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Terms and Policy

Notice of Privacy Practices
Holly Scott, MBA, M.S. LPC
Uptown Dallas Counseling, PLLC
100 Crescent Court

Suite 100
Dallas, Texas 75201

Acknowledgement of Notice of Privacy Practices

Guidelines for Licensed Professional Counselors specify privacy rules for patient records. New HIPPA regulations protect virtually all patients regardless of where they live or where they receive their health care. Every time you see a physician, are admitted to the hospital, fill a prescription, or send a claim to a health plan, your health care provider will need to consider the privacy rule. All health information including paper records, oral communications, and electronic formats (such as email) are protected by the privacy rule.

The privacy rule also provides you certain rights, such as the right to have access to your medical records. However, there are exceptions; these rights are not absolute. I also take precautions to safeguard your health information such as employing computer security measures. Please feel free to ask questions about exercising your rights or how your health information is protected.


Your Information. Your Rights. Our Responsibilities.
This notice describes how medical information about you may be used and disclosed and how you can get access to this information. Please review it carefully.
Your Rights
You have the right to:
- Get a copy of your paper or electronic medical record
- Correct your paper or electronic medical record
- Request confidential communication
- Ask us to limit the information we share
- Get a list of those with whom we've shared your information
- Get a copy of this privacy notice
- Choose someone to act for you
- File a complaint if you believe your privacy rights have been violated
Your Choices
You have some choices in the way that we use and share information as we:
- Tell family and friends about your condition
- Provide disaster relief
- Include you in a hospital directory
- Provide mental health care
- Market our services and sell your information
- Raise funds

Our Uses and Disclosures
We may use and share your information as we:
- Treat you
- Run our organization
- Bill for your services
- Help with public health and safety issues
- Comply with the law
- Address workers' compensation, law enforcement, and other government
- Respond to lawsuits and legal actions
Your Rights
When it comes to your health information, you have certain rights. This section explains your rights and some of our responsibilities to help you.
Get an electronic or paper copy of your medical record
- You can ask to see or get an electronic or paper copy of your medical record and other health information we have about you. Ask us how to do this.
- We will provide a copy or a summary of your health information, usually within 30 days of your request. We may charge a reasonable, cost-based fee.
Ask us to correct your medical record
- You can ask us to correct health information about you that you think is incorrect or incomplete. Ask us how to do this.
- We may say "no" to your request, but we'll tell you why in writing within 60 days. Request confidential communications
- You can ask us to contact you in a specific way (for example, home or office phone) or to send mail to a different address.
- We will say "yes" to all reasonable requests. Ask us to limit what we use or share
- You can ask us not to use or share certain health information for treatment, payment, or our operations. We are not required to agree to your request, and we may say "no" if it would affect your care.
- If you pay for a service or health care item out-of-pocket in full, you can ask us not to share that information for the purpose of payment or our operations with your health insurer. We will say "yes" unless a law requires us to share that information.
Get a list of those with whom we've shared information
- You can ask for a list (accounting) of the times we've shared your health information for six years prior to the date you ask, who we shared it with, and why.
- We will include all the disclosures except for those about treatment, payment, and health care operations, and certain other disclosures (such as any you asked us to make). We'll provide one accounting a year for free but will charge a reasonable, cost-based fee if you ask for another one within 12 months.
Get a copy of this privacy notice
You can ask for a paper copy of this notice at any time, even if you have agreed to receive the notice electronically. We will provide you with a paper copy promptly.
Choose someone to act for you
- If you have given someone medical power of attorney or if someone is your legal guardian, that person can exercise your rights and make choices about your health information.
- We will make sure the person has this authority and can act for you before we take any action. File a complaint if you feel your rights are violated
- You can complain if you feel we have violated your rights by contacting us using the information on page 1.
- You can file a complaint with the U.S. Department of Health and Human Services Office for Civil Rights by sending a letter to 200 Independence Avenue, S.W., Washington, D.C. 20201, calling 1- 877-696-6775, or visiting
- We will not retaliate against you for filing a complaint.
Your Choices
For certain health information, you can tell us your choices about what we share. If you have a clear preference for how we share your information in the situations described below, talk to us. Tell us what you want us to do, and we will follow your instructions.
In these cases, you have both the right and choice to tell us to:
- Share information with your family, close friends, or others involved in your care
- Share information in a disaster relief situation
If you are not able to tell us your preference, for example if you are unconscious, we may go ahead and share your information if we believe it is in your best interest. We may also share your information when needed to lessen a serious and imminent threat to health or safety.
In these cases we never share your information unless you give us written permission:
- Marketing purposes
- Sale of your information
- Most sharing of psychotherapy notes
Our Uses and Disclosures
How do we typically use or share your health information?
We typically use or share your health information in the following ways.
Treat you
We can use your health information and share it with other professionals who are treating you.
Example: A doctor treating you for an injury asks another doctor about your overall health condition.
Run our organization
We can use and share your health information to run our practice, improve your care, and contact you when necessary.
Example: We use health information about you to manage your treatment and services.
Bill for your services
We can use and share your health information to bill and get payment from health plans or other entities.
Example: We give information about you to your health insurance plan so it will pay for your services.
How else can we use or share your health information?
We are allowed or required to share your information in other ways - usually in ways that contribute to the public good, such as public health and research. We have to meet many conditions in the law before we can share your information for these purposes. For more information see:
Help with public health and safety issues
We can share health information about you for certain situations such as:
- Preventing disease
- Helping with product recalls
- Reporting adverse reactions to medications
- Reporting suspected abuse, neglect, or domestic violence
- Preventing or reducing a serious threat to anyone's health or safety

Do research
We can use or share your information for health research.
Comply with the law
We will share information about you if state or federal laws require it, including with the Department of Health and Human Services if it wants to see that we're complying with federal privacy law.
Respond to organ and tissue donation requests
We can share health information about you with organ procurement organizations.
Work with a medical examiner or funeral director
We can share health information with a coroner, medical examiner, or funeral director when an individual dies.
Address workers' compensation, law enforcement, and other government requests
We can use or share health information about you:
- For workers' compensation claims
- For law enforcement purposes or with a law enforcement official
- With health oversight agencies for activities authorized by law
- For special government functions such as military, national security, and presidential protective
Respond to lawsuits and legal actions
We can share health information about you in response to a court or administrative order, or in response to a subpoena.
Our Responsibilities
- We are required by law to maintain the privacy and security of your protected health information.
- We will let you know promptly if a breach occurs that may have compromised the privacy or security of your information.
- We must follow the duties and privacy practices described in this notice and give you a copy of it.
- We will not use or share your information other than as described here unless you tell us we can in writing. If you tell us we can, you may change your mind at any time. Let us know in writing if you change your mind.

The Notice of Privacy Practices is available for review in my office, and also on my website ( It describes how you can exercise your rights with regard to protected health information, and how your confidential health information is protected.

I have had access to the Notice of Privacy Practices and am aware of my rights.

( Type Full Name )
Informed Consent for Treatment



Welcome and thank you for considering Uptown Dallas Counseling Center ("The Center") for your mental health needs.
This document contains important information about our professional services and business policies.

Holly Scott, MBA, MS, LPC ("the therapist") is a licensed professional counselor engaged in private practice providing mental health care services to clients directly. The therapist, using her knowledge of human development and behavior, will make observations about situations as well as suggestions for new ways to approach situations. It will be important for you to explore your own feelings and thoughts and to try new approaches in order for change to occur. You may bring other family members to a therapy session if you feel it would be helpful, or if this is recommended by your therapist.

Appointments are made by calling 214 459 2776, or by emailing Please call to cancel or reschedule at least 24 hours in advance, or you will be charged for the missed appointment.

Number of Visits
The number of sessions needed depends on many factors and will be discussed by the therapist. Your initial session will involve an evaluation of your needs and, depending on your circumstances, further evaluative sessions may be required. At the end of the evaluation process Holly Scott, MBA, MS, LPC will be able to provide you with some first impressions of what therapy may include and a treatment plan. You should evaluate this information along with your own opinions of whether you feel comfortable working with the therapist. Therapy involves a large commitment of time, money and energy, so you should be very careful about the therapist you select. If you have questions about procedures, feel free to discuss them with the therapist at any time.

Your relationship with the therapist is a professional and therapeutic relationship. In order to preserve this relationship, it is imperative that the therapist not have any other type of relationship with you. Personal and/or business relationships undermine the effectiveness of the therapeutic relationship. The therapist cares about helping you but is not in a position to be your friend or to have a social or personal relationship with you.
If the therapist encounters you in public setting, in order not to reveal your identity, the therapist will not acknowledge your presence unless addressed by you client first
Gifts, bartering, and trading services are not appropriate and should not be shared between you and the therapist.

Goals, Purposes and Techniques of Therapy
There may be alternative ways to effectively treat the problems you are experiencing. It is important for you to discuss any questions you may have regarding the treatment recommended by the therapist and to have input into setting the goals of your therapy. As therapy progresses these goals may change.

Holly Scott, MBA, MS, LPC is a Cognitive Behavioral Therapist. She has post-graduate training in the field from the Beck Institute of Cognitive Therapy and New York City Cognitive Behavior Therapy. If you would like more information on the efficacy of CBT, please ask your therapist.

Cancellations must be received at least 24 hours before your scheduled appointment; otherwise you will be charged the session fee for that missed appointment. You are responsible for calling to cancel or reschedule your appointment.

Payment for Services
The charge for each 50-minute therapy session is $150.
These fees are subject to change upon sixty (60) day prior notice to you. The undersigned therapist will look to you for full payment of your account, and you will be responsible for payment of all charges at the time services are rendered.

Discussions between a therapist and a client are confidential. No information will be released without the client's written consent unless mandated or permitted by law. Possible exceptions to confidentiality include but are not limited to the following situations: child abuse; abuse of the elderly or disabled; abuse of patients in treatment facilities; sexual exploitation; AIDS/HIV and other communicable disease infection and possible transmission; court orders, criminal prosecutions; child custody cases; suits in which the mental health of a party is in issue; situations where the therapist has a duty to disclose, or where, in the therapist's judgment, it is necessary to warn, protect, notify or disclose; sexual exploitation by a mental health professional or member of the clergy, fee disputes between the therapist and the client; a negligence suit brought by the client against the therapist; the filing of a complaint with a licensing board or other state or federal regulatory authority; to regulatory authorities in connection with their compliance or investigatory responsibilities; to employees or agents of the practice for operational purposes.


Court Services
In the event the therapist's testimony is requested by you or required by law, regardless of who is responsible for compelling the production or testimony, you will be responsible for and shall pay the costs involved in the hourly rate charged by the therapist at the time of the request or service of the subpoena, current rate is $400 per hour, for the time involved in traveling to and from the testimony location, reviewing records and preparing to testify, waiting at the location, and in giving testimony. Such payments are to be made prior to the time the services are rendered by the therapist. The therapist may require a deposit for anticipated court appearances and preparation.

After-Hours Emergencies
Please know that your therapist and The Center do not provide twenty four (24) hour crisis or emergency therapy services. Should you experience an emergency necessitating immediate mental health attention, immediately call 911, or if you are able to safely transport yourself, go to the nearest hospital emergency room for assistance.

Contacting Your Therapist
Your therapist is often not immediately available by telephone. A reasonable effort will be made to return any call made during normal business hours on the same day it is received, weekends and holidays excepted. Messages left after hours or on weekends or holidays will normally be returned the next business day.

Email and Text Messages
Holly Scott, MBA, MS, LPC uses and responds to email and text messages only to arrange or modify appointments. Please do not send emails related to your treatment or therapy sessions as electronic communications are not completely secure and confidential. Any therapy-related questions will not be addressed by the therapist in any electronic communication, but will be dealt with during your next therapy session.

Social Media Agreement
I understand that Holly Scott, LPC runs the following professional Social Media sites: Facebook Page, Twitter Account, Instagram, Blog, Google+, and LinkedIn account. I further understand and acknowledge that Holly Scott, LPC does not and will not provide counseling services by way of the above-referenced accounts. Public posts are viewable but two-way communication is not encouraged or desired.

I agree not to attempt to contact Holly Scott by way of any of these professional Social Media sites.

Therapist's Incapacity or Death
You acknowledge that, in the event the undersigned therapist becomes incapacitated or dies, it will become necessary for another therapist to take possession of your file and records. By signing this information and consent form below, you give consent to allowing another licensed mental health professional, selected by the undersigned therapist, to take possession of your file and records.

Video or Audio Recordings
You acknowledge and, by signing this information and consent form below, agree that you will not record any part of your sessions, unless you and the therapist mutually agree in writing that the session may be recorded. You further acknowledge that the undersigned therapist objects to you recording any portion of your sessions with out the therapist's written consent.

Consent to Treatment
I, voluntarily, agree to receive (or agree for my child to receive) Mental Health care, treatment, or services, and authorize the undersigned therapist to provide such care, treatment, or services as are considered necessary and advisable.

I understand and agree that I will participate in the planning of my care (or my child's care), treatment, or services, and that I may stop such care, treatment, or services that I receive (or my child receives) through the undersigned therapist at any time.

By signing this Client Information and Consent form, I, the undersigned client (or parent), acknowledge that I have read, understood and agreed to be bound by all the terms, conditions and information it contains. Ample opportunity has been offered to me to ask questions and seek clarification of anything unclear to me.


( Type Full Name )