Notice of Privacy Practices

Self-Love Counseling, LLC
Effective Date: Effective August 10, 2026 (revised from prior version)

Your privacy is deeply important to this practice. Therapy is built on trust, and protecting the confidentiality of your personal information is a central part of ethical and professional care.

THIS NOTICE DESCRIBES HOW HEALTH INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY.

I. MY PLEDGE REGARDING HEALTH INFORMATION

Self-Love Counseling, LLC understands that health information about you and your health care is personal. I am committed to protecting your protected health information (“PHI”). I create and maintain records of the care and services you receive from me. I need these records to provide you with quality care and to comply with certain legal requirements.

This Notice applies to the records of your care maintained by Self-Love Counseling, LLC. It describes the ways in which I may use and disclose PHI about you and your rights regarding the health information I maintain.

I am required by law to:

  • Maintain the privacy of your PHI;

  • Provide you with this Notice describing my legal duties and privacy practices with respect to your PHI;

  • Comply with the terms of this Notice currently in effect; and

  • Notify you following a breach of unsecured PHI when required by law.

I may change the terms of this Notice at any time. Any changes will apply to all PHI I maintain about you. A revised Notice will be available on my website and upon request.

II. HOW I MAY USE AND DISCLOSE HEALTH INFORMATION ABOUT YOU

The following categories describe different ways that I may use and disclose PHI. Not every use or disclosure in a category will be listed, but all permitted uses and disclosures will fall within one of these categories or will otherwise be permitted or required by law.

Treatment, Payment, and Health Care Operations

Federal privacy rules generally permit health care providers to use or disclose PHI without your written authorization for treatment, payment, and health care operations, subject to applicable requirements and limitations.

For example, I may disclose relevant health information to another licensed health care provider for purposes of consultation, coordination of care, referral, or treatment.

Treatment may include coordination or management of your care with another provider, consultation between providers, and referrals for health care services.

When the minimum necessary standard applies, I will make reasonable efforts to limit the use or disclosure of PHI to the minimum necessary to accomplish the intended purpose.

Lawsuits and Disputes

If you are involved in a lawsuit or legal proceeding, I may disclose PHI in response to a court or administrative order. I may also disclose PHI in response to a subpoena, discovery request, or other lawful process when the applicable legal requirements have been satisfied.

Minors

If I provide services to a minor, I may disclose certain PHI to a parent or legal guardian as permitted or required by applicable law.

In some circumstances, state law allows minors to consent to their own treatment or provides special protections regarding confidentiality. I will follow applicable state and federal law when determining whether information may be disclosed to a parent or legal guardian.

III. CERTAIN USES AND DISCLOSURES REQUIRE YOUR AUTHORIZATION

Psychotherapy Notes

I may maintain “psychotherapy notes” as defined by HIPAA. Psychotherapy notes are notes maintained separately from the rest of the medical record that document or analyze the contents of conversations during a counseling session.

Generally, any use or disclosure of psychotherapy notes requires your written authorization, except for limited circumstances permitted by federal law, including:

  • Use by me for your treatment;

  • Use by me for my own training or for training or supervision of mental health practitioners in certain circumstances;

  • Use by me to defend myself in a legal action or other proceeding brought by you;

  • Use or disclosure required by the Secretary of the U.S. Department of Health and Human Services to investigate or determine compliance with HIPAA;

  • Use or disclosure required by law;

  • Certain uses or disclosures for health oversight activities;

  • Use or disclosure to a coroner or medical examiner when required for their duties; or

  • Use or disclosure necessary to prevent or lessen a serious and imminent threat to the health or safety of a person or the public, as permitted by law.

Marketing

I will not use or disclose your PHI for marketing purposes without your written authorization when such authorization is required by law.

Sale of PHI

I will not sell your PHI without your written authorization when such authorization is required by law.

IV. CERTAIN USES AND DISCLOSURES DO NOT REQUIRE AUTHORIZATION

Subject to applicable limitations, I may use or disclose your PHI without your authorization for purposes permitted or required by law, including:

  • When disclosure is required by federal or state law;

  • Public health activities, including certain reports of suspected abuse or neglect;

  • Activities related to preventing or reducing a serious and imminent threat to health or safety;

  • Health oversight activities such as audits or investigations;

  • Judicial or administrative proceedings when authorized by law;

  • Law enforcement purposes as permitted or required by law;

  • Coroners and medical examiners as permitted or required by law;

  • Research when permitted under applicable legal and ethical requirements;

  • Specialized government functions;

  • Workers’ compensation purposes; and

  • Appointment reminders and information about treatment alternatives or other health-related services.

V. USES AND DISCLOSURES WHERE YOU HAVE THE OPPORTUNITY TO OBJECT

Disclosures to Family, Friends, or Others Involved in Your Care

I may disclose relevant PHI to a family member, close personal friend, or another person identified by you who is involved in your care or payment for your care, unless you object or applicable law otherwise limits the disclosure.

In emergency situations where you are unable to express your preference, I may use professional judgment to determine whether a disclosure is in your best interest, consistent with applicable law.

VI. SPECIAL PROTECTIONS FOR SUBSTANCE USE DISORDER RECORDS

Federal law provides additional protections for certain records related to substance use disorder diagnosis, treatment, or referral under 42 CFR Part 2.

Where Part 2 applies, I will comply with its additional requirements regarding the use and disclosure of such records.

Part 2 generally requires a patient’s written consent for the use or disclosure of records protected by Part 2 unless an applicable exception permits or requires the disclosure. Part 2 also provides additional protections regarding the use of such records in certain legal, administrative, or law-enforcement proceedings against a patient.

VII. YOUR RIGHTS REGARDING YOUR PHI

You have the following rights regarding your protected health information, subject to applicable law:

Right to Request Restrictions

You may request restrictions on certain uses and disclosures of your PHI. I am not always required to agree to a requested restriction, except as required by law.

Right to Request Restrictions for Out-of-Pocket Expenses Paid in Full

You have the right to request that PHI not be disclosed to a health plan for payment or health care operations purposes when you have paid for the health care item or service completely out of pocket and the disclosure is not otherwise required by law.

Right to Request Confidential Communications

You may request that I communicate with you about health matters in a particular way or at a particular location. I will accommodate reasonable requests as required by law.

Right to Access Your Records

You generally have the right to inspect and obtain a copy of PHI maintained in your designated record set, subject to applicable exceptions. Psychotherapy notes maintained separately from the medical record are not generally available through this access right.

Right to Request an Amendment

You may request an amendment to PHI that you believe is incorrect or incomplete. I may deny your request under certain circumstances permitted by law.

Right to Receive an Accounting of Disclosures

You may request an accounting of certain disclosures of your PHI made during the applicable period, subject to exceptions provided by law.

Right to Receive a Copy of This Notice

You may request a paper copy of this Notice at any time, even if you have agreed to receive the Notice electronically.

Right to Designate a Personal Representative

You may designate a person to act on your behalf regarding your health information when permitted or required by law. Certain legally authorized representatives may also exercise rights on your behalf.

Requests to exercise these rights should be submitted in writing to Self-Love Counseling, LLC using the contact information below.

VIII. COMPLAINTS

If you believe your privacy rights have been violated, you may file a complaint with Self-Love Counseling, LLC or with the U.S. Department of Health and Human Services Office for Civil Rights.

If applicable, you may also have the right to file a complaint regarding violations of federal substance use disorder confidentiality requirements under 42 CFR Part 2.

You will not be penalized or retaliated against for filing a complaint.

AVAILABILITY OF THIS NOTICE

A current version of this Notice of Privacy Practices is available on the Self-Love Counseling, LLC website and may also be provided to you in paper or electronic form.

You may request a paper copy of this Notice at any time.

For clients receiving services, Self-Love Counseling, LLC will make a good-faith effort to obtain written acknowledgment that the Notice was provided.

CONTACT INFORMATION

If you have questions about this Notice, would like a copy of this Notice, or would like to exercise any of your privacy rights, please contact:

Self-Love Counseling, LLC
Privacy Contact: Amber Behrouzvaziri, LMHC

10255 Commerce Drive, Suite 204

Carmel, IN 46032
Email: amber@selflovecounselingllc.com

You may also contact the U.S. Department of Health and Human Services Office for Civil Rights regarding concerns about your privacy rights.

Effective Date: August 10, 2026