NOTICE OF PRIVACY PRACTICES BPB Counseling Group LLC This notice describes how your health information may be used and disclosed and how you can access this information. Please review it carefully. You may have additional rights under state and local law. If you have any questions regarding your rights to health care information, please seek legal counsel from an attorney licensed in your state. ACKNOWLEDGEMENT OF RECEIPT OF PRIVACY NOTICE Under the Health Insurance Portability and Accountability Act of 1996 (HIPAA), you have specific rights regarding the use and disclosure of your Protected Health Information (PHI). I. My Pledge Regarding Health Information Your health information is personal, and BPB Counseling Group LLC is committed to protecting it. We maintain a record of the care and services you receive to provide quality care and to comply with legal requirements. This notice applies to all records of your care generated by our practice and explains how we may use and disclose your health information. It also outlines your rights concerning your information. We are legally required to keep your PHI private, provide you with this Notice of Privacy Practices outlining our legal duties, and follow the terms of this notice while it is in effect. We may revise this notice at any time, and the changes will apply to all information we maintain. A current version of this notice will always be available upon request, in our office, and on our website. II. How We May Use and Disclose Health Information About You For Treatment, Payment, or Health Care Operations HIPAA allows us to use or disclose your PHI without written authorization for Treatment: We may use and share your PHI with other healthcare providers involved in your care. For example, a clinician may consult with another healthcare professional about your diagnosis or treatment plan. Payment: We may use and disclose PHI for billing and insurance purposes. Health Care Operations: We may use your PHI for administrative purposes, such as appointment reminders, billing, and quality improvement. Disclosures for treatment are not subject to the minimum necessary standard, as providers require full access to medical information to deliver effective care. Lawsuits and Disputes If you are involved in a legal matter, we may disclose health information in response to a court order, subpoena, or other legal process, but only when required by law. III. Certain Uses and Disclosures Require Your Authorization We will obtain your written authorization before using or disclosing psychotherapy notes, except under the following circumstances: For treatment purposes, for training and supervision of mental health professionals, for legal defense in a case initiated by you, for federal compliance investigations, or as required by law. Additionally, we will not use or disclose your PHI for marketing purposes or sell your information. If you provide a testimonial or review containing PHI, you must sign a HIPAA authorization before we can publish it. You may revoke your authorization at any time by submitting a written request, though we cannot retract prior disclosures made with your consent. IV. Uses and Disclosures That Do Not Require Your Authorization We may use and disclose your PHI without your written authorization under specific circumstances, including appointment reminders and health-related benefits, legal obligations including state and federal reporting requirements, public health activities including reporting suspected abuse, health oversight activities including audits and investigations, judicial or administrative proceedings including court orders and subpoenas, law enforcement purposes including reporting crimes on our premises, medical examiner or coroner requests, research purposes under strict privacy conditions, government functions including military and national security requirements, workers’ compensation claims, and organ and tissue donation requests. V. Certain Uses and Disclosures Require Your Opportunity to Object You have the right to object to the disclosure of your PHI to family, friends, or others involved in your care. If you are unable to communicate, such as in an emergency, we may disclose relevant PHI if, in our professional judgment, it is in your best interest. VI. Your Rights Regarding Your PHI Under HIPAA, you have the following rights: The Right to Request Limits on Uses and Disclosures You may request restrictions on how we use or share your PHI. We are not required to agree to all requests, but we will consider them carefully. The Right to Restrict Disclosure for Self-Paid Services If you have paid for services out-of-pocket in full, you may request that we do not disclose your information to your insurance provider. The Right to Choose How We Contact You You may request that we contact you in a specific way, such as by phone, email, or alternate mailing address. We will comply with reasonable requests. The Right to Access Your Medical Records You may request a copy of your medical records in electronic or paper format. We will provide them within 30 days of receiving your written request, and we may charge a reasonable cost-based fee. The Right to an Accounting of Disclosures You may request a list of disclosures made in the past six years, excluding disclosures for treatment, payment, and healthcare operations. We will provide one free disclosure list per year; additional requests may incur a fee. The Right to Request Corrections If you believe your PHI is inaccurate or incomplete, you may request corrections. We will respond within 60 days and may deny your request with an explanation in writing. The Right to a Paper or Electronic Copy of This Notice You have the right to request a paper copy of this notice at any time, even if you have already received an electronic copy. The Right to Designate a Representative If you have appointed a legal representative, they may make decisions regarding your PHI on your behalf. The Right to File a Complaint If you believe your privacy rights have been violated, you may file a complaint by contacting BPB Counseling Group LLC directly or filing a complaint with the U.S. Department of Health & Human Services, Office for Civil Rights at 200 Independence Avenue, S.W., Washington D.C. 20201, Phone: (877) 696-6775, Website: www.hhs.gov/ocr/privacy/hipaa/complaints. We will not retaliate against you for filing a complaint. VII. Changes to This Notice We may change the terms of this notice at any time, and updates will apply to all records we maintain. The revised notice will be available in our office and on our website. If you have questions about this notice or your privacy rights, please contact us. BPB Counseling Group LLC, info@bpbcounseling.com.

CONSENT FOR TREATMENT VIA TELEHEALTH BPB Counseling Group LLC I understand that my health care provider wishes me to engage in a telehealth consultation. I understand video conferencing technology will be used to affect such a consultation and that it will not be an in-person health care provider visit as I will not be in the same room as my provider. I understand that telehealth has potential benefits including easier access to care and the convenience of meeting from a location of my choosing. I understand there are potential risks to this technology, including interruptions, access, and technical difficulties. I understand that my health care provider or I can discontinue the telehealth consult/visit if it is felt that the videoconferencing connections are not adequate for the situation. I will reach out to the clinic support staff if I have questions in regard to this procedure, otherwise I have no questions and I understand the risks and benefits which I understand. CONSENT TO USE THE HIPAA COMPLIANT ZOOM SERVICE Zoom is the technology service we will use to conduct telehealth videoconferencing appointments. It is simple to use and there are no passwords required to log in. By signing this document, I acknowledge: Zoom is NOT an Emergency Service and in the event of an emergency, I will use a phone to call 911. Though my provider and I may be in direct, virtual contact through Zoom, neither BPB Counseling Group LLC nor Zoom provides any medical or healthcare services or advice including, but not limited to, emergency or urgent medical services. Zoom facilitates videoconferencing and is not responsible for the delivery of any healthcare, medical advice, or care. I do not assume that my provider has access to any or all of the technical information in Zoom – or that such information is current, accurate, or up-to-date. I will not rely on my health care provider to have any of this information. To maintain confidentiality, I will not share my telehealth appointment link with anyone unauthorized to attend the appointment. By signing this form, I certify: That I have read or had this form read and/or had this form explained to me. That I fully understand its contents including the risks and benefits of the engagement and that I have been given ample opportunity to ask questions and that any questions have been answered to my satisfaction.

PRACTICE POLICIES BPB Counseling Group LLC APPOINTMENTS AND CANCELLATIONS No-Show / Cancelation Policy: Refunds will not be issued for missed appointments or reschedules/cancelations within 24 hours of appointment time. Clients may cancel or reschedule an appointment anytime via the link in their appointment confirmation email, as long as they provide greater than 24-hour notice. If a client misses or cancels an appointment with less than 24-hour notice, or fail to show up, you will not be reimbursed for the session, you will be charged the full session fee. This is necessary because a time commitment is made to you and is held exclusively for you. If you are late for a session, you may lose some of that session time. The standard meeting time for psychotherapy is 50 minutes. It is up to you, however, to determine the length of time of your sessions. Requests to change the 50-minute session need to be discussed with the therapist in order for time to be scheduled in advance. THERAPIST ACCESSIBILITY Clinicians are not available outside of session time; any needs can be directed to clinic support staff and will be responded to in a reasonable time frame with consideration provided for weekend, evening, holiday and personal time. If a true emergency arises, call 911 or any local emergency room. SOCIAL MEDIA AND TELECOMMUNICATION Due to the importance of your confidentiality and the importance of minimizing dual relationships, clinicians do not accept friend or contact requests from current or former clients on any social networking site such as Facebook or LinkedIn. Adding clients as friends or contacts on these sites compromise confidentiality and respective privacy. It also blurs the boundaries of therapeutic rapport. If you have questions about this, please bring them up when meeting with your clinician. ELECTRONIC COMMUNICATION Any form of electronic communication carries risk of discovery, interference. The clinic will follow best-practice but cannot fully ensure the confidentiality of any form of communication through electronic media, including text messages, direct messages or even email as bad actors have evidenced ability to breach data security protocols. If you prefer to communicate via email or text messaging for issues regarding scheduling or cancellations, consider this. Messages will be returned in a timely manner, no guarantee for immediate response and request that you do not use these methods of communication to discuss therapeutic content or request assistance for emergencies. Services by electronic means, including but not limited to telephone communication, the Internet, facsimile machines, and email, are considered telemedicine by the State of California. Under the California Telemedicine Act of 1996, telemedicine is broadly defined as the use of information technology to deliver medical services and information from one location to another. If you and your therapist choose to use information technology for some or all of your treatment, you need to understand that you retain the option to withhold or withdraw consent at any time without affecting the right to future care or treatment or risking the loss or withdrawal of any program benefits to which you would otherwise be entitled, all existing confidentiality protections are equally applicable, your access to all medical information transmitted during a telemedicine consultation is guaranteed, and copies of this information are available for a reasonable fee, dissemination of any of your identifiable images or information from the telemedicine interaction to researchers or other entities shall not occur without your consent, and there are potential risks, consequences, and benefits of telemedicine. Potential benefits include but are not limited to improved communication capabilities, providing convenient access to up-to-date information, consultations, support, reduced costs, improved quality, change in the conditions of practice, improved access to therapy, better continuity of care, and reduction of lost work time and travel costs. Effective therapy is often facilitated when the therapist gathers within a session or a series of sessions a multitude of observations, information, and experiences about the client. Therapists may make clinical assessments, diagnoses, and interventions based not only on direct verbal or auditory communications, written reports, and third-person consultations but also from direct visual and olfactory observations, information, and experiences. When using information technology in therapy services, potential risks include but are not limited to the therapist's inability to make visual and olfactory observations of clinically or therapeutically potentially relevant issues such as your physical condition including deformities, apparent height and weight, body type, attractiveness relative to social and cultural norms or standards, gait and motor coordination, posture, work speed, any noteworthy mannerisms or gestures, physical or medical conditions including bruises or injuries, basic grooming and hygiene including appropriateness of dress, eye contact including any changes in the previously listed issues, sex, chronological and apparent age, ethnicity, facial and body language, and congruence of language and facial or bodily expression. Potential consequences thus include the therapist not being aware of what he or she would consider important information that you may not recognize as significant to present verbally to the therapist. Blair Bisher is a master's level clinician holding two masters degrees in clinical mental health counseling and health administration, is a certified sex addiction therapist candidate, has successfully passed the boards, or national mental health counselor exam, and is working under the supervision of Dr. Falconer, PhD. MINORS If you are a minor, your parents may be legally entitled to some information about your therapy. I will discuss with you and your parents what information is appropriate for them to receive and which issues are more appropriately kept confidential. For example, if you are threatening serious harm to yourself or others or report that you are being harmed by others, I, as a mandated reporter, am required to disclose this to your parent or guardian and may need to follow up with state agencies as indicated. TERMINATION Ending relationships can be difficult. Therefore, it is important to have a termination process in order to achieve some closure. The appropriate length of the termination depends on the length and intensity of the treatment, treatment plan goals short and long term, achieved or relieved. Clinician may terminate treatment after appropriate discussion with client - or three attempts - and a termination process if determined that the psychotherapy is not being effectively used or treatment is no longer found to be beneficial by client or client is in default on financial policies for treatment. Clinician will not terminate the therapeutic relationship without first discussing and exploring the reasons and purpose of terminating - or attempting to do so. If therapy is terminated for any reason or you request another therapist, you will be provided with a list of qualified psychotherapists to treat you. Client may also choose someone on thier own or from another referral source. Should you fail to schedule an appointment for three consecutive weeks, unless other arrangements have been made in advance, for legal and ethical reasons, the clinic must consider the professional relationship discontinued.

BPB Counseling Group LLC is committed to complying with the No Surprises Act, which aims to protect clients from unexpected medical bills. As part of this commitment, all session fees are clearly displayed on the site (e.g. initial consult, group session, 1:1 session and Intensive session) as a means to clearly provide Good Faith Estimates (GFEs) to all clients, both uninsured and self-pay clients, as well as to any client upon request. The displayed GFE outlines the expected charges for the explicit health care service being offered, helping clients make informed decisions about their care. BPB Counseling Group clearly displays this as clients have the right to receive a GFE for the total expected cost of any non-emergency services. In this clear display the client has permanent access to a GFE same-day as booking, clearly indicating clinical provider, the primary service, charge associated with each service or item, the anticipated date of service is at the client's discretion fully aware that the GFE is always presented real-time. Clients are entitled to receive a GFE for the total expected cost of any non-emergency services. Per regulation via the No Surprises Act, If the billed charges are $400 or more than the GFE, clients have the right to dispute the bill. A copy of the GFE will be retained in the client’s record. Clients are encouraged to keep a copy of their payment receipts for reference. BPB Counseling Group LLC will inform clients of their right to receive stated GFE by posting a notice on our website, displaying a notice in a prominent location in our office if applicable, and providing written notice to clients by way of clear, stated prices on the website. If a client is billed for an amount at least $400 more than the GFE, they can initiate a billing dispute resolution process. Clients can contact Health and Human Services (HHS) to start the dispute process which must be initiated within 120 calendar days of the date on the original bill. For more information visit cms.gov/nosurprises. This policy is in accordance with the No Surprises Act and is designed to ensure transparency and protect clients from unexpected medical bills.

*I agree and attest that I have read and agree with the following: Consent To Treat, Privacy Practices, No Surprises Act, Practice Policies (including no-show and late cancelation policy).* I authorize the described mental health assessment and treatment. Authorization will be in effect until such time as this professional relationship is terminated, or until consent is revoked. Submission of this form is my written consent under the nature and terms as stated above.