NOTICE OF PRIVACY PRACTICES

Effective Date: Upon Acknowledgment This Notice explains how your health information may be used and disclosed and outlines your rights regarding that information. Please read it carefully.

I. OUR COMMITMENT TO YOUR PRIVACY

At Modern Mental Health, we are dedicated to protecting your personal health information. We maintain a record of the care you receive in order to deliver high-quality treatment and to comply with legal and ethical standards. This notice applies to all records maintained by our practice and describes how we may use or disclose your information, as well as your rights and our responsibilities under the law.

As required by the Health Insurance Portability and Accountability Act (HIPAA), we will:

  • Maintain the privacy of your Protected Health Information (PHI)

  • Provide you with this Notice explaining our legal duties and privacy practices

  • Abide by the terms of this Notice, and

  • Notify you of any changes, which will be available in our office and on our website

II. HOW WE MAY USE AND DISCLOSE YOUR HEALTH INFORMATION

For Treatment, Payment, and Health Care Operations We may use or disclose your PHI without written authorization to facilitate your care and ensure proper coordination with other healthcare providers. This includes consultation between providers, referrals, scheduling, billing, or other administrative duties essential to your treatment. However, we at Modern Mental Health make a effort to obtain specific written or verbal permission to release yours or your child’s information. Special forms will be utilized to gain your permission to collaborate with your child’s school, doctors, etc. (in the case of a minor client).

Example: If your therapist consults with another licensed provider regarding your care, relevant information may be shared to support accurate diagnosis or appropriate treatment planning.

Please note: PHI used for treatment purposes is not subject to the “minimum necessary” standard, as complete information may be essential for clinical effectiveness.

Legal Matters We may disclose your health information if required by a court order or lawful process, such as a subpoena, provided reasonable efforts have been made to notify you or obtain a protective order.

III. USES AND DISCLOSURES THAT REQUIRE YOUR AUTHORIZATION

Psychotherapy Notes We maintain psychotherapy notes as defined by HIPAA, and these require your specific written authorization for use or disclosure unless:

  • Used for your treatment or clinical supervision

  • Required by law

  • Necessary for compliance investigations by the U.S. Department of Health and Human Services

  • Needed to protect against serious health or safety threats

  • Part of legal defense if initiated by you

  • Involved in certain coroner or oversight activities

Marketing or Sale of PHI We do not use your PHI for marketing purposes, nor do we sell PHI under any circumstances.

IV. USES AND DISCLOSURES THAT DO NOT REQUIRE AUTHORIZATION

We may use or disclose your PHI without your authorization in situations such as:

  • Compliance with law (e.g., reporting abuse, responding to legal requests)

  • Public health activities (e.g., disease prevention, injury reporting)

  • Health oversight (e.g., audits, inspections)

  • Law enforcement (e.g., reporting crimes on premises)

  • Coroners/Medical Examiners performing legal duties

  • Research (under strict ethical and legal guidelines)

  • Special government functions (e.g., military, correctional institutions)

  • Workers’ Compensation to comply with relevant laws

  • Appointment reminders and alternative services relevant to your care

V. DISCLOSURES WHERE YOU MAY OBJECT

With your verbal or written agreement, or unless you object, we may share limited PHI with family, close friends, or individuals involved in your care. In emergencies, we may do so retroactively if prior consent was not possible.

VI. YOUR RIGHTS REGARDING YOUR PHI

You have the right to:

  • Request Restrictions on how we use or disclose your PHI (though we may not be required to agree)

  • Request restrictions on disclosures to health plans when you’ve paid in full out-of-pocket for services

  • Request Confidential Communications, such as receiving information at a different address or phone number

  • Access Your Records, including electronic or paper copies (excluding psychotherapy notes), within 30 days of request (fees may apply)

  • Receive an Accounting of Disclosures not related to treatment, payment, or operations (free once annually)

  • Request Amendments to your PHI if you believe it’s incomplete or incorrect

  • Receive a Copy of This Notice, whether by email or paper, even if you initially agreed to email delivery

VII. SPECIAL CONSIDERATIONS FOR MINOR CLIENTS

At Modern Mental Health, we understand that working with children and adolescents requires special attention to both legal requirements and family involvement. The confidentiality of minor clients is carefully protected, while also respecting the role of parents and legal guardians in supporting their child’s care.

Who May Access a Minor’s Records: In general, parents or legal guardians have the right to access their child’s health records. However, Missouri law and professional ethical standards recognize that minors also have a right to privacy in certain therapeutic contexts. In these cases, we may limit parental access to protect the minor’s well-being and maintain a trusting therapeutic relationship.

Exceptions Where Information May Be Shared with Parents or Guardians:

  • If the minor is at risk of harm to themselves or others

  • If there is suspected abuse or neglect

  • If disclosure is necessary for treatment coordination or safety planning

  • If disclosure is required by law

  • Minor client’s substance use disclosures are not part of these exceptions

Requests for Confidentiality by Minors: Therapists may honor a minor’s request for limited confidentiality when appropriate and when it does not conflict with legal or safety obligations. This means that some session content may be kept confidential from parents/guardians unless the minor consents to sharing or a significant safety concern arises.

Informed Consent for Treatment: Missouri law generally requires a parent or legal guardian to provide consent for a minor’s treatment. In some limited cases, a minor may consent to their own treatment (e.g., if they are legally emancipated or seeking services under specific state provisions).

Parent-Therapist Communication: We encourage ongoing collaboration between families and clinicians. While we may not always disclose detailed session content , therapists will typically provide general updates on progress, safety, and treatment goals, especially when working with younger children or when collaboration is in the minor’s best interest.

If you have any questions or concerns about privacy and minors, we welcome discussion so we can find the right balance between supporting your child and maintaining therapeutic trust.

ACKNOWLEDGEMENT OF RECEIPT

Under HIPAA, you have the right to receive this Notice. By checking the box provided (electronically or in print), you confirm that you have read, understood, and agree to the terms outlined in this document.

EFFECTIVE DATE OF THIS NOTICE

This notice went into effect immediately after signing.

Acknowledgement of Receipt of Privacy Notice

Under the Health Insurance Portability and Accountability Act of 1996 (HIPAA), you have certain rights regarding the use and disclosure of your protected health information. By checking the box below, you are acknowledging that you have received a copy of HIPAA Notice of Privacy Practices.

Informed Consent for Treatment of a Minor Client

With Consideration for Missouri Law

General Overview

The therapeutic relationship is both a personal and professional agreement. It’s important that you, as the parent or legal guardian, understand what to expect when your child begins therapy at Modern Mental Health. This document outlines the nature of therapy, confidentiality limitations, and your role in supporting the process. Please feel free to ask questions at any time.

By checking the box at the end of this document, you affirm that you have reviewed and understand the information and consent to treatment for your child.

The Therapeutic Process

Choosing therapy for your child is a meaningful and proactive decision. While therapy does not guarantee specific outcomes, it often provides children with tools for emotional growth, self-awareness, and behavioral change. Our therapists will use clinical training and experience to support your child in a developmentally appropriate and trauma-informed manner.

Your consistent support, encouragement, and collaboration in this process are vital to the therapy’s effectiveness. We are specialized in the care of neuro-diverse clients and their families.

Confidentiality and Its Limits

Therapy is most effective when children feel safe to speak openly. To foster this, sessions are generally considered confidential—even from parents or guardians—except where Missouri law requires or allows disclosure.

You may request general updates on your child’s progress, treatment goals, and recommendations. However, detailed session content will only be shared with your child’s consent, unless safety concerns arise or disclosure is required by law.

The following exceptions to confidentiality apply and may require the therapist to disclose information to the appropriate authorities or individuals:

  • If your child makes a credible threat to harm themselves or someone else

  • If there is reasonable suspicion of child abuse, neglect, or exploitation

  • If there is suspicion of abuse or neglect of an elderly or dependent adult

  • If information is required by a valid court order or subpoena

  • If your child is being treated as part of a court-ordered process or legal proceeding

  • If consultation with another licensed professional is needed for your child’s care (identifying details will be excluded whenever possible)

Public Encounters: If we happen to see each other outside of the therapy office (e.g., in the community), I will not initiate contact to protect your family’s privacy. You are welcome to say hello, and I will respond respectfully but will not engage in a therapeutic discussion outside of session.

PRACTICE POLICIES

These policies are intended to ensure transparency, mutual respect, and clarity in our therapeutic relationship. Please read carefully and let us know if you have any questions or concerns.

Method of Treatment

You are entitled to information about the methods and techniques used in therapy, estimated treatment duration, and the fee structure. You may seek a second opinion or discontinue treatment at any time. We encourage open communication to ensure that your needs and expectations are met.

Sessions & Fees

  • Standard therapy sessions are 53 minutes and billed at $115 per session.

  • Initial evaluations (90 minutes) are billed at $200.

  • Payment is due at the time of service unless prior arrangements have been made.

  • If you are using insurance, we will bill the insurance company directly when possible. However, you are responsible for any co-pays, deductibles, services not covered, or unpaid balances.

  • Missed appointments or late cancellations (less than 24 hours' notice) will incur a $35 fee.

  • Returned checks will incur a $50 processing fee.

Appointments & Cancellations

  • Therapy sessions are typically scheduled for 50 minutes. Extended sessions can be arranged in advance, depending on availability.

  • Please provide at least 24 hours’ notice if you need to cancel or reschedule. Late cancellations or no-shows will be charged $35, as your appointment time is reserved specifically for you.

  • If you arrive late, your session will still end at the scheduled time to accommodate other clients.

Confidentiality

Therapy sessions are confidential. Information will only be shared with others (including parents/guardians in the case of minors) with written consent, except as required by law. Exceptions include:

  • Risk of harm to self or others

  • Suspected child, elder, or dependent adult abuse or neglect

  • Court-ordered disclosures or subpoenas

  • Court-ordered therapy or expert evaluation

  • Professional consultations (identifying information withheld whenever possible)

For minor clients, parents or legal guardians will be informed of general progress and treatment recommendations, while respecting the minor’s privacy and clinical need for confidentiality whenever possible.

Minors in Therapy

Missouri law generally allows parents access to their child’s treatment information. However, in the therapeutic setting, children benefit from having a private space to process emotions. We strive to involve parents in meaningful ways while honoring a minor’s developmental need for privacy. Exceptions apply in safety-related or legally mandated situations.

Emergencies

For mental health emergencies, please call 911 or go to the nearest emergency room or urgent care center. We are not equipped for 24-hour emergency services.

Therapist Accessibility

You may contact your therapist via email we aim to return emails within 24 hours, immediate response is not guaranteed. Phone sessions may be available under special circumstances, such as illness or travel.

Electronic Communication

Due to security limitations, we do not discuss clinical concerns via text (only scheduling). For communication specific to treatment concerns, please use the secure client portal messaging system or our secure email. We ask that you avoid using electronic communication for urgent or emergency situations.

Social Media & Telecommunication Policy

To protect your confidentiality and maintain professional boundaries, we do not accept friend or contact requests from clients on any social media platforms (e.g., Facebook, Instagram, LinkedIn). This policy is intended to safeguard your privacy and the integrity of the therapeutic relationship.

Termination of Services

Therapy can end at any time by mutual agreement or at your request. Ideally, a planned termination process allows for closure and review of your progress.
Termination may also occur if:

  • Therapy is not being effectively used

  • You are in default on payments

  • You do not attend sessions for three consecutive weeks without prior arrangement

In the event of termination, we will provide referrals to other qualified mental health providers upon request.

Regulatory Information

Mental health services provided by Modern Mental Health are regulated by the Missouri Committee for Professional Counselors:

Committee for Professional Counselors
3605 Missouri Blvd., P.O. Box 1335
Jefferson City, MO 65102-1335
Phone: (573) 751-0735

Court Appearance Policy

Modern Mental Health – Fredericktown, MO

At Modern Mental Health, we aim to provide therapy in a confidential, therapeutic context. Involvement in legal matters—particularly subpoenas or requests for court testimony—can interfere with this process and may affect the therapeutic relationship. Therefore, clients (and parents/guardians of minor clients) are strongly discouraged from involving their therapist in legal proceedings whenever possible.

Important Considerations

  • If a therapist is subpoenaed or asked to provide testimony, they do not serve as an advocate for either party. The therapist's role is limited to sharing factual information and/or professional opinions based on clinical records and direct observation.

  • For minor clients, therapists are ethically obligated to prioritize the best interests of the child. This means the therapist’s court testimony may reflect concerns, observations, or clinical impressions that are not in alignment with either parent's legal position.

  • Subpoenas issued by an attorney do not guarantee favorable testimony. The therapist will not alter or withhold clinical opinions to support legal strategies.

Court-Related Fees

Due to the time, preparation, and impact on clinical services, the following fee schedule applies to all court-related activities:

ServiceFeeCase preparation and records review$220/hourPhone consultations$220/hourDepositions$250/hourEmail or written correspondence$200/hourCourtroom testimony$250/hourTime away from office (travel, standby, etc.)$220/hourMileage reimbursement$0.54/mileDocument filing with court (plus court fees)$100 flat feeMinimum charge for court appearance$1500

Additional Legal Billing Terms

  • A $1500 retainer is due at least 5 business days before any scheduled court appearance or deposition.

  • Late Notice Fees:

    • Subpoenas or attorney meetings with less than 48 hours’ notice will incur a $250 express processing fee.

    • Rescheduling a court appearance with less than 72 business hours’ notice will result in a $500 rescheduling fee, in addition to the $1500 retainer.

  • If a therapist is required to cancel out-of-town travel or interrupt scheduled time off, all fees will be doubled.

  • Clients or their legal representatives are responsible for any and all additional legal expenses or costs incurred by the therapist as a result of involvement in the legal matter.