PROFESSIONAL DISCLOSURE STATEMENT

InnerSearch Counseling, Daniel Shepherd DMin, LLC,

210 W. University Rochester, MI 48307 Cellphone: 248.687.9251

LMFT License # 4101007174

Focus of Treatment

(For couples) Relationship therapy works best when the focus is on you and your partner – present in the room. That will be our focus. In order to go forward, I ask for your consent on the following agreements.

(For individuals) Mutual trust and respect are necessary ingredients within the counseling processes. I ask for your consent on the following agreements.

Confidentiality

Information disclosed within sessions is confidential. I cannot release that information to anyone without your written permission except where disclosure is permitted or required by law. Those situations are rare, but the main ones are:

(a) when there is reasonable suspicion of abuse to a child, a dependent, or an elder adult;

(b) when a client threatens bodily injury to self or others;

(d) when required pursuant to a legal proceeding.

I consult with colleagues and typically bring questions for advice. In such cases, neither your name nor any identifying information about you is revealed.

Medical records will be kept through Therapy Notes, a secure, online electronic medical record system. Digital communications will be limited to avoid disclosure of confidential information.

No Secrets Policy (For Couples Therapy)

When a couple enters counseling, they are as one. This means my allegiance is to you as a unique entity – not to either partner individually. Both partners must feel safe in the therapy process. I adhere to a “No Secrets” policy. This means I will not keep secrets for either partner. This helps avoid a conflict of interest in which your therapist would form an allegiance with one person over the other, and would also promote mutual distrust.

On occasion, partners may be seen for individual counseling sessions. In this case, the individual session is still considered as part of the couple’s counseling relationship. Information disclosed during individual sessions may prove very important to couple’s counseling. If you choose to share such information, I will recommend you disclose it during a couple’s session, and will provide guidance in the process. If someone refuses to disclose this information within the couple’s session, I may determine that it is necessary to discontinue couple’s counseling. If someone needs a context of individual confidentiality, I can provide referrals to qualified therapists. This policy is intended to maintain integrity within our couple’s/marital counseling relationship.

Court Proceedings/Subpoena of Records (For couples)

The purpose of marital/couple’s therapy is to ameliorate distress within a relationship. Therefore, if both partners request my services as a marriage and family therapist, they are expected not to use information given to me during the therapy process against each other in a judicial setting of any kind, be it civil, criminal, or circuit. Likewise, neither party shall for any reason attempt to subpoena my testimony or my records to be presented in a deposition or court hearing of any kind for any reason, such as a divorce case.

Release of Records

You must provide a consent to release medical records (form available upon request).

(For couples) Both partners must provide their consent to release marital/couple’s counseling records. If one partner does not provide consent, records will not be released.

Course of Treatment

Continued participation in counseling is voluntary. You may suspend or terminate therapy upon request.

(For couples) The continued participation by each person is voluntary. Either participant may suspend or terminate therapy at her or his individual request.

Education and Experience

I am a fully Licensed Marriage and Family Therapist, with a master’s in counseling and post-master’s training in couple’s therapy (from Oakland University), and a certificate from Gottman Institute in Level 1 Clinician Training for couples’ therapy, and a doctorate in sacred studies (Ashland Theological Seminary). I have also gone through psychotherapy as a patient. My work experience includes ten years as a full-time counselor (and seven years of pastoral work prior to that). Family time, exercise, meditation, and spiritual disciplines help keep me balanced.

At this time we accept the following Health Insurance Policies: Blue Cross/Blue Shield, Aetna, UHC, Blue Care Network, and EAP (various providers). Private pay rates for couples range from $100 to $160 per session based on household income. Private pay rates for individuals range from $65 to $150 per session.

Complaints

In the event you need to file a complaint regarding our counseling service, please contact:

Michigan Department of Licensing and Regulatory Affairs Bureau of Professional Licensing Investigations & Inspections Division P.O. Box 30670  Lansing, MI 48909 (517) 241-0205  

HIPPA AND PRIVACY POLICIES

YOUR RIGHTS
Your rights regarding PHI are explained below. To exercise these rights, please submit a written request to the Practice at the address noted below.

To inspect and copy PHI.
• You can ask for an electronic or paper copy of PHI.
• The Practice may deny your request if it believes the disclosure will endanger your life or another person’s life. You may have a right to have this decision reviewed.

To request confidential communications.
• You can ask the Practice to contact you in a specific way. The Practice will say “yes” to all reasonable requests.

To limit what is used or shared.
• You can ask the Practice not to use or share PHI for treatment, payment, or business operations. The Practice is not required to agree if it would affect your care.
• If you pay for a service or health care item out-of-pocket in full, you can ask the Practice not to share PHI with your health insurer.
• You can ask for the Practice not to share your PHI with family members or friends by stating the specific restriction requested and to whom you want the restriction to apply.

To obtain a list of those with whom your PHI has been shared.
• You can ask for a list, called an accounting, of the times your health information has been shared. You can receive one accounting every 12 months at no charge, but you may be charged a reasonable fee if you ask for one more frequently.

To receive a copy of this Notice.
• You can ask for a paper copy of this Notice, even if you agreed to receive the Notice electronically.

To choose someone to act for you.
• If you have given someone medical power of attorney or if someone is your legal guardian, that person can exercise your rights.

OUR USES AND DISCLOSURES
1. Routine Uses and Disclosures of PHI
The Practice is permitted under federal law to use and disclose PHI, without your written authorization, for certain routine uses and disclosures, such as those made for treatment, payment, and the operation of our business. The Practice typically uses or shares your health information in the following ways:

To treat you.
• The Practice can use and share PHI with other professionals who are treating you.
• Example: Your primary care doctor asks about your mental health treatment.

To run the health care operations.
• The Practice can use and share PHI to run the business, improve your care, and contact you.
• Example: The Practice uses PHI to send you appointment reminders if you choose.

To bill for your services.
• The Practice can use and share PHI to bill and get payment from health plans or other entities.
• Example: The Practice gives PHI to your health insurance plan so it will pay for your services.

2. Uses and Disclosures of PHI That May Be Made Without Your Authorization or Opportunity to Object
The Practice may use or disclose PHI without your authorization or an opportunity for you to object, including:

To help with public health and safety issues
• Public health: To prevent the spread of disease, assist in product recalls, and report adverse reactions to medication.
• Required by the Secretary of Health and Human Services: We may be required to disclose your PHI to the Secretary of Health and Human Services to investigate or determine our compliance with the requirements of the final rule on Standards for Privacy of Individually Identifiable Health Information.
• Health oversight: For audits, investigations, and inspections by government agencies that oversee the health care system, government benefit programs, other government regulatory programs, and civil rights laws.
• Serious threat to health or safety: To prevent a serious and imminent threat.
• Abuse or Neglect: To report abuse, neglect, or domestic violence.

To comply with law, law enforcement, or other government requests
• Required by law: If required by federal, state or local law.
• Judicial and administrative proceedings: To respond to a court order, subpoena, or discovery request.
• Law enforcement: For law locate and identify you or disclose information about a victim of a crime.
• Specialized Government Functions: For military or national security concerns, including intelligence, protective services for heads of state, or your security clearance.
• National security and intelligence activities: For intelligence, counterintelligence, protection of the President, other authorized persons or foreign heads of state, for purpose of determining your own security clearance and other national security activities authorized by law.
• Workers’ Compensation: To comply with workers’ compensation laws or support claims.

To comply with other requests
• Coroners and Funeral Directors: To perform their legally authorized duties.
• Organ Donation: For organ donation or transplantation.
• Research: For research that has been approved by an institutional review board.
• Inmates: The Practice created or received your PHI in the course of providing care.
• Business Associates: To organizations that perform functions, activities or services on our behalf.

3. Uses and Disclosures of PHI That May Be Made With Your Authorization or Opportunity to Object
Unless you object, the Practice may disclose PHI:

To your family, friends, or others if PHI directly relates to that person’s involvement in your care.

If it is in your best interest because you are unable to state your preference.

4. Uses and Disclosures of PHI Based Upon Your Written Authorization
The Practice must obtain your written authorization to use and/or disclose PHI for psychotherapy notes.

You may revoke your authorization, at any time, by contacting the Practice in writing, using the information above. The Practice will not use or share PHI other than as described in Notice unless you give your permission in writing.

OUR RESPONSIBILITIES
• The Practice is required by law to maintain the privacy and security of PHI.
• The Practice is required to abide by the terms of this Notice currently in effect. Where more stringent state or federal law governs PHI, the Practice will abide by the more stringent law.
• The Practice reserves the right to amend Notice. All changes are applicable to PHI collected and maintained by the Practice. Should the Practice make changes, you may obtain a revised Notice by requesting a copy from the Practice, using the information above, or by viewing a copy on the website WWW.InnerSearch.Net.
• The Practice will inform you if PHI is compromised in a breach.

This Notice is effective on 17 October 2025