LiveWell Therapy Services, LLC
Notice of Privacy Practices
This notice describes how mental health information about you may be used and disclosed, as well as how you may have access to your mental health information. Please review it carefully and sign at the end of this form to indicate that you understand the information presented and that we have discussed how your mental health records may be used. You may request a copy of this form at anytime. If you would like additional information or have any questions, please feel free to talk with me.
Understanding Your Mental health Information and Records
LiveWell Therapy Services, LLC understands that mental health information about you and your health is personal. LiveWell Therapy Services, LLC is committed to protecting the privacy of your mental health information and records. You should be aware that LiveWell Therapy Services, LLC creates a record of the services you receive. This record is needed both to provide quality care and to comply with certain legal requirements. This record also is important for planning your treatment. It can also serve as a means of communication for coordinating treatment with other healthcare professionals you would like involved in your care while receiving therapy services with me. This document is being given to you in order to help you make informed decisions before authorizing the disclosure of your clinical information to others.
Understanding Your Rights
You have the right to request restrictions and disclosure of your health information. Your rights also include a request to review or obtain a paper copy of the information, and to be given an accounting of certain disclosures.
Understanding LiveWell Therapy Services, LLC Agreement and Responsibilities
LiveWell Therapy Services, LLC maintains the privacy of your mental health information. LiveWell Therapy Services, LLC is providing you with this notice of our legal commitment and privacy practices with respect to the information LiveWell Therapy Services, LLC collects and maintains about you. Other than for reasons described in this notice, or by law, LiveWell Therapy Services, LLC agrees not to disclose your mental health information without your authorization. All LiveWell Therapy Services, LLC; staff, volunteers, or members and/or clients of therapeutic/support groups will be made aware of this policy and its conditions. LiveWell Therapy Services, LLC, is not responsible if third parties (such as other client members of a group, couples, or members of a family unit) breach confidentiality. However, LiveWell Therapy Services, LLC, takes reasonable steps to inform all clients and staff that confidentiality and privacy must be upheld in accordance with its policy and the law.
Treatment: LiveWell Therapy Services, LLC may use mental health information about you to provide you with or coordinate mental health treatment or services. For instance we may discuss your mental health information with other healthcare professionals to coordinate care, prescriptions, health concerns, other forms of counseling or counseling programs. LiveWell Therapy Services, LLC may use and disclose mental health information to tell you about health related benefits or services that may be of interest to you.
Payment: LiveWell Therapy Services, LLC may disclose some healthcare information for the purposes of obtaining authorized sessions from insurance companies or release codes and diagnosis for billing statements that you submit to your insurance company. LiveWell Therapy Services, LLC may also disclose mental health information about you in the event that a family member, friend, or guardian is paying for your care or services at LiveWell Therapy Services, LLC provided you or your guardian consent to this arrangement.
Healthcare Operations and Consulting With Associates: Information regarding your mental health records may be disclosed to other healthcare associates or professionals in an effort to improve treatment, technique, or counseling services to you, give or receive consultation and/or find treatment options or alternatives that may be of interest to you. Measures will always be taken to be discreet and protect identifying information.
Emergency Notification: As required by law, LiveWell Therapy Services, LLC may use and disclose mental health information about you when necessary to prevent a serious threat to your health and safety or the health and safety of the public or another person. This may include, but is not limited to, notifying the police or potential victim(s), notifying your family, or formulating a treatment plan reasonably calculated to eliminate the threat.
Research/Educational: As always, special precautions will be taken to protect your identity and the identity of those who are part of your treatment. Your identity is always safeguarded and will never be revealed unless you choose to do so. LiveWell Therapy Services, LLC will communicate in advance and give you the right not to have your case file information included in any research.
Food and Drug Administration: As required by law, LiveWell Therapy Services, LLC may disclose to the FDA health information relative to adverse effects with respect to medication, food, supplements, product and product defects, or post marketing surveillance information to enable product recalls, repairs or replacement.
Correctional Institutions: If you are the inmate of a correctional institute or under the custody of a law enforcement official, LiveWell Therapy Services, LLC may release mental health information to the correctional institute or law enforcement official to provide you with healthcare; to protect your health and safety or the health and safety of others; or for the safety and security of the correctional institute.
Military, National Security, Law Enforcement, Lawsuits, Legal Disputes and Proceedings: LiveWell Therapy Services, LLC may release mental health information if required to do so by law in response to a subpoena, warrant, summons, or similar process. LiveWell Therapy Services, LLC may also release mental health information about a death we believe to be the result of criminal conduct, about criminal conduct at our place of business, or in mental health emergency situations. LiveWell Therapy Services, LLC may disclose to military authorities protected mental health information of armed force personnel under certain circumstances, as required by law.
Workers Compensation: LiveWell Therapy Services, LLC may disclose health information to the extent authorized by and necessary to comply with laws related to workers compensation.
Medical Examiners and Coroners: In the unfortunate event of your death, LiveWell Therapy Services, LLC may disclose to the Medical Examiner or Coroner information about your mental health treatment to the extent authorized by law.
Public Health Risks and Safety: LiveWell Therapy Services, LLC may disclose mental health information about you involving public health risks, as permitted or required by law. LiveWell Therapy Services, LLC may also report any reasonable suspicion of child abuse or neglect, abuse or neglect of vulnerable adults, and any other conduct or situation required by law.
Appointment Reminders: When using an agreed upon phone number, email, voicemail, answering machine, or all the above LiveWell Therapy Services, LLC may use and disclose mental health information to contact you as a reminder that you have an appointment. If you do not wish for LiveWell Therapy Services, LLC to leave our name and appointment information on your voicemail, email or answering machine please inform LiveWell Therapy Services, LLC of a confidential way to contact you. It is your responsibility to let LiveWell Therapy Services, LLC know if your contact information or preference for communication of this nature changes.
Professional Disclosure Statement
In accordance with the Annotated Code of Maryland, Health Occupations, 17-308, Authority granted by license, 17-309, Supervised clinical practice, 17-507, Professional disclosure statement.
Audrey Scheerer, M, Ed., NCC Licensed Graduate Professional Counselor
LiveWell Therapy Services, LLC 7520 Main Street Suite:101 Sykesville, Maryland 21784
Master of Education School Counseling Program Loyola College
Authorized to provide services involving the application of Counseling Principles and methods in the diagnosis, prevention, treatment and amelioration of psychological problems, emotional conditions, or mental conditions of individuals and groups
Under the Clinical Supervision
Sharon E. Cheston
Approved Clinical Supervisor
22 West Padonia Rd.
Lutherville, MD 21093
Intake/Initial appointment Individual: $ 200.00
Intake/Initial appointment Couples: $ 250.00
Individual Therapy Session: $ 120.00
Couples Therapy Session: $ 170.00
Missed appointments individual: $ 120.00
Missed appointments Couples: $ 170.00
Medical Record Request: $ 15.00
This information is required by the Board of Professional Counselors and Therapists, which regulates all licensed and certified counselors. Record requests are regulated under Health-General Article section 4-304 (c) (3)