New Patient Information
Requesting a First Appointment with a Therapist or Psychiatrist
To request a new patient appointment with a provider, call 215-947-8654 and press “5”. Please have your insurance information ready when you call. Or, you can fill out the GOC New Patient Online Intake Form
Online Requests for Social Skills Group Therapy
If you or your child is interested in receiving social skills group therapy, please see our available groups and you can fill out an request form at the bottom of the page or you may call us at 215-947-8654 for more information.
Forms for Your First Appointment
To save you time on your first therapy visit, feel free to print out the following forms, fill them out, and bring them with you to your first appointment.
Acknowledgement of Receipt of Notice of Privacy Practices (Important: You may access our “Notice of Privacy Practices Statement” below)
Developmental History (for patients age 18 and under)
Notice of Privacy Practices Statement
This describes your rights concerning your PHI (Protected Health Information), including how your medical information may be used and disclosed, and how you can get access to your information. If you would like to download a copy for your records please click here.
GROWTH OPPORTUNITY CENTER NOTICE OF PRIVACY PRACTICES
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.
We are required by applicable federal and state law to maintain the privacy of your health information. We are also required to give you this Notice about our privacy practices, legal obligations, and your rights concerning your health information (“Protected Health Information” or “PHI”). We must follow the privacy practices that are described in this Notice (which may be amended from time to time). For more information about our privacy practices, or for additional copies of this Notice, please contact us by using the information listed in Section II G of this Notice.
I. USES AND DISCLOSURES OF PROTECTED HEALTH INFORMATION
A. Permissible Uses and Disclosures without Your Written Authorization
We may use and disclose PHI without your written authorization, excluding Psychotherapy Notes as described in Section II, for certain purposes as described below. The examples provided in each category are not meant to be exhaustive, but instead are meant to describe the types of uses and disclosures that are permissible under federal and state law.
- Treatment: We may use and disclose PHI in order to provide treatment to you. For example, we may use PHI to diagnose and provide counseling service to you. In addition, we may disclose PHI to other health care providers involved in your treatment.
- Payment: We may use or disclose PHI so that services you receive are appropriately billed to, and payment is collected from, your health plan. By way of example, we may disclose PHI to permit your health plan to take certain actions before it approves or pays for treatment services.
- Health Care Operations: We may use and disclose PHI in connection with our health care operations, including quality improvement activities, training programs, accreditation, certification, licensing or credentialing activities.
- Required or Permitted by Law: We may use or disclose PHI when we are required or permitted to do so by law. For example, we may disclose PHI to appropriate authorities if we reasonably believe that you are a possible victim of abuse, neglect, or domestic violence or the possible victim of other crimes. In addition, we may disclose PHI to the extent necessary to avert a serious threat to your health or safety or the health or safety of others.
Other disclosures permitted or required by law include the following: disclosures for public health activities; health oversight activities including disclosures to state or federal agencies authorized to access PHI; disclosures to judicial and law enforcement officials in response to a court order or other lawful process; disclosures for research when approved by an institutional review board; and disclosures to military or national security agencies, coroners, medical examiners, and correctional institutions or otherwise as authorized by law.
B. Uses and Disclosures Requiring Your Written Authorization
- Psychotherapy Notes: Notes recorded by your clinician documenting the contents of a counseling session with you (“Psychotherapy Notes”) will be used only by your clinician and will not otherwise be used or disclosed without your written authorization.
- Marketing Communications: We will not use your health information for marketing communications without your written authorization.
- Other Uses and Disclosures: Uses and disclosures other than those described in Section I.A. above will only be made with your written authorization. For example, you will need to sign an authorization form before we can send PHI to your life insurance company, to a school, or to your attorney. You may revoke any such authorization at any time.
II. YOUR INDIVIDUAL RIGHTS
- Right to Inspect and Copy. You may request access to your medical record and billing records maintained by us in order to inspect and request copies of the records. All requests for access must be made in writing. Under limited circumstances, we may deny access to your records. We may charge a fee for the costs of copying and sending you any records requested. If you are a parent or legal guardian of a minor, please note that certain portions of the minor’s medical record may not be accessible to you.
- Right to Alternative Communications. You may request, and we will accommodate,
any reasonable written request for you to receive PHI by alternative means of communication or at alternative locations.
- Right to Request Restrictions. You have the right to request a restriction on PHI used
for disclosure for treatment, payment or health care operations. You must request any such restriction in writing addressed to the Privacy Officer as indicated below. We are not required to agree to any such restriction you may request.
- Right to Accounting of Disclosures. Upon written request, you may obtain an
accounting of certain disclosures of PHI made by us after April 14, 2003. This right applies to disclosures for purposes other than treatment, payment or health care operations, excludes disclosures made to you or disclosures otherwise authorized by you, and is subject to other restrictions and limitations.
- Right to Request Amendment. You have the right to request that we amend your
health information. Your request must be in writing, and it must explain why the information should be amended. We may deny your request under certain circumstances.
- Right to Obtain Notice. You have the right to obtain a paper copy of this Notice by submitting a request to the Privacy Officer at any time.
- Questions and Complaints. If you desire further information about your privacy rights, or are concerned that we have violated your privacy rights, you may contact the Privacy Officer, Dr. Kenneth Barber at (215)947-8654. You may also file written complaints with the Director, Officer for Civil Rights of the U.S. Department of Health and Human Services. We will not retaliate against you if you file a complaint with the Director or myself.
III. EFFECTIVE DATE AND CHANGES TO THIS NOTICE
- Effective Date. This Notice is effective on April 14, 2003.
- Changes to this Notice. We may change the terms of this Notice at any time. If we change this Notice,we may make the new notice terms effective for all PHI that we maintain, including any information created or received prior to issuing the new notice. If we change this Notice, we will post the revised notice in the waiting area of our office. You may also obtain any revised notice by contacting the Privacy Officer. This Form is educational only, does not constitute legal advice, and covers only federal, not state, law.