Your private health information is confidential. It will NOT be disclosed, sold, or used to market unless express written permission is received, or disclosure is required by law. Private heath information may be disclosed for one of these reasons:

• Suspected child abuse or dependent adult or elder abuse, which we are required by law to report to the appropriate authorities immediately.

• Reasonable belief that disclosure may prevent a serious threat to your health or safety or the health or safety of others.

• Misconduct of other mental health professionals.

• Other disclosures permitted or required by law include the following: disclosures for public health activities; health oversight activities including disclosures to state or federal agencies authorized to access your PHI; disclosures to judicial and law enforcement officials in response to a court order or other lawful process.

Good Faith Estimate

You have the right to receive a “Good Faith Estimate” explaining how much your medical and mental health care will cost.

Under the law, healthcare providers need to give patients who don’t have insurance or who are not using insurance an estimate of the expected charges for medical services, including psychotherapy services.

You have the right to receive a Good Faith Estimate for the total expected cost of any non- emergency healthcare services, including psychotherapy services.

You can ask your health care provider, and any other provider you choose, for a Good Faith Estimate before you schedule a service.

If you receive a bill that is at least $400 more than your Good Faith Estimate, you can dispute the bill. Make sure to save a copy or picture of your Good Faith Estimate.

For questions or more information about your right to a Good Faith Estimate, visit www.cms.gov/nosurprises.

Late Cancellations

In order to protect everyone’s time, there is a strict 48-hour cancellation policy. If a session is cancelled within 48-hours of session time, full payment for the time will be required.

Paperwork Completion

Intake paperwork MUST be completed within 48-hours of scheduling an appointment or the scheduled session will be released. Please reach out to Irene if you have questions or concerns.

Gottman Relationship Checkup

The Gottman Relationship Checkup is a 400-questionnaire for couples. The assessment costs $39, paid directly to The Gottman Institute. All couples are required to complete the assessment 24-hours before their individual sessions so Irene has adequate time to read it. Irene will be unable to meet with you if the assessment is not completed. Please answer the questions separately and do not share your answers with your partner. The assessment feedback will be provided during your fourth session with Irene (the second session where both couples attend).