The views and descriptions herein of My Rooted Soul Counseling website constitute the opinions and thoughts of the writer and are considered to be educative in nature and form. No form of this website is viewed as therapeutic treatment, psychological therapy, legal advice, absolutes, or continuing education units. As such the user should understand its use to be at one’s own risk. Should adverse events, writing consideration, use of views, creation of an event or enforcement of such views on the self or public cause pain, problems or changes that are unwelcome the writer is not liable for said circumstances unless participating in a mutual legally binding treatment consent contract provided during initial scheduling and first appointments to all clients.





ACKNOWLEDGEMENT RECEIPT OF NOTICE OF PRIVACY PRACTICES: By signing your NEW CLIENT INFORMATION AND REGISTRATION FORM when you begin receiving professional services from Andrew Siefers Counseling LLC Dba My Rooted Soul, you acknowledge and confirm you have been given this Notice of Privacy Practices. This paperwork is provided through encrypted digital services directly by HIPAA compliant email for your record and brought by the client in paper form with signatures to the initial session when you begin counseling. These records are maintained for the duration time as indicated and administered by the Texas LPC Board or its subsequently named administrative body.

 Your health record contains personal information about you and your health. This information, which may identify you and relates to your past, present or future physical or mental health or condition and related health care services, is referred to as Protected Health Information (“PHI”). This Notice of Privacy Practices describes how I may use and disclose your PHI in accordance with applicable law. It also describes your rights regarding how you may gain access to and control your PHI.

I am required by law to maintain the privacy of PHI and to provide you with notice of my legal duties and privacy practices with respect to PHI. I am required to abide by the terms of this Notice of Privacy Practices. I reserve the right to change the terms of our Notice of Privacy Practices at any time. Any new Notice of Privacy Practices will be effective for all PHI that I maintain at that time and I will have a copy of the revised Notice available at


FOR TREATMENT: Your PHI may be used and disclosed by those who are involved in your care for the purpose of providing, coordinating, or managing your health care treatment and related services. This includes consultation with other treatment team members. I may disclose PHI to any other consultant only with your authorization.

FOR PAYMENT: I may use or disclose PHI so that I can receive payment for the treatment services provided to you. This will only be done with your authorization. Examples of payment-related activities are: making a determination of eligibility of coverage for insurance benefits, processing claims with your insurance company, reviewing services with managed care to determine if more services are needed, or doing required utilization review. If it becomes necessary to use collection processes due to lack of payment for services, I will only disclose the minimum amount of PHI necessary for purposes of collection.

FOR HEALTH CARE OPERATIONS: I may use or disclose, as needed, your PHI in order to support business activities including, but not limited to, reminding you of appointments, to provide information about treatment alternatives or other health related benefits and services, licensing, and conducting or arranging for other business activities. For example, I may share your PHI with third parties that perform various business activities (e.g., billing or typing services) provided I have a written contract with the business to safeguard the privacy of your PHI. For training or teaching purposes PHI will be disclosed only with your authorization.

REQUIRED BY LAW: Under the law, I must make disclosures of your PHI to you upon your request. In addition, I must make disclosures to the Secretary of the Department of Health and Human Services for the purpose of investigating or determining compliance with the requirements of the Privacy Rule.

WITHOUT AUTHORIZATION: Applicable law and ethical standards permit me to disclose information about you without your authorization only in a limited number of other situations. The types of uses and disclosures that may be made without your authorization are those that are:

  • Required by law, such as the mandatory reporting of child abuse or neglect or mandatory government agency audits or investigations (such as the social work licensing board or health department)

  • Required by Court Order

  • Necessary to prevent or lessen a serious and imminent threat to the health or safety of a person or the public.  If information is disclosed to prevent or lessen a serious threat, it will be disclosed to a person or persons reasonably able to prevent or lessen the threat, including the target of the threat.

VERBAL PERMISSION: I may use or disclose your information to family members that are directly involved in your treatment with your verbal permission.

WITH AUTHORIZATION: Uses and disclosures not specifically permitted by applicable law will be made only with your written authorization, which may be revoked.

YOUR RIGHTS REGARDING YOUR PHI: You have the following rights regarding your personal PHI maintained by my office. To exercise any of these rights, please submit your request in writing to Andrew Siefers Counseling PLLC, at the address listed above:

  • Right of Access to Inspect and Copy. You have the right, which may be restricted only in exceptional circumstances, to inspect and copy PHI that may be used to make decisions about your care. Your right to inspect and copy PHI will be restricted only in those situations where there is compelling evidence that access would cause serious harm to you. I may charge a reasonable, cost-based fee for copies.

  • Right to Amend. If you feel that the PHI I have about you is incorrect or incomplete, you may request an amendment to the information, although I am not required to agree to the amendment.

  • Right to an Accounting of Disclosures. You have the right to request an accounting of certain disclosures that I make of your PHI. I may charge you a reasonable fee if you request more than one accounting in any 12-month period.

  • Right to Request Restrictions. You have the right to request a restriction or limitation on the use or disclosure of your PHI for treatment, payment, or health care operations. I am not required to agree to your request.

  • Right to Request Confidential Communication. You have the right to request that I communicate with you about medical matters in a certain way or at a certain location.

  • Right to a Copy of this Notice. You have the right to a copy of this Notice.

  • Electronic Transactions Standards.

COMPLAINTS: If you believe I have violated your privacy rights, you have the right to file a complaint in writing with Andrew Siefers Counseling PLLC, or with the Texas State Department of Health Services at P.O. Box 141369, Austin, Texas 78714-1369 or call their complaint hotline at 1-800-942-5540.