The Bravo Institute Professional Disclosure Statement and Consent for Treatment
Camilla Bravo, DCC, PhD, LPC-S
Please understand – the majority of this document is mandated by both South Carolina state law and Public Law 104-191; it is provided for your protection. The Bravo Institute has tried to anticipate any risks you may have faced as a result of being in therapy, or coaching. If you have any questions regarding the documents you have received, please feel free to discuss them with Dr. Bravo.
The Bravo Institute is located at:
24 Vardry Street
Greenville, S.C. 29601
(864) 320-1648 (mobile)
(864) 248-4786 (office)
This is also the mailing address. The usual office hours are 9:00 a.m. – 5:00 p.m., with early morning and later evening hours available upon request. Please be aware, these hours are variable, as field/educational work takes me away from the office throughout the week. I try to reserve Saturday appointments for LPC Intern supervision, however will schedule appointments on a case-by-case basis.
Camilla Bravo, DCC, PhD, LPC-S is the owner and Clinical Director of The Bravo Institute. Her credentials are listed below. Dr. Bravo received her Master’s Degree at Winthrop University and her Doctorate at Clayton College
· Ph.D. in Holistic Nutrition
· M.Ed. in Counseling and Development
· Master Life and Wellness Coach
· Distance Credentialed Counselor
· Licensed Professional Counselor
· Licensed Professional Counselor Supervisor
Dr. Bravo provides several psychotherapeutic services which include:
· Therapy for depressive symptoms and anxiety
· Therapy for those recovering from physical trauma
· Therapy for those with a negative body image
· Group work for all above listed, as well as chronic pain
Fees: It is customary to pay for professional services at the time they are rendered. The hourly fee for individual therapy is $100 per hour. Group therapy is $20 per hour per person (unless otherwise noted) – groups are scheduled for at least 2 hours per session.
Confidentiality: The information you share in psychotherapy is protected health information and is generally considered confidential by both South Carolina statute law and federal regulations. Your therapy file can be subpoenaed in South Carolina through a court order (signed by a judge) but it is considered privileged in the federal courts. Dr. Bravo is mandated by standards – through Duty to Warn – to breach confidentiality if she discovers: (1) you are threatening self-harm or suicide; (2) you are threatening to harm another, or homicide; (3) a child has been or is being abused, or neglected, and/or; (4) a vulnerable adult has been, or is being abused or neglected. Finally, if you wish your protected health information released to another party, you must sign a Release of Information.
Dr. Bravo follows the Code of Ethics of the following organizations:
· SC Board of Examiners for Licensed Professional Counselors, Marriage and Family Therapists and Psycho-Educational Specialists
Any type of sexual behavior between therapist and client is unethical. It is never appropriate and will not be condoned.
You will be asked to sign the last page of this document. Your signature verifies you have been given this document and the HIPAA document that follows; that you have read and understand these documents, and that you consent to treatment. Further, you need to be aware:
· Treatment isn’t always successful and may open unexpected emotionally sensitive areas.
· Dr. Bravo is not a physician and does not prescribe medications.
· Dr. Bravo may need to consult with your physician, attorney, or other counselor.
· Dr. Bravo is not available 24 hours a day.
· Appointments may be cancelled as late as 24 hours in advance. If this is not done, you will be charged $50 for the missed appointment.
· Dr. Bravo is licensed through the SC Board of Examiners for the Licensure of Professional Counselor, Marriage and Family Therapists, and Psycho-Educational Specialists. This board is located at the Synergy Center (Kingstree Building) in Columbia, SC. Phone number = 803-896-4652 (mailing address is PO Box 11329, Columbia, SC 29211-1329).
· The Executive Administrator for The Bravo Institute is Camilla Bravo. She is a confidential administrator under state and federal law. She will be your major contact for appointments, problems, complaints and commendations.
HEALTH INSURANCE PORTABILITY AND ACCOUNTABILITY ACT OF 1996 (HIPAA): 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. This document may be updated without notice so please review it each time you visit us. A copy of this statement is always available upon request.
All information revealed by you in a counseling session and most information placed in your file (all medical records or other individually identifiable health information held or disclosed in any form [electronic, paper or oral]) is considered “protected health information” by HIPAA. As such, your protected health information cannot be distributed to anyone else without your express informed and voluntary written consent or authorization. The exceptions to this are defined immediately below. Additional information regarding your rights as a client can be found in your therapist’s Professional Disclosure Statement and Consent for Treatment.
Use or disclosure if the following protected health information does not require your consent or authorization:
1. Uses and disclosures required by law – like files court-ordered by a judge
2. Uses and disclosures about victims of abuse, neglect or domestic violence
3. Uses and disclosures for health and oversight activities – such as correcting records
4. Uses and disclosures for judicial and administrative proceedings
5. Uses and disclosures for law enforcement purposes
6. Uses for disclosures for research purposes (client confidentiality will be maintained)
7. Uses for disclosures to avert a serious threat to health or safety
8. Uses and disclosures for Workers’ Compensation
Your Rights as a Counseling Client under HIPAA
· As a client, you have the right to see your counseling file. Psychotherapy notes are afforded special privacy protection under the HIPAA regulations and are excluded from this right.
· As a client, you have the right to receive a copy of your counseling file. This copy will consist of only documents generated by us. You will be charged copying fees @$.20/page. Psychotherapy notes are afforded special privacy protection under the HIPAA regulations and are excluded from this right.
· As a client, you have the right to request amendments to your counseling file.
· As a client, you have the right to receive a history of all disclosures of protected health information. You will be charged copying fees @$.20/page.
· As a client, you have the right to restrict the use and disclosure of your protected health information for the purposes of treatment and operations. If you choose to release any protected health information, you will be required to sign a Release of Information form detailing exactly to whom and what information you wish disclosed.
· As a client, you have the right to register a complaint with the Security of Health and Human Services if you feel your rights, herein explained, have been violated.