Therapy Services

 Please read this carefully. This document explains how I protect your privacy, how I use and share your health information, and what your rights are.

As your therapist, I want you to understand exactly how your personal information is handled. Your trust matters deeply, and transparency around privacy is part of that commitment.

This notice describes:

• How your protected health information (PHI) may be used or shared
   
• Your rights regarding your information
   
• How you can access or request changes to your records
   
• What to expect around privacy, confidentiality, and communication with me
   

I am legally required to give you this information under the Health Insurance Portability and Accountability Act (HIPAA). I am also ethically committed to honoring your privacy as part of trauma-informed, client-centered care.

I. My Commitment to Your Privacy

I understand that information about your mental health is deeply personal. I am committed to protecting it. I create a clinical record of our work together so I can provide high-quality care and meet legal and ethical requirements.

By law, I must:

• Keep your PHI private
   
• Give you this Notice explaining how I protect and use your information
   
• Follow the terms of this Notice
   
• Notify you if any part of this Notice changes
   

Any updates will be posted on my website and made available to you upon request.

II. How Your Information May Be Used or Shared

HIPAA allows me to use and disclose your PHI for certain purposes without needing additional authorization from you. Below is a clear explanation of when this happens and why.

1. Treatment

This means providing, coordinating, or managing your care.

Examples include:

• Documenting our sessions in your clinical record
   
• Consulting with another provider (with your written authorization unless de-identified)
   
• Coordinating care if you are seeing multiple professionals
   

I use SimplePractice, a HIPAA-compliant electronic health record and telehealth platform, for all documentation, scheduling, and communication.

2. Payment

If you use insurance, this includes:

• Billing your insurance company
   
• Providing the minimum necessary information for reimbursement
   
• Verifying your benefits
   

If you pay out-of-pocket, your information is still protected and handled only as needed for receipts or superbills.

3. Health Care Operations

These are activities that help me run a safe, ethical practice.

Examples include:

• Keeping records up to date
   
• Engaging in professional consultation (always de-identified unless you sign a Release of Information)
   
• Complying with audits or credentialing requirements
   

I do not share identifiable details in consultation without your permission unless the law requires it.

III. Situations When I May Have to Disclose Your Information Without Authorization

I only disclose information without your permission when legally required or allowed in order to protect your safety or comply with the law.

These situations include:

1. Mandated Reporting

I must report suspected:

• child abuse
   
• elder abuse
   
• abuse of a dependent adult
   

2. Serious Threat to Safety

If I believe there is a clear, immediate danger to you or someone else, I may need to share limited information to prevent harm.

3. Judicial or Legal Requirements

If I receive a court order, I must comply.

Important:

I do not provide forensic evaluations, custody recommendations, fitness-for-duty statements, or expert testimony. If I receive a subpoena that is not a court order, I will:

• Notify you
   
• Give you the opportunity to obtain legal counsel
   
• Release only what the law requires and only the minimum necessary

4. Health Oversight 

Such as audits, licensing board inquiries, or compliance checks.

5. Public Health and Safety

Limited disclosures may be required to reduce or prevent a serious threat or respond to certain public safety events.

6. Appointment Reminders / Administrative Messages

I may contact you about:

• upcoming appointments
   
• scheduling
   
• information about services you already receive
   

I keep communications minimal and professional. Texting is used for logistics only.

IV. Situations That Require Your Written Authorization

I will not release your PHI unless you sign a written Release of Information (ROI) for:

• Collaborating with another provider
   
• Sharing information with a family member or support person
   
• Coordinating with schools, workplaces, attorneys, or partners
   
• Any request not covered under treatment, payment, or operations
   

I do not disclose information to family or friends unless you explicitly give written permission, except in an emergency when you cannot consent and disclosure would prevent harm.

V. What I Do Not Do With Your Information

To be clear:

• I do not use your information for marketing
   
• I do not sell your information
   
• I do not conduct research that uses client records
   
• I do not keep separate HIPAA-defined “psychotherapy notes”
   
• I do not provide forensic assessments or court-related evaluations
   

All my notes are standard clinical progress notes stored securely in SimplePractice and are part of your medical record.

VI. Your Rights Regarding Your Protected Health Information

HIPAA gives you the following rights:

1. Right to Request Restrictions

You may ask me not to use or share certain information.

I will consider your request, but I may not always be able to agree if it would limit your care or violate legal requirements.

2. Right to Restrict Insurance Disclosure When Paying Out-of-Pocket

If you pay for a service fully out-of-pocket, you may request that I do not share the information with your insurance.

3. Right to Choose How I Contact You

You can request communication via a certain phone number, email, address, etc.

I will agree to all reasonable requests.

4. Right to Access Your Records

You can request a copy of your clinical record at any time.

I provide electronic copies at no cost.

If you request printed copies, a reasonable cost-based fee may apply.

All record requests can be made directly through the SimplePractice client portal or by emailing me.

5. Right to Request an Amendment

If you believe your record contains an error, you may request a correction.

I will review the request and respond in writing within 60 days.

6. Right to an Accounting of Disclosures

You may request a list of any disclosures I have made of your PHI other than those for treatment, payment, or operations.

7. Right to a Copy of This Notice

You may request a paper or electronic copy at any time, even if you originally signed electronically.

VII. How to Contact Me About Privacy or Records

If you have questions, concerns, or requests regarding your privacy or your records, you may contact me directly at:

chelsie@evolvemke.com

(414) 207-4799

If you believe your privacy rights have been violated, you can also file a complaint with the U.S. Department of Health and Human Services. I will provide you with the contact information upon request, and you will not be penalized in any way for filing a complaint.

VIII. Acknowledgment of Receipt

You will receive this notice through the SimplePractice client portal.

By electronically signing your intake documents, you acknowledge:

• that you received and reviewed this Notice of Privacy Practices,
   
• that you understand your rights and how your information may be used,
   
• and that you may ask questions at any time.