To support continued growth in my practice and the ability to give a high level of care, my fees will be increasing as of February 6, 2023.  

As of February 6, 2023, fees are as follows:

       $175 for a 50-minute session

       $250 for an 80-minute session

       $350 for a Initial Discernment Session

       $60 for a group session

       Full fee assessed for Missed Appointment / Late Cancellation Fee (Less than 24-hour notice)

$175 per hour for other professional services you may need, billed in 15-minute increments. These services include, but are not limited to: preparation of records, report writing, telephone conversations lasting longer than 10 minutes, and attendance at meetings or at consultations with other professionals which you have authorized and requested.

If you have concerns about this increase, I would be happy to discuss the matter with you or to give you referrals to other providers that may be covered by your insurance.

Provider Name: Kristine M. Erickson LICSW

License Number: MN #12353

Provider Address: 3209 W 76th Street, Suite 202A, Edina, MN 55435

Provider Phone: 952-470-5319

Provider Tax ID: #46-2283081  

Provider NPI Number: 1003085697

You are entitled to receive this "Good Faith Estimate" of what the charges could be for psychotherapy services provided to you. While it is not possible for a psychotherapist to know, in advance, how many psychotherapy sessions may be necessary or appropriate for a given person, this form provides an estimate of the cost of services provided.  Your total cost of services will depend upon the number of psychotherapy sessions you attend, your individual circumstances, and the type and amount of services that are provided to you. This estimate is not a contract and does not obligate you to obtain any services from the provider(s) listed, nor does it include any services that may be recommended during treatment to you that are not identified here.  

This Good Faith Estimate is not intended to serve as a recommendation for treatment or a prediction that you may need to attend a specified number of psychotherapy visits. The number of visits that are appropriate in your case, and the estimated cost for those services, depends on your needs and what you agree to in consultation with your therapist.  You are entitled to disagree with any recommendations made to you concerning your treatment and you may discontinue treatment at any time.  

I consent to have Kristine Erickson, LICSW of Healing Hope Counseling to perform psychotherapy and/or related mental health assessments and treatments when deemed necessary or advisable by appropriate members of the professional staff.

PRIVACY AND CONFIDENTIALITY

Brief notes are maintained on all of our meetings and related communications. Privacy of all information and records is strictly maintained. Except in the situations described below, only you and I have access to anything in your file. Your signed release would allow me to share information only with specific person or agencies specified by you.

EXCEPTIONS: The therapist is required by law to break confidentiality to prevent serious harm from occurring to me and another person. This law includes reporting known or suspected incidents of abuse or neglect of children or vulnerable adults. If subpoenaed, I understand that the therapist must comply with a court's request for access to my records. I understand the guarantees and limits of privacy of my records.


CANCELLATION POLICY

Healing Hope Counseling requests that cancellations be made at least 24 hours prior to the scheduled session. I reserve the right to charge the full session fee for no-shows and cancellations with less than 24 hours notice. You will receive courtesy reminders regarding your appointments, however you are responsible for knowing when your appointments are and being sure you are scheduled on my calendar. 

I have read and understand the above statements. My signature below indicates that I have read this form and agree to the terms described.

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 health and claims records
- Correct your health and claims records
- 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:
- Answer coverage questions from your family and friends
- Provide disaster relief
- Market our services and sell your information

Our Uses and Disclosures

We may use and share your information as we:
- Help manage the health care treatment you receive
- Run our organization
- Pay for your health services
- Administer your health plan
- Help with public health and safety issues
- Do research
- Comply with the law
- Respond to organ and tissue donation requests and work with a medical examiner or funeral director
- Address workers' compensation, law enforcement, and other government requests
- Respond to lawsuits and legal action


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 a copy of health and claims records
- You can ask to see or get a copy of your health and claims records 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 and claims records, usually within 30 days of your request. We may charge a reasonable, cost-based fee.
Ask us to correct health and claims records
- You can ask us to correct your health and claims records if you think they are 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 consider all reasonable requests, and must say "yes" if you tell us you would be in danger if we do not.
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.
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 www.hhs.gov/ocr/privacy/hipaa/complaints/.
- 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 payment for 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

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.
Help manage the health care treatment you receive
We can use your health information and share it with professionals who are treating you.
Example: A doctor sends us information about your diagnosis and treatment plan so we can arrange additional services.

Run our organization
- We can use and disclose your information to run our organization and contact you when necessary.
- We are not allowed to use genetic information to decide whether we will give you coverage and the price of that coverage.

This does not apply to long term care plans.
Example: We use health information about you to develop better services for you.

Pay for your health services

We can use and disclose your health information as we pay for your health services.
Example: We share information about you with your dental plan to coordinate payment for your dental work.

Administer your plan

We may disclose your health information to your health plan sponsor for plan administration.
Example: Your company contracts with us to provide a health plan, and we provide your company with certain statistics to explain the premiums we charge.

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: www.hhs.gov/ocr/privacy/hipaa/understanding/consumers/index.html.

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.

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 services

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.
For more information see: www.hhs.gov/ocr/privacy/hipaa/understanding/consumers/noticepp.html.

- We do not create or maintain psychotherapy notes.
- We do not share your information for fund raising or marketing purposes.

Changes to the Terms of this Notice

We can change the terms of this notice, and the changes will apply to all information we have about you. The new notice will be available upon request, on our web site, and we will mail a copy to you.

Other Instructions for Notice
- Privacy officer: Kristine M. Erickson, MSW, LICSW, 952-470-5319, kristine@healinghopemn.com
- Effective Date: October 5, 2018

Email & Texting Risk Information

Use of Counsol video chat (HIPPA compliant platform for telehealth) or Zoom

Regarding Email:

Technical experts often describe email as being like a postcard, in that it can be viewed by all hands it passes through.

- Are you familiar with the risks of emails being viewed by various engineers, administrators, and bad actors (hackers) as it passes through the Internet?

Think about where you read and write emails, and what devices you do that on. Think about who can see you reading and writing emails in these places, and who can access the devices you use to read and write emails.

- Would there be any negative consequences to any of those people reading or glancing at emails exchanged with your therapist?
- Are there certain kinds of email contents that you would feel safe letting these people see and other kinds of contents you would not feel safe letting them see?
- Let your therapist know the answers to these questions if you wish to use email with him or her.

Think about which email address(es) you might use with your therapist.

- Who has access to each address?
- If you use a work email address, know that your employer may legally view all the emails your send receive with that address. Be aware that engineers and administrators at your email service provider may be able to view your emails.
- How quickly do you normally receive replies from others via email?
- Do you expect replies more quickly than your therapist's stated response time?
- Can you see any negative consequences occurring if your therapist does not or cannot reply to an email as quickly as others in your life typically do?

Your therapist's email services are through these companies: Google Apps for Work. New client inquiries are forwarded from Healing Hope's website, hosted through Squarespace. Alert messages from the electronic health record, Counsol, are used to communicate changes within the medical record (i.e. changed / cancelled appointments, new forms to complete, when a new message is waiting for you, etc.)

You have access to a secure email that allows you to send and receive messages with your therapist though the client portal of your electronic health record, in Counsol. This is the preferred means of communication between clients and their therapist. All messages sent through this portal become part of your medical record, and care should be taken to appropriately disclose information.

Regarding Texting:

Text messages are often sent using the Internet, even though they are usually a part of one's phone service.

- Are you familiar with the risks of texts being viewed by various engineers, administrators, and bad actors (hackers) as it passes through the Internet?
- Are you aware that text messages wait on phone company computers until they are retrieved, and may remain there indefinitely?
- Can you imagine any negative consequences if engineers, administrators, or law enforcement personnel viewed these stored texts from or to your therapist?

Think about where you read and write text messages, and what devices you do that on. Think about who can see you reading and writing texts in these places, and who can access the devices you use to read and write texts.

- Would there be any negative consequences to any of those people reading or glancing at texts exchanged with your therapist?
- Are there certain kinds of text contents that you would feel safe letting these people see and other kinds of contents you would not feel safe letting them see?
- Let your therapist know the answers to these questions if you wish to use texting with him or her.
- How quickly do you normally receive replies from others via text?
- Do you expect replies more quickly than your therapist's stated response time?
- Can you see any negative consequences occurring if your therapist does not or cannot reply to a text as quickly as others in your life typically do?

Your therapist uses the following device(s) and phone service(s) to send and receive text messages: Apple IPhone, in conjunction with Verizon Wireless Services. Note that if you use an iPhone, your text messages may not be typical SMS text messages, and instead may be iMessage chat messages.  Your therapist uses VSEE video calling in the event that there is inclement weather, a client needs to "call in" from their workplace or home due to scheduling or illness.  Sessions are not cancelled due to inclement weather, however you will be given the option to utilize VSEE in order to keep therapy on track.  

Consumers of social work services offered by social workers licensed by the State of MN have the right:

- To be informed of the social worker's license status, education, training and experience;

- To examine public records maintained by the Board of Social Work which contains the credentials of a social worker;

- To obtain a copy of the Grounds for Disciplinary or Corrective Action Standards of Practice and Ethical Conduct from the Minnesota Board of Social Work from the State Register and Public Documents Division, Department of Administration, 117 University Avenue, St. Paul, MN 55114-1095;

- To report complaints to the Minnesota Board of Social Work; 2829 University Avenue SE; Suite 340; Minneapolis, MN 55414-3237;

- To be informed of the cost of professional services before receiving services;

- To privacy as defined by rule and law;

- To be free from being the object of discrimination on the basis of race, religion, gender, or other unlawful category while receiving social work services;

- To have access to their records as provided in subpart 1a and Minnesota Statutes, Section 144.355, subdivision 2; and

- To be free from exploitation for the benefit or advantage of the social worker.

Information about clients and their families is confidential with exception to the following:

1) Written authorization by the client and/or family (valid authorization form).
2) Therapist's duty to warn another in the case of potential suicide, homicide or threat of imminent, serious harm to another individual.
3) Therapist's duty to report suspicion of abuse or neglect of children or vulnerable adults.
4) Therapist's duty to report prenatal exposure to cocaine, heroin, phencyclidine, methamphetamine, and amphetamine or their derivatives, THC, or excessive & habitual alcohol use. 
5) Therapist's duty to report the misconduct of mental health or health care professionals.
6) Therapist's duty to provide a spouse or parent of a deceased client access to their child or spouse's records.
7) Therapist's duty to provide parents of minor children access to their child's records. Minor clients can request, in writing, that particular information not be disclosed to parents. Such a request should be discussed with the therapist.
8) Therapist's duty to release records if subpoenaed by the courts.
9) Therapist's obligations to contracts (e.g. to employer of client, to an insurance carrier or health plan).