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Sarah Byrd Coaching, LLC
(720) 295-9527 | Highlands Ranch, CO | sarahbyrd.com
NOTICE OF
PRIVACY PRACTICES
THIS NOTICE DESCRIBES HOW HEALTH INFORMATION MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY.
MY PLEDGE REGARDING HEALTH INFORMATION
I understand that health information about you and your health care is personal. I am committed to protecting health information about you. I create a record of the care and services you receive from me. I need this record to provide you with quality care and to comply with certain legal requirements. This notice applies to all of the records of your care generated by this mental health care practice. This notice will tell you about the ways in which I may use and disclose health information about you. I also describe your rights to the health information I keep about you, and describe certain obligations I have regarding the use and disclosure of your health information. I am required by law to:
Make sure that protected health information (“PHI”) that identifies you is kept private.
Give you this notice of my legal duties and privacy practices with respect to health information.
Follow the terms of the notice that is currently in effect.
I can change the terms of this Notice, and such changes will apply to all information I have about you. The new Notice will be available upon request, in my office, and on my website.
HOW I MAY USE AND DISCLOSE HEALTH INFORMATION ABOUT YOU
The following categories describe different ways that I use and disclose health information. For each category of uses or disclosures I will explain what I mean and try to give some examples. Not every use or disclosure in a category will be listed. However, all of the ways I am permitted to use and disclose information will fall within one of the categories.
For Treatment Payment, or Health Care Operations: Federal privacy rules (regulations) allow health care providers who have direct treatment relationship with the patient/client to use or disclose the patient/client’s personal health information without the patient’s written authorization, to carry out the health care provider’s own treatment, payment or health care operations. I may also disclose your protected health information for the treatment activities of any health care provider. This too can be done without your written authorization. For example, if a clinician were to consult with another licensed health care provider about your condition, we would be permitted to use and disclose your person health information, which is otherwise confidential, in order to assist the clinician in diagnosis and treatment of your mental health condition.
Disclosures for treatment purposes are not limited to the minimum necessary standard. Because coaches and other health care providers need access to the full record and/or full and complete information in order to provide quality care. The word “treatment” includes, among other things, the coordination and management of health care providers with a third party, consultations between health care providers and referrals of a patient for health care from one health care provider to another.
Lawsuits and Disputes: If you are involved in a lawsuit, I may disclose health information in response to a court or administrative order. I may also disclose health information about your child in response to a subpoena, discovery request, or other lawful process by someone else involved in the dispute, but only if efforts have been made to tell you about the request or to obtain an order protecting the information requested.
CERTAIN USES AND DISCLOSURES REQUIRE YOUR AUTHORIZATION
1.Psychotherapy Notes. I do keep “psychotherapy notes” as that term is defined in 45 CFR § 164.501, and any use or disclosure of such notes requires your Authorization unless the use or disclosure is:
a.For my use in treating you.
b.For my use in defending myself in legal proceedings instituted by you.
c.For use by the Secretary of Health and Human Services to investigate my compliance with HIPAA.
d.Required by law and the use or disclosure is limited to the requirements of such law.
e.Required by law for certain health oversight activities pertaining to the originator of the psychotherapy notes.
f.Required by a coroner who is performing duties authorized by law.
g.Required to help avert a serious threat to the health and safety of others.
2. Marketing Purposes. As a coach/therapist in training, I will not use or disclose your PHI for marketing purposes.
3. Sale of PHI. As a coach/therapist in training, I will not sell your PHI in the regular course of my business.
CERTAIN USES AND DISCLOSURES DO NOT REQUIRE YOUR AUTHORIZATION
Subject to certain limitations in the law, I can use and disclose your PHI without your Authorization for the following reasons:
1.When disclosure is required by state or federal law, and the use or disclosure complies with and is limited to the relevant requirements of such law.
2.For public health activities, including reporting suspected child, elder, or dependent adult abuse, or preventing or reducing a serious threat to anyone’s health or safety.
3.For health oversight activities, including audits and investigations.
4.For judicial and administrative proceedings, including responding to a court or administrative order, although my preference is to obtain an Authorization from you before doing so.
5.For law enforcement purposes, including reporting crimes occurring on my premises.
6.To coroners or medical examiners, when such individuals are performing duties authorized by law.
7.For research purposes, including studying and comparing the mental health of patients who received one form of coaching versus those who received another form of coaching for the same condition.
8.Specialized government functions, including, ensuring the proper execution of military missions; protecting the President of the United States; conducting intelligence or counter-intelligence operations; or, helping to ensure the safety of those working within or housed in correctional institutions.
9.For workers' compensation purposes. Although my preference is to obtain an Authorization from you, I may provide your PHI in order to comply with workers' compensation laws.
10.Appointment reminders and health related benefits or services. I may use and disclose your PHI to contact you to remind you that you have an appointment with me. I may also use and disclose your PHI to tell you about treatment alternatives, or other health care services or benefits that I offer.
CERTAIN USES AND DISCLOSURES REQUIRE YOU TO HAVE THE OPPORTUNITY TO OBJECT
1.Disclosures to family, friends, or others. I may provide your PHI to a family member, friend, or other person that you indicate is involved in your care or the payment for your health care, unless you object in whole or in part. The opportunity to consent may be obtained retroactively in emergency situations.
YOU HAVE THE FOLLOWING RIGHTS WITH RESPECT TO YOUR PHI
1.The Right to Request Limits on Uses and Disclosures of Your PHI. You have the right to ask me not to use or disclose certain PHI for treatment, payment, or health care operations purposes. I am not required to agree to your request, and I may say “no” if I believe it would affect your health care.
2.The Right to Request Restrictions for Out-of-Pocket Expenses Paid for In Full. You have the right to request restrictions on disclosures of your PHI to health plans for payment or health care operations purposes if the PHI pertains solely to a health care item or a health care service that you have paid for out-of- pocket in full.
3.The Right to Choose How I Send PHI to You. You have the right to ask me to contact you in a specific way (for example, home or office phone) or to send mail to a different address, and I will agree to all reasonable requests.
4.The Right to See and Get Copies of Your PHI. Other than “coaching notes,” you have the right to get an electronic or paper copy of your medical record and other information that I have about you. I will provide you with a copy of your record, or a summary of it, if you agree to receive a summary, within 30 days of receiving your written request, and I may charge a reasonable, cost based fee for doing so.
5.The Right to Get a List of the Disclosures I Have Made.You have the right to request a list of instances in which I have disclosed your PHI for purposes other than treatment, payment, or health care operations, or for which you provided me with an Authorization. I will respond to your request for an accounting of disclosures within 60 days of receiving your request. The list I will give you will include disclosures made in the last six years unless you request a shorter time. I will provide the list to you at no charge, but if you make more than one request in the same year, I will charge you a reasonable cost based fee for each additional request.
6.The Right to Correct or Update Your PHI. If you believe that there is a mistake in your PHI, or that a piece of important information is missing from your PHI, you have the right to request that I correct the existing information or add the missing information. I may say “no” to your request, but I will tell you why in writing within 60 days of receiving your request.
7. The Right to Get a Paper or Electronic Copy of this Notice. You have the right get a paper copy of this Notice, and you have the right to get a copy of this notice by e-mail. And, even if you have agreed to receive this Notice via e-mail, you also have the right to request a paper copy of it.
EFFECTIVE DATE OF THIS NOTICE
This notice went into effect on July 4, 2025
Acknowledgement of Receipt of Privacy Notice
Under the Health Insurance Portability and Accountability Act of 1996 (HIPAA), you have certain rights regarding the use and disclosure of your protected health information. By checking the box below, you are acknowledging that you have received a copy of HIPPA Notice of Privacy Practices.
By submitting my name and date below I am agreeing that I have read, understood, and agree to the items contained in this document.
INFORMED CONSENT FOR COACHING
GENERAL INFORMATION
The coaching relationship is unique in that it is a highly personal and at the same time, a contractual agreement. Given this, it is important for us to reach a clear understanding about how our relationship will work, and what each of us can expect. This consent will provide a clear framework for our work together. Feel free to discuss any of this with me. Please read and indicate that you have reviewed this information and agree to it by filling in the checkbox at the end of this document.
THE COACHING PROCESS
You have taken a very positive step by deciding to seek coaching. The outcome of your treatment depends largely on your willingness to engage in this process, which may, at times, result in considerable discomfort. Remembering unpleasant events and becoming aware of feelings attached to those events can bring on strong feelings of anger, depression, anxiety, etc. There are no miracle cures. Your coach cannot promise that your behavior or circumstance will change. We can promise to support you and do our very best to understand you and repeating patterns, as well as to help you clarify what it is that you want for yourself.
INCREASED RATES
From time to time, the practice and/or your coach may increase their fee-for- service. This rate increase will be communicated with you in a timely manner. If any rate change creates any hardship for you or you have any questions about it, please don’t hesitate to reach out to your coach in order to collaborate on the most effective support moving forward.
CONFIDENTIALITY
The session content and all relevant materials to the client’s treatment will be held confidential unless the client requests in writing to have all or portions of such content released to a specifically named person/persons. Limitations of such client-held privilege of confidentiality exist and are itemized below:
1.If a client threatens or attempts to commit suicide or otherwise conducts him/herself in a manner in which there is a substantial risk of incurring serious bodily harm.
2.If a client threatens grave bodily harm or death to another person.
3.If the coach has a reasonable suspicion that a client or other named victim is the perpetrator, observer of, or actual victim of physical, emotional or sexual abuse of children under the age of 18 years.
4.Suspicions as stated above in the case of an elderly person who may be subjected to these abuses.
5.Suspected neglect of the parties named in items #3 and # 4.
6.If a court of law issues a legitimate subpoena for information stated on the subpoena.
7.If a client is in coaching or being treated by order of a court of law, or if information is obtained for the purpose of rendering an expert’s report to an attorney.
Occasionally your coach may need to consult with other professionals in their areas of expertise in order to provide the best treatment for you. Information about you may be shared in this context without using your name.
If we see each other accidentally outside of the coaching office, your coach will not acknowledge you first. Your right to privacy and confidentiality is of the utmost importance to me, and your coach does not wish to jeopardize your privacy. However, if you acknowledge your coach first, they will be more than happy to speak briefly with you, but feel it appropriate not to engage in any lengthy discussions in public or outside of the coaching office.
By submitting my name and date below I am agreeing that I have read, understood, and agree to the items contained in this document.
Practice Policies
APPOINTMENTS AND CANCELLATIONS
Your visit has been reserved for you. As such, 24-hour notice is required for cancellations. Your first late cancelation or no-show will be excused and I will remind you of my policy. The subsequent late cancelations or no-shows will be charged the agree-upon amount as laid out in the completed Financial Agreement/No Show Policy form that has been sent to you. Should I need to cancel your sessions for any reason, you will not be charged. If you have already paid for a session canceled by me, you will immediately be refunded that session fee, or that fee may be applied to the next session.
The standard meeting time for coaching is 50 minutes. It is up to you, however, to determine the length of time of your sessions. Requests to change the 50-minute session need to be discussed with the coach in order for time to be scheduled in advance.
TELEPHONE ACCESSIBILITY
If you need to contact me between sessions, please leave a message on my voicemail, send me an email, or text me. I am typically quite responsive, but I am often not immediately available; however, I will attempt to return your call within 24 hours. If a true emergency situation arises, please call 911 or any local emergency room.
SOCIAL MEDIA AND TELECOMMUNICATION
Due to the importance of your confidentiality and the importance of minimizing dual relationships, I do not accept friend or contact requests from current or former clients on any social networking site (Facebook, LinkedIn, etc). I believe that adding clients as friends or contacts on these sites can compromise your confidentiality and our respective privacy. It may also blur the boundaries of our therapeutic relationship. If you have questions about this, please bring them up when we meet and we can talk more about it. Any public professional social media accounts, including my professional or business, may be followed at your discretion.
ELECTRONIC COMMUNICATION
I cannot ensure the confidentiality of any form of communication through electronic media, including text messages. If you prefer to communicate via email or text messaging for issues regarding scheduling or cancellations, I will do so. While I may try to return messages in a timely manner, I cannot guarantee immediate response and request that you do not use these methods of communication to discuss therapeutic content and/or request assistance for emergencies.
Services by electronic means, including but not limited to telephone communication, the Internet, facsimile machines, and e-mail is considered telemedicine by the State of Colorado. Under Colorado law (HB21-1190), telemedicine is defined as the delivery of medical services through technologies that are used in a manner that is compliant with the federal Health Insurance Portability and Accountability Act of 1996 (HIPAA), including information, electronic, and communication technologies, remote monitoring technologies, and store-and- forward transfers, to facilitate the assessment, diagnosis, consultation, or treatment of a patient while the patient is located at an originating site and the person who provides the service is located at a distant site. If you and your coach choose to use information technology for some or all of your treatment, you need to understand that:
(1) You retain the option to withhold or withdraw consent at any time without affecting the right to future care or treatment or risking the loss or withdrawal of any program benefits to which you would otherwise be entitled.
(2) All existing confidentiality protections are equally applicable.
(3) Your access to all medical information transmitted during a telemedicine consultation is guaranteed, and copies of this information are available for a reasonable fee.
(4) Dissemination of any of your identifiable images or information from the telemedicine interaction to researchers or other entities shall not occur without your consent.
(5) There are potential risks, consequences, and benefits of telemedicine. Potential benefits include, but are not limited to improved communication capabilities, providing convenient access to up-to-date information, consultations, support, reduced costs, improved quality, change in the conditions of practice, improved access to coaching, better continuity of care, and reduction of lost work time and travel costs. Effective coaching is often facilitated when the coach gathers within a session or a series of sessions, a multitude of observations, information, and experiences about the client. Coaches may make clinical assessments, diagnosis, and interventions based not only on direct verbal or auditory communications, written reports, and third-person consultations, but also from direct visual and olfactory observations, information, and experiences. When using information technology in coaching services, potential risks include, but are not limited to the coach’s inability to make visual and olfactory observations of clinically or therapeutically potentially relevant issues such as: your physical condition including deformities, apparent height and weight, body type, attractiveness relative to social and cultural norms or standards, gait and motor coordination, posture, work speed, any noteworthy mannerism or gestures, physical or medical conditions including bruises or injuries, basic grooming and hygiene including appropriateness of dress, eye contact (including any changes in the previously listed issues), sex, chronological and apparent age, ethnicity, facial and body language, and congruence of language and facial or bodily expression. Potential consequences thus include the coach not being aware of what he or she would consider important information, that you may not recognize as significant to present verbally the coach.
MINORS
You must be 18 years or older to receive coaching services.
LITIGATION POLICY AND FEES FOR COURT-RELATED SERVICES
It is the stated policy of this practice that I do not participate in lawsuits of any type on the plaintiff’s behalf, unless compelled to do so by a subpoena or court order. This is because involving myself in the legal or litigation process damages the therapeutic relationship that I care so deeply about maintaining. If you become involved in legal proceedings that require my participation, you are expected to pay for all of my professional time, including preparation, deposition, telephone time, transportation costs, court appearances, report writing, consultation and supervision, even if I am called to testify by another party. By agreeing to this document, you acknowledge my position and agree to abide by my litigation policy.
If you involve me in your litigation, or if you or your attorneys subpoena me to provide my records, testify in court or give a deposition in violation of this agreement and against my stated wishes, I will comply with lawfully issued subpoenas. MY HOURLY CHARGE FOR ALL TIME RELATED TO COURT CASES OR LITIGATION IS $350.00 AN HOUR. By agreeing to this document, you also agree to execute and sign a Credit Card Authorization and provide a valid credit card to ensure payment for the time I must spend dealing with your litigation.
If I am required to testify in court or give a deposition in Douglas County (or county in which coaching is taking place in person), I will charge an hourly fee of $350.00 per hour for a minimum of 4 hours, and this includes preparation time, travel time, and attendance at any legal proceeding. If I am required to testify in court or give a deposition outside of Douglas County, the hourly fee will be $450.00 for a minimum of 6 hours. If the testimony or deposition exceeds 4 hours (in Douglas County or county in which coaching is taking place in person) or 6 hours (outside of Douglas County or county in which coaching is taking place in person), there will be an additional charge of $350.00 for every hour spent in court or deposition.
When I go to court or give a deposition, I have to clear my entire schedule and not see other clients, so there is a 48-hour cancelation policy for court and depositions. Any cancelations that occur within the 48-hour time frame of the court appearance are NON-REFUNDABLE.
TERMINATION
Ending relationships can be difficult. Therefore, it is important to have a termination process in order to achieve some closure. The appropriate length of the termination depends on the length and intensity of the treatment. I may terminate treatment after appropriate discussion with you and a termination process if I determine that the coaching is not being effectively used or if you are in default on payment. I will not terminate the therapeutic relationship without first discussing and exploring the reasons and purpose of terminating. If coaching is terminated for any reason or you request another coach, I will provide you with a list of qualified coaches to treat you. You may also choose someone on your own or from another referral source.
Should you fail to schedule an appointment for three consecutive weeks, unless other arrangements have been made in advance, for legal and ethical reasons, I must consider the professional relationship discontinued.
REPORTING
Should you need to report any Licensed Professional Counselor to their licensing board for violations, please contact:
Colorado State Board of Professional Counselor Examiners Division of Professions and Occupations
1560 Broadway, Suite 1350
Denver, CO 80202
(303) 894-7800 dora_dpo_licensing@state.co.us
By submitting my name and date below I am agreeing that I have read, understood, and agree to the items contained in this document.
NO SURPRISES ACT
In compliance with the No Surprises Act that goes into effect January 1, 2022, all healthcare providers are required to notify clients of their Federal rights and protection against "surprise billing." This Act requires that we notify you of your federally protected rights to receive a notification when services are rendered by an out-of-network provider, if a client is uninsured, or if a client elects to not use their insurance. Additionally, we are required to provide you with a Good Faith Estimate of the cost or services. It is difficult to determine the true length of treatment for mental health care, and each client has a right to decide how long they would like to participate in mental health care. Therefore, you are provided a fee schedule for services typically offered by your coach, and we will collaborate with you on a regular basis to determine how many sessions you may need. It is a Federal requirement that we have each client sign this form to begin/resume treatment. Please sign and date before your next appointment. If you have any questions, please don't hesitate to ask.
By submitting my name and date below I am agreeing that I have read, understood, and agree to the items contained in this document.
FINANCIAL AGREEMENT & NO SHOW POLICY
FINANCIAL AGREEMENT
Intake appointments are $50, with subsequent individual 50-minute sessions being $50. You are responsible for payment at the time of service.
ADDITIONAL FINANCIAL POLICIES
If you request any letters, forms, or any other paperwork to be completed, such as FMLA or disability forms, please be advised that there is a fee for paperwork. My fee is $100.00 per hour. Most paperwork generally requires a minimum of 30 minutes to complete, due to the need for supporting clinical documentation. The time required to make copies or prepare and send faxes, and any other administrative business (e.g. preparing releases of information or requests for records; phone calls to lawyers or other non-clinical calls) not directly related to the provision of clinical services, will also be assessed based on a rate of $100.00, with an additional cost of $0.25 per printed page.
I will not complete any FMLA, disability, other paperwork or letters of support unless I have met with you for at least 6-8 sessions. I will also not complete any FMLA or disability paperwork if I do not believe I can support it based on what you have presented at intake and during sessions.
NO SHOW / LATE CANCELLATION POLICY
Your visit has been reserved for you. As such, 24-hour notice is required for cancellations. A visit is considered a no-show if you are late by 20 minutes or more. A cancellation is excused with a doctor's note or standing medical diagnosis. Late cancelations or no-shows will be charged $50. If you are able to reschedule by the end of the week, you will not be charged; my weeks typically fill up, so this is not a reliable choice.
After three late cancelations or one no-show, we will discontinue our work together for an agreed-upon time period, or terminate our work together. I will provide three referrals for you to seek out therapeutic support if you so desire.
Should I need to cancel your sessions for any reason, you will not be charged. If you have already paid for a session canceled by me, you will immediately be refunded that session fee, or that fee may be applied to the next session.
By submitting my name and date below I am agreeing that I have read, understood, and agree to the items contained in this document.