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Practice Policies




Your health record contains personal information about you and your health. This information, which may identify you and relates to your past, present or future physical or mental health or condition and related health care services, is referred to as Protected Health Information (“PHI”). This Notice of Privacy Practices describes how we may use and disclose your PHI in accordance with applicable law. It also describes your rights regarding how you may gain access to and control your PHI.

We are required by law to maintain the privacy of PHI and to provide you with notice of our legal duties and privacy practices with respect to PHI. We are required to abide by the terms of this Notice of Privacy Practices. We reserve the right to change the terms of our Notice of Privacy Practices at any time. Any new Notice of Privacy Practices will be effective for all PHI that we maintain at that time. We will provide you with a copy of the revised Notice of Privacy Practices by posting a copy on our website, sending a copy to you in the mail upon request, or providing one to you at your next appointment.


Therapy Appointments and Cancellations

Appointments are scheduled in advance, at a cadence we agree on, based on your goals, treatment needs, and our mutual availability. Payments for each appointment will be made through Headway by debit or credit card or ACH transfer.

You may cancel appointments 24 Hours in advance without charge. For appointment no-shows or last-minute cancellations, you will be charged a fee of $75-$100. Please reach out to me directly if you have additional questions.

Availability and After-Hours Emergencies

Providers check for voice mail messages during normal business hours. Messages left outside of normal hours of operation will be picked up the next business day. If you are experiencing suicidal or homicidal thoughts, are in crisis, or need immediate help, please call 911 or go to the nearest emergency department.

Contacting Me

I am often not immediately available by telephone. I do not answer my phone when I am with clients or otherwise unavailable. At these times, you may leave a message on my confidential voicemail and I will return your call once I’ve reviewed your chart, but it may take a day or two for non-urgent matters. I will make every attempt to inform you in advance of planned absences. If I need to cancel an appointment at the last-minute, I will reach out as soon as possible and reschedule, or have a member of my staff connect with you.

Discharge Process

There are several reasons why we may eventually end our professional relationship. You may decide you would prefer to work with a different provider. I may refer you to another provider or different level of care. Regardless of the case, I will first discuss with you the reasons for discharging, and if you request, provide you with a list of other qualified providers. I will also extend the discharge process length if necessary.

Please note that ongoing failure to pay for treatment, attend sessions, or communicate with me in a respectful and timely manner can also result in discharge from my practice. In these instances, to ensure you have continued access to care, I will still make every reasonable effort to get in touch with you and provide referrals to a new provider before I consider our relationship ended.


Required by Law. Under the law, we must make disclosures of your PHI to you upon your request. In addition, we must make disclosures to the Secretary of the Department of Health and Human Services for the purpose of investigating or determining our compliance with the requirements of the Privacy Rule.

Following is a list of the categories of uses and disclosures permitted by HIPAA without an authorization.

 Abuse and Neglect

Emergencies Law Enforcement

National Security

 Judicial and Administrative Proceedings

Law Enforcement

Public Safety (Duty to Warn)

Without Authorization. Applicable law and ethical standards permit us to disclose information about you without your authorization only in a limited number of other situations. The types of uses and disclosures that may be made without your authorization are those that are:

·         Required by law, such as the mandatory reporting of child abuse or neglect or mandatory government agency audits or investigations (such as the social work licensing board or health department)

·         Required by Court Order

·         Necessary to prevent or lessen a serious and imminent threat to the health or safety of a person or the public. If information is disclosed to prevent or lessen a serious threat, it will be disclosed to a person or persons reasonably able to prevent or lessen the threat, including the target of the threat.

Verbal Permission. We may use or disclose your information to family members that are directly involved in your treatment with your verbal permission.

With Authorization. Uses and disclosures not specifically permitted by applicable law will be made only with your written authorization, which may be revoked.



For Treatment. Your PHI may be used and disclosed by those who are involved in your care for the purpose of providing, coordinating, or managing your health care treatment and related services. This includes consultation with clinical supervisors or other treatment team members. We may disclose PHI to any other consultant only with your authorization.

For Payment. We may use or disclose PHI so that we can receive payment for the treatment services provided to you. This will only be done with your authorization. Examples of payment-related activities are: making a determination of eligibility or coverage for insurance benefits, processing claims with your insurance company, reviewing services provided to you to determine medical necessity, or undertaking utilization review activities. If it becomes necessary to use collection processes due to lack of payment for services, we will only disclose the minimum amount of PHI necessary for purposes of collection.

For Health Care Operations. We may use or disclose, as needed, your PHI in order to support our business activities including, but not limited to, quality assessment activities, employee review activities, reminding you of appointments, to provide information about treatment alternatives or other health related benefits and services, licensing, and conducting or arranging for other business activities. For example, we may share your PHI with third parties that perform various business activities (e.g., billing or typing services) provided we have a written contract with the business that requires it to safeguard the privacy of your PHI. For training or teaching purposes PHI will be disclosed only with your authorization.



You have the following rights regarding your personal PHI maintained by our office. To exercise any of these rights, please submit your request in writing to our Privacy Officer, Demarque Mitchell, LCSW, at Demarque's Empowerment Group, PLLC., 3000 S Hulen Street, Suite 124-933, Fort Worth, TX 76109.

  • Right of Access to Inspect and Copy. You have the right, which may be restricted only in exceptional circumstances, to inspect and copy PHI that may be used to make decisions about your care. Your right to inspect and copy PHI will be restricted only in those situations where there is compelling evidence that access would cause serious harm to you. We may charge a reasonable, cost-based fee for copies.

  • Right to Amend. If you feel that the PHI we have about you is incorrect or incomplete, you may ask us to amend the information, although we are not required to agree to the amendment.

  • Right to an Accounting of Disclosures. You have the right to request an accounting of certain of the disclosures that we make of your PHI. We may charge you a reasonable fee if you request more than one accounting in any 12-month period.

  • Right to Request Restrictions. You have the right to request a restriction or limitation on the use or disclosure of your PHI for treatment, payment, or health care operations. We are not required to agree to your request.

  • Right to Request Confidential Communication. You have the right to request that we communicate with you about medical matters in a certain way or at a certain location.

  • Right to a Copy of this Notice. You have the right to a copy of this Notice.

  • Electronic Transactions Standards.


Court and Legal Fees Notification Form

(Disclosure for All Clients)

For clients who plan to have me subpoenaed or have me provide records for the purpose of litigation. Even though you are responsible for the court fee, it does not mean that my testimony will be solely in your favor. I can only testify to the facts of the case and to my professional opinion. If I am to receive a subpoena, the attorney or office staff will need to call my office and set up a time for the subpoena to be served during office hours. I request a minimum of 72 hours notice of any court appearance so that schedule changes for my clients can be made within a reasonable time frame. Please note: If a subpoena or notice to meet attorney(s) is received without a minimum of 72 hour notice, there will be an additional $250 express charge, which must be paid prior to my appearance in the courtroom. When it comes to court action, the following fees are in effect:

*Report Writing, 60 minutes $200.00.

*Court Testimony, Initial $1500 retainer; $225/hour for each hour thereafter.


All attorney fees and costs that are incurred by me as a result of the legal action. A retainer of $1500 is due at least 72 business hours before the scheduled court appearance. The remainder of the costs will be billed after the court appearance and will be due upon receipt.



If you believe we have violated your privacy rights, you have the right to file a complaint in writing with Demarque Mitchell, LCSW, our Privacy Officer, at Demarque's Empowerment Group, PLLC, or with the Secretary of Health and Human Services at 200 Independence Avenue, S.W., Washington, D.C. 20201, or by calling (202) 619-0257. We will not retaliate against you for filing a complaint.

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