Client Handbook and Privacy Policy

Mental Health Rights and Patient Responsibilities

We recognize that each patient has the right to the following:

Use and Disclosure of Protected Health Information:

For Treatment - We use and disclose your health information internally in the course of your treatment.  If we wish to provide information outside of our practice for your treatment by another health care provider, we will have you sign an authorization for release of information.  Furthermore, an authorization is required for most uses and disclosures of psychotherapy notes.

For Payment - We may use and disclose your health information to obtain payment for services we provide to you.

For Operations - We may use and disclose your health information within Willow Tree Therapy Services, LLC as part of our internal operations.  For example, this could mean a review of records to assure quality.  We may also use your information to tell you about services, educational activities, and programs that we feel might be of interest to you.

Patient's Rights:

Right to Confidentiality - You have the right to have your health care information protected.  If you pay for a service or health care item out-of-pocket in full, you can ask us not to share that information for the purpose of payment or our operations with your health insurer.  We will agree to such unless a law requires us to share that information.

Right to Request Restrictions - You have the right to request restrictions on certain uses and disclosures of protected health information about you.  However, we are not required to agree to a restriction you request.

Right to Receive Confidential Communications by Alternative Means and at Alternative Locations - You have the right to request and receive confidential communications of PHI by alternative means and at alternative locations.

Right to Inspect and Copy - You have the right to inspect or obtain a copy (or both) of PHI.  Records must be requested in writing and release of information must be completed.  Furthermore, there may be a copying fee charge of $1.00 per page.  Please make your request well in advanced and allow 2 weeks to receive the copies.  If we refuse your request for access to your records, you have a right of review, which we will discuss with you upon request. 

Right to Amend - If you believe the information in your records is incorrect and/or missing important information, you can ask us to make certain changes, also known as amending, to your health information.  You have to make this request in writing.  You must tell us the reasons you want to make these changes, and we will decide if it is and if we refuse to do so, we will tell you why within 60 days.  

Right to a copy of this notice - If you received the paperwork electronically, you have a copy in your email.  If you completed this paperwork in the office at your first session a copy will be provided to you per your request or at any time. 

Right to an Accounting - You generally have the right to receive an accounting of disclosures of PHI regarding you.  On your request, we will discuss with you the details of the accounting process.

Right to choose someone to act for you - If someone is your legal guardian, that person can exercise your rights and make choices about your health information; we will make sure the person has this authority and can act for you before we take any action.  

Right to Choose - You have the right to decide not to receive services with us.  If you wish, we will provide you with names of other qualified professionals.  

Right to Terminate - You have the right to terminate therapeutic services with us at any time without any legal or financial obligations other than those already accrued.  We ask that you discuss your decision with your therapist in session before terminating or at least contact your therapist or their supervisor by phone letting them know you are terminating services. 

Right to Release Information with Written Consent - With your written consent, any part of your record can be released to any person or agency you designate.  We will discuss whether or not we think releasing the information in question to that person or agency might be harmful to you. 

Therapist’s Duties:

We are required by law to maintain the privacy of PHI and to provide you with a notice of our legal duties and privacy practices with respect to PHI.  We reserve the right to change the privacy policies and practices described in this notice.  Unless we notify you of such changes, however, we are required to abide by the terms currently in effect.  If we revise our policies and procedures, we will provide you with a revised notice in office during your session.

Grievance Procedures

You can send us any feedback, complaints, etc. to Amanda@willowtreetherapyservices.org

If you think we may have violated your privacy rights, or you disagree with a decision we made about access to your protected health information, you may file a complaint with the person listed below. You also may file a written complaint with the Secretary of the U.S. Department of Health and Human Services at 200 Independence Avenue SW, Washington D.C., 20201. We will take no retaliatory action against you if you make such complaints.

Florida Patient's Bill of Rights Consumer Assistance Notice

For concerns about your HMO or medical care call:
(Si tiene preoccupaciones sobre su seguro HMO o su cuidado medico, llame a:)

HMO/MANAGED CARE HOTLINE 1-800-226-1062
Agency for Health Care Administration
2727 Mahan Drive, Building 1, Mailstop #27
Tallahassee, FL 32308

DEPARTMENT OF INSURANCE CONSUMER 1-800-342-2762
SERVICES HELPLINE
Division of Consumer Services
200 E. Gaines Street
Tallahassee, FL 32399-0322

HEALTH CARE CONSUMER 1-850-921-5458
ASSISTANCE HOTLINE
The Statewide Provider and Subscriber Assistance Panel
2727 Mahan Drive, Building 1, Mailstop #27
Tallahassee, FL 32308

If you require assistance in obtaining the address and toll free telephone number of your HMO's Grievance Department please ask the staff of this office to assist you.

Statewide Consumer Call Center

Consumer Complain, Publication and Information Call Center - 888-419-3456 / 800 - 955-8771 (TDD Number)

• Option 1 - Available Monday - Friday, 8:00 A.M. to 5:00 P.M., EST. To file a complaint about a health care facility, such as a hospital, nursing home, assisted living facility, home health agency, or other type of health care facility. Your patient care complaint may also be filed at any time, by completing the Health Care Facility Complaint Form. Please search our FloridaHealthFinder.gov site to see if the facility you have concerns about is one that is regulated by our Agency

• Option 2- To obtain general information about Medicaid or to report Medicaid Fraud. If you’re calling about the services provided under your Medicaid health insurance plan, such as transportation, dental services or prescription coverage, or if you want to change your plan, you may also reach our Medicaid Contact Center directly at 1-877-254-1055.
  To find out if you qualify for Medicaid services, need a replacement Gold card, need to add a family member, or want information about the Medically Needy Program, please call the Department of Children and Families at 1-866-762-2237.

Option 3 - Available Monday - Friday, 8:00 A.M. to 5:00 P.M., EST. To file a complaint against a health maintenance organization (HMO). If you are having problems with the HMO's internal grievance process. If you have completed the internal grievance process and wish to appeal. If you need referral numbers to member services or the grievance coordinators.

Access to Services:

Counseling services are generally available during normal business hours (Monday - Thursday 10 AM - 5 PM) throughout the year, except on designated holidays. If it is after office hours and you are in a medical emergency please call 911 or visit your local emergency room. If you are experiencing a mental health crisis and would like to speak to someone immediately, you may contact the following numbers

(877) 870-4673 (HOPE). For youth, contact 800-448-3000. I will notify you in advance with any office closures in the event of an emergency (e.g., natural disaster, health emergency) that requires office closure.

Fees

Fees are charged for services rendered on behalf of Willow Tree Therapy Services, LLC. The fee schedule is as follows if you are opting to not bill your insurance company (e.g., pay out of pocket): • Intake/Assessments/Evaluations (up to 120 minutes): $140 • Individual sessions (45 minutes $80 or 60 minutes - $110) • Family sessions (90 minutes - $140) • Court appearances: $200 per hour (door to door), paperwork processing for court hearings will be charged at $250 per hour.  These fees will be required before services are rendered. At this time, I will no longer offer a sliding scale fee.

If you request any letters, forms, or any other paperwork to be competed, such as FMLA or disability forms, please be advised that there is a fee for paperwork.  My fee is $90 per hour.  I will not complete any FMLA, disability, or other letters of support unless I have met with you for 6-8 sessions.  I will also not complete any FMLA or disability paperwork if I do not believe I can support it based on what you have presented at intake and during sessions.

Payment and Insurance Reimbursement:

You are fully responsible for the payment of all fees for services provided regardless of any insurance coverage you may have. You understand that it is Willow Tree Therapy Services, LLC policy that the fee for any session is payable at the beginning of the session. Willow Tree Therapy Services, LLC accepts cash, checks or credit cards as forms of payment. All sessions are 45 - 55 minutes in length. The fee for an initial intake session is $140.00. Follow up session fees for individuals (55 minutes - $135), (45 minutes - $75), Individual/Family Session (90 minutes - $140).  While sessions are not conducted by phone, if an emergency phone consultation is initiated by the client, the first 15-minutes are at no charge. However, $25.00 will be billed to your account for each subsequent 15- minute period. I understand that if I have insurance, Willow Tree Therapy Services, LLC will either file the claim on my behalf or will provide me with the necessary information so that I can file the claim. I understand that I am ultimately responsible for any therapy fee(s) not covered by my insurance carrier. Co-pays and non-covered services are payable at time of service unless other arrangements have been made. In the event that insurance is billed on my (the client) behalf, I authorize payment of mental health benefits to Willow Tree Therapy Services, LLC.

In the event of a lapse of insurance coverage; the client has three options. 

1. Continue with services and pay the full therapy fees as listed above.

2. Request a referral to a provider who accepts insurance or your preferred method of payment.

3. Request to be discharged from services.

No-Show/Late Cancellation Charge:

I appreciate prompt arrival for appointments. Please notify me at 904-349-5299 for any late arrivals. If a client does not provide notice within 24 hours of his/her scheduled appointment, a fee of $85 will be charged to the client’s account and will be asked to pay this balance prior to scheduling his/her next appointment. Clients may leave a message on Willow Tree Therapy Services, LLC voicemail to cancel an appointment; however this message must be left at least 24 hours before the scheduled appointment. If you are more than 15 minutes late for a session, your appointment may be cancelled and a fee will be added to your account. If we have a reoccurring appointment, I will wait for 24 hours after the missed appointment to confirm for the next scheduled appointment. If there is no contact, you will be discharged or placed on a waiting list. This is to ensure that you are not charged two times for a no-show fee.

If insurance prohibits this therapist from charging a no-show fee, I will allow one “no show” before I must consider the professional relationship discontinued, for ethical and legal purposes.  If court ordered, a summary outlining reason for discharge will be provided including dates of missed sessions.

NOTICE OF PRIVACY PRACTICES

Effective February 16, 2026

NOTICE OF PRIVACY PRACTICES

THIS NOTICE DESCRIBES HOW HEALTH INFORMATION MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY.

I. MY PLEDGE REGARDING HEALTH INFORMATION:

I understand that health information about you and your health care is personal. I am committed to protecting health information about you. I create a record of the care and services you receive from me. I need this record to provide you with quality care and to comply with certain legal requirements. This notice applies to all of the records of your care generated by this mental health care practice. This notice will tell you about the ways in which I may use and disclose health information about you. I also describe your rights to the health information I keep about you, and describe certain obligations I have regarding the use and disclosure of your health information. I am required by law to:

• Make sure that protected health information (“PHI”) that identifies you is kept private.

• Give you this notice of my legal duties and privacy practices with respect to health information.

• Follow the terms of the notice that is currently in effect.

• I am also required by law to provide you with adequate notice of your rights and my legal duties if I create or maintain records protected by 42 C.F.R. Part 2.

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

II. HOW I MAY USE AND DISCLOSE HEALTH INFORMATION ABOUT YOU:

The following categories describe different ways that I use and disclose health information. For each category of uses or disclosures I will explain what I mean and try to give some examples. Not every use or disclosure in a category will be listed. However, all of the ways I am permitted to use and disclose information will fall within one of the categories.

For Treatment, Payment, or Health Care Operations: Federal privacy rules (regulations) allow health care providers who have direct treatment relationship with the patient/client to use or disclose the patient/client’s personal health information without the patient’s written authorization, to carry out the health care provider’s own treatment, payment or health care operations. I may also disclose your protected health information for the treatment activities of any health care provider. This too can be done without your written authorization. For example, if a clinician were to consult with another licensed health care provider about your condition, we would be permitted to use and disclose your personal health information, which is otherwise confidential, in order to assist the clinician in diagnosis and treatment of your mental health condition.

If your records are protected under 42 C.F.R. Part 2, certain uses and disclosures permitted by HIPAA for treatment, payment, and health care operations are materially limited by the stricter standards of those regulations. Furthermore, information disclosed pursuant to these rules may be subject to redisclosure by the recipient and may no longer be protected by federal privacy standards.

Disclosures for treatment purposes are not limited to the minimum necessary standard. Because therapists and other health care providers need access to the full record and/or full and complete information in order to provide quality care. The word “treatment” includes, among other things, the coordination and management of health care providers with a third party, consultations between health care providers and referrals of a patient for health care from one health care provider to another.

Lawsuits and Disputes: If you are involved in a lawsuit, I may disclose health information in response to a court or administrative order. I may also disclose health information about your child in response to a subpoena, discovery request, or other lawful process by someone else involved in the dispute, but only if efforts have been made to tell you about the request or to obtain an order protecting the information requested. However, for records protected by 42 C.F.R. Part 2, such records or testimony relaying their content shall not be used or disclosed in civil, criminal, administrative, or legislative proceedings against you unless you provide specific written consent or a court order is issued in accordance with 42 C.F.R. Part 2.

III. CERTAIN USES AND DISCLOSURES REQUIRE YOUR AUTHORIZATION:

1. Psychotherapy Notes. I do keep “psychotherapy notes” as that term is defined in 45 CFR § 164.501, and any use or disclosure of such notes requires your Authorization unless the use or disclosure is:

   • For my use in treating you.

   • For my use in training or supervising mental health practitioners to help them improve their skills in group, joint, family, or individual counseling or therapy.

   • For my use in defending myself in legal proceedings instituted by you.

   • For use by the Secretary of Health and Human Services to investigate my compliance with HIPAA.

   • Required by law and the use or disclosure is limited to the requirements of such law.

   • Required by law for certain health oversight activities pertaining to the originator of the psychotherapy notes.

   • Required by a coroner who is performing duties authorized by law.

   • Required to help avert a serious threat to the health and safety of others.

2. Substance Use Disorder (SUD) Counseling Notes. I may also maintain “SUD counseling notes,” which are notes recorded by a substance use disorder provider documenting the contents of a counseling session. Any use or disclosure of these notes requires your separate written authorization, which cannot be combined with a consent for other types of records. You can revoke your consent at any time except to the extent that I have already acted upon it to disclose these notes in accordance with your initial authorization.

3. Marketing Purposes. As a psychotherapist, I will not use or disclose your PHI for marketing purposes.

4. Sale of PHI. As a psychotherapist, I will not sell your PHI in the regular course of my business.

IV. CERTAIN USES AND DISCLOSURES DO NOT REQUIRE YOUR AUTHORIZATION:

Subject to certain limitations in the law, I can use and disclose your PHI without your Authorization for the following reasons:

1. When disclosure is required by state or federal law, and the use or disclosure complies with and is limited to the relevant requirements of such law.

2. For public health activities, including reporting suspected child, elder, or dependent adult abuse, or preventing or reducing a serious threat to anyone’s health or safety.

3. For health oversight activities, including audits and investigations.

4. For judicial and administrative proceedings, including responding to a court or administrative order, although my preference is to obtain an Authorization from you before doing so.

5. For law enforcement purposes, including reporting crimes occurring on my premises.

6. To coroners or medical examiners, when such individuals are performing duties authorized by law.

7. For research purposes, including studying and comparing the mental health of patients who received one form of therapy versus those who received another form of therapy for the same condition.

8. Specialized government functions, including ensuring the proper execution of military missions; protecting the President of the United States; conducting intelligence or counter-intelligence operations; or helping to ensure the safety of those working within or housed in correctional institutions.

9. For workers’ compensation purposes. Although my preference is to obtain an Authorization from you, I may provide your PHI in order to comply with workers’ compensation laws.

10. Appointment reminders and health related benefits or services. I may use and disclose your PHI to contact you to remind you that you have an appointment with me. I may also use and disclose your PHI to tell you about treatment alternatives, or other health care services or benefits that I offer.

V. CERTAIN USES AND DISCLOSURES REQUIRE YOU TO HAVE THE OPPORTUNITY TO OBJECT:

1. Disclosures to family, friends, or others. I may provide your PHI to a family member, friend, or other person that you indicate is involved in your care or the payment for your health care, unless you object in whole or in part. The opportunity to consent may be obtained retroactively in emergency situations.

2. Fundraising. If I intend to use or disclose your records protected by 42 C.F.R. Part 2 for fundraising for my benefit, I will provide you with a clear and conspicuous opportunity to opt-out before any such use or disclosure occurs.

VI. YOU HAVE THE FOLLOWING RIGHTS WITH RESPECT TO YOUR PHI:

1. The Right to Request Limits on Uses and Disclosures of Your PHI. You have the right to ask me not to use or disclose certain PHI for treatment, payment, or health care operations purposes. I am not required to agree to your request, and I may say “no” if I believe it would affect your health care.

2. The Right to Request Restrictions for Out-of-Pocket Expenses Paid for In Full. You have the right to request restrictions on disclosures of your PHI to health plans for payment or health care operations purposes if the PHI pertains solely to a health care item or a health care service that you have paid for out-of-pocket in full.

3. The Right to Choose How I Send PHI to You. You have the right to ask me to contact you in a specific way (for example, home or office phone), or to send mail to a different address, and I will agree to all reasonable requests.

4. The Right to See and Get Copies of Your PHI. Other than “psychotherapy notes” and “SUD counseling notes” you have the right to get an electronic or paper copy of your medical record and other information that I have about you. I will provide you with a copy of your record, or a summary of it, if you agree to receive a summary, within 30 days of receiving your written request, and I may charge a reasonable, cost-based fee for doing so.

5. The Right to Get a List of the Disclosures I Have Made. You have the right to request a list of instances in which I have disclosed your PHI for purposes other than treatment, payment, or health care operations, or for which you provided me with an Authorization. I will respond to your request for an accounting of disclosures within 60 days of receiving your request. The list I will give you will include disclosures made in the last six years unless you request a shorter time. I will provide the list to you at no charge, but if you make more than one request in the same year, I will charge you a reasonable cost-based fee for each additional request. You also have the right to request an accounting of disclosures specifically for your substance use disorder records protected under 42 C.F.R. Part 2.

6. The Right to Correct or Update Your PHI. If you believe that there is a mistake in your PHI, or that a piece of important information is missing from your PHI, you have the right to request that I correct the existing information or add the missing information. I may say “no” to your request, but I will tell you why in writing within 60 days of receiving your request.

7. The Right to Get a Paper or Electronic Copy of this Notice. You have the right to get a paper copy of this Notice, and you have the right to get a copy of this notice by e-mail. And, even if you have agreed to receive this Notice via e-mail, you also have the right to request a paper copy of it.