PLAY THERAPY INFORMATION AND GUIDELINES

Welcome to NYC Therapy Group. We are glad that you are here and we are commited to providing you with quality care. When engaging in play or adolescent therapy for your child, it’s important to keep the following suggestons in mind to ensure a productve therapeutc experience.

WHAT IS PLAY THERAPY?• Play therapy is to children what talk therapy is to adults.• Children don’t always have the ability to express themselves with words.• Play therapy allows children to communicate through play, their most natural form of expression.• The toys the children use in play therapy help them play out what they may be feeling, what they have experienced, and what

they would like to be diferent.

WHY DOES MY CHILD NEED PLAY THERAPY?• Difcultes at home, in school, divorce/separaton, etc.• Witnessing or experiencing a trauma or an abuse.• Problematc behaviors (anger outbursts, withdrawn, mood swings, etc.)• Not getng help now can lead to greater problems for you and your child later on.

WHAT CAN I EXPECT FROM PLAY THERAPY?• During the therapy tme, every thought, feeling, and most actons of the child are accepted within consistent, clearly defned

limits.• There is no such thing as "wrong" or "bad" behavior in play therapy.• The therapist will not "pump" the child for informaton about their life or an abusive or traumatc incident.• Children are allowed to work through their problems at their own pace.• Play therapy can be messy. Please dress your child in play clothes!• It is important to know that working through these experiences in play therapy, while necessary, can be painful and

emotonal. It is therefore normal for children to display an increase in actng out behaviors at various tmes throughout the course of their play therapy.

WHAT TO TELL YOUR CHILD ABOUT PLAY THERAPY• Say that they will be coming to a safe playroom with a grown-up named _____________ (Insert therapist’s name here).• Say something like, "When things are difcult for you at home, school, in the family, etc., sometmes it helps to have a safe

place to play."• You may also tell them that it is OK to talk about those things in the playroom.• Please never tell your child that he or she has to talk.

BEFORE AND AFTER EACH SESSION• Please do not tell your child to have "fun" or to be "good" when the session is to begin.• Please do not ask your child what he or she played with or talked about when the session has ended. It is important that your

child does not feel the need to give an account of what happens in the play therapy room. • If your child brings artwork from the session, simply comment on the colors they used or what you see. "You covered the

whole page with blue, red, and black." Hidden meanings may be present in artwork, so it is best not to ofer praise ("How prety!") or to critcize ("That's not the way to draw it"), or ask questons ("Who is that?", "What did you draw").

PSYCHOTHERAPY AGREEMENT

Client Name_________________________________________Phone(s)__________________________

Address ___________________________________________________ City ______________________

State____________ Zip _____________ Email ________________________________________

Date of Birth_______________________________(*please print clearly and legibly)

Welcome to NYC Therapy Group. These guidelines have been writen to inform you, the client, about the basic terms, conditons and professional practces that promote a successful therapy experience.

About TherapyPartcipatng in therapy can help you learn new and important things about yourself and others as well as new and beter ways of handling feelings or problems. Although there are no guarantees, coming to therapy should help you feel beter and produce benefcial results.

While therapy is obviously meant to improve your quality of life, the process can sometmes be challenging as difcult feelings and concerns emerge and are being addressed. It is normal to sometmes feel worse while the issues are being worked through, and this feeling worse may actually be a sign that therapy is working.

If at any tme you have questons about the therapeutc process, please feel free to discuss them with your therapist. You are also invited to ask about your therapist's experience and training.

AppointmentsThe typical therapy appointment consists of a 50-minute session for the individual hour, and a 60-minute session for the couple/family hour. In order to be efectve, therapy needs to take place on a regular basis. Appointments need to be scheduled in advance. The best results occur when you consistently schedule appointments and maintain regular atendance at your therapy sessions.

Fees and Payments for ServicesYour fee will be $ ______ per therapy session. Fees are assessed once every year and are sometmes raised. Feeswill not be raised without frst discussing the issue with you. Please discuss with your therapist any changes in your fnancial situaton during the course of your therapy.

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Payment is due in full by check or cash at the tme services are provided unless you and your therapist have agreed upon other arrangements. Your fnancial obligaton contnues as long as we are providing professional services or untl you inform your therapist in person or in writng that you wish to terminate therapy. You are responsible for payment of all services provided up untl the tme the therapeutc relatonship has concluded.

Cancellatons and AtendanceYour regularly scheduled appointment tme is held for you each week/bi-weekly as determined and agreed uponwith your therapist. Cancelled, missed or rescheduled appointments with less than a 48-hour notce will be charged the full fee. If your therapy is covered by your health insurance, than you will be responsible to pay the full reimbursable amount as an out-of-pocket fee including any and all co-payments via check, cash or credit card directly to NYC Therapy Group. Exceptons to this policy include an unforeseen and documented illness and emergency situatons as reviewed.

However, if you must cancel an appointment you may schedule an alternate session at no additonal charge – pending therapist availability – to take place within the same week of the cancelled appointment. The more notce you are able to provide regarding absence, the more scheduling fexibility it is likely your therapist will have and the beter we can accommodate you. On occasion, pending on circumstances, availability and the nature or the focus of your therapeutc work, a phone session may be scheduled at your regular tme.

If your therapist is unable to keep an appointment, they will try to reschedule it within the week or fve business days. During the course of a year your therapist may take between two to four weeks for vacaton, seminars andtrainings. In most cases you will be provided with at least one month’s notce prior to your therapist's absence. During these tmes that your therapist is out of the ofce, you will be provided the name and phone number of another therapist who will be available to assist you.

ConfdentalityThe contents of all therapy sessions, including client notes and records, will be treated as confdental. No informaton will be revealed to anyone not present in therapy without the permission of the client or legally authorized representatve unless an applicable legal or ethical excepton exists. As therapists, we are required bylaw to report any suspected child, elder, or dependent adult abuse and any situaton where the client threatens violence to an identfable victm. The law also permits the therapist to break confdentality when the client presents a danger of violence to others or is likely to harm him or herself unless protectve measurements are taken. In additon, disclosures may be required in certain legal proceedings and actons. Please do take the tme to read through thoroughly the HIPAA Notce of Privacy Practces that is included in this informaton packet as it describes in fuller detail your rights as a patent in regards to your Protected Health Informaton (PHI).

Telephone and Email ContactYou can call your therapist for assistance at________________________, their personal phone number as they provide to you or by dialing 646-389-5801. There is a 24-hour voice mail to handle your calls if your therapist is unable to answer. The usual tmeframe during which your therapist can answer the phone is between ______am and _______pm. If you are in need of help between ofce hours, please dial 911. Otherwise, please leave a message with your phone number, your therapist will return your call as soon as is possible – usually by the end of the day or within 24 hours of receiving your call/message.

Your therapist can also be contacted via email at__________________________________,their personal email or at info@nyctherapygrp.com and via text message on their cell phone number as indicated above. Please notethough, email is usually checked less frequently than voice mail and text. Also, sometmes modern technology isnot infallible – if you have not heard back from your therapist within 24 hours, it is possible that your message or email did not go through or we are experiencing technical difcultes. Please try again. We do not answer

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mailto:info@nyctherapygrp.com

phone, email or text messaging while in session and if we antcipate a situaton in which we will not have access to either a cell phone or email for a period of tme, we will do our best to advise you of that ahead of tme.

TerminatonYour therapeutc relatonship contnues as long as we are providing professional services, or untl you, the client,informs your therapist in person or in writng that you wish to end the therapeutc relatonship. If you wish to end your therapy, it is recommended that you meet with your therapist for at least two additonal sessions in order to process your reasons for ending therapy and the work you have done thus far and for a sense of closure. You reserve the right to end your therapy at any tme. If your therapist believes that he/she is unable tohelp you with your concerns, he/she will provide you with referrals to another therapist or agency. There may also be circumstances where we recommend other modes of treatment in additon to our work together.

Please sign below to indicate that you have read, understood and agree to the above terms and conditons.

Signed ____________________________________________________Date _______________

Parent/Guardian Please Print and Sign Your Name Below (when applicable):

__________________________________________________________Date________________

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PSYCHOTHERAPY AGREEMENT ADDENDUM FOR TREATMENT WITH A MINOR

Dear Client, If you are under eighteen years of age, please be aware that the law may provide your parent(s)/legal guardian the right to examine your treatment records. It is the policy of NYC Therapy Group to request an agreement from your parent(s)/legal guardian, as indicated below, to respect the confdentality of your individual psychotherapy treatment sessions. If they agree, then we will provide them only with general informaton aboutthe work you perform together with your therapist in the psychotherapeutc process, unless NYC Therapy Groupand/or your therapist feels there is a risk to your general health and safety posed either by yourself or another or if someone else, as indicated by you, may be at risk to be harmed. In this case, NYC Therapy Group and/or your therapist will notfy your parents of this concern. Before giving them any informaton, NYC Therapy Group and/or your therapist will discuss the mater with you, if possible, and do our best to handle any objectons you may have with what is being prepared to be discussed with them.Your signature below indicates that you understand and agree with the informaton provided above.

__________________________________________________________ ____________Signature of Minor Client Date

PARENT AGREEMENT FOR PSYCHOTHERAPY WITH A MINOR:

I, __________________________________________________________, the parent(s)/legal guardian of the minor,______________________________________, give my/our permission for them to receive therapeutc services provided by _________________________ of NYC Therapy Group without a parent or guardian present.I have read, understood and signed the Psychotherapy Agreement and HIPAA Notce of Privacy Practces as provided by ________________________and understand the risks and benefts of receiving these services as well as the risks and benefts of not receiving these services for both this minor and his/her family. Furthermore, I understand that my/our partcipaton in ________________ 's treatment in the form of additonal parental/guardian individual and/or family sessions could be benefcial for them and our family. Your signature below indicates that you understand and agree with the informaton provided above.

_____________________________________________________________ ____________Signature of Parent(s)/Legal Guardian Date

CHILD & ADOLESCENT THERAPEUTIC INTAKE FORM

Today’s Date_______________ Whom may we thank for referring you to our ofce? __________________

Child/Adolescent Name: __________________________ Birthdate: ______________ SS#: ________________Address: __________________________________City: ______________ State: _____ Zip Code: ___________Home Ph#: _____________________ Work Ph#: __________________ Cell Ph#: _______________________Parent(s) /Legal Guardian Name:_______________________________________________________________Parent(s) /Legal Guardian Phone:_______________________________________________________________Whom may we contact in case of emergency: Name _______________________________________________ Relatonship____________________________ Phone ______________________________________________Address____________________________________________________________________________________(*Please notfy this person that they are listed as an emergency contact with our organizaton)Email address if you would like to be contacted for administraton purposes:____________________________

INSURANCE INFORMATION:Name of Insurance: ___________________ Primary Insured Name and DOB:___________________________Member/Policy/Subcriber ID#: ____________________________ Group #: ____________________________

GENERAL INFORMATION ON CHILD/ADOLESCENT :Why have you decided to seek therapy at this tme?________________________________________________________________________________________________________________________________________

Mother’s Name ________________________ Age____ ___ Address/Phone # same as above: Yes/No If NO: Current Address___________________________ City______________ State____ Zip______________

Home Ph#____________________ Work Ph#___________________ Cell # ________________Father’s Name _________________________ Age_______ Address/Phone # same as above: Yes/No If NO: Current Address___________________________ City______________ State_____ Zip_____________

Home Ph#____________________ Work Ph#__________________ Cell #________________Step Parent(s)/Legal Guardian: Name(s)_____________________________________Age(s)______________Address/Phone # same as above: Yes/No If NO: Current Address______________________________City______________ State____ Zip___________Home Ph#:____________________ Work Ph#:_______________________ Cell Ph #:____________________

Child’s Physician: ____________________________________________Phone#_________________________Has your child ever been tested by a psychologist? Yes/No If yes, please give name, date and reason: __________________________________________________________________________________________

Has your child ever been placed in a psychiatric hospital? Yes/No If yes, please give name, date and reason:

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__________________________________________________________________________________________GENERAL INFORMATION (CONT):Is your child currently in therapy/counseling? Yes/No Has your child received therapy/counseling in the past? Yes/NoIf yes, to either of the above, please fll out the following informaton: Reason___________________________________________________________________________________________________________________What was/wasn’t helpful about this treatment:_____________________________________________________________________________________________________________________________________________Name, Address and Phone of Therapist: _________________________________________________________Date/Length of treatment________________Has your child previously taken any medicatons for emotonal/behavioral problems? Yes/NoIf yes, please describe:________________________________________________________________________

FAMILY DYNAMICS :People currently living in the home:Name:__________________________Age:__________ Relatonship to the child:__________________Name:__________________________Age:__________ Relatonship to the child:__________________Name:__________________________Age:__________ Relatonship to the child:__________________Name:__________________________Age:__________ Relatonship to the child:__________________

Please describe any additonal informaton about the child’s family that would be useful for the therapist to know (ie, family/marital confict, alcohol/drug abuse, health/medical conditons, fnancial distress/loss of job)____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

EDUCATION INFORMATION :Is your child currently enrolled in School/Daycare now? YES/ NO How many schools daycares has your child atended in the last year? __________________________________Name of school/daycare: ______________________________Grade: _______ Name of Teacher: ___________Describe your child’s academic performance over the past school year: GOOD FAIR POORIf POOR, please explain: ______________________________________________________________________Is your child’s behavior a problem in his/her school? Yes/No If yes, please describe:______________________________________________________________________________________________________________

HEALTH INFORMATION ON CHILD/ADOLESCENT :Does your child have any chronic illnesses, genetc illnesses, allergies or handicaps? YES/NOIf yes, please describe and include treatment protocol (ie, medicatons, procedures, hospitalizatons): ______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

DEVELOPMENTAL HISTORY:Was pregnancy planned or unplanned: __________________________________________________________Experience of pregnancy on the mother, favorable/unfavorable, please describe:__________________________________________________________________________________________________________________Did any trauma occur during the pregnancy or soon afer birth:_______________________________________Was pregnancy full term, premature or late: ______________________________________________________Describe delivery (ie, smooth, complicated, c-secton):______________________________________________Was your child born with a low/average/high birth weight and height: _________________________________

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Was your child exposed to prenatal drug use? Yes/No If yes, what kind_______________________________Did mother experience postpartum depression: ___________________________________________________DEVELOPMENTAL HISTORY (CONT):When did your child frst:Babble_____________ Sit Unassisted_____________ Roll Over___________Crawl_____________________Walk ______________First Words (what were they and age)____________________Talk__________________Poty Trained______________________________

RELATIONSHIPS :Are the child’s biological parents: ___Married/living together ____Married/living apart ___Not married/living together ___ Not married/living apart ____Separated/DivorcedHow long has this been the arrangement: ________________________________________________________Age of child at tme of separaton/divorce _____ Are the child’s biological parents stll living? Yes/NoIf No, age of child when parent died_______ Length of relatonship with step-parent/legal guardian ________ Describe the following relatonships:Mother and child:___________________________________________________________________________ Father and child:____________________________________________________________________________ Siblings and child:___________________________________________________________________________ Step Parent/Legal Guardian (or other signifcant relatonships) and child:_______________________________

BEHAVIORAL INFORMATION :Have there been any signifcant events in your child’s life in the past 12 months? Yes/NoIf YES, please explain:_____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________Does your child have difcultes in any of the following areas? (Check all that apply)Health: Emotons: Sleep:__weight loss/gain __mood swings __bed wetng__diet/eatng __frequent crying __nightmares__uses drugs/alcohol __depressed __waking up/going to bed__cafeine/nicotne __suicide ideatons/atempts

__irritablePlease describe in more detail here: _______________________________________________________________________________________________________________________________________________________Development: Behaviors: Relatonships:__soils pants __lying/exaggeratng __getng along with other kids__sucks thumb __cruelty to animals __getng along with other adults__motor skills __fascinaton with fre/weapons __datng__language skills __sexual actng out

__nervous habits__truancy__involvement with law enforcement

Describe your child’s fears:____________________________________________________________________How does your child show afecton?____________________________________________________________ How does your child show anger?_______________________________________________________________What are some of your child’s favorite actvites?__________________________________________________

DISCIPLINE TECHNIQUES :Mother:___________________________________________________________________________________Father:____________________________________________________________________________________

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Step Parent/Legal Guardian:___________________________________________________________________Other Caregiver(s):___________________________________________________________________________

ABUSE INFORMATION :As far as you are aware, has your child/adolescent experienced abuse:

Physically? Yes/No If Yes, Date:_______ was ACS notfed? Yes/No Date:__________ ACS Case #_________________ Child’s age at the tme of the incident_____ Who did your child frst tell about the incident?_____________________________ Name and relatonship of Perpetrator_________________________________________________ Please describe:__________________________________________________________________

Sexually? Yes/No If Yes, Date:_______ was ACS notfed? Yes/No Date:_________ ACS Case #_________________ Child’s age at the tme of the incident_____ Who did your child frst tell about the incident?_____________________________ Name and relatonship of Perpetrator_________________________________________________ Please describe:__________________________________________________________________

Emotonally? Yes/No If Yes, Date:_______ was ACS notfed? Yes/No Date:_________ ACS Case #_________________ Child’s age at the tme of the incident______ Who did your child frst tell about the incident?_____________________________ Name and relatonship of Perpetrator_________________________________________________ Please describe:__________________________________________________________________

Neglect? Yes/No If Yes, Date:_______ was ACS notfed? Yes/No Date:___________ ACS Case #_________________ Child’s age at the tme of the incident_________ Who did your child frst tell about the incident?______________________________ Name and relatonship of Perpetrator_________________________________________________ Please describe:__________________________________________________________________

What was your child’s reacton to the abuse/investgaton/outcome:__________________________________ ______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

ADDITIONAL PERTINENT INFORMATION: Please use this space to share any additonal informaton that couldbe useful in helping us learn about your child and/or family and in developing a treatment plan for your child and/or family:____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

YOUR SIGNATURE BELOW INDICATES THAT THE INFORMATION YOU HAVE PROVIDED IN THIS DOCUMENT IS ACCURATE AND TO BE USED IN PROVIDING THERAPEUTIC TREATMENT FOR YOUR CHILD/FAMILY.

Parent or Legal Guardian’s Signature:______________________________________ Date: _____________Print Parent/Legal Guardian Name: _______________________________________ Date:_____________

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HIPAA NOTICE OF PRIVACY PRACTICES

I. THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. WE (NYC THERAPY GROUP, LCSW’s PSYCHOTHERAPY PROFESSIONALS PLLC) ARE PROVIDING YOU WITH THIS NOTICE SO THAT YOU CAN BETTER UNDERSTAND OUR RESPONSIBILITIES AND YOUR RIGHTS REGARDING THE USE AND DISCLOSURE OF YOUR PROTECTED HEALTH INFORMATION (PHI). PLEASE REVIEW ITCAREFULLY.

II. IT IS OUR LEGAL DUTY TO SAFEGUARD YOUR PHI. By law we are required to insure that your PHI is kept private. The PHI consttutes Informaton created or noted by me that can be used to identfy you. It contains data about your past, present, or future health or conditon, the provision of health care services to you, or the payment for such health care. Specifcally excluded from PHI are process notes, properly designated Psychotherapy Notes, which are reserved exclusively for our own private use, are not considered a part of your health record, and disclosed to no one. We are required to provide you with this Notce about our privacy procedures. This Notce must explain when, why, and how wewould use and/or disclose your PHI. Use of PHI means when we share, apply, utlize, examine, or analyze informaton within our practce, PHI is disclosed, when we release, transfer, give, or otherwise reveal it to a third party outside our practce. With some exceptons, we may not use or disclose more of your PHI than is necessary to accomplish the purpose for which the use or disclosure is made; however, we are always legally required to follow the privacy practces described in this Notce.

Please note that we reserve the right to change the terms of this Notce and our privacy policies at any tme. Any changes will apply to PHI already on fle with NYC Therapy Group. Before we make any important changes to this policy we will immediately change this Notce and post a new copy of it in our ofce. You may also request a copy of this Notce from us.

III. HOW WE WILL USE AND DISCLOSE YOUR PHI.

We will use and disclose your PHI for many diferent reasons. Some of the uses or disclosures require your prior writen authorizaton; others will not. Below you will fnd the diferent categories of our uses and disclosures, with some examples

A. Uses and Disclosures Related to Treatment, Payment, or Health Care Operatons Do Not Require Your Prior WritenConsent. We may use and disclose your PHI without your consent for the following reasons:

I. For treatment. We may disclose your PHI to physicians, psychiatrists, psychologists, and other licensed health care providers who provide you with health care services or are otherwise involved in your care. Example: If a psychiatrist is treatng you, we may disclose your PHI to her/him in order to coordinate your care.

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2. For health care operatons. We may disclose your PHI to facilitate the efcient and correct operaton of our practce. Examples: Quality control – we might use your PHI in the evaluaton of the quality of health care services that you have received or to evaluate the performance of the health care professionals who provided you with these services. We may also provide your PHI to our atorneys, accountants, consultants and others to make sure we are in compliance with the applicable laws.

3. To obtain payment for treatment. We may use and disclose your PHI to bill and collect payment for the treatment and services we provided you. Example: We might send your PHI to your insurance company or health plan in order to get payment for the health care services that we have provided to you. We could also provide your PHI to business associates, such as billing companies, claims processing companies, and others that process health care claims.

4. Other disclosures. Examples: Your consent isn’t required if you need emergency treatment provided that we atempt to get your consent afer treatment is rendered. In the event that we try to get your consent but you are unable to communicate with me (for example, if you are unconscious or in severe pain) but we think that you would consent to such treatment if you could, we may disclose your PHI.

B. Certain Other Uses and Disclosures Do Not Require Your Consent. We may use and/or disclose your PHI without your consent or authorizaton for the following reasons:

1. When disclosure is required by federal, state, or local law; judicial, board, or administratve proceedings; or, law enforcement. Example: We may make a disclosure to the appropriate ofcials when a law requires us to report informaton to government agencies, law enforcement personnel and/or an administratve proceeding.

2. If disclosure is compelled by a party to a proceeding before a court on an administratve agency pursuant to its lawful authority.

3. If disclosure is required by a search warrant lawfully issued to a governmental law enforcement agency.

4. If disclosure is compelled by the patent or the patent’s representatve pursuant to state health and safety codes orto corresponding federal statutes or regulatons, such as the Privacy Rule that requires this Notce.

5. To avoid harm. We may provide PHI to law enforcement personnel or persons able to prevent or mitgate a serious threat to the health or safety of a person or the public,

6. If disclosure is compelled or permited by the fact that you are in such mental or emotonal conditon as to be dangerous to yourself or the person or property of others, and if we determine that disclosure is necessary to preventthe threatened danger.

7. If disclosure is mandated by state child abuse and neglect reportng laws. For example, if we have a reasonable suspicion of child abuse or neglect.

8. If disclosure is mandated by state elder/dependent adult abuse reportng laws. For example, if we have a reasonable suspicion of elder abuse or dependent adult abuse.

9. If disclosure is compelled or permited by the fact that you tell us of a serious/imminent threat of physical violence by you against a reasonably identfable victm or victms.

10. For public health actvites. Example: In the event of your death, if a disclosurepermited or compelled, we may need to give the county coroner informaton about you.

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11. For health oversight actvites. Example: we may be required to provide informaton to assist the government in the course of an investgaton or inspecton of a health care organizaton or provider.

12. For specifc government functons. Examples: we may disclose PHI of military personnel and veterans under certain circumstances. Also, we may disclose PHI in the interests of natonal security, such as protectng the President of the United States.

13. For research purposes. In certain circumstances we may provide PHI in order to conduct medical research.

14. For Workers’ Compensaton purposes. We may provide PHI in order to comply with Workers’ Compensaton laws.

15. Appointment reminders and health related benefts or services. Examples: We may use PHI to provide appointmentreminders. We may use PHI to give you informaton about alternatve treatment optons, or other health care services orbenefts we ofer. We may use PHI to provide accountants, consultants, and others to make sure that we are in compliance with applicable laws.

16. If an arbitrator or arbitraton panel compels disclosure. For example, when arbitraton is lawfully requested by either party, pursuant to subpoena daces tectum (e. g., a subpoena for mental health records) or any other provision authorizing disclosure in a proceeding before an arbitrator or arbitraton panel.

17. We are permited to contact you, without your prior authorizaton, to provide appointment reminders or informaton about alternatve or other heath-related benefts and services that may be of interest to you.

18. If disclosure is required or permited to a health oversight agency for oversight actvites authorized by law. Example: When compelled by U. S. Secretary of Health and Human Services to investgate or assess our compliance with HIPAA regulatons.

19. If disclosure is otherwise specifcally required by law.

C. Certain uses and Disclosures Require You to Have the Opportunity to Object.

1 Disclosures to family, friends, or others. We may provide your PHI to a family member, or other individual who you indicate is involved in your care or responsible for the payment for your health care, unless you object in whole or in part. Retroactve consent may be obtained in emergency situatons.

D. Other Uses and Disclosures Require Your Prior Writen Authorizaton. In any other situaton not described in Sectons IIIA, IIIB, and IIIC above, we will request your writen authorizaton before using or disclosing any of your PHI. Even if you have signed an authorizaton to disclose your PHI, you may later revoke that authorizaton, in writng, to stopany future uses and disclosures (assuming that we haven’t taken any acton subsequent to the original authorizaton) of your PHI by us.

IV. WHAT RIGHTS YOU HAVE REGARDING YOUR PHI.

A. The Right to See and Get Copies of Your PHI. In general, you have the right to see your PHI that is in our possession, or to get copies of it: however, you must request it in writng. If we do not have your PHI, but know who does, we will advise you how you can get it. You will receive a response from us within 30 days of our receiving your writen request. Under certain circumstances, we may feel we must deny your request, but if we do, we will give you, in writng, the reasons for the denial. We will also explain your right to have our denial reviewed. If you ask for copies of your PHI, We will charge you not more than $.25 per page. We may see ft to provide you with a summary or explanaton of the PHI but only if you it, as well as to the cost, in advance.

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B. The Right to Request Limits on Uses and Disclosures of Your PHI. You have the right to ask that we limit how we use and disclose your PHI. While we will consider your request, we are not legally bound to agree. If we do agree to your request, we will put those limits in writng and abide by them except in emergency situatons. You do not have the right to limit the uses and disclosures that we are legally required or permited to make.

C. The Right to Choose How We Send Your PHI to You. It is your right to ask that your PHI sent to you at an alternate address (for example, sending informaton to your work address rather than your home address) or by an alternate method (for example, via email instead of by regular mail). I am obliged to agree to your request providing that I can give you the PHI, in the format you requested, without undue inconvenience.

D. The Right to Get a List of the Disclosures I Have Made. You are enttled to a list of disclosures of your PHI that we have made. The list will not include uses or disclosures to which you have already consented, i.e., those for treatment payment or health care operatons, sent directly to you, or to your family; neither will the list include disclosures made for natonal security purposes, or for correctons or law enforcement personnel. Disclosure records will be held for six years from the date your treatment period commenced. We will respond to your request for an accountng of disclosures within 60 days of receiving your request. The list we give you will include disclosures made in the previous sixyears unless you indicate a shorter period. The list will include the date of the disclosure, to whom PHI was disclosed (including their address, if known), a descripton of the informaton disclosed, and the reason for the disclosure. We will provide the list to you at no cost unless you make more than one request in the same year, in which case we will charge you a reasonable sum based on a set fee for each additonal request.

E. The Right to Amend Your PHI. If you believe that there is some error in your PHI or that important informaton has been omited, it is your right to request that we correct the existng informaton or add the missing informaton. Your request and the reason for the request must made in writng. You will receive a response within 60 days of our receipt ofyour request: we may deny your request, in writng, if we fnd that the PHI is (a) correct and complete, (b) forbidden to be disclosed, (c) not part of our records, or (d) writen by someone other than us. Our denial must be in writng and must state the reasons for the denial. It must also explain your right to fle a writen statement objectng to the denial. If you do not fle a writen objecton, you stll have the right to ask that your request and our denial be atached to any future disclosures of your PHI. If we approve your request, we will make the changes) to your PHI. Additonally, we will tell you that the changes have been made, and we will advise all others who need to know about the change(s) to your PHI.

F. The Right to Get This Notce by Email. You have the right to get this notce by email. You have the right to request a paper copy of it, as well.

V. HOW TO COMPLAIN ABOUT MY PRIVACY PRACTICES

If, in your opinion, we may have violated your privacy rights, or if you object to a decision we made about access to your PHI, you are enttled to fle a complaint with the person/business listed in Secton VI below. You may also send a writen complaint to the Secretary of the Department of Health and Human Services at 200 Independence Avenue S. W. Washington, D. C. 20201. If you fle a complaint about our privacy practces, we will take no retaliatory acton against you.

VI. PERSON TO CONTACT FOR INFORMATION ABOUT THIS NOTICE OR TO COMPLAIN ABOUT MY PRIVACY PRACTICES

If you have any questons about this notce or any complaints about my privacy practces, or would like to know how to fle a complaint with the Secretary of the Department of Health and Human Services please contact us at NYC Therapy Group , 5731 Mosholu Avenue, 2nd Floor, Bronx, NY 10471 (646)389-5801

VII. EFFECTIVE DATE OF THIS NOTICE: This notce went into efect on April 1, 2014.

4

ACKNOWLEDGEMENT OF RECEIPT OF HIPPA NOTICE OF PRIVACY PRACTICES

Your signature below indicates that you have received, read and understand the informaton included in the HIPPA Notce of Privacy Practces.

Signed _____________________________________________________Date _______________

Parent/Guardian Please Print and Sign Your Name Below (when applicable):

___________________________________________________________Date_______________

Credit Card Authorization Form

THIS INFORMATION IS PRIVATE AND CONFIDENTIAL AND WILL ONLY BE KEPT ON FILE BY

_____________________________________

Name as it appears on credit card:___________________________________

Phone number:__________________________________________________

Billing address of credit card with zip code: ___________________________

______________________________________________________________

Email address:__________________________________________________

Card (Choose One) ___Visa ___Master Card ___Discover ___American Express

Credit Card Number:______________________________________________

Expiration Date: Month/Year ____________________

CCV OR CID Code: ______________________________________________

All patients are required to have an active credit card on file. Payment is due at the time of service, or at the session following a "no show" defined as a cancellation with less than 24 hours notice. If you prefer to pay by cash or check, please do so at the time of service, or at the session following a "no show." If payment is not received at the time of service or at the next session following a "no show," we will wait fourteen (14) days for a check to be received by mail. After 14 days your credit card will be charged for any balance due.

I hereby authorize this credit card to be used for payments for services rendered by_________________________. This authorization will remain in effect until the expiration date of the card or a written request to revoke the authorization is sent to us at:

_____________________________________________________________________________.(Address)

Please advise us immediately if your card is lost and/or stolen.

Card Holder Signature: _____________________________ Date:___________

Policy Regarding Telephone, Text and Email Contact Between Scheduled Sessions

As your therapists, we commit ourselves to supportng you working towards your best health and well-being. As such, we give you our fullest atenton and personal presence at your regularly scheduled appointment to help you work towards the goals you wish to achieve.

We understand though that there may be tmes between your regularly scheduled appointments in which issues or concerns may arise that need immediate atenton. Ofen such concerns can be addressed in either a brief 5-10-minute phone call or a concise text or email and we will do our best to accommodate your concerns in a tmely manner.

However, some issues or concerns may require more tme than that. In order to best serve you and out of respect for the quality of care we ofer and the integrity of our schedule, instances in which a telephone or email exchange stretches beyond a 10 min window, tme increments utlized will be billed and prorated according to your regular hourly session fee.

Thank you in advance for your understanding.

___________________________________________________ _________________________Print Name of Client or Guardian Date

___________________________________________________ _________________________Signature of Client or Guardian Date

1a Child PLAY THERAPY INFORMATION AND GUIDELINES1b Child PSYCHOTHERAPY AGREEMENT1c Child PSYCHOTHERAPY AGREEMENT ADDENDUM - TREATMENT WITH A MINOR2 Child-Adolescent Therapeutic Intake Form3 HIPAA NOTICE OF PRIVACY PRACTICES4 HIPPA Signature Page5 Credit Card Authorization Form6 Telephone and Email Contact Between Sessions