RECOMMENDATION FOR EXAMINATION BY A PHYSICIAN

that you be examined by a physician regarding the condition for which you are seeking acupuncture treatment.

I understand this recommendation.

COACHING AGREEMENT

This agreement is made between Carlos Durana (“COACH”) and (“CLIENT”). Please read this carefully and indicate your agreement by signing at the bottom of the page. Let me know if you have any questions or concerns.

Coaching Guidelines and Commitment

Coach has positive expectations for a coaching relationship that helps Client create the life he/she wants to live. The opportunity for Client’s success increases considerably because of Client’s and Coach’s relationship and the commitment involved from the two.

Coaching is a structure that facilitates the process of personal and professional development. Coaching may address life balance and quality of life, health and wellbeing, personal projects or job performance satisfaction. Client and Coach agree that the coaching relationship will be designed together.

Coaching is for persons who are psychologically healthy and who want to make changes to empower themselves. Coaching is not counseling or therapy.

Client and Coach acknowledge that Client wants to make progress and change in his/her life. Coaching is a process. Many people create change for themselves in a short time. However, to refine and sustain change takes several months. Progress and change are specific to each individual. Although not binding, Client and Coach commit to working together for an initial three-month period. This allows the necessary time to develop objectives and progress through obstacles and successes. If the coaching is not working as Client wishes, Client should inform Coach immediately so that steps can be taken to correct any problems.

Coaching Session Guidelines

Coaching sessions are conducted in person or by telephone, unless otherwise arranged. After the initial three-month period, coaching sessions are arranged as needed. Sessions are started and concluded on time. If Client is late for a session, the time will not be extended after the allocated time. Fees are paid at the time of the appointment. For telephone sessions, Client will pay for telephone charges. To reschedule a session, please allow at least 24 hours’ notice, or the session fee will be charged. Coach wants to have a coaching relationship that is honest, direct, open and trusting. Telephone or email communication may pose extra challenges since we cannot see facial expressions, body language, etc. Therefore, Client and Coach each agree to promptly ask for clarification if there is a misunderstanding and we are using either of these methods of communication.

In between coaching sessions, Client may feel free to email or call Coach. Calls made between the scheduled calls are permissible. Coach will conduct calls of five minutes or less free of charge, but Client will be charged accordingly for longer calls. There is no commitment beyond month to month, but Client is asked to give Coach a week’s notice if he/she thinks he/she will be ending our Coaching together.

Confidentiality

The coaching relationship is built on trust. Coach agrees to keep all information and conversations with Client private and confidential. No personal information expressed by Client will be shared with anyone except with the written permission of Client or by a court order.

Confidentiality is followed to the fullest extent of the law and so long as Coach does not fear for Client’s or another’s safety.

Coach Agreement

Coach cannot guarantee results. Client’s intentions, choices, courage and determination to take actions in his/her life will create the results Client desires.

Coach will fully collaborate with Client to identify and achieve Client’s personal and professional goals. If issues come up for Client that should be handled by a physician, therapist or other health professional, Coach will recommend that Client attend to his/her health by contacting the appropriate professional.

Coach will bring support, understanding, and a belief in Client and Client’s commitment to his/her own success. Part of Coach’s job is to challenge Client, offer different perspectives, make suggestions (including assigning homework) and acknowledge Client’s successes.

Client Agreement

Client is committed and motivated to take action on his/her personal and professional goals. Client acknowledges that only his/her intentional full participation will lead to success. Client realizes that the process of change can involve feelings of discomfort and frustration.

Client accepts full responsibility for himself/herself and the actions he/she takes that might result from coaching. Client acknowledges that he/she is healthy enough to engage in coaching.

Client has read the Coaching Agreement and agrees with its terms.

HIPAA NOTICE OF PRIVACY PRACTICES

This notice describes how medical information about you may be used and disclosed, and how you can gain access to this information. Please review it carefully. Protected Health Information (PHI), about you, is maintained as a written and/or electronic record of your contacts or visits for healthcare services with me. Specifically, PHI is information about you, including demographic information (i.e., name, address, phone, etc.), that may identify you and relates to your past, present or future physical or mental health condition and related healthcare services. I am required to follow specific rules on maintaining the confidentiality of your PHI, using your information, and disclosing or sharing this information with other healthcare professionals involved in your care and treatment. This Notice describes your rights to access and control your PHI. It also describes how we follow applicable rules and use and disclose your PHI to provide your treatment, obtain payment for services you receive, manage our healthcare operations and for other purposes that are permitted or required by law.

Your Health Information Rights

Inspect and Copy: You have the right to inspect and copy the protected health information that I maintain about you in my designated record set for as long as I maintain that information.
This designated record set includes your medical and billing records, as well as any other
records I use for making any decision about you. Any psychotherapy notes that may have been included in records I received about you are not available for your inspection or copying by law. I may charge you a fee for the costs of copying, mailing, or other supplies used in fulfilling your request.
If you wish to inspect or copy your medical information, you must submit your request in
writing. You may mail in your request, or bring it to my office. I will have 30 days to respond to your request for information that I maintain at my practice site. If the information is stored
offsite, I am allowed up to 60 days to respond but must inform you of this delay.

Request Amendment: You have the right to request that I amend your medical information if you feel that it is incomplete or inaccurate. You must make this request in writing, statingexactly what information is incomplete or inaccurate and the reasoning that supports your request. I will respond in writing within 60 days of your request.

I am permitted to deny your request if it is not in writing or does not include a reason to support the request. I may also deny your request if:

• The information was not created by me, or the person who created it is no longer available to make the amendment;
• The information is not part of the record which you are permitted to inspect and copy:
• The information is not part of the designated record set kept by this practice; or if it is the opinion of the health care provider that the information is accurate and complete.

I will respond within 60 days, in writing, explaining if the request was accepted or denied.

Request An Alternative Means of Confidential Communication: You have the right to ask me to contact you about medical matters using an alternative method (i.e., email, telephone), and to a destination (i.e., cell phone number, alternative address, etc.) designated by you. You must inform me in writing as to how you wish to be contacted if other than the address/phone number that I have on file. I will follow all reasonable requests.

 Request a Restriction of Your PHI: This means you have the right to ask me, in writing, not to use or disclose any part of your Protected Health Information for the purposes of treatment, payment or healthcare operations. If I agree to the requested restriction, I will abide by it, except in emergency circumstances when the information is needed for your treatment. In certain cases,

I may deny your request for a restriction. You will have the right to request, in writing, that I restrict communication to your health plan regarding a specific treatment or service that you, or someone on your behalf, has paid for in full, out-of-pocket. I am not permitted to deny this specific type of requested restriction.

 An Accounting of Disclosure: You have the right to request a list of the disclosures of your health information I have made outside of my practice that were not for treatment, payment, or health care operations. Your request must be made in writing and must state the time period for the requested information. You may not request information for any dates greater than six years (my legal obligation to retain information).

Your first request for a list of disclosures within a 12-month period will be free. If you request an additional list within 12-months of the first request, I may charge you a fee for the costs of providing the subsequent list. I will accommodate all reasonable requests.

 A Paper Copy of This Notice: You have the right to receive a paper copy of this notice upon request. You may obtain a copy by calling and asking me to mail you a copy.

 File a Complaint: If you believe your privacy rights have been violated you may file a complaint with the Secretary of the Department of Health and Human Services. All complaints must be submitted in writing. You will not be penalized or discriminated against for filing a complaint. If you have any questions about this Notice, or would like to know how to file a complaint with the Secretary of the Department of Health and Human Services, please contact me:

Carlos Durana, Ph.D., M.Ac., Lic. Ac.
[email protected]
703-716-0906

Authorize Other Use and Disclosure: You have the right to authorize any use or disclosure of PHI that is not specified within this notice. For example, I would need your written authorization to use or disclose your PHI for marketing purposes, for most uses or disclosures of psychotherapy notes, or if I intended to sell your PHI. You may revoke an authorization, at any time, in writing, except to the extent that your healthcare provider, or my practice, has taken an action in reliance on the use or disclosure indicated in the authorization.

I may contact you to provide information about health-related benefits and services offered by my office, for fundraising activities, share information in a disaster relief situation, include your information in a hospital directory, or with respect to a group health plan, to disclose information to the health plan sponsor. You will have the right to opt out of such special notices, and each such notice will include instructions for opting out.

Ways in Which I May Use and Disclose Your Protected Health Information

The following paragraphs describe different ways that I use and disclose your protected health information. I have provided an example for each category, but these examples are not meant to be exhaustive. I assure you that all of the ways I am permitted to use and disclose your health Information fall within one of these categories.

Treatment: I will use and disclose your protected health information to provide, coordinate, or manage your health care and any related services. I will also disclose your health information to other physicians who may be treating you. Additionally -- I may from time to time disclose your health information to another physician whom I have requested to be involved in your care. For example -- I should disclose your health information to a specialist to whom I have referred you for a diagnosis to help in your treatment.

Health Care Operations: I will use and disclose your protected health information to support the business activities of my practice. For example – I may use medical information about you to review and evaluate my treatment and services or to evaluate my staff’s performance while caring for you. In addition, I may disclose your health information to third-party business associates who perform billing, consulting, or transcription services for our practice.

Payment: I will use and disclose your protected health information to obtain payment for the health care services I provide you. For example -- I may include information with a bill to a third-party payer that identifies you, your diagnosis, procedures performed, and supplies used in rendering the service.

Other Ways I May Use and Disclose Your Protected Health Information
Public Health: I will use and disclose your protected health information in certain situations to help with public health and safety issues. Some of the situations include:

• Preventing disease;
• Helping with product recalls;
• Reporting adverse reactions to medications;
• Reporting suspected abuse, neglect, or domestic violence; or
• Preventing or reducing a serious threat to anyone’s health or

Research: I will use and disclose your protected health information to researchers provided the research has been approved by an institutional review board that has reviewed the research proposal and established protocols to ensure the privacy of your health information.

 As Required by Law: I will use and disclose your protected health information when required to by federal, state, or local law. You will be notified of any such disclosures.

Other Permitted and Required Uses and Disclosures: I am also permitted to use or disclose your PHI without your written authorization for the following purposes:

• To comply with Food and Drug Administration requirements;
• Legal proceedings;
• Coroners;
• Funeral directors;
• Organ donation;
• Criminal activity;
• Military activity;
• National security;
• Worker's compensation;
• When an inmate is in a correctional facility; or
• If requested by the Department of Health and Human Services in order to investigate or determine my compliance with the requirements of the Privacy Rule.

My Responsibilities

I am required by law to maintain the privacy and security of your protected health information. I will let you know promptly if a breach occurs that may have compromised the privacy or security of your information.

I must follow the duties and privacy practices described in this notice and give you a copy of it. I will not use or share your information other than as described here unless you tell us I can in writing. If you tell me I can, you may change your mind at any time. Let me know in writing if you change your mind.

By signing this form you acknowledge you were advised of the HIPAA Notice of Privacy Practices. My HIPAA Notice of Privacy Practices provides information about how I may use and disclose your protected information. I encourage you to read it in full. My Notice of Privacy Practices is subject to change. You may request a copy of the Notice of Privacy.

Dear Patients,

This document contains important information about our decision (yours and mine) to resume in-person services in light of the public health crisis.

Your Responsibility to Minimize Your Exposure:
To obtain services in person, you agree to take certain precautions which will help keep everyone (you, me, our families, and other patients) safer from exposure, and sickness.

Circle your answer to the following:

If you show up for your appointment and I feel that you are showing symptoms, you will be asked to reschedule. I may change the above precautions if additional local, state or federal orders or guidelines are published. If that happens, we will talk about any necessary changes.

My Commitment to Minimize Exposure:
My practice has taken steps to reduce the risk of spreading the virus within the office. Please let me know if you have questions about these efforts. These efforts include the wearing of masks by both myself and my patient. I will also wear gloves during our acupuncture appointment. Masks will be provided if needed. If you arrive by car, please wait in your car until I call you. Appointments will be staggered to ensure limited exposure to others.

Your Confidentiality in the Case of Infection:
If you have tested positive for the coronavirus, I may be required to notify local health authorities that you have been in the office. If I have to report this, I will only provide the minimum information necessary for their data collection and will not go into any details of the reason(s) for our visits. By signing this form, you are agreeing that I may do so without an additional signed release.

Informed Consent:
This agreement supplements the general informed consent/business agreement that we agreed to at the start of our work together.
Your signature below shows that you agree to these terms and conditions.

PROBLEM DIAGNOSIS QUESTIONNAIRE (INDIVIDUAL)

CLIENT INFORMATION SHEET AND INDIVIDUAL CONSENT FOR TREATMENT

The Nature of Psychotherapy: Therapy works best when you are an active partner in the process, so please know that I welcome your feedback or questions about our work at any time. Participating in therapy may result in benefits, including, but not limited to: improved interpersonal relationships; reduced stress and anxiety; better communication with loved ones; increased capacity for intimacy; a decrease in negative thoughts and/or self-sabotaging behaviors; increased comfort in social, work and family settings; increased self-confidence and self-acceptance; greater ability to experience life more fully; more balance in life; and deeper self-awareness. Such benefits may require substantial effort on your part, including active participation in the therapeutic process, honesty, and a willingness to change feelings, thoughts and behaviors as needed. There is no guarantee that therapy will yield any or all of the benefits listed above. The counseling process involves responsibility and commitment on the part of the clinician and on the part of the client. You will receive the most benefit from counseling if you attend your sessions regularly and participate actively in the counseling process. Please arrive on time for your appointments and make arrangements to stay for the duration of the session.

Participating in therapy may involve discomfort, including discussing difficult feelings and experiences, and may evoke strong emotions, including anger, sadness, and fear. During the therapeutic process, many clients find that they may initially feel worse before they feel better. This is generally a normal course of events. Personal growth and change may be easy and swift at times while slow or frustrating at other times. You may also at times feel conflicted about attending sessions. If this is the case, I urge you to bring up your concerns so that we can address them. The process of therapy may sometimes result in unanticipated outcomes, such as changes in personal or career relationships and goals. Please be aware that any decisions about your relationships, personal life, or work life are your responsibility.

Confidentiality: Psychotherapy is designed to be a safe place for you to talk about any personal issues you choose to explore. Please know that whatever we discuss in psychotherapy is legally held as private and is generally confidential. This means that I will not divulge anything you tell me to anyone except under one of the following conditions:

• You give me your written permission to talk to another, such as a health care professional who is providing you treatment, and/or to provide your health records to another;
• You tell me something that I am legally required to reveal to others in order to protect you and/or another person; or
• I am otherwise legally required to divulge the information and/or health records.

For example, I have a duty to report any suspected cases of child abuse and/or neglect to the Virginia Child Protective Services and to report any suspected cases of the abuse, neglect, and/or exploitation of an adult to Virginia Adult Protective Services. I also have a duty to report when there is a reasonable suspicion that a client poses a threat to herself/himself or to others.

Additionally, if you become involved in a lawsuit, especially a lawsuit in which you or your spouse are seeking a divorce or in which the care and custody of your children is at issue, I may have to disclose information and/or health records pertaining to you. Unless you give me written consent to release any requested information or health records, I will only disclose such information or health records in accordance with a lawful Subpoena duces tecum or Witness Subpoena.

Further, a federal law known as The Patriot Act (2001) requires therapists and others in certain circumstances to provide the FBI with client records and other items, and can prohibit the therapist from disclosing to the client that the FBI sought or obtained the items under the Act.

If you are seeing me for couple’s or family therapy, I consider your relationship to be the client. During the course of our work, I may see one of you individually for one or more sessions or for part of a session. All sessions should be seen as part of the work that I am doing with the couple or the family unless otherwise indicated.

Finally, from time to time I consult with other licensed, experienced therapists on how I can better help my client. These consultants are bound by the same laws of confidentiality outlined here. However, when this is done, no personal identifiers such as names are used.

Fees and cancellation policy: Therapy sessions are normally 50 minutes long. Fees are payable each session by check, cash, or credit card (MasterCard/Visa). Longer sessions are pro-rated at the per hour rate. When we schedule an appointment, that time is reserved entirely for you. Therefore, if you need to cancel an appointment, please let me know at least 24 hours in advance; otherwise, I will have to charge you for the missed session since I will not be able to fill the appointment time on short notice.

Also, there is no charge for brief phone calls (up to five minutes), but longer phone sessions with you or with any professionals or others you ask me to speak with on your behalf are subject to a charge based on the length of the call. My hourly rate for these calls will be $150.00.

If you become involved in a lawsuit and you request or require me to testify on your behalf, or I am required to respond to requests for information and/or health records, you will be charged for my time. My hourly rate for any time spent in Court will be $250.00, and my hourly rate for my travel time to and from Court will be $140.00. Any preparation time, including time spent responding to requests for information and/or health records, will be billed at $150.00 per hour.
It is not my preference to become involved with any legal actions involving my client.

Therapist availability and emergency procedures: You can leave messages for me at any time. I normally return phone calls within 1 business day. In a life-threatening emergency, always call 911 immediately.

Completion of Therapy: The length of your therapy depends on the specifics of your situation and the progress we achieve. As we approach the completion of your goals, I will discuss with you a plan for ending therapy. If during therapy you come to feel that the issues for which you are seeking therapy are not being satisfactorily addressed and you wish to see another therapist, I will offer you referrals to other therapists to assist in a smooth transition if you desire. If it becomes clear to me that you are not benefiting from our work together, I am ethically bound to stop treating you, and I will provide you with referrals to other sources for therapy. You may discontinue therapy at any time. Should you choose to end your therapy, I will generally recommend that we meet for at least one final visit to facilitate a positive termination experience and give us an opportunity to reflect on the work that has been done.

If you have any questions about the above, please ask me. Otherwise, please sign below. By signing, you acknowledge that you have reviewed this document and fully understand everything in it, you have had any questions with regard to this document answered by me and you consent to participate in psychotherapy with me.

Note: If you have printed out this form and are faxing it back or scanning it and emailing it back, please sign your name on the first line below. If you are filling out this form on an electronic device, please type your name in both the “sign name” and “print name” lines. Doing so will serve as your electronic signature to indicate that you understand and agree to the above.

ACUPUNCTURE CONSENT

I,................, being ....... years of age and residing at,.......................................................................................................................... do hereby voluntarily consent to be treated by Acupuncture administered by ...............

I understand that Acupuncture is performed by the insertion of needles, with or without the addition of an electric current, through the skin or by the application of heat to the skin or by both, at certain points on or near the surface of the body in an attempt to treat body dysfunctions or diseases, to modify or prevent the body of pain and to make normal the body’s physiological functions. The procedure has been fully explained to me.

I am aware that certain side effects may result. These could include, but are not limited to, some local bruising, slight bleeding and temporary aggravation of symptoms existing prior to Acupuncture treatment.

I am aware that if there is a worsening of my ailment or condition or if it does not improve within the time estimated by the Acupuncturist at the beginning of treatment, that I should consult a licensed physician.

I am also aware that the Federal Government considers Acupuncture “experimental” at this time. I understand that no guarantees concerning its use and effects are given to me and that I am free to stop Acupuncture treatment at any time.

None of the foregoing provisions preclude the administration to me of conventional medical therapy by the licensed physician when at his discretion such therapy is deemed appropriate.

Clients are expected to pay for services at the time they are rendered unless other arrangements have been made. Checks are to be made out to Carlos Durana.

Since the scheduling of an appointment involves the reservation of time specifically for you, a minimum of 24 hours advance notice is required for rescheduling or cancellation of an appointment. The full fee will be charged for missed sessions without such prior notification.

All information disclosed within sessions is confidential and may not be revealed to anyone without written permission, except where disclosure is required by law, i.e. when there is a reasonable suspicion that the client presents a danger of violence to others or where the client is likely to harm him or herself unless protective measures are taken. Disclosure may also be required pursuant to a legal proceeding.