Psychotherapy Registration Packet

Notice of Privacy Policies

THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN ACCESS THIS INFORMATION. PLEASE REVIEW IT CAREFULLY.

Your Rights

You have certain rights regarding your health information, and we are committed to helping you understand and exercise those rights.

You have the right to inspect and obtain a copy of your health information, including an electronic copy if available. We will provide a copy or summary of your health information, usually within 30 days of your request. A reasonable, cost-based fee may apply.

You have the right to ask us to correct health information about you that you believe is incorrect or incomplete. If we deny your request, we will provide a written explanation within 60 days.

You have the right to request that we restrict how we use or disclose your health information for treatment, payment, or healthcare operations. While we are not required to agree to all requests, we will comply when you request that we not disclose information to your health plan if you have paid for services in full out-of-pocket, unless disclosure is required by law.

You have the right to request that we communicate with you in a certain way or at a certain location. For example, you may ask that we contact you at work or send mail to a different address. We will agree to all reasonable requests.

You have the right to request an accounting of certain disclosures of your health information made over the past six years, excluding disclosures for treatment, payment, healthcare operations, and certain other disclosures. You are entitled to one accounting per year at no cost.

You have the right to request a paper copy of this Notice at any time, even if you have agreed to receive it electronically.

Your Choices

In certain situations, you have the right to tell us your preferences about how we share your information.

You may choose whether we share information with your family members, close friends, or others involved in your care or payment for your care. You may also choose whether we share information in a situation involving disaster relief.

If you are unable to communicate your preferences, we may share your information if we believe it is in your best interest.

Our Uses and Disclosures

We typically use or share your health information in the following ways:

For treatment, we may use your health information and share it with other professionals who are treating you to coordinate your care.

For payment, we may use and share your health information to bill and receive payment from health plans or other entities.

For healthcare operations, we may use and share your health information to run our organization, improve your care, and contact you when necessary. This may include activities such as quality assessment, staff training, compliance monitoring, auditing, and administrative functions.

We may also share your information with third parties known as business associates who perform services on our behalf, such as billing, data storage, or information technology services. These business associates are required by law to safeguard your information.

Appointment Reminders and Communications

We may contact you by phone, email, text message, or through a patient portal to remind you of appointments or to provide information about services or treatment options that may be helpful to you.

Electronic Communication and Telehealth

We may communicate with you electronically and may provide services through telehealth technologies. While we use reasonable safeguards to protect your information, electronic communication may involve some level of risk. Telehealth services may involve the electronic transmission of your health information, and we take steps to protect confidentiality in accordance with applicable laws.

How Else We Can Use or Share Your Health Information

We are allowed or required to share your information in other ways, usually in ways that contribute to the public good or are required by law.

We may share your health information for public health purposes, such as preventing disease, reporting adverse reactions to medications, reporting suspected abuse or neglect, and preventing or reducing a serious threat to health or safety.

We may share your information for health oversight activities, including audits, inspections, and investigations conducted by government agencies.

We may disclose your information in response to legal proceedings, including court orders, subpoenas, or administrative requests.

We may share your information with law enforcement officials when required or permitted by law.

We may disclose your information for workers’ compensation claims or similar programs.

We may also share your information for certain specialized government functions, including military, national security, or protective services.

Uses and Disclosures That Require Your Authorization

We will obtain your written authorization before using or disclosing your health information for purposes not described in this Notice.

This includes most uses and disclosures of psychotherapy notes, uses of your information for marketing purposes, and the sale of your health information.

If you provide authorization, you may revoke it at any time in writing, except to the extent that we have already relied on it.

Fundraising

We may contact you for fundraising efforts, but you have the right to opt out of receiving such communications at any time.

Our Responsibilities

We are required by law to maintain the privacy and security of your protected health information.

We will notify you 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 provide you with 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.

Changes to the Terms of This Notice

We can change the terms of this Notice, and the changes will apply to all information we have about you. The new Notice will be available upon request, in our office, and on our website.

Complaints

If you believe your privacy rights have been violated, you may file a complaint with Rumi’s Den Marriage & Family Therapy or with the U.S. Department of Health and Human Services Office for Civil Rights.

To file a complaint with Rumi’s Den Marriage & Family Therapy, please contact:

Rumi’s Den Marriage & Family Therapy, Attn: Privacy Officer, [practice mailing address]

You may also call our Compliance office at [compliance phone], or send an email to [privacy officer email]

You may also file a complaint with the Office for Civil Rights by visiting https://www.hhs.gov/ocr/privacy/hipaa/complaints/

You will not be retaliated against for filing a complaint.

Acknowlegement and Consent:

I acknowledge that I have received, read, and understand the contents of this document, and that I have been afforded the opportunity to ask questions and have them answered to my satisfaction. I further acknowledge that this document may be executed electronically and that my electronic signature shall have the same legal validity and admissibility as my handwritten signature.

AI Tools Consent

You may choose to use artificial intelligence (AI) tools, such as apps, websites, or chatbots, for mental health support. For example, when you are feeling anxious or overwhelmed, you might turn to an AI tool for reassurance, coping strategies, or advice instead of reaching out to a friend, family member, or your therapist.

While these tools can sometimes feel helpful, they may also provide information that is incomplete, inaccurate, or not appropriate for your situation. It is important that you understand their limits and risks.

The information below explains what you should know before using these tools.

AI Is Not a Substitute for Professional Care

AI tools are not a replacement for therapy, clinical judgment, or emergency services. They cannot fully understand your personal history, current situation, or needs, and they do not provide individualized care.

Information from AI tools may be incorrect, incomplete, or not appropriate for you. In some cases, it may not match or may interfere with your treatment. You are encouraged to talk with your provider before making decisions based on information from an AI tool.

Privacy and Confidentiality Risks

When you use AI tools, the information you enter may not be private. These tools are not covered by the same confidentiality laws as your healthcare provider (such as HIPAA).

This means:

Your information may be stored by the company
Your information may be reviewed or used by others
Your information may not be fully secure

You should be cautious about sharing personal or sensitive information when using AI tools.

Risk of Incorrect or Harmful Information

AI tools can sometimes give answers that are wrong, misleading, or not appropriate for your situation. They may misunderstand what you are asking or provide advice that is not safe.

You are responsible for how you use the information from these tools. Your provider and Rumi’s Den Marriage & Family Therapy are not responsible for any decisions, actions, or outcomes related to your use of AI tools.

Legal Considerations

The use of AI tools for mental health support may be regulated by state or federal law, especially when minors are involved. These tools are not the same as services provided by licensed healthcare professionals.

Emergency or Crisis Situations

AI tools are not appropriate for emergencies or crisis situations.

If you are in crisis, having suicidal thoughts, or feel unsafe:

Call or text 988 (Suicide and Crisis Lifeline)
Call 911
Go to the nearest emergency room

You may also contact your provider using the usual methods, but do not rely on your provider or an AI tool alone in an emergency. Get immediate help from emergency services.

Acknowledgment and Consent

By signing below, you confirm that:

You have read and understand this information
You understand the risks and limits of using AI tools
You understand that AI tools are separate from the services provided by Rumi’s Den Marriage & Family Therapy
You agree that your provider and Rumi’s Den Marriage & Family Therapy are not responsible for outcomes related to your use of AI tools
You will inform your provider if you are using or plan to use AI tools as part of your mental health support

Staying Connected About Your Care (TCPA Consent)

At Rumi’s Den Marriage & Family Therapy, clear and timely communication is an important part of supporting your care.

We may contact you by phone, text message, or email to help with things like appointment reminders, scheduling, care coordination, and billing. The Telephone Consumer Protection Act (TCPA) is a federal law that requires healthcare providers to obtain your permission before sending certain automated calls or text messages.

These communications may be sent using automated technology, including autodialed calls, text messages, and prerecorded or artificial voice messages. Message and data rates may apply.

We will only share limited, care-related information in these communications, such as your name, your provider’s name, and appointment details.

Please note that standard text messaging and email are not always secure forms of communication. By proceeding, you acknowledge and accept the potential risks associated with these methods.

You’re always in control of how we communicate with you. You may opt out of text messages at any time by notifying us through a Change of Information request, informing your provider, or calling us at [practice phone] to update your preferences.

Your decision to consent is entirely optional and is not required to receive care at Rumi’s Den Marriage & Family Therapy. You may withdraw your consent at any time.

Acknowledgement and Consent:

I hereby consent to receive automated phone calls and text messages for the specified purposes. I further acknowledge that this document may be executed electronically and that my electronic signature shall have the same legal validity and admissibility as my handwritten signature.

Electronic Communications Policy

In today’s world, many of us rely on email, text messaging, social media, and other digital tools to stay connected. These methods can be convenient and helpful, but they also come with limitations—especially when it comes to privacy and confidentiality in a mental health setting.

At Rumi’s Den Marriage & Family Therapy, your privacy and well-being are very important to us. Because of the sensitive nature of the work we do together, we take a thoughtful and careful approach to how we use electronic communication. This policy is meant to help you understand what to expect, why certain boundaries are in place, and how we can best support your care while protecting your confidentiality.

As technology continues to evolve, we may update this policy from time to time. If we do, we will make sure you receive an updated version. If anything here feels unclear or raises questions for you, we encourage you to bring it up so we can talk through it.

A Thoughtful Approach to Communication

Electronic communication can be useful for certain types of contact, but it is not a substitute for the depth and care that happens in therapy sessions. We aim to use these tools in ways that support your treatment while also maintaining clear boundaries and protecting your privacy.

It’s also important to know that electronic communication is not always immediate or fully secure. Because of this, it should not be used in urgent or emergency situations. If you are in crisis or need immediate support, please call 911 or your local crisis hotline.

Email

We typically use email for practical matters, such as scheduling appointments, handling billing questions, or sharing general office information.

Because email is not a secure form of communication, we ask that you avoid sharing sensitive or personal information about your treatment through email. While we take reasonable steps to protect your information, there are limits to how secure email can be.

Emails that are sent or received may become part of your clinical record.

Text Messaging and Mobile Communication

Text messaging (including iMessage and similar services) can feel quick and convenient, but it is not a secure way to communicate.

For that reason, we do not use text messaging for clinical conversations. In some cases, you may choose to receive appointment reminders or brief administrative messages, especially through secure systems. These are typically short and informational.

If you receive automated reminders, please know that replies to those messages are not monitored.

Secure Messaging and Client Portals

If you are using a secure messaging system or client portal with Rumi’s Den Marriage & Family Therapy, this is generally the safest way to communicate electronically.

Even so, we encourage keeping messages brief. If something feels important, complex, or emotionally significant, it’s often best saved for your session, where your provider can be fully present with you.

Telehealth

If you meet with your provider through telehealth, we will use a secure, HIPAA-compliant platform.

We encourage you to choose a private and comfortable space where you feel safe to speak openly. To protect your privacy and the integrity of the work, sessions should not be recorded unless we have discussed and agreed to that ahead of time.

If technology doesn’t cooperate, we will work with you to find another way to stay connected.

Use of Artificial Intelligence (AI) and Digital Tools

As part of practicing in a modern, digital world, providers may use technology to support their work. At the same time, protecting your confidentiality remains central.

We do not enter identifying information about clients into public AI tools (such as ChatGPT or similar platforms). Any tools we use are chosen with care and are not a replacement for the clinical judgment, attention, and relationship that are at the heart of therapy.

We also gently encourage you to be mindful when using AI tools yourself, as they are not private or therapeutic spaces.

Social Media

Social media is a common part of everyday life, and it’s natural that our paths might cross there. At the same time, maintaining clear and respectful boundaries is an important part of protecting your care.

Providers at Rumi’s Den Marriage & Family Therapy do not accept friend or follow requests from current or former clients on personal accounts. This helps preserve the professional relationship and protects your confidentiality. If a connection happens accidentally, it will be removed.

You are always welcome to view or follow our professional pages, where we may share general information, resources, or updates. These posts are meant for broad audiences and are not a substitute for therapy or individualized care.

If you choose to interact with these pages—by liking, commenting, or sharing—it’s important to be aware that this may be visible to others. If something could identify you as a client, we may need to limit or remove that interaction to protect your privacy.

We do not communicate with clients through direct messages on social media.

Online Reviews

You may come across Rumi’s Den Marriage & Family Therapy or your provider on public review sites like Google or Yelp.

While you are free to share your experience if you choose, we do not ask for testimonials, and we are not able to respond to reviews in order to protect your confidentiality.

If you ever have feedback—positive or negative—we truly value hearing it directly. Bringing those thoughts into your sessions can be an important part of your care.

Online Searches

Respecting your privacy means that we do not routinely search for information about you online.

In rare situations where there are concerns about your safety and we are unable to reach you through usual means, a provider may look for publicly available information to help ensure your well-being. If this ever happens, it will be documented and discussed with you.

Websites

Our website and any provider websites are there to share general information about our services and approach. They are not a substitute for therapy or personalized guidance.

Location-Based Services

Some apps and devices track your location or allow you to “check in” to places you visit. If these features are enabled, others may be able to infer that you are visiting our office.

We encourage you to review your privacy settings and make choices that feel right for you.

Response Times and Expectations

We do our best to respond to electronic messages within one to two business days. Messages sent outside of business hours may be seen the next business day.

Because these channels are not continuously monitored, they are not the best way to reach us for urgent concerns.

Acknowledgement and Consent:

By participating in services at Rumi’s Den Marriage & Family Therapy, I acknowledge that I understand the benefits and limitations of electronic communication. Our shared goal is to use these tools in a manner that supports my care while maintaining the privacy and security of my information to the greatest extent possible. I further acknowledge that this document may be executed electronically and that my electronic signature shall have the same legal validity and admissibility as my handwritten signature.