Chrysalis Counseling Center Policies and Informed Consent

CHRYSALIS COUNSELING CENTER, LLC

Practice Policies and Financial Agreement West Des Moines, Iowa

APPOINTMENTS, CANCELLATIONS, AND RESCHEDULING

Your therapist reserves appointment time specifically for you. Because we maintain a waitlist, we require a minimum of 24 hours’ notice to cancel or reschedule an appointment.

The preferred method of communication is through the secure client portal. You may also leave a voicemail, text message, or email to cancel or reschedule. The date and time your message is received will determine whether sufficient notice was provided.

If you fail to attend a scheduled appointment or provide less than 24 hours’ notice from the appointment start time, you will be charged an $80 late cancellation/no-show fee. Insurance does not cover this fee.

Late cancellation/no-show fees must be paid prior to scheduling future appointments unless otherwise determined by your therapist.

Missed appointments due to documented emergencies, hospitalization, or circumstances beyond your control may be considered exceptions at the clinician’s discretion.

Consistent attendance is necessary for effective treatment and continuity of care. A no-show/no-call is defined as failure to attend a scheduled appointment without prior notice.

Clients who accumulate three (3) no-shows or late cancellations within a three-month period may be discharged due to non-engagement in treatment. Prior to discharge, reasonable efforts will be made to contact the client to support re-engagement. Discharge decisions are based on clinical judgment and are not punitive.

Clients may request re-establishment of services following discharge, subject to clinical appropriateness and provider availability.

HEALTH INSURANCE, BILLING, AND PAYMENT

If you are using health insurance, it is your responsibility to verify your coverage, co-pay, deductible, and any preauthorization requirements prior to services being rendered.

If your insurance does not cover services, or if required authorization is not obtained, you are financially responsible for all services provided.

Full payment of co-pays, deductibles, or private-pay fees is expected at the time of service.

If your account balance reaches $200 or more, services may be suspended until the balance is brought current, subject to clinical appropriateness and safety considerations.

Returned checks are subject to a $25 service charge.

Credit card payments will appear as “Chrysalis Counseling Center, LLC.” Administrative fees may apply to disputed credit card charges. If a charge is disputed in error, it is the client’s responsibility to promptly resolve the matter with their credit card company. Services may be paused until disputed balances are resolved.

COMMUNICATION POLICY

Office hours are generally Monday through Friday, 8:00 a.m. – 5:00 p.m., though therapists are often in session during these hours.

Messages may be left via the secure client portal, voicemail, email, or text message. Please allow up to one business day for a response.

The secure client portal through Simple Practice is the preferred method of communication.

While we take reasonable measures to protect confidentiality, electronic communications (including email and text messaging) carry inherent privacy risks. By choosing to communicate through these methods, you acknowledge and accept those risks.

Electronic communication should not be used for therapeutic content or emergencies.

In the event of an emergency, call 911, 988, your medical provider, or go to the nearest emergency room.

Your signature authorizes Chrysalis Counseling Center to use the contact information you provide to send appointment reminders, billing communications, and insurance-related information via email, mail, or text message.

SOCIAL MEDIA POLICY

To protect confidentiality and professional boundaries, therapists do not accept friend or contact requests from current or former clients on social media platforms (e.g., Facebook, LinkedIn, Instagram).

This policy protects your privacy and preserves the integrity of the therapeutic relationship.

CONFIDENTIALITY

Information shared in therapy is confidential and will not be released without your written authorization, except as required or permitted by law.

Exceptions may include:

• Suspected child, elder, or dependent adult abuse

• Serious and imminent risk of harm to yourself or others

• Court orders or legal mandates

• Health oversight activities

Some records related to substance use disorder diagnosis or treatment may be protected under federal law (42 CFR Part 2), which provides additional confidentiality protections.

If you authorize disclosure of your Protected Health Information (PHI), you must complete a Release of Information form.

Limited information necessary for billing and insurance processing may be disclosed to third-party payers. Your signature authorizes the release of information necessary for insurance filing and payment processing.

TERMINATION OF SERVICES

Ending therapy can be an important part of the treatment process. Whenever possible, termination will involve discussion and planning.

Your therapist may terminate services if:

• Treatment is not being effectively utilized

• There is repeated non-attendance

• Financial obligations remain unresolved

• Treatment is no longer clinically appropriate

Termination decisions are made using clinical judgment and ethical standards.

If therapy is terminated, referrals to alternative providers will be offered when appropriate.

If you have not attended a session or made contact within 90 days, your case may be considered inactive and your file may be closed. You may request to resume services at any time, subject to clinical appropriateness and provider availability.

THERAPEUTIC RELATIONSHIP

The therapeutic relationship is professional in nature. Your therapist agrees to work collaboratively with you to support your treatment goals.

If you encounter your therapist outside of the office, the therapist will not initiate contact in order to protect your confidentiality. If you choose to acknowledge your therapist first, brief interaction may occur, but therapeutic discussion will not take place in public settings.

NOTICE OF PRIVACY PRACTICES

Chrysalis Counseling Center, LLC West Des Moines, Iowa

Effective Date: February 16, 2026

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

I. OUR PLEDGE REGARDING YOUR HEALTH INFORMATION

Your health information is personal. Chrysalis Counseling Center, LLC is committed to protecting the privacy of your protected health information (“PHI”). We create records of the care and services you receive to provide quality care and to comply with legal requirements.

This Notice describes how we may use and disclose your PHI, your rights regarding your PHI, and our legal duties to protect it.

We are required by law to:

• Maintain the privacy of your PHI

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

• Follow the terms of the Notice currently in effect

We reserve the right to change this Notice at any time. Changes will apply to all PHI we maintain. The updated Notice will be available in our office and on our website.

II. HOW WE MAY USE AND DISCLOSE YOUR HEALTH INFORMATION

The following categories describe ways we may use and disclose your PHI. Not every example is listed, but all permitted uses fall within these categories.

A. Treatment, Payment, and Health Care Operations

We may use and disclose your PHI without your written authorization for:

Treatment – Providing, coordinating, or managing your health care. Example: Consulting with another licensed provider regarding your care.

Payment – Billing and collecting payment for services.

Health Care Operations – Administrative, quality assurance, training, supervision, and business functions.

Disclosures for treatment purposes are not limited to the “minimum necessary” standard because providers require full access to records to provide quality care.

B. Lawsuits and Legal Proceedings

We may disclose PHI in response to a valid court or administrative order.

However, records related to substance use disorder treatment that are protected under 42 CFR Part 2 may only be disclosed in accordance with specific federal requirements, including a court order that complies with 42 CFR Part 2.

We prefer to obtain your written authorization whenever possible before responding to legal requests.

C. Uses and Disclosures Required by Law

We may disclose PHI when required by federal or state law.

D. Public Health and Safety

We may disclose PHI:

• To report suspected child abuse, elder abuse, or dependent adult abuse

• To prevent or reduce a serious threat to health or safety

E. Health Oversight Activities

We may disclose PHI to health oversight agencies for audits, investigations, inspections, or licensure actions.

F. Law Enforcement

We may disclose PHI to law enforcement when required by law or to report crimes occurring on our premises.

G. Coroners and Medical Examiners

We may disclose PHI to coroners or medical examiners as authorized by law.

H. Research

We may use or disclose PHI for approved research purposes, subject to legal protections.

I. Specialized Government Functions

We may disclose PHI for certain government functions, including military, national security, or correctional institution activities, when required by law.

J. Workers’ Compensation

We may disclose PHI to comply with workers’ compensation laws.

K. Appointment Reminders and Health-Related Services

We may use and disclose PHI to:

• Remind you of appointments

• Inform you about treatment alternatives or services we offer

III. SPECIAL PROTECTIONS FOR SUBSTANCE USE DISORDER RECORDS (42 CFR PART 2)

Some health information may relate to substance use disorder (SUD) diagnosis, treatment, or referral.

Federal law (42 U.S.C. § 290dd-2 and 42 CFR Part 2) provides additional privacy protections for these records.

If we create or maintain records subject to 42 CFR Part 2:

• These records generally may not be used or disclosed without your written authorization.

• They may not be disclosed for use in civil, criminal, administrative, or legislative proceedings without your specific written consent or a qualifying court order.

• You may revoke your authorization in writing at any time, except to the extent action has already been taken in reliance on it.

Prohibition on Unauthorized Redisclosure

If information protected under 42 CFR Part 2 is disclosed with your authorization, federal law generally prohibits the recipient from further using or disclosing that information for civil, criminal, administrative, or legislative proceedings without your specific written consent or a court order.

IV. USES AND DISCLOSURES THAT REQUIRE YOUR AUTHORIZATION

We will obtain your written authorization for uses or disclosures not otherwise permitted by law.

You may revoke an authorization at any time in writing.

A. Psychotherapy Notes

We maintain psychotherapy notes as defined in 45 CFR § 164.501.

Use or disclosure of psychotherapy notes requires your written authorization except:

• For our use in treating you

• For training or supervision of mental health practitioners

• To defend ourselves in legal proceedings brought by you

• When required by law

• For health oversight of the originator of the notes

• By the Secretary of HHS to investigate compliance

• To avert a serious threat to health or safety

B. Marketing and Sale of PHI

We will not use or disclose your PHI for marketing purposes.

We will not sell your PHI.

V. USES AND DISCLOSURES WHERE YOU MAY OBJECT

We may disclose PHI to family members or others involved in your care or payment for care unless you object.

In emergencies, we may disclose information if consistent with your best interests.

VI. YOUR RIGHTS REGARDING YOUR PHI

You have the following rights:

Right to Request Restrictions

You may request limits on how we use or disclose your PHI. We are not required to agree unless the request involves services paid out-of-pocket in full.

Right to Restrict Disclosure to Health Plans

If you pay for services in full out-of-pocket, you may request that we not disclose related PHI to your health plan.

Right to Request Confidential Communications

You may request we contact you in a specific way or at a specific location.

Right to Access and Receive Copies

You may request electronic or paper copies of your record (excluding psychotherapy notes). We will respond within 30 days and may charge a reasonable cost-based fee.

Right to an Accounting of Disclosures

You may request a list of disclosures made in the past six years, excluding those for treatment, payment, and operations.

Right to Amend Records

You may request corrections to your PHI. We may deny your request but will respond in writing.

Right to Receive a Copy of This Notice

You may request a paper or electronic copy at any time.

VII. RIGHT TO FILE A COMPLAINT

If you believe your privacy rights have been violated, you may file a complaint with:

Privacy Officer Chrysalis Counseling Center, LLC West Des Moines, IA info@chrysalis-counseling-center.com

or

U.S. Department of Health & Human Services Office for Civil Rights www.hhs.gov/ocr/privacy/hipaa/complaints

You will not be retaliated against for filing a complaint.

1. CONSENT FOR TELEHEALTH CONSULTATION

1. I understand that I may choose to have a virtual Telehealth visit with my health care provider at a later date.

2. I understand that I have the right to withdraw consent at any time without affecting my right to future care, services, or program benefits to which I would otherwise be entitled.

3. This form is informing me that the video conferencing technology that will be used to affect such a session will not be the same as a direct client/health care provider visit due to the fact that I will not be in the same room as my provider.

4. I understand that a telehealth session has potential benefits including easier access to care and the convenience of meeting from a location of my choosing within the state of Iowa.

5. I understand there are potential risks to this technology, including interruptions, unauthorized access, technical difficulties, and/or limited ability to respond to emergencies. I understand that my health care provider or I can discontinue the telehealth consult/visit if it is felt that the videoconferencing connections are not adequate for the situation.

6. I understand that there will be no recording of any of the online sessions by either party. All information disclosed within sessions and written records pertaining to those sessions are confidential and may not be disclosed to anyone without written authorization, except where the disclosure is permitted and/or required by law.

7. I understand that the privacy laws that protect the confidentiality of my protected health information (PHI) also apply to telemental health unless an exception to confidentiality applies (i.e. mandatory reporting of child, elder, or vulnerable adult abuse; danger to self or others).

8. I understand that if I am having suicidal or homicidal thoughts, actively experiencing psychotic symptoms or experiencing a mental health crisis that cannot be resolved remotely, it may be determined that telemental health services are not appropriate and a higher level of care is required.

9. I understand that my therapist may need to contact my emergency contact and/or appropriate authorities in case of an emergency.

10. I understand that I may ask questions at any point before during or after a Telehealth session if I am unsure about the process or the technology used. I also understand that I must personally be in within the state of Iowa during my Telehealth session, due to the limitations of my healthcare provider’s license.

By signing this credit card authorization agreement, you authorize Chrysalis Counseling Center, LLC to make charges to your Health Savings Account, Flex, Debit/Credit or Other card on file for sessions (including co-pays, deductibles, and/or coinsurance and insurance denials of claims), late cancellation/no-show fees, letter-writing, phone consultation fees and other office fees. The card(s) will be processed when there is a balance due.