Client Forms

I am honored to have the opportunity to work with you. This page contains information and forms that I will need to have on file for the first meeting.

Please review and complete the following forms:

• Disclosure Statement — to be reviewed and signed
• Client Intake Form — to be completed before the first session.
• Notice Form of HIPAA Legislation — to be reviewed and signed.
• Telemedicine Informed Consent Form — to be reviewed and signed.

Disclosure Statement

Thank you for deciding to seek counseling with Dr. Rebecca Gold. The following information will help you understand many of the details about your therapy. Rebecca is committed to providing you with 1 evidence-based, time-effective treatment to individuals, couples and families regardless of age, race, sex, or religious affiliation.

SESSIONS Individual, couples, and family sessions are typically scheduled for 50 minutes at a frequency to be determined by Rebecca and client. In case of an emergency, please call 911.

CANCELLATIONS We understand that it may, at times, be necessary to cancel an appointment. To help us be most efficient and responsible in the use of our time, we require that any changes or cancellations be made at least 24 hours in advance. Thank you for your consideration regarding this important matter.

CONFIDENTIALITY Contents of all therapy sessions are considered to be confidential. Both verbal information and written records about a client cannot be shared with another party without the written consent of the client or the client’s legal guardian. Noted exceptions are as follows:

Duty to Warn and Protect: When a client discloses intentions or a plan to harm another person, the mental health professional is required to warn the intended victim and report this information to legal authorities. In cases in which the client discloses or implies a plan for suicide, the health care professional is required to notify legal authorities and make reasonable attempts to notify the family of the client.

Abuse of Children and Vulnerable Adults: If a client states or suggests that he or she is abusing a child (or vulnerable adult) or has recently abused a child (or vulnerable adult), or a child (or vulnerable adult) is in danger of abuse, the mental health professional is required to report this information to the appropriate social service and/or legal authorities.

Prenatal Exposure to Controlled Substances: Mental Health care professionals are required to report admitted prenatal exposure to controlled substances that are potentially harmful.

Minors/Guardianship Parents or legal guardians of non-emancipated minor clients have the right to access the clients’ records.

Insurance Providers (when applicable) Insurance companies and other third-party payers are given information that they request regarding services to clients. Information that may be requested includes, but is not limited to types of services, dates/times of service, diagnosis, treatment plan, description of impairment, progress of therapy, case notes, and summaries.

FINANCIAL AGREEMENT AND AUTHORIZATION FOR TREATMENT: I have been informed of and read the preceding information and agree to it. I authorize treatment of the person named below and agree to pay all fees as stated above.

Client Intake Form

Notice Form of HIPAA Legislation

As required by the privacy regulations created as a result of the Health Insurance Portability and Accountability Act of 1996 (HIPAA). This notice describes how health information about you (as a client of this practice) may be used and disclosed and how you can get access to your individually identifiable health information. Please review this notice carefully. A. Our commitment to your privacy: Our practice is dedicated to maintaining the privacy of your individually identifiable health information (also called protected health information, or PHI). In conducting our business, we will create records regarding you and the treatment and services we provide to you. We are required by law to maintain the confidentiality of health information that identifies you. We also are required by law to provide you with this notice of our legal duties and the privacy practices that we maintain in our practice concerning your PHI. By federal and state law, we must follow the terms of the Notice of Privacy Practices that we have in effect at the time. We realize that these laws are complicated, but we must provide you with the following important information: • How we may use and disclose your PHI, • Your privacy rights in your PHI, • Our obligations concerning the use and disclosure of your PHI. The terms of this notice apply to all records containing your PHI that are created or retained by our practice. We reserve the right to revise or amend this Notice of Privacy Practices. Any revision or amendment to this notice will be effective for all of your records that our practice has created or maintained in the past, and for any of your records that we may create or maintain in the future. Our practice will post a copy of our current Notice in our offices in a visible location at all times, and you may request a copy of our most current Notice at any time. B. If you have questions about this Notice, please contact: Dr. Rebecca Gold C. We may use and disclose your PHI in the following ways: The following categories describe the different ways in which we may use and disclose your PHI. 1. Treatment. Our practice may use your PHI to treat you. For example, we may ask you to have laboratory tests (such as blood or urine tests), and we may use the results to help us reach a diagnosis. We might use your PHI in order to write a prescription for you, or we might disclose your PHI to a pharmacy when we order a prescription for you. Many of the people who work for our practice – including, but not limited to, our doctors and nurses – may use or disclose your PHI in order to treat you or to assist others in your treatment. Additionally, we may disclose your PHI to others who may assist in your care, such as your spouse, children or parents. Finally, we may also disclose your PHI to other health care providers for purposes related to your treatment. 2. Payment. Our practice may use and disclose your PHI in order to bill and collect payment for the services and items you may receive from us. For example, we may contact your health insurer to certify that you are eligible for benefits (and for what range of benefits), and we may provide your insurer with details regarding your treatment to determine if your insurer will cover, or pay for, your treatment. We also may use and disclose your PHI to obtain payment from third parties that may be responsible for such costs, such as family members. Also, we may use your PHI to bill you directly for services and items. We may disclose your PHI to other health care providers and entities to assist in their billing and collection efforts. 3. Health care operations. Our practice may use and disclose your PHI to operate our business. As examples of the ways in which we may use and disclose your information for our operations, our practice may use your PHI to evaluate the quality of care you received from us, or to conduct cost-management and business planning activities for our practice. We may disclose your PHI to other health care providers and entities to assist in their health care operations. 4. Appointment reminders. Our practice may use and disclose your PHI to contact you and remind you of an appointment. 5. Treatment options. Our practice may use and disclose your PHI to inform you of potential treatment options or alternatives. 6. Health-related benefits and services. Our practice may use and disclose your PHI to inform you of health-related benefits or services that may be of interest to you. 7. Release of information to family/friends. Our practice may release your PHI to a friend or family member that is involved in your care, or who assists in taking care of you. For example, a parent or guardian may ask that a baby sitter take their child to the pediatrician’s office for treatment of a cold. In this example, the baby sitter may have access to this child’s medical information. 8. Disclosures required by law. Our practice will use and disclose your PHI when we are required to do so by federal, state or local law. D. Use and disclosure of your PHI in certain special circumstances: The following categories describe unique scenarios in which we may use or disclose your identifiable health information: 1. Public health risks. Our practice may disclose your PHI to public health authorities that are authorized by law to collect information for the purpose of: • Maintaining vital records, such as births and deaths, • Reporting child abuse or neglect, • Preventing or controlling disease, injury or disability, • Notifying a person regarding potential exposure to a communicable disease, • Notifying a person regarding a potential risk for spreading or contracting a disease or condition, • Reporting reactions to drugs or problems with products or devices, • Notifying individuals if a product or device they may be using has been recalled, Notifying your employer under limited circumstances related primarily to workplace injury or illness or medical surveillance. 2. Health oversight activities. Our practice may disclose your PHI to a health oversight agency for activities authorized by law. Oversight activities can include, for example, investigations, inspections, audits, surveys, licensure and disciplinary actions; civil, administrative and criminal procedures or actions; or other activities necessary for the government to monitor government programs, compliance with civil rights laws and the health care system in general. 3. Lawsuits and similar proceedings. Our practice may use and disclose your PHI in response to a court or administrative order, if you are involved in a lawsuit or similar proceeding. We also may disclose your PHI in response to a discovery request, subpoena or other lawful process by another party involved in the dispute, but only if we have made an effort to inform you of the request or to obtain an order protecting the information the party has requested. 4. Law enforcement. We may release PHI if asked to do so by a law enforcement official: • Regarding a crime victim in certain situations, if we are unable to obtain the person’s agreement, • Concerning a death we believe has resulted from criminal conduct, • Regarding criminal conduct at our offices, • In response to a warrant, summons, court order, subpoena or similar legal process, • To identify/locate a suspect, material witness, fugitive or missing person, • In an emergency, to report a crime (including the location or victim(s) of the crime, or the description, identity or location of the perpetrator). 5. Deceased patients. Our practice may release PHI to a medical examiner or coroner to identify a deceased individual or to identify the cause of death. If necessary, we also may release information in order for funeral directors to perform their jobs. 6. Organ and tissue donation. Our practice may release your PHI to organizations that handle organ, eye or tissue procurement or transplantation, including organ donation banks, as necessary to facilitate organ or tissue donation and transplantation if you are an organ donor. 7. Research. Our practice may use and disclose your PHI for research purposes in certain limited circumstances. We will obtain your written authorization to use your PHI for research purposes except when an Internal Review Board or Privacy Board has determined that the waiver of your authorization satisfies all of the following conditions: (A) The use or disclosure involves no more than a minimal risk to your privacy based on the following: (i) an adequate plan to protect the identifiers from improper use and disclosure; (ii) an adequate plan to destroy the identifiers at the earliest opportunity consistent with the research (unless there is a health or research justification for retaining the identifiers or such retention is otherwise required by law); and (iii) adequate written assurances that the PHI will not be re-used or disclosed to any other person or entity (except as required by law) for authorized oversight of the research study, or for other research for which the use or disclosure would otherwise be permitted; (B) The research could not practicably be conducted without the waiver, (C) The research could not practicably be conducted without access to/use of the PHI. 8. Serious threats to health or safety. Our practice may use and disclose your PHI when necessary to reduce or prevent a serious threat to your health and safety or the health and safety of another individual or the public. Under these circumstances, we will only make disclosures to a person or organization able to help prevent the threat. 9. Military. Our practice may disclose your PHI if you are a member of U.S. or foreign military forces (including veterans) and if required by the appropriate authorities. 10. National security. Our practice may disclose your PHI to federal officials for intelligence and national security activities authorized by law. We also may disclose your PHI to federal and national security activities authorized by law. We also may disclose your PHI to federal officials in order to protect the president, other officials or foreign heads of state, or to conduct investigations. 11. Inmates. Our practice may disclose your PHI to correctional institutions or law enforcement officials if you are an inmate or under the custody of a law enforcement official. Disclosure for these purposes would be necessary: (a) for the institution to provide health care services to you, (b) for the safety and security of the institution, and/or (c) to protect your health and safety or the health and safety of other individuals. 12. Workers’ compensation. Our practice may release your PHI for workers’ compensation and similar programs. E. Your rights regarding your PHI: You have the following rights regarding the PHI that we maintain about you: 1. Confidential communications. You have the right to request that our practice communicate with you about your health and related issues in a particular manner or at a certain location. For instance, you may ask that we contact you at home, rather than work. In order to request a type of confidential communication, you must make a written request to Dr. Rebecca Gold. specifying the requested method of contact, or the location where you wish to be contacted. Our practice will accommodate reasonable requests. You do not need to give a reason for your request. 2. Requesting restrictions. You have the right to request a restriction in our use or disclosure of your PHI for treatment, payment or health care operations. Additionally, you have the right to request that we restrict our disclosure of your PHI to only certain individuals involved in your care or the payment for your care, such as family members and friends. We are not required to agree to your request; however, if we do agree, we are bound by our agreement except when otherwise required by law, in emergencies or when the information is necessary to treat you. In order to request a restriction in our use or disclosure of your PHI, you must make your request in writing to Dr. Rebecca Gold Your request must describe in a clear and concise fashion: • The information you wish restricted, • Whether you are requesting to limit our practice’s use, disclosure or both, • To whom you want the limits to apply. 3. Inspection and copies. You have the right to inspect and obtain a copy of the PHI that may be used to make decisions about you, including patient medical records and billing records, but not including psychotherapy notes. You must submit your request in writing to Dr. Rebecca Gold in order to inspect and/or obtain a copy of your PHI. Our practice may charge a fee for the costs of copying, mailing, labor and supplies associated with your request. Our practice may deny your request to inspect and/or copy in certain limited circumstances; however, you may request a review of our denial. Another licensed health care professional chosen by us will conduct reviews. 4. Amendment. You may ask us to amend your health information if you believe it is incorrect or incomplete, and you may request an amendment for as long as the information is kept by or for our practice. To request an amendment, your request must be made in writing and submitted to Dr. Rebecca Gold. You must provide us with a reason that supports your request for amendment. Our practice will deny your request if you fail to submit your request (and the reason supporting your request) in writing. Also, we may deny your request if you ask us to amend information that is in our opinion: (a) accurate and complete; (b) not part of the PHI kept by or for the practice; (c) not part of the PHI which you would be permitted to inspect and copy; or (d) not created by our practice, unless the individual or entity that created the information is not available to amend the information. 5. Accounting of disclosures. All of our patients have the right to request an “accounting of disclosures.” An “accounting of disclosures” is a list of certain non-routine disclosures our practice has made of your PHI for purposes not related to treatment, payment or operations. Use of your PHI as part of the routine patient care in our practice is not required to be documented – for example, the doctor sharing information with the nurse; or the billing department using your information to file your insurance claim. In order to obtain an accounting of disclosures, you must submit your request in writing to Dr. Rebecca Gold. All requests for an “accounting of disclosures” must state a time period, which may not be longer than six (6) years from the date of disclosure. The first list you request within a 12-month period is free of charge, but our practice may charge you for additional lists within the same 12-month period. Our practice will notify you of the costs involved with additional requests, and you may withdraw your request before you incur any costs. 6. Right to a paper copy of this notice. You are entitled to receive a paper copy of our notice of privacy practices. You may ask us to give you a copy of this notice at any time. To obtain a paper copy of this notice, contact Dr. Rebecca Gold. 7. Right to file a complaint. If you believe your privacy rights have been violated, you may file a complaint with our practice or with the Secretary of the Department of Health and Human Services. To file a complaint with our practice, contact Dr. Rebecca Gold. All complaints must be submitted in writing. You will not be penalized for filing a complaint. 8. Right to provide an authorization for other uses and disclosures. Our practice will obtain your written authorization for uses and disclosures that are not identified by this notice or permitted by applicable law. Any authorization you provide to us regarding the use and disclosure of your PHI may be revoked at any time in writing. After you revoke your authorization, we will no longer use or disclose your PHI for the reasons described in the authorization. Please note: we are required to retain records of your care. Again, if you have any questions regarding this notice or our health information privacy policies, please contact Dr. Rebecca Gold.

Telemedicine Informed Consent Form

I hereby consent to engaging in telemedicine with Rebecca Gold, PsyD, LPCC as part of my psychotherapy. I understand that “telemedicine” includes the practice of health care delivery, diagnosis, consultation, treatment, transfer of medical data, and education using interactive audio, video, or data communications. I understand that telemedicine also involves the communication of my medical/mental information, both orally and visually, to health care practitioners located in California.   Because of recent advances in communication technology, the field of tele-therapy has evolved.  It has allowed individuals who may not have local access to a mental health professional to use electronic means to receive services.  Because it is relatively new, there is not a lot of research indicating that it is an effective means of receiving therapy.  An important part of therapy is sitting face to face with an individual, where non-verbal communication (body signals) are readily available to both therapist and client.  Without this information, tele-therapy may be slower to progress or less effective.  With the telephone, the client’s tone of voice, pauses and choice of words become especially important and therefore an important focus of the sessions.  With therapy via email, the written word is the exclusive focus.  What is important here is that you are aware that tele-therapy may or may not be as effective as in-person therapy and therefore we must pay close attention to your progress and periodically evaluate the effectiveness of this form of therapy. Because I may not have met you in person, I may request that you be interviewed by a professional in your area and allow me to talk to that individual before proceeding with therapy.   With tele-therapy, there is the question of where is the therapy occurring – at the therapist’s office or the location of the client?  The law has not yet clarified this issue, therefore it is my policy to inform clients that they are receiving services from my office (as if they were physically traveling to my office) and therefore are bound by the laws of the State of California.  These laws are primarily related to confidentiality as outlined in this form and my disclosure form.    I understand that I have the following rights with respect to telemedicine:   (1) I have the right to withhold or withdraw consent at any time without affecting my right to future care or treatment nor risking the loss or withdrawal of any program benefits to which I would otherwise be entitled. (2) The laws that protect the confidentiality of my medical information also apply to telemedicine. As such, I understand that the information disclosed by me during the course of my therapy is generally confidential. However, there are both mandatory and permissive exceptions to confidentiality, including, but not limited to reporting child, elder, and dependent adult abuse; expressed threats of violence towards an ascertainable victim; and where I make my mental or emotional state an issue in a legal proceeding.  I also understand that the dissemination of any personally identifiable images or information from the telemedicine interaction to researchers or other entities shall not occur without my written consent. (3) I understand that there are risks and consequences from telemedicine, including, but not limited to, the possibility, despite reasonable efforts on the part of my psychotherapist, that: the transmission of my medical information could be disrupted or distorted by technical failures; the transmission of my medical information could be interrupted by unauthorized persons; and/or the electronic storage of my medical information could be accessed by unauthorized persons.  In addition, I understand that telemedicine based services and care may not be as complete as face-to-face services. I also understand that if my psychotherapist believes I would be better served by another form of psychotherapeutic services (e.g. face-to-face services) I will be referred to a psychotherapist who can provide such services in my area. Finally, I understand that there are potential risks and benefits associated with any form of psychotherapy, and that despite my efforts and the efforts of my psychotherapist, my condition may not be improved and in some cases may even get worse.  (4) I understand that I may benefit from telemedicine, but that results cannot be guaranteed or assured.  (5) I understand that I have a right to access my medical information and copies of medical records in accordance with California law. I have read and understand the information provided above. I have discussed it with my psychotherapist, and all of my questions have been answered to my satisfaction.   Signature of patient/parent/guardian/conservator.  If signed by other than patient, indicate relationship.