HIPAA Agreement

Informed Consent and Notice of Privacy Practices

Please complete the form below, or print and fill out the PDF HIPAA Agreement, and bring it to your first appointment.

To provide you with information about my policies, I have prepared the following statements for your reference. In selecting these topics, I hope that I have anticipated many of the questions that you may have. Should there be matters that I have not covered, please feel free to address them with me.


This is an outpatient private practice setting that provides psychotherapy and counseling services to individuals.


I have a license to practice in the state of Michigan. I have practiced counseling among various populations in my experience within private practice, inpatient, partial hospitalization, outpatient and community settings in both my professional and graduate study work.

I am obligated, in accordance with my license, to abide by Michigan’s Professional Counseling regulatory rules, laws and ethics codes. I am responsible to adhere to ethical guidelines associated with my professional affiliations, as well. I must also regularly attend relevant continuing education courses. I find this as an asset to practice and continued learning. However, I will not reveal any identifying information about you without your written permission.

Permission would also be required from you if I should request that we tape one of our sessions. My practice style is flexible in that, I may use different therapies and disciplines as I see fit to your specific treatment needs. In general, I am an action-oriented therapist in that I will assume that you are here because you are open to change in some area in your life. I will also assume that you are seeking assistance with learning how to cope, change or find fulfillment in your life in some way and that you would like me to guide and teach you how to manage your life in a more productive way. We will work as a team in looking at your treatment goals together.


There are no guarantees that any or all of your problems will be remedied by pursuing treatment with me. You may experience stress, strained relationships, or other difficulties as a result of working in therapy. At times, therapy requires the sharing of painful feelings and thoughts. As a result, you may experience unpleasant feelings. Growth is difficult and things may feel worse before they feel better during our work together. You may experience anxiety as you face major life decisions that surface in therapy.

There are many benefits to therapy – benefits that have been established by scientific research as well as by clinical anecdotes. It is my job to ensure that, for the most part, the benefits of therapy outweigh the risks. I will also keep you informed, to the best of my ability, of the risks as we make treatment decisions together, and to assist you in getting to another treatment resource if, after a reasonable time of working together, you are not benefiting from my services. My philosophy is generally optimistic and hopeful. When your agenda is one of healing and problem solution, there is usually always something that has not yet been tried that will be helpful, even if you have consulted with other therapists unsuccessfully in the past. If your agenda is to control someone else, to collect evidence for court proceedings, to seek revenge, to prove someone else wrong, to remain a victim, or to pursue other nonhealing goals, positive change will be extremely difficult.


At this time, I have flexible hours during the day and evenings. There is no receptionist available. Please call my voicemail at 248-840-5517 to schedule an appointment or make a cancellation. Texting and email are also acceptable.


Emergency Phone Calls

I am not an emergency mental health service, so if you need to speak with me or a mental health professional immediately and are unable to reach me, call the emergency mental health number in your county of residence, call 911, or go directly to your nearest emergency room.

Vacations, holidays, etc.

When I am out of town, or will be otherwise unavailable for a period of time other than a weekend or holiday, the expectation is that you will be able to leave a message and I will return my call upon returning to the office. In case of emergency, it is expected that you will use your judgment, and if necessary call 911 or go to the nearest emergency room.


If an interruption of services does occur, due to hospitalization treatment needs, I will work to provide your psychiatrist with any information necessary. Upon your discharge, I shall assess with you your outpatient needs and make plans for ongoing services with myself or make appropriate referrals.


Shores of Hope, PLLC will require a 24 hour advance notice for appointment cancellations or you will be charged a $50.00 fee. Likewise, you will be charged if you don’t show up for an appointment that you have scheduled with me. I understand that there may be an occasional emergency that interferes with your notifying me within the 24-hour window of time and will always take these circumstances into consideration. I do require that I keep a credit card on file for all clients in order to secure your appointments and that credit card will be charged if you make no effort to contact me regarding a missed appointment.



I do not accept friend or contact requests from current or former clients on any social networking site (Facebook, Linkedin, etc.) I believe that adding clients as friends or contacts on these sites can compromise your confidentiality and our respective privacy. It may also blur the boundaries of our therapeutic relationship. If you have questions about this, please bring them up when we meet and we can talk more about it.


Information that you share with me may be entered into records in written form. My responsibility to you is to maintain all identifiable information about you in confidence and to not release it to any person or facility without your written permission. The only exceptions are listed below.

I am required by law to reveal information about you to other persons or agencies without your permission:

  • If you threaten to harm either yourself or someone else and I believe your threat to be serious, I am obligated under the law to take whatever action seems necessary to protect you and others from harm. This may include divulging confidential information to others but would only be done under circumstances in which someone’s life appeared to be in danger.
  • If I have reason to believe that you are neglecting or abusing children or the elderly, I am obligated by law to report this to the appropriate agency. The law is designed to protect children and the elderly from harm and my legal obligation to report suspected abuse or neglect is clear.
  • If you are involved in litigation of any kind and inform the court of mental health services received from me, this may make your mental health an issue before the court. If your records are court ordered via a subpoena, your right to keep records confidential may be waived. Consult your attorney before you disclose that you have received treatment!
  • If a court has referred you to me, you can assume that the court will wish to receive a report or evaluation. Discuss with me and with your attorney exactly what information will be included in a report to the court before you disclose any confidential information to me. In this instance, you have a right to tell me only what you wish me to know.

If you are participating in a psychotherapy group, please know that by signing this agreement you understand that you are expected to keep information, interactions and anything shared during the group confidential, as well.


  • You have the right to be treated by me in a consistently competent, ethical, and respectful manner.
  • You have the right to a personal, individualized assessment of your treatment needs in which your expertise about yourself is as important as is my professional opinion about you.
  • You have the right to referrals to other competent professionals and services when this is indicated by your treatment needs.
  • You have the right to ask questions about the approach and methods I use and to decline the use of certain therapeutic techniques.
  • You have the right to confidential treatment except in the circumstances already described. This means that you determine the amount of information to be released to anyone outside this setting by signing a permission form that is specific to each situation and that determines the length of time in which the information may be released, and may be canceled by you at any time.
  • You have the right to stop receiving therapy from me without any obligation other than to pay for the services that you have already received.
  • You have the right to resume service following termination.
  • You have the right to discuss your treatment, concerns, questions, complaints or any other matter with me.

By signing below, you acknowledge that you have read and understand the “Informed Consent and Information for My Clients” handout (which includes Benefits and risks of treatment, emergency needs, fee schedule, cancellation policy, confidentiality, Social Media Policies, termination, and client rights, HIPPA laws and Notice of Privacy Practices) described herein and you have discussed with me any information provided that you do not understand.