest extent. Additionally, your therapist will always keep everything your child says to him/her completely confidential, with the following exceptions: (1) you direct your therapist to tell someone else and you sign a "Release of Information" form; (2) your therapist determines that your child is a danger to himself or to others; (3) your child reports information about the abuse of a child, an elderly person, or a disabled individual who may require protection; or (4) your therapist is ordered by a judge to disclose information. In the latter case, your therapist's license does provide them 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 counselor. The state of Georgia 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. We cannot guarantee that the appeal will be sustained, but we will do everything in our power to keep what your child says confidential.

I understand that all e-mail messages are sent over the Internet. I understand that my e-mail communications with my clinician will not be encrypted and, therefore, neither my therapist(s) nor Kaleidoscope Family Therapycan guarantee the confidentiality and security of any information sent and received via email. I understand that if I do not wish to have my therapist or Kaleidoscope Family Therapy communicate with me via email, I can notify my therapist of this in writing.


- $150: Intake (CPT Code 90791)

- $125: Individual Therapy 50-minute Session (CPT Code 90834)

- $140: Family Therapy/Couples Therapy 50-minute Session (CPT Code 90846 or 90847)

- $125: Parent Meeting and/or Feedback Session (CPT Code 90846)

- $65: Group 60-minute Weekly Session (CPT Code 90853)

- $75: 30-minute session  (CPT code 90832)


We love working with your children and find ourselves busy keeping in touch with other professionals in your life. We are happy to make phone calls, emails, and other communication with professionals to make sure your child has the best multi-disciplinary treatment and has a caring team of professionals who are all on the same . The following are our fees for this communication:

- $125 per hour for any communication exceeding 15 minutes in a week between therapist and collateral contacts(including parents, teachers, psychiatrists, school counselors, guardian or any other professionals)

- $125 per hour for phone calls, emails and letter-writing exceeding 15 minutes per week

- $350 for school observations with written report.



We discourage sharing confidential client information regarding specific statements by the client for use of court procedures. In our experience this devalues the therapeutic relationship and the trust that the client has in the therapist. If court appearances are required however, please note the fee below.

- $500 per hour, 4 hour minimum required


- Therapy sessions are scheduled to be 50 minutes. We understand that traffic and other reasons may cause you to be late; however, we still must conclude the session at the scheduled stop time (meaning if you are 20 minutes late, your session will be 30 minutes).


- Your appointment time is reserved exclusively for you. If you are unable to attend your appointment, please notify us by email or phone.

- We require a 24 hour notice for any cancelled appointment.

- Failure to follow cancellation policy will result in being billed for the full session amount for the time that

was reserved for you.


The 50 minute therapy session includes the parent-check in at the end (if applicable). Any additional time spent in the therapist's office will be billed at a rate of $125 an hour. Once the 50 minutes has been reached, therapist will inform you and give you the option to continue the conversation (if the therapist has time available) but please note that if you choose to extend the session time, you will be billed at a prorated rate.

- Please pick up your child on time. We are not responsible for unaccompanied children after the scheduled session


The fee for each session will be due at the beginning of the session. We will provide you with a receipt of payment upon request. 

The receipt of payment may also be used as a statement for insurance if you so choose. Insurance companies have many 

rules and requirements specific to certain plans. Unless otherwise negotiated, it is your responsibility to find out your insurance company's policies and to file for insurance reimbursement. We 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.


We provide therapy services for adults and children whose families are going through divorce or separation. Because this process can be difficult for both parents and children, we have found reason to develop specific guidelines:


1. If we are seeing a child whose parents are in the process of divorce or are already divorced, we require a copy of the standing court order demonstrating the custodial rights of each parent and/or the parenting agreement that is signed by both parents at the judge at the intake session. We will need to have contact with the parent who has legal custodial decision making for medical issues before we see the child for counseling and will need to obtain written consent for the child to participate in counseling from the legal custodian(s) and prefer to have contact with both parents prior to seeing the child.

2. We will be available to provide an interview with a guardian ad litem (GAL) assigned to investigate the best interest of any child we are counseling upon production of court order demonstrating the GAL's right to examine your clinical record or speak with me. Otherwise, the adult client or parents of child client will need to sign a release for me to speak with the GAL. The client will be charged a full session fee for me to have such a meeting with the GAL.

3. We will provide identical summaries of a child's therapy progress, treatment plan, and parent recommendations to both parents who share legal custody of the child we are seeing. We will encourage both parents to participate in the therapeutic process of the child


Kaleidoscope Family Therapy Family Therapy is considered an outpatient facility, and we are set up to accommodate individuals who are reasonably safe and resourceful. Generally, your therapist will return phone calls within 24-48 hours. If you have a mental health emergency, we encourage you not to wait for a call back, but to do one or more of the following:

- Ridgeview Institute (ages 11-18 and adults): 770-434-4567

- Peachford Hospital (ages 4-18 and adults): 770-454-2302

- Fulton County Mental Health Crisis Line: 770-422-0202

- Georgia Crisis Line: 1-800-715-4225


Psychotherapy is a professional service we will provide to your child. Because of the nature of therapy, your relationship (and your relationship) with the therapist 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 your child and his/her therapist were to interact in any other ways, you 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 interests might not be put first. In order to offer all of our clients the best care, your therapist's judgment needs to be unselfish and purely focused on your

needs. This is why you and your relationship with your therapist 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' secret. As much as your therapist would like to, for your confidentiality he/she will not address you in public unless you speak to him/her first. Your therapist also must decline any invitation to attend gatherings with your family or friends. Lastly, when your therapy is completed, your therapist will not be able to be a friend to you like your other friends. In sum, it is the duty of your therapist 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.


Kaleidoscope Family Therapy Family Therapy assures you that our services will be rendered in a professional manner consistent with the ethical standards of the American Association For Marriage and Family Therapy. If at any time you feel that your therapist is not performing in an ethical or professional manner, we ask that you please let him or her know immediately.

We are sincerely looking forward to facilitating you and/or your child on his/her journey toward healing and growth. If you have any questions about any part of this document, please ask the therapist. Please print, date, and sign your name below indicating that you have read and understand the contents of this form, you agree to the policies of the relationship with your therapist and you are authorizing the therapist to begin treatment.


Health Insurance Portability and Accountability Act (HIPAA)


Effective 5/7/2016

I. COMMITMENT TO YOUR PRIVACY: Kaleidoscope Family Therapy, is 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. This Notice of Privacy Practices ("Notice") is required by law to provide you with the legal duties and the privacy practices that Kaleidoscope Family Therapy, 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, Kaleidoscope Family Therapy, is required to ensure that your PHI is kept private. This Notice explains when, why, and how Kaleidoscope Family Therapy 

would use and/or disclose your PHI. Use of PHI means when Kaleidoscope Family Therapy shares, applies, utilizes, examines, or analyzes information within its practice; PHI is disclosed when Kaleidoscope Family Therapy, releases, transfers, gives, or otherwise reveals it to a third party outside of the Institute. With some exceptions, Kaleidoscope Family Therapy Therapy

& Consultations , 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, Kaleidoscope Family Therapy, 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 Kaleidoscope Family Therapy, . Please note that Kaleidoscope Family Therapy 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 Kaleidoscope Family Therapy, has created or maintained in the past and for any of your records that Kaleidoscope Family Therapy, may create or maintain in the future. Kaleidoscope Family Therapy, 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

Kaleidoscope Family Therapy, 's Notice of Privacy Practices.


IV. HOW YOUR NAME MAY USE AND DISCLOSE YOUR PHI: Kaleidoscope Family Therapy, 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: Kaleidoscope Family Therapy, 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, Kaleidoscope Family Therapy, may


disclose your PHI to her/him in order to coordinate your care. Except for in an emergency, Kaleidoscope Family Therapy, will always ask for your authorization in writing prior to any such consultation.

2. For Health Care Operations: Kaleidoscope Family Therapy, may disclose your PHI to facilitate the efficient and correct operation of

its practice. Example: Quality control - Kaleidoscope Family Therapy, may provide your PHI to its office personnel, accountants, practice consultants, attorneys and others to make sure that Kaleidoscope Family Therapy is in compliance with applicable practices and laws. It is Kaleidoscope Family Therapy practice to conceal all client names in such an event and maintain confidentiality. However, there is still a possibility that your PHI may audited for such purposes.

3. To Obtain Payment for Treatment: Kaleidoscope Family Therapy, may use and disclose your PHI to bill and collect payment for the treatment and services Kaleidoscope Family Therapy, provided you. Example: Kaleidoscope Family Therapy, 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. Kaleidoscope Family Therapy, could also provide your PHI to billing companies, claims processing companies, and others that process health care claims for Kaleidoscope Family Therapy, 's office if either you or your insurance carrier are not able to stay current with your account. In this latter instance, Kaleidoscope Family Therapy, 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 Kaleidoscope Family Therapy, 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, Kaleidoscope Family Therapy, 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 Kaleidoscope Family Therapy, .

V. USE AND DISCLOSURE OF YOUR PHI IN CERTAIN SPECIAL CIRCUMSTANCES - YOUR NAME may use and/or disclose your PHI without your consent or authorization for the following reasons:

1. Law Enforcement: Subject to certain conditions, Kaleidoscope Family Therapy, may disclose your PHI when required by federal, state, or local law; judicial, board, or administrative proceedings; or, law enforcement. Example: Kaleidoscope Family Therapy, may make a disclosure to the appropriate officials when a law requires Kaleidoscope Family Therapy, to report information to government agencies, law enforcement personnel and/or in an administrative proceeding.

2. Lawsuits and Disputes: Kaleidoscope Family Therapy, may disclose information about you to respond to a court or administrative order or a search warrant. Kaleidoscope Family Therapy, 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.

Kaleidoscope Family Therapy, 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: Kaleidoscope Family Therapy, 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): Kaleidoscope Family Therapy, 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: Kaleidoscope Family Therapy, 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 Kaleidoscope Family Therapy, determines in good faith that disclosure is necessary to prevent the threatened danger. Under these circumstances, Kaleidoscope Family Therapy Therapy &

Consultations, 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), Kaleidoscope Family Therapy, may be compelled to release certain types of information to your parents or guardian in accordance with applicable law.

7. Abuse and Neglect: Kaleidoscope Family Therapy, may disclose PHI if mandated by Georgia child, elder, or dependent adult abuse andneglect reporting laws. Example: If Kaleidoscope Family Therapy, has a reasonable suspicion of child abuse or neglect, Kaleidoscope Family Therapy, will report this to the Georgia Department of Child and Family Services.

8. Coroners, Medical Examiners, and Funeral Directors: Kaleidoscope Family Therapy, 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. Kaleidoscope Family Therapy, may also disclose PHI to funeral directors, consistent with applicable law, to carry out their duties.

9. Communications with Family, Friends, or Others: Kaleidoscope Family Therapy, 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, Kaleidoscope Family Therapy, 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, Kaleidoscope Family Therapy, may release PHI about you as required by military command authorities. Kaleidoscope Family Therapy, may also release PHI about foreign military personnel to the appropriate military authority.


11. National Security, Protective Services for the President, and Intelligence Activities: Kaleidoscope Family Therapy Therapy & Consultations , 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, Kaleidoscope Family Therapy, 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, Kaleidoscope Family Therapy, 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 a n 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: Kaleidoscope Family Therapy, may provide PHI in order to comply with

Workers' Compensation or similar programs established by law.

15. Appointment Reminders: Kaleidoscope Family Therapy, 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: Kaleidoscope Family Therapy, 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 Kaleidoscope Family Therapy, 's compliance with HIPAA regulations.

17. If Disclosure is Otherwise Specifically Required by Law.


VI. Other Uses and Disclosures Require Your Prior Written Authorization: In any other situation not covered by this notice, Kaleidoscope Family Therapy, 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 Kaleidoscope Family Therapy, in writing of your decision. You understand that Kaleidoscope Family Therapy, is unable to take back any disclosures it has already made with your permission, Kaleidoscope Family Therapy, will continue to comply with laws that require certain disclosures, and Kaleidoscope Family Therapy, is required to retain

records of the care that its therapists have provided to you.



1. The Right to See and Get Copies of Your PHI: In general, you have the right to see your PHI that is in Kaleidoscope Family Therapy Therapy & Consultations , 's possession, or to get copies of it; however, you must request it in writing. If Kaleidoscope Family Therapy, does not have your PHI, but knows who does, you will be advised how you can get it. You will receive a response from Kaleidoscope Family Therapy, within 30 days of receiving your written request. Under certain circumstances, Kaleidoscope Family Therapy, may feel it must deny your request, but if it does, Kaleidoscope Family Therapy, will give you, in writing, the reasons for the denial. Kaleidoscope Family Therapy, will also explain your right to have its denial reviewed. If you ask for copies of your PHI, you will be charged not more than $.25 per  and the fees associated with supplies and postage. Kaleidoscope Family Therapy, 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 Kaleidoscope Family Therapy, limit how it uses and discloses your PHI. While Kaleidoscope Family Therapy, will consider your request, it is not legally bound to agree. If Kaleidoscope Family Therapy, does agree to your request, it will put those limits in writing and abide by them except in emergency situations. You do not have the right to limit the uses and disclosures that Kaleidoscope Family Therapy, is legally required or permitted to make.

3. The Right to Choose How Kaleidoscope Family Therapy Family TherapySends 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). Kaleidoscope Family Therapy, 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 Kaleidoscope Family Therapy, 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. Kaleidoscope Family Therapy, 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. Kaleidoscope Family Therapy, 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 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 Kaleidoscope Family Therapy, 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 Kaleidoscope Family Therapy, 's receipt of your request. Kaleidoscope Family Therapy, 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 Kaleidoscope Family Therapy, 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 Kaleidoscope Family Therapy Therapy & Consultations

, 's denial will be attached to any future disclosures of your PHI. If Kaleidoscope Family Therapy, approves your request, it will make the change(s) to your PHI. Additionally, Kaleidoscope Family Therapy, 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 to Kaleidoscope Family Therapy, 's lead therapist , LeNaya Smith, at the address' listed at the top of this document.

VIII. COMPLAINTS: If you are concerned your privacy rights may have been violated, or if you object to a decision Kaleidoscope Family Therapy, 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. Kaleidoscope Family Therapy, 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 below indicates that you Acknowledge receipt of this Notice:


Date of Last Revision: 12/19/2019

( Type Full Name )