Informed Consent, Privacy Policy and Limits of Confidentiality, and Terms of Service for On-Line Psychotherapy (Telehealth)

Welcome to my on-line (telehealth) practice. There are many terms for telehealth as it applies to mental health therapy or counseling, including Virtual Presence Therapy (VPTherapy), Telepsychotherapy, E-Therapy and On-Line Psychotherapy. This document contains important information about my professional services and policies with respect to telehealth. It also contains summary information concerning my privacy and confidentiality practices and the Health Insurance Portability and Accountability Act (HIPAA), a federal law that provides privacy protections and patient rights about the use and disclosure of Protected Health Information (PHI) for the purposes of treatment, payment, and health care operations. Although this document is lengthy, it is very important that you read and understand it.
Accessing my telehealth platforms is an agreement between us that you have read this document and agree to the terms contained in it. We can discuss any questions you may have about this document at any time in the course of our work together. If you access my teletherapy platforms, including audio and video communications, chat e-mail and other messaging technologies, you are agreeing to the terms and conditions contained in it. If you do not agree to the terms and conditions contained in this document, do not access my teletherapy platforms.
Important Information about On-Line (Telehealth) Therapy
The State of California regulates my practice of psychotherapy and telehealth through the Board of Behavioral Sciences according to Business and Professions Code §2290.5 and 16 CCR §1815.5 and requires that I disclose that I am licensed to practice Marriage and Family Therapy and hold MFC License Number 39231. My NPI number is 1104986108.
Under California law I am required to verbally obtain your full name as well as the address of your present location and to assess whether you are appropriate for telehealth including, but not limited to, consideration of your psychosocial situation. You agree to provide this information truthfully. I do not knowingly provide telepsychotherapy to patients in jurisdictions that require a license to practice psychotherapy in which I am not licensed.
Contact Information
In the event you need to contact me, my mailing address of record with the California Board of Behavioral Sciences is 836 Southampton Road B115, Benicia CA. 94510. My e-mail address is martymalin@vptherapy.com. Telephone (non-urgent messages only) 707-745-1059. My teletherapy office is located at https://doxy.me/martymalin.
You agree to contact me using only the methods above. We both agree that our relationship is professional and not personal and we will not follow or interact each other on Social Media.
Therapy
Therapy or counseling is a relationship between people that works in part because of clearly defined rights and responsibilities held by each person. As a patient in therapy, you have certain rights and responsibilities that are important for you to understand. There are also legal limitations to those rights of which you should be aware. As your therapist, I have corresponding rights and responsibilities to you. These rights and responsibilities are described in the following sections.
Risks and Benefits of Psychotherapy
For you to provide informed consent for psychotherapy, you need to know that psychotherapy has both benefits and risks. Risks may include experiencing uncomfortable feelings, such as sadness, guilt, anxiety, anger, frustration, loneliness and helplessness, because the process of psychotherapy often requires discussing sensitive or unpleasant aspects of your life.  It may cause you to re-experience trauma. It may challenge your beliefs or perspectives and cause you discomfort. You may feel worse in therapy before you feel better. However, psychotherapy has been shown to have benefits. Therapy often leads to a significant reduction in feelings of distress, increased satisfaction in interpersonal relationships, greater personal awareness and insight, increased skills for managing stress and resolutions to specific problems.  But, there are no guarantees that therapy will be helpful for you.  Therapy requires a very active, sustained effort on your part. In order to be most successful, you will have to work on things we discuss outside of sessions. The foregoing are not all the risks and benefits of engaging in psychotherapy. If you would like to discuss risks and benefits further, please let me know.
Alternatives to Telehealth Therapy
Some people choose to address their issues outside of therapy or as an alternative to psychotherapy. For example, you may elect to do nothing and see if your issues resolve themselves over time. You can attend community-based peer support groups and read self-help books written by laypeople, peers or professionals. You can also talk with friends, family members or your healthcare providers. You can look for information on the internet or in the library. You might also make lifestyle changes or try other strategies including meditation, prayer, exercise or changes in diet if you think these might help. I may suggest some or all of these to you in our work together. It will be helpful if you make me aware of any alternatives to formal psychotherapy you are engaging in. You should also tell me about any prescription medications or over-the-counter remedies you are taking.
Outcomes and Options
Good outcomes in therapy are closely correlated with a good working "match" between patient and therapist. The first two to four sessions will usually involve my clinical evaluation of your presenting concerns. By the end of the evaluation, I will be able to offer you some initial impressions of what our work might include. Together, we will discuss your treatment goals and agree upon how to proceed. I may or may not make a formal diagnosis but I will document my clinical impressions as appropriate.
You should evaluate this information, as well as our interactions, and make your own assessment about whether you feel comfortable working with me. If you have questions, we should discuss them whenever they arise. If at any time you decide you would like to work with someone else I encourage you to do so and will refer you to another teletherapy platform or make other recommendations as appropriate.
Similarly, I may feel that your interests would be better served by working with another professional or in another type of therapy. Since I may not personally know professionals in your particular community, I may only be able to make referrals of a general nature. I ask that if you decide to switch to another therapist or terminate with me that you discuss your decision with me so we can work together for a smooth transition.
Special Considerations
Teletherapy depends upon electrical service and connections to the internet. Sometimes calls or video sessions are dropped because of a variety of technical problems. If that happens in the middle of your session, please end the call and I will reinitiate contact as quickly as possible or message you. Please note that the quality of sessions depends upon having appropriate bandwidth available. It is best if you initiate your session from a computer with a stable, high-bandwidth connection for video calls. Connecting from cell phones usually is successful but please make sure you are on a network with sufficient signal strength to support the call.
In the event my Internet Service Provider (ISP) is experiencing an outage in my service area, I may not be immediately available to you for an appointment or for notification. Electrical outages in my area will also have the same effect. From time to time, because of planned absences or unforeseen personal emergencies or illness, I may not be available to you. I will notify you of these situations in advance, when I am able, or as soon as possible when advance notification is not possible. You agree to hold me harmless in any situation where I am unable to connect with you because of technical issues or personal emergency.
It is impossible to guarantee that conversations during telehealth sessions and/or communication or transmission of materials over the internet will not be intercepted or compromised. Nevertheless, some platforms are more secure and confidential than others. E-mail, unless it is end-to-end encrypted such as Proton Mail, is not considered to be secure or confidential. Please do not include any sensitive information in non-encrypted e-mails. Sensitive or confidential information can be securely transmitted using Dropbox. I prefer to communicate with you using the doxy.me, Proton Mail, and Dropbox platforms which incorporate strong encryption. However, I will work with you on any mutually acceptable platform as long as you are aware of the risks to your privacy and confidentiality and agree to accept them. Please note that recording any phone or video session without permission is illegal.
You agree to hold me harmless in all situations arising from breach of HIPAA Protected Health Information arising from security issues inherent in using the internet to communicate
Urgent or Emergency Service
Telehealth is never appropriate if you are in crisis or immediate need of support. In crisis situations you should call 911 or other emergency services in your community or go directly to the emergency room of your local hospital. You can also call the National Suicide Prevention Hotline at 1-800-273-TALK (8255) without charge to talk to someone right away.
Fees for Service
My fee for professional services is $150 per one-hour (nominally 50 minute) session and $75 for a half-hour (nominally 25 minute) session payable in advance via PayPal or Stripe. Your payment is due at the time you schedule your session. If you cancel less than 24 hours before the session or do not keep the appointment, you may incur a fee of $50.00. I am happy to discuss these arrangements in case of urgent or emergent situations. I am unable to accept cash, personal check, money orders, or cryptocurrency. I accept most credit cards through Stripe or or PayPal. I am not a provider for any commercial health-insurance provider, Medicare or MediCal. Upon request, I will provide you with a statement of services rendered which you may use to attempt to claim reimbursement from your insurance provider.
Forensic Services
If you are involved in a court case, or anticipate becoming involved in one, I recommend that we discuss this fully before you waive any right to confidentiality. In discussing matters of privilege and confidentiality with you, I am not providing legal advice. If you require legal advice, you should contact your attorney. If your clinical case requires my interaction with the legal system, for example, in the event of a subpoena for records or testimony, you will be expected to pay for my professional time in 15-minute increments at my current rate of $150.00/hr, including travel, preparation time and expenses even if someone other than you compels me to appear.
I will conduct Court-ordered therapy only upon referral from your attorney with the concurrence of the Court of jurisdiction in your case. I will provide simple documentation attesting to progress or completion of Court-ordered therapy as appropriate at no additional cost. If your case requires my participation in any other legal process, including preparation of more extensive reports, consultation with your attorney or opposing counsel, you are responsible for paying for my professional time, including travel time and expenses, even if another party compels me to testify or otherwise participate.
Outside Consultations and Peer Consultation
In my work with you, I may recommend that you seek outside professional services such as a specialized consultation, psychological testing, physical exam or other medical consultation or test. I will review the results of such consultations without additional charge. I regularly consult with peers about cases as appropriate, without providing identifying information, at no additional charge to you.
Records
I am required to keep records of our work in therapy. I maintain records as encrypted computer files. My records generally include brief notes about our sessions and may include information you or I send as e-mails, attachments or other documentation you send me, reports from other individuals involved in your care and copies of records I send to others with your permission. In most circumstances you have the right to a copy of records I maintain. Because these are professional records, they may not be appropriate for untrained readers.  For this reason, I ask that you initially review them with me or request that they be sent to another mental health professional to discuss with you. I may legally refuse your request for access to your records for clinical reasons and I will discuss this decision with you. You have the right to request that a copy of your file be made available to any other health care provider at your written request. I may legally recover costs of providing such copies to you or your representatives.
Privacy and Confidentiality

Notice of Privacy Policies and Limits of Confidentiality
“Notice of Privacy Practices”

THIS NOTICE INVOLVES YOUR PRIVACY RIGHTS AND DESCRIBES HOW INFORMATION ABOUT YOU MAY BE DISCLOSED, AND HOW YOU CAN OBTAIN ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY.
I. Confidentiality
As a rule, you have the legal right to privacy and confidentiality in your work with me if you are eighteen years old or older, or you are a minor age 12 or older who meets the criteria set forth in the California Family Code §6924 or Health and Safety Code §124260. Your communications with me are “privileged” and, if you are unable to do so for any reason, I will assert the privilege on your behalf. Under most circumstances, you can waive privilege. If you do not waive privilege, I will disclose no information about you, or the fact that you are my patient, without your written consent. My formal Mental Health Record describes the services provided to you and contains the dates of our sessions, any applicable diagnosis, brief session notes, and reports or correspondence. Health care providers are legally allowed to use or disclose records or information for treatment, payment, and health care operations purposes.
II. “Limits of Confidentiality”
Possible Uses and Disclosures of Mental Health Records without Consent or Authorization
There are some important exceptions to confidentiality – some exceptions created by my own policies and some required by law. When you agree to this Informed Consent by accessing my teletherapy platform, you agree that I may use or disclose records or other information about you without your consent or authorization in the following circumstances:
• Emergency. If I am aware that you are involved in in a life-threatening emergency, I will share information with others I believe will be helpful to you.
• Child Abuse Reporting. If I have reason to suspect child abuse or neglect, I am required by California law to report the matter to Law Enforcement and Child Protective Services or their equivalents in the jurisdiction in which you live.
• Adult Abuse Reporting. If I have reason to suspect that an elderly or incapacitated adult is abused, neglected or exploited, I am required by California law to report the matter the Adult Protective Services or its equivalent in the jurisdiction in which you live.
• Health Oversight. If you report misconduct by Mental Health or other Health Care Providers I may explain to you how to report to their oversight Licensing Boards or report such conduct myself. If you are yourself a Mental Health or other Health Care Provider and I believe your condition places the public or any individual at risk, I will report to your licensing board that you are in treatment with me and that I believe your condition poses such a risk. Most Licensing Boards have the authority, when necessary, to subpoena relevant records in investigating a complaint of provider incompetence or misconduct.
• Court Proceedings. If you are involved in a court preceding and a request is made for information or records relevant to your diagnosis and treatment I will assert privilege on your behalf and I will not release information unless you provide written authorization or a judge issues a court order. If I receive a subpoena for records or testimony, I will notify you, if I am legally permitted, so you can file a motion to quash (block) the subpoena. Protections of privilege may not apply if I do an evaluation for a third party or where the evaluation is court-ordered.
• Serious Threat to Health or Safety. If I am engaged in my professional duties and you communicate to me a specific and immediate threat to cause serious bodily injury or death to an identified or identifiable person, or a family member communicates such information to me, I may be required to take steps to protect third parties. At my discretion, I may also use and disclose medical information about you when necessary to prevent an immediate, serious threat to your own health and safety.
• Workers Compensation. If you file a worker’s compensation claim, I may be required to submit your relevant mental health information to you, your employer, the insurer, or an authorized provider.
• Records of Minors. California has a number of laws that limit privilege and the confidentiality of the records of minors. You should check with your attorney concerning the limits of confidentiality with respect to minors.
Other uses and disclosures of information not covered by this notice or by the laws that apply to me will be made only with your written permission.
III. Patient’s Rights and Provider’s Duties:
• Right to Request Restrictions-You have the right to request restrictions on certain uses and disclosures of protected health information about you. You also have the right to request a limit on the medical information I disclose about you to someone who is involved in your care or the payment for your care. If you ask me to disclose information to another party, you may request that I limit the information I disclose. However, I am not required to agree to a restriction you request. To request restrictions, you must make your request in writing, and tell me: 1) what information you want to limit; 2) whether you want to limit my use, disclosure or both; and 3) to whom you want the limits to apply.
• Right to Receive Confidential Communications by Alternative Means and at Alternative Locations — You have the right to request and receive confidential communications of PHI by alternative means and at alternative locations. (For example, you may not want a family member to know that you are seeing me. Upon your request, I will send correspondence to another address. You may also request that I contact you only at work, or that I do not leave voice mail messages.) To request alternative communication, you must make your request in writing, specifying how or where you wish to be contacted.
• Right to an Accounting of Disclosures – You generally have the right to receive an accounting of disclosures of PHI for which you have neither provided consent nor authorization (as described in section III of this Notice). On your written request, I will discuss with you the details of the accounting process
• Right to Inspect and Copy – In most cases, you have the right to inspect and copy your medical and billing records. To do this, you must submit your request in writing. If you request a copy of the information, I may charge a fee for costs of copying and mailing. I may deny your request to inspect and copy in some circumstances. I may refuse to provide you access to certain psychotherapy notes or to information compiled in reasonable anticipation of, or use in, a civil criminal, or administrative proceeding.
• Right to Amend – If you feel that protected health information I have about you is incorrect or incomplete, you may ask me to amend the information. To request an amendment, your request must be made to me in writing. In addition, you must provide a reason that supports your request. I may deny your request if you ask me to amend information that: 1) was not created by me; I will add your request to the information record; 2) is not part of the medical information kept by me; 3) is not part of the information which you would be permitted to inspect and copy; 4) is accurate and complete.
• Right to a copy of this notice – You have the right to a paper copy of this notice. You may at any time request in writing that I give you a paper copy of this notice and I will mail one to you.
• Changes to this notice - I reserve the right to change my policies and/or to change this notice, and to make the changed notice effective for medical information I already have about you as well as any information I receive in the future. The notice will contain the effective date. A new copy will be mailed to you on request.
• Complaints - If you believe your privacy rights have been violated, you may file a complaint. To do this, you must submit your request in writing to my office. You may also send a written complaint to the U.S. Department of Health and Human Services.

EFFECTIVE DATE: January 1, 2018

Attestation:
I agree that accessing Dr. Malin's teletherapy platforms means that I have read, understood and accepted his Informed Consent, Privacy Policy and Limits of Confidentiality, and Terms of Service for On-Line Psychotherapy (Telehealth).