Minnesota Residents Please read the Privacy/Confidentiality/HIPAA notification attached If you have any questions please contact us laura@magnoliacounseling.co Legal Name * By typing my name below I agree I have received notification of my Minnesota Client Rights/Confidentiality/HIPAA Notification First Name Last Name Email * A copy will be sent to you Magnolia Counseling, LLC Client Bill of Rights, Privacy and Confidentiality Consumers of marriage and family therapy services offered by marriage and family therapists licensed by the State of Minnesota have the right: 1. To expect that a therapist has met the minimal qualifications of training and experience required by state law. 2. To examine public records maintained by the Board of Marriage and Family Therapy which contain the credentials of a therapist. 3. To obtain a copy of the code of ethics from the Board of Marriage and Family Therapy, 2829 University Avenue SE, Suite 330, Minneapolis, MN 55414-3222. 4. To report complaints to the Board of Marriage and Family Therapy by calling (612) 617-2220. 5. To be informed of the cost of professional services before receiving the services. 6. To privacy as defined by rule and law. 7. To be free from being the subject of discrimination on the basis of race, religion, gender, or other unlawful category while receiving services. 8. To have access to their records as provided in Minnesota Statutes, section 144.335, subdivision 2. 9. To be free from exploitation for the benefit or advantage of a therapist. Privacy and Confidentiality: Magnolia Counseling, LLC is bound by the provisions of the Minnesota Privacy Act. No information will be released to persons or agencies outside of Magnolia Counseling, LLC without your consent, except by court order. If anyone inquires about information from Magnolia Counseling, LLC , related to you, or your record, your written permission is required. Before granting permission, you must be satisfied that the information is really required. Be sure that the information being given out and that giving it out will help you. You may wish to refuse permission or withdraw it after it has been given. When parents sign a permission form, minors may request that information in their file not be made available to their parents. However, Magnolia Counseling, LLC, may not provide therapy services to minors without parental permission. Exceptions to Confidentiality: There are seven situations in which client confidentiality is not maintained: 1. If Magnolia Counseling, LLC, has knowledge of, or reasonable cause to believe, a child is being neglected or physically or sexually abused, in which case Minnesota statutes (1976, Section 626.656, Subdivision 3) require that such information be reported. 2. Maltreatment of Vulnerable Adults (as specified in the Vulnerable Adults Act, Minnesota Statute 626.557) must be reported. 3. If Magnolia Counseling, LLC, has reason to believe there may be physical harm done to any person. 4. If Magnolia Counseling, LLC, is required by specific court order to disclose information. 5. The Minnesota Department of Human Services may, on occasion, monitor Magnolia Counseling, LLC,files to assist in program and fiscal planning. This is provided for in the Minnesota Data Privacy Act of 1975. 6. If Magnolia Counseling, LLC, has knowledge of, or reasonable cause to believe a pregnant woman is taking drugs, Minnesota statutes require such information to be reported. 7. If Magnolia Counseling, LLC, needs to disclose your name to collection agencies for the purpose of obtaining delinquent payment for services rendered. By providing my full legal name and submitting this form I acknowledge that I have read and understand the Minnesota Client Bill of Rights and Privacy and Confidentiality. * Thank you!
