Registration is only required if you do not have a username. Please check your spam & junk mail folders to ensure you have not already received an email with a username and password. If you already have a username log in here

Each account must have a unique email address associated with it. Please contact us if you need multiple accounts with the same email address (i.e. related family members).

Client Information

/ Middle Initial

( optional )


( for Text Message Reminders )

Bill To Contact

/ Middle Initial

Log in Details

( If client is a minor, the legal guardian must enter their email address below. )

Between 8 and 40 letters and numbers

Challenge Questions

( These will be used to retrieve your password. Answers must be between 4 and 30 characters, cannot contain any spaces. )

( If you feel you must write down your questions in order to remember them, make sure to keep it in a safe place. )

Terms and Policy

Effective June 15, 2012


This notice applies to all Protected Health Information (PHI) contained in your health records maintained by Rebecca A. Eldredge, Ph.D.  Maintaining the privacy and confidentiality of your PHI is extremely important to me as well as a valuable part of therapy. I keep a record of the care and services you receive during our therapy relationship to provide you with quality care and fulfill legal and ethical requirements. Please read this notice and discuss any questions you have; this contains important information about your privacy rights, my responsibilities, and how your PHI may be used or disclosed.

I. Uses and Disclosures for Treatment, Payment, and Health Care Operations

Situations in which I may use or disclose your protected health information (PHI) with your consent include treatment, payment, or health care operations.  Under any circumstance, I will use or disclose only the minimum amount of information necessary from your medical records to accomplish the intended purpose of the disclosure. To help clarify these terms, here are some definitions:

PHI or Protected Health Information refers to information in your health record that could identify you.

Use applies only to activities within my office such as sharing, employing, applying, utilizing, examining, and analyzing information that identifies you.

Disclosure applies to activities outside of my office, such as releasing, transferring, or providing access to information about you to other parties.

The following examples describe some of the types of uses and disclosures that may be made by my office once you have provided Consent.

Treatment:  I will use your health information to make decisions about the provision, coordination, or management of your healthcare.  Examples may include disclosure of PHI to consult with another health care provider regarding your treatment or to contact you to remind you of an appointment.

Payment:  I may need to use or disclose information in your health record to obtain reimbursement from you or from a third party (e.g. health insurance) for services rendered to you.  Examples may include disclosure of PHI for billing, claims management, collection, determination of eligibility or coverage, and related healthcare data processing through my system.

Operations:  Your health records may be used in my business planning and development of operations, including improvements in my methods of operation and general administrative functions.  I may also use the information in my overall compliance planning, healthcare review activities, and arranging for legal and auditing functions.

II. Uses and Disclosures Requiring Authorization

I may only use or disclose PHI for purposes outside of treatment, payment, or health care operations when your appropriate authorization is obtained. An authorization is written permission above and beyond the general consent that permits only specific disclosures. In those instances when I am asked for information for purposes outside of treatment, payment or health care operations, I will obtain an authorization from you before releasing this information. I will also not release “Psychotherapy Notes” without authorization. “Psychotherapy Notes” are notes I may have made about our conversation during a private, group, or joint session, which I have kept separate from the rest of your medical record. These notes are given a greater degree of protection than PHI.

You may revoke any authorizations (of PHI or Psychotherapy Notes) at any time, by providing a written request of the revocation. You may not revoke an authorization to the extent that (1) I have relied on that authorization; or (2) if the authorization was obtained as a condition of obtaining insurance coverage, law provides the insurer the right to contest the claim under the policy. I will not be liable for any disclosure of PHI that occurred before I knew you revoked your permission.

III. Uses and Disclosures with Neither Consent nor Authorization

Although I will make an effort to inform you and obtain your authorization, there are some circumstances in which I may be required to disclose your PHI without your consent or authorization. These may include:

Abuse of children, elderly, or persons with disabilities: If I have reasonable cause to suspect abuse of children, elderly, or persons with disabilities, I will make a report to the appropriate authorities as required or permitted by law to protect those who may be unable to protect themselves.

Adult and Domestic Abuse: If I have reasonable cause to suspect you have been criminally abused, I may report this suspicion to the appropriate authorities if required by law.

Imminent danger to self or others: If you communicate an imminent risk (e.g. the apparent intent and ability to act on the threat in the foreseeable future) to inflict serious physical harm on yourself or an identifiable third party, I may disclose relevant PHI and take reasonable steps to prevent the threatened harm. If there is a medical emergency, I will disclose the information deemed necessary to medical personnel to provide medical care to you.

Legal requirements: If I am required to disclose your PHI by any Federal, State, or Local law, I will abide by the law. Legal disclosures may be required by subpoena, court order, or your written authorization. If information is requested as part of a court case in which you are involved, I will not make the disclosure without your written authorization or a court order. This privilege would not apply, however, if I am evaluating you based on a court order and I would inform you in advance of these limitations.

Worker’s compensation: I may disclose protected health information regarding you as authorized by and to the extent necessary to comply with laws relating to worker’s compensation or other similar programs, established by law, that provide benefits for work-related injuries or illness without regard to fault.

There may be additional disclosures of PHI that I am required or permitted by law to make without your consent or authorization, however the disclosures listed above are the most common.

IV. Patient’s Rights

Right to Request Restrictions: You may request that I limit some of the uses and disclosures of your PHI.  I am not required to agree to the restriction; however, if we agree, I will comply with it. I cannot limit uses or sharing that are required by law.

Right to Receive Confidential Communications by alternative Means and at Alternative Locations: You have a right to request receipt of confidential communications at a different place or different form (e.g. email, phone, mail). I will respect your request as long as it is reasonable. (For example, you may not want a family member to know that you are seeing me. On your request, I will send your bills to another address.)

Right to Inspect and Copy: You have the right to inspect or obtain a copy (or both) of PHI in my mental health and billing records used to make decisions about you for as long as the PHI is maintained in the record. I may deny your access to PHI under certain circumstances, but in some cases you may have this decision reviewed. On your request, I will discuss with you the details of the request and denial process. I may charge a reasonable fee for providing a copy of your health records, or a summary of those records, which includes the cost of copying, postage, and preparation or an explanation or summary of the information.

Right to Amend: You have the right to request an amendment of PHI for as long as the PHI is maintained in the record. I may deny your request. On your request, I will discuss with you the details of the amendment process.

Right to an Accounting of Disclosures: You have a right to receive a list of disclosures I have made of your PHI. The list will not include releases for treatment, payment and healthcare operations, releases based on your written Authorization, releases made to people involved in your care, or releases otherwise allowed by law. 
Right to a paper copy: You may request a printed copy of this notice at any time.

V. Psychologist’s Duties

I am required by law to maintain the privacy of the protected health information in your records and to provide you with this Notice of my legal duties and privacy practices with respect to that information.
I am required to abide by the terms of this Notice currently in effect.

I reserve the right to change the terms of this Notice at any time; If I revise my policies and procedures, the new provisions will become effective for all health information and records that I have and continue to maintain.  All changes in this Notice will be prominently displayed and available at my office. I will inform you by email of the update and provide a revised copy at your request.

VI. Questions and Complaints

If you have questions about this notice, disagree with a decision I make about access to your records, or have other concerns about your privacy rights, you may contact me at 832-260-6110.

If you believe that your privacy rights have been violated and wish to file a complaint with my office, you may send your written complaint to me at or the current mailing address on my website:

You may also send a written complaint to the Secretary of the U.S. Department of Health and Human Services. I will provide you with the appropriate address upon request.

You have specific rights under the Privacy Rule. I will not retaliate against you for exercising your right to file a complaint.
( Type Full Name )
Welcome to my practice. This document (the Agreement) contains important information about my professional services and business policies. It also contains summary information about the Health Insurance Portability and Accountability Act (HIPAA), a federal law that provides privacy protections and patient rights with regard to the use and disclosure of Protected Health Information (PHI) used for the purpose of treatment, payment, and health care operations. HIPAA requires that I provide you with a Notice of Privacy Practices (the Notice) for use and disclosure of PHI for treatment, payment and health care operations. The Notice, which is attached to this Agreement, explains HIPAA and its application to your personal health information in greater detail. The law requires that I obtain your signature acknowledging that I have provided you with this information by the end of this session. Although these documents are long and sometimes complex, it is very important that you read them carefully. We can discuss any questions you have about the procedures at any time. When you sign this document, it will also represent an agreement between us.

Therapist Qualifications: I am a licensed psychologist in Texas and Michigan. If you would like more information, or you would like to file a formal complaint, please contact the Texas State Board of Examiners of Psychologists at (512) 305-7700 or or Michigan’s Department of Licensing & Regulatory Affairs BHP/Health Investigation Division at (517) 373-9196 or based on your state of residence.

Therapy Services: I will provide primarily individual, couples, and group therapy for individuals seeking personal growth and awareness. I reserve the right to deny services to individuals whose concerns are beyond my scope of competence as well as to any individual that abuses or misuses services in any manner (e.g. non-compliance with treatment, frequent missed appointments, delinquent payment, etc.). If I am unable to offer you services for your specified needs, I will discuss other local treatment options and possible referrals with you.

The Therapy Process: The therapy process is a partnership between you and I to work on areas of concern or dissatisfaction in your life, develop growth and insight, and help you achieve your desired goals and improve your overall well-being. In order for therapy to be effective, it is necessary for both you and I to take an active role in this process. Participation involves being honest, discussing concerns about the process, completing outside assignments when appropriate, being open to different thoughts and ideas, and providing on-going feedback to me about the process.

During the initial 2-4 sessions, we can both assess if I am the best person to provide the services that you need in order to meet your treatment goals. If psychotherapy is begun, you and I will negotiate your frequency of sessions, number of sessions, goals, and type of counseling (e.g. individual, couples, or group). I will generally meet with you once/week for 45 minute sessions. You and I may re-evaluate the frequency or length of your sessions as situations arise and/or as you move towards your goals. While counseling is often beneficial for many people, some people may not find therapy helpful. The counseling process may evoke strong feelings and sometimes produce unanticipated changes in one’s behaviors, thoughts, and feelings. In order for you to maximize your experience, it is helpful to discuss any questions or discomfort you may be experiencing during the therapeutic process with me. I will work to help you to understand the experience and/or use different methods or techniques that may be more satisfying.

I will respect you as an individual and will give you my complete attention during sessions. You have the right to ask any questions, at any time, about what you and I do during therapy, and to receive answers that satisfy you. If you wish, I will explain my style to you. You have the right not to allow the use of any therapy technique. If I plan to use any unusual technique, I will inform you and discuss its benefits and risks.

My goal is for you to get the support you need, whether that is working with me or someone else. You have the right to decide not to enter therapy with me. If you feel that you are not making progress towards your goals, you may terminate the therapeutic relationship at any time. Upon request, I will provide you with a list of referrals for therapists in the community. In effort to help you transition, I will request one last formalized session, so you can provide feedback and consider your next steps. You will be responsible for any outstanding payments for services received.

Cancellation Policy: Therapy is more effective when an individual attends appointments in a consistent manner. It is expected that you will be prompt for your appointment. Sometimes emergencies come up. If I need to cancel or change an appointment time, I will make every effort to give you more than 24 hours notice, as I know you will have reserved the time for the appointment. Likewise, I expect that you will give me more than 24 hours notice if you must cancel or reschedule an appointment. If, for any reason, you cannot let me know more than 24 hours in advance that you will not attend a scheduled appointment, you will be charged the regular fee for the time reserved. It is important to note that insurance companies do not provide reimbursement for cancelled sessions. If you attempt to reschedule your appointment earlier than it was scheduled and an earlier time is available, you will not be charged for the original appointment. However, if your appointment is rescheduled for later the same day or week without more than 24 hours notice, you will be charged for the reserved time. Please inform your therapist of cancellations by phone to ensure timely receipt of your message.

Fees: Therapy is a personal investment in one’s own growth and overall well-being. It is expected that you will pay for the therapeutic services provided. My standard (45 minutes) session fee is $150 and my hourly fee is $200. In addition to weekly appointments, I charge this amount for other professional services you may need, though I will break down the hourly cost if I work for periods of less than one hour. Other services include report writing, telephone conversations lasting longer than 14 minutes, consulting with other professionals with your permission, preparation of records or treatment summaries, and the time spent performing any other service you may request of me. If you become involved in legal proceedings that require my participation, you will be expected to pay for all of my professional time, including preparation and transportation costs, even if I am called to testify by another party. [Because of the difficulty of legal involvement, I charge $400 per hour for preparation and attendance at any legal proceeding.]

Payment for services is expected at the end of each appointment; payment schedules for other professional services will be agreed to when they are requested. Payments may be made with cash, personal check, debit card, or credit card. I offer limited sliding fee scale options for persons who can document severe financial hardship. If you are eligible for a discounted fee, the initial appointment will be $150.00 and the reduced fee will apply for subsequent appointments.

If you have, and would like to use, insurance coverage to help cover your costs of therapy, I will be glad to provide you with documentation showing you attended and paid, including the information required by the insurance for reimbursement to you; please be aware that I am asked to provide a clinical diagnosis on insurance documentation. Sometimes I am asked to provide additional clinical information such as treatment plans or summaries, or copies of your entire Clinical Record. This information will become part of the insurance company files and your permanent medical record. Though all insurance companies claim to keep such information confidential, I have no control over what they do with it once it is in their hands. Please let me know if you would like additional information regarding the potential risks and benefits of using insurance to seek reimbursement.

If your account has not been paid for more than 60 days and arrangements for payment have not been agreed upon, I have the option of using legal means to secure the payment. This may involve hiring a collection agency or going through small claims court which will require me to disclose otherwise confidential information. In most collection situations, the only information I release regarding a patient’s treatment is his/her name, the nature of services provided, and the amount due. [If such legal action is necessary, its costs will be included in the claim.]

Therapy is a significant personal and financial commitment. Please do not hesitate to discuss financial matters with your therapist.

Phone calls/Emails: Your therapist recognizes that situations may arise in which you may wish to communicate with your therapist between sessions. Due to my work schedule, I am often not immediately available by telephone. When I am unavailable, my telephone is answered by voice mail; please leave a message, as I do not store client information on my phone to further protect your confidentiality. I will make every effort to return your call on the same day you make it, with the exception of weekends and holidays. If you are unable to reach me and feel that you can’t wait for me to return your call, contact your family physician or the nearest emergency room and ask for the psychologist or psychiatrist on call. If I will be unavailable for an extended time, I will provide you with the name of a colleague to contact, if necessary. Please be aware that you will be billed in 15 minute increments beginning at the first 15 minutes (e.g. less than 15 minutes does not incur a charge, once 15 min. is reached, there will be a charge based on my hourly fee).

Email: Although e-mail has become a major means of communication between individuals, internet communication has significant limitations. Please note the following guidelines for use of e-mail as a form of communication with me.

-I will not provide personal counseling through e-mail

-I cannot guarantee that your e-mail will remain confidential. Although I may keep your e-mail messages private and encourage you to use the secure, HIPAA compliant email via the secure Client portal, I cannot ensure administrators of the system and experienced computer users will not be able to access e-mail.

-Although e-mail may seem like a fast way to contact someone, I may not have the ability to check e-mail as frequently and as consistently. Absence from the office, a busy schedule, unexpected illness, or difficulty getting online may mean that several days go by before a message is received. Please call me on the designated phone line to ensure communication.

Confidentiality: Confidentiality is essential to effective counseling. It is also heavily protected by both ethical guidelines and legal requirements. In order for therapy to work best, you must feel safe about sharing your personal information in therapy. I will maintain this information ethically and legally confidential and it will be released to other parties only with your consent on this document, authorization, or as otherwise required or permitted by law. Some examples of releases allowed by your consent are as follows:

-Consultation: I may occasionally consult other health and mental health professionals. During a consultation, I make every effort to avoid revealing the identity of my client. The other professionals are also legally bound to keep the information confidential. If you don’t object, I will not tell you about these consultations unless I feel that it is important to our work together.

-In-office staff and colleagues: Please be aware that I practice with other mental health professionals and that I may employ administrative staff. In some cases, I need to share protected information with these individuals for both clinical and administrative purposes, such as scheduling, billing and quality assurance. All of the mental health professionals are bound by the same rules of confidentiality. Any staff members will be given training about protecting your privacy and agree not to release any information outside of the practice without the permission of a professional staff member.

-I also have a contract with a web-based company for email, scheduling, videoconferencing, and similar services. As required by HIPAA, I have a formal business associate contract with this business, in which it promises to maintain the confidentiality of this data except as specifically allowed in the contract or otherwise required by law. If you wish, I can provide you with the names of these organizations and/or a blank copy of this contract.

-Disclosures required by health insurers or to collect overdue fees are discussed elsewhere in this Agreement.

-If a patient threatens to harm himself/herself, I may seek hospitalization for him/her, notify relevant health or law enforcement personnel, or contact family members or others who can help provide protection.

There are some situations where I am permitted or required to disclose information without either your consent or Authorization. These are also described in the Privacy notice, and are summarized again here. Some situations may necessitate me revealing information pertaining to a client’s treatment to protect others from harm; these situations are unusual in my practice. Examples of exceptions to confidentiality may include, but are not limited to:

-If I have reasonable cause to suspect child abuse or neglect, the law requires that I file a report with the appropriate agency. Once such a report is filed, I may be required to provide additional information.

-If I have reasonable cause to suspect the “criminal abuse” of an adult client, I may be required to report it to the police. Once such a report is filed, I may be required to provide additional information.

-If a client communicates a threat of physical violence against a reasonably identifiable third person with the apparent intent and ability to carry out that threat in the foreseeable future, I may disclose information in order to take protective action. These actions may include notifying the potential victim (or, if the victim is a minor, his/her parents and the county Department of Social Services) and contacting the police, and/or seeking hospitalization for the client.

-If a government agency is requesting the information for health oversight activities, I may be required to provide it for them.

-If a patient files a complaint or lawsuit against me, I may disclose relevant information regarding that patient in order to defend myself.

-If I am being compensated for providing treatment to you as a result of your having filed a worker’s compensation claim, I must, upon appropriate request, provide information necessary for utilization review purposes.

-If you are involved in a court proceeding and a request is made for information concerning your diagnosis and treatment, such information is protected by the psychologist-patient privilege law. I cannot provide any information without your written authorization, or a court order. If you are involved in or contemplating litigation, you should consult with your attorney to determine whether a court would be likely to order me to disclose information.

-Where otherwise legally required.

-Information that you also share outside of therapy, willingly and publicly, will not be considered protected or confidential by a court.

If any such situation arises, I will make every effort to fully discuss it with you before taking any action and I will limit my disclosure to what is necessary. The above is considered a summary. If you have questions about specific situations or any aspects of confidentiality, please feel free to discuss your concerns with me. The laws governing confidentiality can be quite complex, and I am not an attorney. In situations where specific advice is required, formal legal advice may be needed to best protect your interests.

Access to Records: Pursuant to HIPAA, I may keep Protected Health Information about you in two sets of professional records. One set, which is required, constitutes your Clinical Record. Except in unusual circumstances, you may examine and/or receive a copy of your Clinical Record if you request it in writing. Because these are professional records, they can be misinterpreted and/or upsetting to untrained readers. For this reason, I recommend that you initially review them in my presence, or have them forwarded to another mental health professional so you can discuss the contents. In most circumstances, I am allowed to charge a fee for the time and resources of the copy. If I refuse your request for access to your Clinical Records, you have a right of review [except for information supplied to me confidentially by others], which I will discuss with you upon request.

In addition, I may, at times, also keep a set of Psychotherapy Notes. These Notes are for my own use and are designed to assist me in providing you with the best treatment. While the contents of Psychotherapy Notes vary from client to client, they can include the contents of our conversations, my analysis of those conversations, and how they impact on your therapy. They also contain particularly sensitive information that you may reveal to me that is not required to be included in your Clinical Record. [They also may include information from others provided to me confidentially.] These Psychotherapy Notes are kept separate from your Clinical Record. Your Psychotherapy Notes are not available to you and cannot be sent to anyone else, including insurance companies without your written, signed Authorization. Insurance companies cannot require your authorization as a condition of coverage nor penalize you in any way for your refusal to provide it.

Patient Rights: HIPAA provides you with several new or expanded rights with regard to your Clinical Records and disclosures of protected health information. These rights include requesting that I amend your record; requesting restrictions on what information from your Clinical Records is disclosed to others; requesting an accounting of most disclosures of protected health information that you have neither consented to nor authorized; determining the location to which protected information disclosures are sent; having any complaints you make about my policies and procedures recorded in your records; and the right to a paper copy of this Agreement, the attached Notice form, and my privacy policies and procedures. I am happy to discuss any of these rights with you.

The signature here shows that I have read, discussed, understand the information, and I agree to abide by the points presented above and also serves as an acknowledgement that you have received the HIPAA Notice Form described above.
( Type Full Name )