Informed Consent & Confidentiality

Confidentiality and Informed Consent for Psychotherapy Services
 
Provider: Eric M. Riesterer, LPCC Independently Licensed Professional Clinical Counselor Licensed in: Ohio (E.2606791), Minnesota (LPC-MN-717), and Arizona (LPC-AZ-717)
 
This document explains important information about confidentiality, your rights, and your responsibilities when receiving psychotherapy services. Please read it carefully before signing.
 
1. Nature of Psychotherapy
Psychotherapy is a healthcare service involving assessment, diagnosis, and treatment of mental health concerns. Sessions may explore difficult emotions, thoughts, relationships, and past experiences. While many clients benefit from therapy, no specific outcome is guaranteed. Progress depends on your active participation and honesty. You have the right to ask questions, accept or decline any technique, and discontinue therapy at any time.
 
2. Confidentiality and Your Privacy Rights
All information you share in therapy is confidential and will not be disclosed without your written authorization, except as required or permitted by law. We follow the Health Insurance Portability and Accountability Act (HIPAA) and applicable Ohio laws. A separate HIPAA Notice of Privacy Practices explains how your protected health information may be used and disclosed.
 
3. Limits of Confidentiality
We may disclose the minimum necessary information without your consent in the following situations:------ Mandated Reporting: We are legally required to report suspected abuse or neglect of a child (Ohio Rev. Code sec. 2151.421) or of an older adult or vulnerable adult (sec. 5101.63). Risk of Serious Harm: If we believe there is a serious and imminent risk that you will harm yourself or an identifiable person, we may take steps to protect safety, including contacting emergency services or law enforcement. Medical Emergencies: Information may be shared to address a medical emergency. Court Orders and Legal Requirements: We may be required to release records or testify under a valid court order or subpoena. Licensing Board Matters: We may disclose information to the Ohio CSWMFT Board for professional compliance or investigations. Professional Consultation: We may consult with other professionals to improve care while minimizing identifying information.
 
4. Use of Electronic Health Records and Secure Communication
This practice uses two HIPAA-compliant platforms, both covered by Business Associate Agreements (BAAs):-- ClinikEHR - Our Electronic Health Record (EHR) system. All clinical notes, treatment records, and intake documents are stored securely in ClinikEHR under a BAA. Proton Mail (proton.me) - Our primary email and secure document storage system. Proton provides end-to-end encryption and is covered by a BAA. While we use secure systems, no form of electronic communication is 100% risk-free. If you communicate with us from a non-secure email account, the security of that transmission is outside our control.
 
5. Session Formats and Locations
Psychotherapy may be provided in different formats depending on clinical appropriateness and mutual agreement:
a. Telehealth (Doxy.me) Telehealth sessions are conducted through a HIPAA-compliant video platform. You must be physically located in Ohio, Arizona, or Minnesota during the session.
b. In-Office Sessions In-office sessions provide the highest level of privacy.
c. Walk-and-Talk Therapy (Outdoor/Public Spaces) You may choose to have sessions while walking outdoors. By selecting this format, you acknowledge:-- Confidentiality is reduced in public or outdoor settings. Conversations may be seen or overheard by others. You are responsible for your own physical safety, appropriate clothing/footwear, and awareness of weather and terrain. You may request to switch to telehealth or an indoor session at any time.
d. Public Meeting Places (e.g., Panera Bread, Library, Cafe) You may choose to meet in a semi-public indoor location. By selecting this format, you acknowledge:-- Conversations may be overheard by others. We will choose a discreet table when possible, but complete privacy cannot be guaranteed. Any food or drink purchases are your responsibility and are not part of the therapeutic service.
You may change your preferred session format at any time. The provider may determine that a particular format is clinically inappropriate and recommend an alternative.
 
6. Practice Model - Cash-Pay and Voluntary Charity Care

This practice operates on a cash-pay and voluntary charity (pro-bono) care model only. We do not bill Medicaid, Medicare, or any private insurance. All services are provided outside the Medicaid program. No claims are submitted to Medicaid on behalf of any client. Pro-bono services are available for clients experiencing significant financial hardship and are provided as voluntary charity care in accordance with this practice's faith-based mission. Approval must be confirmed in writing before services begin.
 
7. Client Rights and Responsibilities

You have the right to receive respectful care, ask questions about your treatment, refuse any technique, discontinue services at any time, and file a grievance without retaliation. You are responsible for providing accurate information, participating honestly in therapy, and paying fees according to the agreed terms.