Legal Disclaimer

The information on this website is for general information purposes only. Nothing on this site should be taken as healthcare advice for any individual case or situation. This information is not intended to create, and receipt or viewing does not constitute a healthcare professional-patient relationship. We do our best to keep the information accurate and up to date, however, mistakes do happen, and we cannot make guarantees regarding the accuracy of our information. We are not liable for any information on this website or your reliance upon it.

Website Terms of Use and Privacy Policy

The following TERMS OF USE AND PRIVACY POLICY is subject to change at any time and at the sole discretion of Maple Grove Therapy and Wellness (“Maple Grove Therapy and Wellness,” “we,” “us,” “our,” or “Company”) and www.maplegrovetherapyandwellness.com. Please visit the site regularly for updates.

Terms of Use and Privacy Policy

Welcome to our Website! This Website is maintained as a service to our customers and clients. By using this Website, you agree to comply with and be bound by the following terms and conditions of use. Please review these terms and conditions carefully. If you do not agree to these terms and conditions, you should not use this site.

  1. Agreement.

This Agreement (the “Agreement”) specifies the Terms and Conditions for access to and use of www.maplegrovetherapyandwellness.com (the “Website”) and describe the terms and conditions applicable to your access to and use of the Website. This Agreement may be modified at any time by Maple Grove Therapy and Wellness upon posting of the modified agreement. Any such modifications shall be effective immediately. You can view the most recent version of these terms at any time at www.maplegrovetherapyandwellness.com. Each use by you shall constitute and be deemed your unconditional acceptance of this Agreement.

  1. Intellectual Property Ownership.

(a) Our Content. All content included on the Website is and shall continue to be the property of Maple Grove Therapy and Wellness or its content suppliers and is protected under applicable copyright, patent, trademark, and other proprietary rights. Any copying, redistribution, use or publication by you of any such content or any part of the Website is prohibited without express permission by Maple Grove Therapy and Wellness. Under no circumstances shall you acquire any ownership rights or other interest in any content by or through your use of the Website. Other product and company names mentioned on this Website may be trademarks of their respective owners.

(b) Personal Use. Maple Grove Therapy and Wellness grants you a limited, revocable, nonexclusive license to use the Website solely for your own personal use and not for republication, distribution, assignment, sublicense, sale, preparation of derivative works, or other use. You agree not to copy materials on the Website, reverse engineer or break into the Website, or use materials, products or services in violation of any law. The use of the Website is at the discretion of Maple Grove Therapy and Wellness and Maple Grove Therapy and Wellness may terminate your use of the Website at any time.

(c) Other Uses. All other use of Content from the Website, including, but not limited to uploading, downloading, modification, publication, transmission, participation in the transfer or sale of, copying, reproduction, republishing, creation of derivative works from, distribution, performance, display, incorporation into another website, reproducing the Website (whether by linking, framing or any other method), or in any other way exploiting any of the Content, in whole or in part, is strictly prohibited without Maple Grove Therapy and Wellness prior express written consent.

  1. Disclaimers.

(a) DISCLAIMER OF WARRANTIES. THE INFORMATION ON THIS WEBSITE IS PROVIDED ON AN “AS IS,” “AS AVAILABLE” BASIS. YOU AGREE THAT USE OF THIS WEBSITE IS AT YOUR SOLE RISK. MAPLE GROVE THERAPY AND WELLNESS DISCLAIMS ALL WARRANTIES OF ANY KIND, INCLUDING BUT NOT LIMITED TO ANY EXPRESS WARRANTIES, STATUTORY WARRANTIES, AND ANY IMPLIED WARRANTIES OF: MERCHANTABILITY, FITNESS FOR A PARTICULAR PURPOSE, AND NON-INFRINGEMENT. YOUR SOLE AND EXCLUSIVE REMEDY RELATING TO YOUR USE OF THE WEBSITE SHALL BE TO DISCONTINUE USING THE WEBSITE.

FURTHERMORE, MAPLE GROVE THERAPY AND WELLNESS DOES NOT WARRANT THAT USE OF THE WEBSITE WILL BE UNINTERRUPTED, AVAILABLE AT ANY TIME OR FROM ANY LOCATION, SECURE OR ERROR-FREE, THAT DEFECTS WILL BE CORRECTED, OR THAT THE SERVICE IS FREE OF VIRUSES OR OTHER HARMFUL COMPONENTS. MAPLE GROVE THERAPY AND WELLNESS, ITS SUBSIDIARIES, VENDORS AND AFFILIATES DISCLAIM ANY RESPONSIBILITY FOR THE DELETION, FAILURE TO STORE, OR UNTIMELY DELIVERY OF ANY INFORMATION OR MATERIALS, AND ANY MATERIAL DOWNLOADED OR OTHERWISE OBTAINED THROUGH THE WEBSITE. USE OF THE WEBSITE’S SERVICES IS DONE AT YOUR OWN DISCRETION AND RISK, AND YOU WILL BE SOLELY RESPONSIBLE FOR ANY DAMAGES TO YOUR COMPUTER SYSTEMS OR LOSS OF DATA THAT MAY RESULT FROM THE DOWNLOAD OF SUCH INFORMATION OR MATERIAL.

(B) LIMITATION OF LIABILITY. MAPLE GROVE THERAPY AND WELLNESS SHALL NOT BE RESPONSIBLE OR LIABLE TO PROVIDERS OR ANY THIRD PARTIES UNDER ANY CIRCUMSTANCES FOR ANY INDIRECT, CONSEQUENTIAL, SPECIAL, PUNITIVE OR EXEMPLARY DAMAGES OR LOSSES, INCLUDING BUT NOT LIMITED TO, DAMAGES FOR LOSS OF PROFITS, GOODWILL, USE, DATA OR OTHER INTANGIBLE LOSSES WHICH MAY BE INCURRED IN CONNECTION WITH MAPLE GROVE THERAPY AND WELLNESS OR THE WEBSITE, OR USE THEREOF, OR ANY OF THE DATA OR OTHER MATERIALS TRANSMITTED THROUGH OR RESIDING ON THE WEBSITE OR ANY SERVICES, OR INFORMATION PURCHASED, RECEIVED OR SOLD BY WAY OF THE WEBSITE, REGARDLESS OF THE TYPE OF CLAIM OR THE NATURE OF THE CAUSE OF ACTION, EVEN IF MAPLE GROVE THERAPY AND WELLNESS HAS BEEN ADVISED OF THE POSSIBILITY OF DAMAGE OR LOSS.

(c) IF THE FOREGOING LIMITATIONS OR THE LIMITATIONS WITHIN THE TERMS AND CONDITIONS OF USE ARE HELD TO BE UNENFORCEABLE, THE PROGRAM OPERATOR’S LIABILITY FOR DAMAGES UNDER THIS AGREEMENT TO ANY PERSON OR ENTITY SHALL NOT EXCEED THE AMOUNT OF FEES PAID BY THAT PERSON OR ENTITY FOR THE PRODUCT, SERVICE, AND/OR SOFTWARE (LICENSE).

(d) Before participating in any medical program or using any medical products or services that may be described and/or made accessible in or through our Website, we strongly recommend that you consult with a physician or other healthcare provider. While some of Maple Grove Therapy and Wellness’s staff may be professional care providers, Maple Grove Therapy and Wellness, its staff and its content providers are not rendering professional advice of any kind to you personally, including without limitation: medical, psychological, emotional, relationship or personal growth advice, counseling, therapy, treatment or coaching, but are merely providing general education and information to you about medical topics, unless otherwise agreed to in writing. You acknowledge and agree that when participating in any medical program or other activity or program described in our services there is the possibility of physical injury, emotional distress and/or death, and you assume the risk and responsibility for any such results. This Website and the services provided by Maple Grove Therapy and Wellness DO NOT necessarily create a doctor-patient or therapist-patient relationship. Information provided on this Website DOES NOT create a doctor-patient or healthcare practitioner-patient relationship between you and Maple Grove Therapy and Wellness or its practitioners.

(e) To the extent you have in any manner violated or threatened to violate our intellectual property rights, we may seek injunctive or other appropriate relief in any court located in Hennepin or Ramsey County, Minnesota, USA and you consent to exclusive jurisdiction and venue in such courts. Use of our Website is unauthorized in any jurisdiction that does not give effect to all provisions of these terms and conditions, including without limitation this paragraph. You agree that no joint venture, partnership, employment, or agency relationship exists between you and Maple Grove Therapy and Wellness as a result of this agreement or use of the Website, products, and/or services. Our performance of this agreement is subject to existing laws and legal process, and nothing contained in this agreement is in derogation of the right to comply with governmental, court and law enforcement. If any provision is determined to be invalid or unenforceable pursuant to applicable law including, but not limited to, the warranty disclaimers and liability limitations set forth above, then the invalid or unenforceable provision will be deemed superseded by a valid, enforceable provision that most closely matches the intent of the original provision and the remainder of the agreement shall continue in effect. YOU HEREBY IRREVOCABLY WAIVE ANY AND ALL RIGHT TO TRIAL BY JURY IN ANY ACTION, SUIT, PROCEEDING, CLAIM OR COUNTERCLAIM ARISING UNDER OR IN RELATION TO THIS AGREEMENT.

(f) This Agreement shall be governed and construed in accordance with the laws of Minnesota, USA applicable to agreements made and to be performed in Minnesota, USA.

(g) Dispute Resolution, Attorneys’ Fees. You agree that Minnesota law will govern this Agreement and that any action, suit, proceeding, or claim arising out of or related to this Agreement must be brought exclusively in federal or state courts located in Ramsey County, Minnesota. You hereby submit to the in personam jurisdiction and venue of such courts and waive any objection based on inconvenient forum. You agree to indemnify Maple Grove Therapy and Wellness for all of its reasonable attorneys’ fees and costs incurred as a result of any action, suit, proceeding or claim brought by You or Maple Grove Therapy and Wellness in which Maple Grove Therapy and Wellness is found to be the prevailing party. YOU HEREBY IRREVOCABLY WAIVE ANY AND ALL RIGHT TO TRIAL BY JURY IN ANY ACTION, SUIT, PROCEEDING, CLAIM OR COUNTERCLAIM ARISING UNDER OR IN RELATION TO THIS AGREEMENT.

  1. Miscellaneous.

(a) Prohibition Against Data Mining. You are prohibited from data mining, scraping, crawling, email harvesting or using any process or processes that send automated queries to the Maple Grove Therapy and Wellness Website. You may not use the Maple Grove Therapy and Wellness Website to compile a collection of listings, including a competing listing product or service. You may not use the Website or any materials for any unsolicited commercial e-mail.

(b) Intended Audience. The Website is intended for adults only. The Website is not intended for any children under the age of 18 unless the individual is otherwise able to consent individually under applicable law.

(c) Compliance with Laws. You agree to comply with all applicable laws regarding your use of the Website. You further agreed that information provided by you is truthful and accurate to the best of your knowledge.

(d) Indemnification. You agree to indemnify, defend and hold Maple Grove Therapy and Wellness and our partners, employees, and affiliates, harmless from any liability, loss, claim and expense, including reasonable attorney’s fees, related to your violation of this Agreement or use of the Website.

(e) DMCA Notice. If you believe your work has been copied in a way that constitutes copyright infringement, please provide a notice containing all of the following information to our Copyright Agent:

(1) An electronic or physical signature of the person authorized to act on behalf of the owner of the copyright interest;

(2) A description of the copyrighted work that you claim has been infringed;

(3) A description of where the material that you claim is infringing is located on the Website;

(4) Your address, telephone number, and e-mail address;

(5) A statement by you that you have a good faith belief that the disputed use is not authorized by the copyright owner, its agent, or the law; and

(6) A statement by you, made under penalty of perjury, that the above information in your notice is accurate and that you are the copyright owner or authorized to act on the copyright owner’s behalf.

Our Copyright Agent for Notice of claims of copyright infringement on the Website is Maple Grove Therapy and Wellness, who can be reached as follows:

By Mail: 7200 Forestview Ln N, Maple Grove, MN 55369

By e-mail: kwesner@mgtwellness.com

Copyright © 2023

(f) Links. These terms of use apply only to our Sites, and not to the Sites of any other companies or organizations, including those we link to. We do not maintain, create, endorse, or take any responsibility for the contents, advertising, products or other materials made available through any other site, including those we link to. Under no circumstances will we be held responsible or liable, directly or indirectly, for any loss or damage that is caused or alleged to have been caused to you in connection with your use of any content, goods or services available on any other site. Other Sites may link to our Sites by permission only. To seek our permission, you may contact us at the information above. We reserve the right to rescind any permission granted to you or any organization in which we approve linking to our Sites, and to require termination of any such link to any of the Sites, at our discretion at any time.

(g) Force Majeure. Maple Grove Therapy and Wellness shall not be responsible for delays or failures in performance resulting from acts of God, strikes, lockouts, riots, acts of war and terrorism, embargoes, boycotts, changes in governmental regulations, epidemics, fire, communication line failures, power failures, earthquakes, other disasters or any other reason where failure to perform is beyond the control of, and not caused by, the non-performing party.

  1. Privacy


(a) Except as otherwise provided in this Policy, Maple Grove Therapy and Wellness does not collect personally identifiable information from individuals unless they provide it to Maple Grove Therapy and Wellness voluntarily and knowingly. The Maple Grove Therapy and Wellness only collects personal information for specific purposes such as responding to requests for information or to provide medical services. Maple Grove Therapy and Wellness will not sell or provide your information to unaffiliated companies for any purpose unrelated to the business of Maple Grove Therapy and Wellness. Except as provided herein, Maple Grove Therapy and Wellness will not disclose any information about you to unaffiliated companies or organizations without your consent, unless:

  1. required by law;
  2. we believe it necessary to respond to an inquiry or provide you with a service which you have requested;
  3. to implement the terms of our medical services;

(b) Maple Grove Therapy and Wellness recognizes the trust you place in it when you give out personal information. In order to operate the Website or deliver medical services within the State of Minnesota, Maple Grove Therapy and Wellness may sometimes share your minimal personal information with a service provider under strictly confidential conditions in order to assist you in your medical matter. Maple Grove Therapy and Wellness will not otherwise disclose your personal information to anyone without your explicit consent.

  1. Security

(a) Maple Grove Therapy and Wellness will take all reasonable steps to keep secure any information held about you, and to keep this information accurate and up-to-date. Any information you submit is stored on secure servers that are protected in controlled facilities. Maple Grove Therapy and Wellness and data processors respect the confidentiality of any personal information held by Maple Grove Therapy and Wellness. No data can be guaranteed to be 100% secure. Maple Grove Therapy and Wellness cannot give an absolute assurance that the information you provide will be secure at all times. Likewise, Internet, email and other electronic communication between you and Maple Grove Therapy and Wellness may be particularly susceptible to eavesdropping or unauthorized interception.

  1. Cookies and Other Information

(a) To Maple Grove Therapy and Wellness’s knowledge, Maple Grove Therapy and Wellness does not endorse, place or collect “cookies” on this web site for any reason. “Cookies” are small text files a Web site can use to recognize repeat users, facilitate the user’s ongoing access to and use of the site and to track usage behavior of, for example, the Web pages you visit.

(b) While Maple Grove Therapy and Wellness does not participate, benefit, or condone such information gathering, Maple Grove Therapy and Wellness’s web site software, web domain hosting service, or others in the chain of internet communication, may automatically collect Cookies and or other information and compile aggregate data for statistical purposes to improve content and services.

  1. Access to Your Information


(a) If at any time you want to know exactly what personal information we hold about you or wish to change personal information that is inaccurate or out of date, please contact us and Maple Grove Therapy and Wellness will amend the records.

  1. Viruses


(a) Maple Grove Therapy and Wellness uses appropriate commercially available anti-virus mechanisms to ensure that this Website does not contain or carry viruses. However, due to the rapidly developing nature of viruses and the Internet, it is strongly recommended that you employ anti-virus software when accessing the Maple Grove Therapy and Wellness’ web site. Maple Grove Therapy and Wellness makes no warranty that the web site or its e-mail correspondence is free from such viruses.

We respect your privacy as well as the privacy of our clients. We know that many visitors to the website may be concerned about the information they may provide and how that information is used. The following is provided to address those concerns. If you have any questions about this Policy, you may contact Maple Grove Therapy and Wellness or write to:

Maple Grove Therapy and Wellness
7200 Forestview Ln N
Maple Grove, MN 55369

We look forward to working with you.

Consent to Participate in a Telehealth Consultation

1. Telehealth

Telehealth includes the practice of health care delivery, diagnosis, consultation, treatment, transfer of protected health information, and education using synchronous or asynchronous audio, video, or data communications. I understand that my health care provider, through the Company (the “Company”). wishes me to engage in a Telehealth consultation with the Company. This means that I, or a designee, will, through an interactive video connection, or via telephone means if approved due to COVID, be able to consult with a designated healthcare practitioner about my condition.

2. Identity Verification

I may be expected to provide a copy of my driver’s license and other identity verifying documentation requested by the healthcare practitioner before any health services are provided.

3. Privacy and Security of Communications

All electronic communications between me and the healthcare practitioner will be transmitted using reasonable measures to ensure confidentiality. I will be responsible to secure and protect the functionality, integrity, and privacy of my hardware, files, and communication. Password protection for accessing my hardware and files is recommended. If others will be accessing the same computer, be aware that programs exist that copy every keystroke I make. It is recommended that I schedule my sessions with the undersigned healthcare practitioner when and where I can ensure the greatest level of privacy for all communications. Be sure to fully exit all programs and hardware at the end of each session. I explicitly waive confidentiality if there is another individual at my distant site I am using Telehealth at.

4. Risks Associated With Distance Services

There are privacy and security risks and consequences associated with Telehealth despite the policies and procedures in place to guard against them. The risks and consequences include, but are not limited to, interrupted or distorted transmission of data or information due to technical failures and access or interception of my protected health information by unauthorized persons.

By signing this information and consent form below, I acknowledge the limitations inherent in ensuring client confidentiality of information transmitted in Telehealth and agree to waive my privilege of confidentiality with respect to any confidential information that may be accessed by

an unauthorized third party despite the reasonable efforts of the Company to arrange a secure line of communication.

My health care provider has explained to me how the video conferencing technology will be used.

I understand that this consultation will not be the same as a face-to-face visit since I will not be in the same room as the healthcare practitioner, and that some parts of a visit may be conducted by individuals present with me at the direction of the healthcare practitioner. I also understand individuals may be present at either location to operate the audio/video equipment and that these individuals must maintain the confidentiality of health information disclosed, or if they join I at my discretion, then confidentiality may be waived.

I understand there are possible risks of an incomplete or ineffective consultation because of the technology, and that if any of the risks occur, the consultation may terminate. The risks may include:

  1. Failure, interruption or disconnection of the audio/video connection;
  • A picture that is not clear enough to meet the needs of the consultation;
  • A minor risk of access to the consultation through the interactive connection by electronic tampering.

I understand that in place of this Telehealth session I may seek face-to-face consultation with a health care provider.

I understand that I will not receive any royalties or other compensation for taking part in this Telehealth session or for the authorized use of any consultation images or audio.

I release the Company, its employees, agents and assigns from any and all liability which may arise from this Telehealth consultation, the use of interactive audio/visual connections, or from the taking or authorized use of any images or audio obtained.

5. Communication Interruptions

If I am unable to connect with the Telehealth platform or are disconnected during a session due to a technological breakdown, I will try to reconnect within 5 minutes. If reconnection is not possible the Company can be reached at the business phone number.

6. E-Mail and Text Messages

The undersigned healthcare practitioner may use and respond to e-mail and text messages only to arrange or modify appointments. Please do not send e-mails related to my treatment electronic

communications are not completely secure and confidential. Any health related questions or issues will not be addressed by the healthcare practitioner in any electronic communication but will be dealt with during my next health session. Any electronic transmissions of information by me are retained in the logs of my service providers. While it is unlikely that someone will be looking at these logs, they are, in theory, available to be read by the system administrator(s) of the service providers. I should know that any e-mails or any communications sent via Facebook, online and specifically the Company website are not secure, and I assume the risks of the insecure transmission.

7. Audio and Video Recordings

I acknowledge and, by signing this information and consent form below, agree that neither I nor the undersigned healthcare practitioner will record any part of my sessions unless I and the Company mutually agree in writing that the health session may be recorded. I further acknowledge that the Company objects to me recording any portion of my sessions without the Company’s written consent. I expressly agree that audio and video recordings used for security or legal and documentation purposes are not part of my health records, and are therefore not protected by confidentiality or any other provisions under this agreement.

8. Consent to Treatment Using Telehealth and Distance Health Services

I voluntarily agree to receive synchronous (or asynchronous) assessment, care, treatment, and services through the use of email and texts and authorize the Company to provide such care, treatment, or services as are considered necessary and advisable. Ample opportunity has been offered to me to ask questions and seek clarification of anything unclear to me.

9. COVID

To minimize public health risks associated with the virus (COVID-19) and the national public health emergency, the Company is limiting the provision of in-person services until further notice. During this time, employees, contractors and staff will encourage individuals receiving our services to take care of their health and continue receiving services over the phone or virtually, as allowed by law.

  • Individuals will be contacted in order to inform them of the suspension of in-person services.
  • “Virtual” services refer to services provided through video conferencing software, with the verbal consent of the individual or their legal guardian if written consent is unavailable.
  • Individuals will be given the option to engage in virtual services and will be required to provide verbal consent to this form of communication in order to engage in these services, if written consent is unavailable.
  • Verbal consent will be accepted in place of signature when individuals consent to services at Intake, consent to receive virtual services, or wish to authorize the release of information to coordinate services both verbally and in writing.
  • When the option of in-person services becomes available again, all individuals who gave verbal consent and wish to continue services will be notified. At that time, individuals will need to provide signature for a written consent in order to continue services.
  • By signing this agreement, I acknowledge the contagious nature of COVID-19 and voluntarily assume the risk that I may be exposed to or infected by COVID-19 by receiving or providing services and that such exposure or infection may result in personal injury, illness, permanent disability, and death. I understand that the risk of becoming exposed to or infected by COVID-19 may result from the actions, omissions, or negligence of myself and others, including, but not limited to, Company employees, contractors and agents. I voluntarily agree to assume all of the foregoing risks and accept sole responsibility for any injury to myself (including, but not limited to, personal injury, disability, and death), illness, damage, loss, claim, liability, or expense, of any kind, that I may experience. I hereby release, covenant not to sue, discharge, and hold harmless the Company, its employees, agents, and representatives, of and from all liabilities, claims, actions, damages, costs or expenses of any kind arising out of or relating thereto. I understand and agree that this release includes any claims based on the actions, omissions, or negligence of the Company, its employees, agents, and representatives. I agree to follow directions of the Company, state and federal agencies in regard to safe conduct in regard to COVID-19.

USE OF VIDEO CONFERENCING TO RECEIVE SERVICES DURING COVID

There are potential benefits to receiving services through video conferencing or phone during this time. Two main benefits are: 1) we can initiate or continue to provide necessary health services, including talking about how I am doing and what may be helpful for me during this time of the virus, and 2) we reduce the health risks for me and for the general public (everyone) by minimizing personal contact and the potential spread of illness.

There are potential risks to receiving services this way, including limits to confidentiality. There is a small risk for phone and video conferencing communications to be intercepted or disrupted (e.g., cut off due to lost internet connection). The Company will use only secure programs for these meetings, unless insecure programs are allowable by law and chosen by me and the Company, however there is always a risk that confidentiality of any electronic communication can be broken or compromised. This applies to email, phone, and text messages that I send every day as well; it is not new to this time or situation. While the Company providers will

provide services in private spaces and take all precautions to maintain the confidentiality of the phone/video conference/email/text communications with me, the Company cannot guarantee that such communications will not be intercepted.

Confidentiality still applies for video conferencing services, and the Company will not record the session. The Company provider will be in a private space and make every effort to avoid or minimize interruptions. This also applies to interpreters. My provider will explain how to access and use the video conferencing tool.

I may need to use a webcam (laptop with a camera) or smartphone during the video conferencing session.

It is important to not be in a public place (library, café) and to be in a space that is as quiet and private as possible during the session. It is preferred to use a secure internet connection.

If I have a legal guardian, we need the permission of my legal guardian for me to participate in video conference sessions.

HOW AND WHEN TO DISCONTINUE TELEHEALTH SERVICES

Telehealth services and care may not be as effective as face-to-face services. The Company will continually assess the appropriateness of Telehealth for me. If the Company determines that I would be better served by receiving different services, such as face-to-face services, recommendations for treatment and treatment providers or facilities will be provided to me. I may also communicate to my provider that Telehealth services are no longer appropriate for me. My provider will consider patient safety (e.g., suicidality) and health concerns (e.g. viral risk; mobility; immune function), community risk, and the psychologist health when deciding to do Telehealth services versus in-person.

VERBAL CONSENT

Verbal consent will be accepted in place of written signatures. Employees and Contractors and staff will review all documents with I over the phone and documents will be available to view on the Company website. Paper copies can be mailed by request.

Records will include the statement, “Consent obtained verbally due to current health and safety concerns related to COVID-19 pandemic. Company will make efforts to obtain new forms with written signatures once we return to face to face service delivery.”

I can revoke consent to this Agreement at any time. If consent is revoked or not given, services may be interrupted during the time that Company staff and many others are working remotely due to the public health emergency. We encourage I to try video conferencing or other communication methods while we are not able to see I in person.

If I give verbal consent for communication with other service providers or members of my care team, I may withdraw consent at any time.

Patient/Representative Signature Date

Relationship to Patient Witness Signature if applicable

Initial Here if consent obtained verbally due to current health and safety concerns related to COVID-19 pandemic. Company will make efforts to obtain new forms with written signatures once we return to face to face service delivery.

Notice of Privacy Practices and HIPAA Consent Form

Effective January 1, 2021

This notice describes how mental health information about you may be used and disclosed and how you can get access to this information. Please review it carefully.

I, Kelly Wesner of Maple Grove Therapy and Wellness, am required by law to maintain the privacy of your protected health information (PHI) and to provide you with notice of your privacy rights and my legal duties and privacy practices with respect to your PHI. I am required to abide by the terms of this notice with respect to your PHI but reserve the right to change the terms of this notice and make the new notice provisions effective for all PHI that I maintain. I will provide you with a copy of the revised notice sent by regular mail to the last address you have provided to me for this communication purpose.

Understanding Your Personal Health Information

Each time you visit a hospital, physician, mental health professional, or other health care provider, a record of your visit is made. Typically, this record contains your symptoms; examination and test results; diagnoses; treatment; in the case of a mental health professional, psychotherapy notes; and a plan for future care or treatment. This information, often referred to as your health or medical record, serves as a:

  • Basis for planning your care and treatment.
  • Means of communication among the many health professionals who contribute to your care.
  • Legal document describing the care you received.
  • Means by which you or a third-party payer can verify that services billed were actually provided, a tool in educating health professionals.
  • Source of data for medical research.
  • Source of information for public health officials charged with improving the health of the nation, a source of data for facility planning and marketing.
  • Tool with which we can assess and continually work to improve the care we render and the outcomes we achieve.

Understanding what is in your record and how your health information is used helps you to:

  • Means to ensure its accuracy.
  • Way to better understand who, what, when, where, and why others may access your health information.
    • Means to make more informed decisions when authorizing disclosure to others.

Your Health Information Rights

Although your health record is the physical property of my practice, the facility that compiled it, the information belongs to you. You have the following privacy rights:

  1. The right to request restrictions on the use and disclosure of your PHI to carry out treatment, payment, or health care operations.

You should note that I am not required to agree to be bound by any restrictions that you request but am bound by each restriction that I do agree to.

  • In connection with any patient directory, the right to request restrictions on the use and disclosure of your name, location at this treatment facility, description of your condition and your religious affiliation. I do not maintain a patient directory.
  • To receive confidential communication of your PHI unless I determine that such disclosure would be harmful to you.
  • To inspect and copy your PHI unless I determine in the exercise of my professional judgment that the access requested is reasonably likely to endanger your life, emotional or physical safety or that of another person.

You may request copies of your PHI by providing me with a written request for such copies. I will provide you with copies within ten (10) business days of your request at my office. You may be charged for each page copied and you will be expected to pay for the copies at the time you pick them up.

  • To amend your PHI upon your written request to me setting forth your reasons for the requested amendment. I have the right to deny the request if the information is incomplete or has been created by another entity.

I am required to act on your request to amend your PHI within sixty (60) days but this deadline may be extended for another thirty (30) days upon written notice to you. If I deny your requested amendment, I will provide you with written notice of my decision and the basis for my decision. You will then have the right to submit a written statement disagreeing with my decision which will be maintained with your PHI. If you do not wish to submit a statement of disagreement, you

may request that I provide your request for amendment and my denial with any future disclosures of your PHI.

  • Upon request to receive an accounting of disclosures of your PHI made within the past 6 years of your request for an accounting. Disclosures that are exempt from the accounting requirement include the following:
    • Disclosures necessary to carry out treatment, payment, and health care operations.
    • Disclosures made to you upon request.
    • Disclosures made pursuant to your authorization.
    • Disclosures made for national security or intelligence purposes.
    • Permitted disclosures to correctional institutions or law enforcement officials.
    • Disclosures that are part of a limited data set used for research, public health, or health care operations. I am required to act on your request for an accounting within sixty (60) days but this deadline may be extended for another thirty (30) days upon written notice to you of the reason for the delay and the date by which I will provide the accounting. You are entitled to one (1) accounting in any twelve (12) month period free of charge. For any subsequent request in a twelve (12) month period you will be charged a reasonable fee allowed by law for each page copied and you will be expected to pay for the copies at the time you pick them up.
  • To receive a paper copy of this privacy notice even if you agreed to receive a copy electronically.
  • To pay out-of-pocket for a service and the right to require that I not submit PHI to your health plan.
  • To be notified of a breach of your unsecured PHI.
  1. The right to complain to me and to the Secretary of the U.S. Department of Health and Human Services if you believe your privacy rights have been violated. You may submit your complaint to me in writing setting out the alleged violation. I am prohibited by law from retaliating against you in any way for filing a complaint with me or Health and Human Services.
  2. If your records are maintained electronically, the right to receive a copy of your PHI in an electronic format and to direct in writing that a third party receive a copy of your PHI in an electronic format.

Uses and Disclosures

Your written authorization is required before I can use or disclose my psychotherapy notes which are defined as my notes documenting or analyzing the contents of our conversations

during our sessions and that are separated from the rest of your clinical file. Psychotherapy notes do not include medication prescription and monitoring, session start and stop times, the modalities and frequencies of treatment furnished, results of clinical tests, and any summary of the following items: diagnosis, functional status, the treatment plan, symptoms, prognosis, and progress to date.

It is my policy to protect the confidentiality of your PHI to the best of my ability and to the extent permitted by law. There are times however, when use or disclosure of your PHI, including psychotherapy notes, is permitted or mandated by law even without your authorization.

Situations where I am not required to obtain your consent or authorization for use or disclosure of your PHI psychotherapy notes include the following circumstances:

  • By myself or my office staff for treatment, payment, or health care operations as they relate to you.
    • For example: Information obtained by me will be recorded in your record and used to determine the course of treatment that should work best for you. I will document in your record our work together and when appropriate I will provide a subsequent health care provider with copies of various reports that should assist him or her in treating you once we have terminated our therapeutic relationship.
    • For example: A bill may be sent to you or a third-party payer. The information on or accompanying the bill may include information that identifies you, as well as your diagnosis, procedures, and supplies used.
    • In the event of an emergency to any treatment provider who provides emergency treatment to you.
    • To defend myself in a legal action or other proceeding brought by you against me.
    • When required by the Secretary of the Department of Health and Human Services in an investigation to determine my compliance with the privacy rules.
    • When required by law insofar as the use or disclosure complies with and is limited to the relevant requirements of such law.
      • Examples: To a public health authority or other government authority authorized by law to receive reports of child abuse or neglect.
    • If I reasonably believe an adult individual to be the victim of abuse, neglect or domestic violence, to a governmental authority, including a social services agency authorized by law to receive such reports to the extent the disclosure is required by or authorized by law or you agree to the disclosure and I believe that in the exercise of my professional judgment disclosure is necessary to prevent serious harm to you or other potential victims. If I make such a report I am obligated to inform you unless I believe informing the adult individual will place the individual at risk of serious injury.

In the course of any judicial or administrative proceeding in response to:

  • An order of a court or administrative tribunal so long as only the PHI expressly authorized by such order is disclosed.
    • A subpoena, discovery request, or other lawful process, that is not accompanied by an order of a court or administrative tribunal so long as reasonable efforts are made to give you notice that your PHI has been requested or reasonable efforts are made to secure a qualified protective order, by the person requesting the PHI.
    • Child custody cases and other legal proceedings in which your mental health or condition is an issue are the kinds of suits in which your PHI may be requested. In addition I may use your PHI in connection with a suit to collect fees for my services.
    • In compliance with a court order or court ordered warrant, or a subpoena or summons issued by a judicial officer, a grand jury subpoena or summons, a civil or an authorized investigative demand, or similar process authorized by law provided that the information sought is relevant and material to a legitimate law enforcement inquiry and the request is specific and limited in scope to the extent reasonably practicable in light of the purpose for which the information is sought and de-identified information could not reasonably be used.
    • To a health oversight agency for oversight activities authorized by law as they may relate to me (i.e., audits; civil, criminal, or administrative investigations, inspections, licensure, or disciplinary actions; civil, administrative, or criminal proceedings or actions).
    • To a coroner or medical examiner for the purpose of identifying a deceased person, determining a cause of death, or performing other duties as authorized by law.
    • To funeral directors consistent with applicable law as necessary to carry out their duties with respect to the decedent.
    • To the extent authorized by and the extent necessary to comply with laws relating to workers compensation or other similar programs established by law.
    • If use or disclosure is necessary to prevent or lessen a serious and imminent threat to the health or safety of a person or the public and the disclosure is made to a person or persons reasonably able to prevent or lessen the threat, including the target of the threat.
    • To a public health authority that is authorized by law to collect or receive such information for the purposes of preventing or controlling a disease, injury, or disability, including, but not limited to, the reporting of disease, injury, vital events such as birth, death, and the conduct of public surveillance, public health investigations, and public health interventions.
    • To a person who may have been exposed to a communicable disease or may otherwise be at risk of contracting or spreading a disease or condition, if the covered entity or public health authority is authorized by law to notify such persons as necessary in the conduct of a public health intervention or investigation.
    • To a public health authority or other appropriate governmental authority authorized by law to receive reports of child abuse or neglect.
  • To a law enforcement official if I believe in good faith that the PHI constitutes evidence of criminal conduct that occurs on my premises.
    • Using my best judgment, to a family member, other relative or close personal friend, or any other person you identify, I may disclose PHI that is relevant to that person’s involvement in your care or payment related to your care.
    • To authorized federal officials for the conduct of lawful intelligence, counterintelligence, and other national security activities authorized by the National Security Act and implementing authority.
    • To Business Associates under a written agreement requiring Business Associates to protect the information. Business Associates are entities that assist with or conduct activities on my behalf including individuals or organizations that provide legal, accounting, administrative, and similar functions.
    • To family members and others involved in your care prior to your death, unless doing so would be inconsistent with any prior expressed preferences you have made known to me, but limited to PHI relevant to the family member or other person’s involvement in your health care or payment.

I may contact you with appointment reminders or information about treatment alternatives or other health related benefits and services that may be of interest to you.

If you have any questions and would like additional information you should bring this to my attention at the first opportunity. I am the designated Privacy Officer for my practice and will be glad to respond to your questions or request for information.

Practitioner Name: Kelly Wesner

Business Name: Maple Grove Therapy and Wellness

Business Address: 7200 Forestview Ln N, Maple Grove, MN 55369 Telephone number: 763-200-1466

Client Consent Form

I understand that as part of my health care, the undersigned therapist originates and maintains health records describing my health history, symptoms, evaluations and test results, diagnosis, treatment, psychotherapy notes, and any plans for future care or treatment. I understand that this information is utilized to plan my care and treatment, to bill for services provided to me, to communicate with other health care providers, and to carry out other routine health care operations such as assessing quality and reviewing competence of healthcare professionals.

The Notice of Privacy Practices for Maple Grove Therapy and Wellness provides specific information and a thorough description of how my personal health information may be used and disclosed. I have been provided a copy of or access to the Notice of Privacy Practices and I have been given the opportunity to review the notice prior to signing this consent. Before implementation of any revised Notice of Privacy Practices, the revised Notice will be mailed to me at the address I designate below. I understand that I have the right to restrict the use and/or disclosure of my personal health information for treatment, payment, or health care operations and that I am not required to agree to the restrictions requested. I may revoke this consent at any time in writing except to the extent that Maple Grove Therapy and Wellness has already taken action in reliance on my prior consent. This consent is valid until revoked by me in writing.