Dr. Piper Glasier, MSW, LCSW, Psy.D


License #LCS 20600

25301 Cabot Road, Suite 216

Laguna Hills, CA 92653

P.O. Box 6262

Laguna Niguel, CA 92607

Business Phone: 949-443-2222

Cell phone for texting: 949-292-0725








Welcome to my practice.  This document (the Agreement) contains important information about the Health Insurance Portability and Accountability Act (HIPAA), a federal law that provides privacy protections and patient rights with regard to the use and disclosure of your Protected Health Information (PHI) used for the purposes of treatment, payment, and health care operations.  HIPAA requires that I provide you with a Notice of Privacy Practices (the Notice) for use and disclosure of PHI for treatment, payment, and health care operations.  The Notice, which is part of this Agreement, explains HIPAA and its application to your personal health information in greater detail.  The law requires that I obtain your signature acknowledging that I have provided you with this information.  It is important that you read through this information carefully.  We can discuss any questions you have about the procedures.  When you sign this document, it will also represent an agreement between us.  You may revoke this Agreement in writing at any time or in the course of discussion between us. This revocation will be binding on me unless I have taken action in reliance on it; if there are obligations imposed on me by your health insurer in order to process or substantiate claims made under your policy; or if you have not satisfied any financial obligations you have incurred.




Psychotherapy Services


Psychotherapy is not easily described in general statements.  It varies depending on the personalities of the psychotherapist and patient, and the particular problems you are experiencing.  There are many different methods I may use to deal with the problems you hope to address.  Psychotherapy calls for a very active effort on your part.  In order for therapy to be most successful, you will have to work on things we talk about both during sessions and between sessions.  Psychotherapy can have benefits and risks.  Since therapy involves discussing unpleasant aspects of your life, you may experience uncomfortable feelings like sadness, guilt, anger, frustration, loneliness, loss, and helplessness.  On the other hand, psychotherapy has been shown to have many benefits.  Therapy often leads to better relationships, solutions to specific problems, and a significant reduction in feelings of distress.  There are no guarantees of what you will experience.







Sessions are 45 minutes in length.  One hour sessions are available, as well as double sessions.  Often clients opt to come more than once a week so the work can reach a deeper level more quickly, and themes can remain open and built upon the next session without having to wait a full week.


Cancellation of Session


I consider the time I schedule for you, whether it is one time per week or multiple times per week, as a "lease" of my time.  I reserve this time specifically for you.  If you cannot make it to the session (whether due to illness, any type of emergency, or any other reason), and we cannot reschedule a time during the same week, I will charge you for the missed session.  The exception to this is if you give me at least two weeks notice of an upcoming vacation.  In this case, I will not charge you for the missed session(s).




Payment is to be made by cash, check, or credit card at the time of the appointment.  I would appreciate it if you make out your check before the session begins in order to maximize your valuable session time.  Insurance is the responsibility of each patient.  You will receive a statement at the end of each session from the previous session, which is acceptable for submission by most insurance companies.


Professional Fees


My 45 minute session fee is listed on my website. Full hour sessions as well as double sessions are available. In addition to session time, I charge this amount for other professional services you may need, though I will proportion the cost if I work for periods of more or less than one session.  Other services include report writing, telephone sessions, consulting with other professionals with your permission, preparation of records or treatment summaries, and the time spent performing any other services that you may request of me that I agree to perform.  If you become involved in legal proceedings that require my participation, you will be expected to pay for all of my professional time, including preparation and transportation costs, even if I am called to testify by another party.  Because of the difficulty of legal involvement and the potential disruption to my schedule, I may charge a proportionately higher per hour fee for preparation and attendance at any legal proceeding.  I generally do not agree to be involved in legal proceedings if it is left to my choice.


Contacting Me


Due to my work schedule, I am often not immediately available by telephone.  You may leave a message on my voice mail, at: 949-443-2222 or at my email address: drglasier@gmail.com, or by leaving me a text on my cell phone: 949-292-0725, all of which I monitor frequently.  I will make every effort to return your call on the same day you make it, with the exception of weekends and holidays.  If you are difficult to reach, please inform me of some times when you will be available.  If you are unable to reach me and feel that you cannot wait for me to return your call, contact your family physician or the nearest emergency room and ask for the psychotherapist or psychiatrist on call.  If I will be unavailable for an extended time, I will provide you with the name of a colleague to contact, if necessary, on my business telephone: 949-443-2222.


Billing and Payments


You will be expected to pay for each session at the time of each session, unless we agree otherwise. Payment schedules for other professional services will be agreed to when they are requested. In circumstances of unusual financial hardship, I may be willing to negotiate a fee adjustment.  We will also agree to periodic review of raising your fee with regard to changes in your circumstances and/or cost of living adjustment.




Insurance Reimbursement


In order for us to set realistic treatment goals and priorities, it is important to evaluate what resources you have available to pay for your treatment.  If you have a "PPO" health insurance policy, it will usually provide some coverage for mental health treatment.  You will be responsible for billing your own insurance. I will respond to requests from your insurance company only after discussing it with you.  I will provide you with whatever assistance I can in helping you receive the benefits to which you are entitled; however, you (not your insurance company) are responsible for full payment of my fees.  It is very important that you find out exactly what mental health services your insurance policy covers. You should carefully read the section in your insurance coverage booklet that describes mental health services. I will generally be considered an "out-of-network" provider. If you have questions about the coverage, call your plan administrator.


You should also be aware that your contract with your health insurance company may require that I provide it with information relevant to the services I provide you.  I am required to provide a clinical diagnosis.  Sometimes I am required to provide additional clinical information such as treatment plans or summaries, or copies of your entire Clinical Record. Before I can disclose this information, both you and I must receive written notification from the insurer stating what they are requesting, why they are requesting it, how long it will be kept, and what will be done with the information when they are finished with it.  In such situations, I will make every effort to release only the minimum information about you that is necessary for the purpose requested.  This information will become part of the insurance company files and will probably be stored in a computer.  Though all insurance companies claim to keep such information confidential, I have no control over what they do with it once it is in their hands. In some cases, they may share the information with a national medical information databank. I will provide you with a copy of any reports I submit, if you request it.  By signing this Agreement, you agree that I can provide requested information to your insurance carrier.


Once we have all the information about your insurance coverage, we will discuss what we can expect to accomplish with the benefits that are available and what will happen if they run out before you feel ready to end your sessions.  It is important to remember that you always have the right to pay for my services yourself to avoid problems described above.





Limits on Confidentiality


The law protects the privacy of all communications between a patient and a psychotherapist.  In most situations, I can only release information about your treatment to others if you sign a written authorization form that meets certain legal requirements imposed by state law and/or HIPAA.  But, there are some situations where I am permitted or required by law to disclose information without either your consent or authorization:


  • I may occasionally find it helpful to consult with other health and mental health professionals about a case.  During a consultation, I make every effort to avoid revealing the identity of my patient.  The other professionals are also legally bound to keep the information confidential.  If you don't object, I will not tell you about these consultations unless it is important to our work together.  I will note all consultations in your clinical record.

  • If a patient threatens to harm him/herself, I may be obligated to seek hospitalization for him/her, or to contact family members or others who can help provide protection.


  • If you are involved in a court proceeding and a request is made for information about the professional services that I have provided you and/or the records thereof, such information is protected by psychotherapist-patient privilege law.  I cannot provide any information without your (or your legally-appointed representative's) written authorization, a court order, or compulsory process (a subpoena) or discovery request from another party to the court proceeding where that party has given you proper notice (when required), has stated valid legal grounds for obtaining PHI, and I do not have grounds for objecting under state law (or you have instructed me not to object).  If you are involved in contemplating litigation, you should consult with your attorney to determine whether a court would be likely to order me to disclose information.


  • If a government agency is requesting the information for health oversight activities pursuant to their legal authority, I may be required to provide it for them.


  • If a patient files a complaint or lawsuit against me, I may disclose relevant information regarding that patient in order to defend myself.


  • If a patient files a worker's compensation claim, I must, upon appropriate request, disclose information relevant to the claimant's condition, to the worker's compensation insurer.


    There are some situations in which I am legally obligated to take actions, which I believe are necessary to attempt to protect others from harm and I may have to reveal some information about a patient's treatment.


  • If I have knowledge of a child under 18 or I reasonably suspect that a child under 18 that I have observed has been the victim of child abuse or neglect, the law requires that I file a report with the appropriate governmental agency.  I also may make a report if I know or reasonably suspect that mental suffering has been inflicted on a child or that his or her emotional well being is endangered in any other way (other than physical or sexual abuse, or neglect).  Once such a report is filed, I may be required to provide additional information.


  • If I observe or have knowledge of an incident that reasonably appears to be physical abuse, abandonment, abduction, isolation, financial abuse or neglect of an elder or dependent adult, or if an elder or dependent adult credibly reports that he or she has experienced behavior including an act or omission constituting physical abuse, abandonment, abduction, isolation, financial abuse, or neglect, or reasonably suspects that abuse, the law requires that I report to the appropriate government agency.  Once such a report is filed, I may be required to provide additional information.


  • If a patient communicates a serious threat of physical violence against an identifiable victim, I must take protective actions, including notifying the potential victim and contacting the police.  I may also seek hospitalization of the patient, or contact others who can assist in protecting the victim.


  • If I have reasonable cause to believe that the patient is in such mental or emotional condition as to be dangerous to him or herself, I may be obligated to take protective action, including seeking hospitalization or contacting family members or others who can help provide protection.  If such a situation arises, I will make every effort to fully discuss it with you before taking any action and I will limit my disclosure to what is necessary.


    While this summary of exceptions to confidentiality should prove helpful in informing you about potential problems, it is important that we discuss any questions or concerns that you may have now or in the future.  The laws governing confidentiality can be quite complex, and I am not an attorney.  In situations where specific advice is required, formal legal advice may be needed.



    Professional Records


    You should be aware that, pursuant to HIPAA, I keep Protected Health Information (PHI) about you in two sets of professional records.  One set constitutes your Clinical Record.  It includes minimal information about your reasons for seeking therapy, your diagnosis, the goals that we have set for your treatment, your progress toward these goals, brief pertinent medical, social, and treatment history, plus any past treatment records that I receive from other providers, reports of any professional consultations, your billing records, and any reports that have been sent to anyone, including reports to your insurance carrier.  Except in unusual circumstances if that disclosure would physically endanger you and/or others or makes reference to another person (unless such other person is a health care provider), you may examine and/or receive a copy of your Clinical Record, if you request it in writing.  Because these are professional records, they can be misinterpreted and/or might be upsetting to untrained readers.  For this reason, I recommend that you initially review them in my presence, or have them forwarded to another mental health professional so you can discuss the contents.


    In addition, I also keep a set of Psychotherapy Notes.  These are for my own use and are designed to assist me in providing you with the best treatment.  While the contents of Psychotherapy Notes vary from patient to patient, they can include the contents of our conversations, my analysis of those conversations, and how they impact your therapy.  They also contain particularly sensitive information that you may reveal to me that is not required to be included in your Clinical Record.  These Psychotherapy Notes are kept separate from your Clinical Record. Psychotherapy Notes are not available to you and cannot be sent to anyone else, including insurance companies.


    Patient Rights


    HIPAA provides you with several new or expanded rights with regard to your Clinical Records and disclosures of protected health information.  These rights include requesting that I amend your record; requesting restrictions on what information from your Clinical Record is disclosed to others; requesting an accounting of most disclosures of protected health information that you have neither consented to or authorized; determining the location to which protected information disclosures are sent; having any complaints you make about my policies and procedures recorded in your records; the right to a paper copy of this Agreement, the attached Notice form, and my privacy policies and procedures; the right to breach notification including what happened and what you can do to protect yourself.  I am happy to discuss any of these rights with you.


    As a social worker licensed in this state and as a member of the National Association of Social Workers, it is my practice to adhere to more stringent privacy requirements for disclosures without an authorization.  The following addresses these categories to the extent consistent with the NASW and Code of Ethics and HIPAA.


    Child Abuse or Neglect:  I may disclose your PHI to a state or local agency that is authorized by law to receive reports of child abuse or neglect.


    Judicial and Administrative Proceedings:  I may disclose your PHI pursuant to a subpoena (with your written consent), court order, administrative order or similar process.


    Deceased Patients:  I may disclose PHI regarding deceased patients as mandated by state law, or to a family member that was involved in your care or payment for care prior to death, based on your prior consent.  A release of information regarding deceased patients may be limited to an executor or administrator of a deceased person's estate or the person identified as next-of-kin.  PHI of persons that have been deceased for more than fifty (50) years is not protected under HIPAA.


    Medical Emergencies:  I may use or disclose your PHI in a medical emergency situation to medical personnel only in order to prevent serious harm.  I will try to provide you a copy of this notice as soon as reasonably practical after the resolution of the emergency.


    Family Involvement in Care:  I may disclose information to a close family member or friends directly involved in your treatment based on your consent or as necessary to prevent serious harm.


    Health Oversight:  If required, I may disclose PHI to a health oversight agency for activities authorized by law, such as audits, investigations, and inspections.  Oversight agencies seeking this information include government agencies and organizations that provide financial assistance to the program (such as third-party payors based on your prior consent) and peer review organizations performing utilization and quality control.


    Law Enforcement:  I may disclose PHI to a law enforcement official as required by law, in compliance with a subpoena (with your written consent), court order, administrative order or similar document, for the purpose of identifying a suspect, material witness or missing person, in connection with the victim of a crime, in connection with a deceased person, in connection with the reporting of a crime in an emergency, or in connection with a crime on the premises.


    Specialized Government Functions:  If you are in the military, I may have to use or disclose your PHI to for national security purposes, including protecting the President of the United States or conducting intelligence operations.


    Public Health:  If required, I may use or disclose your PHI for mandatory public health activities to a public health authority authorized by law to collect or receive such information for the purpose of preventing or controlling disease, injury, or disability, or if directed by a public health authority, to a government agency that is collaborating with that public health authority.


    Public Safety:  I may disclose your PHI if necessary to prevent or lessen a serious 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.


    Research:  PHI may only be disclosed after a special approval process or with your authorization.


    Verbal Permission:  I may also 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 at any time, except to the extent that we have already made a use or disclosure based upon your authorization. 




    If you believe I have violated your privacy rights, you have the right to file a complaint in writing to my office at: 25301 Cabot Road, Suite 216, Laguna Hills, CA 92653 or with the Secretary of Health and Human Services at: 200 Independence Avenue, S.W. Washington, D.C. 20201 or by calling 202-619-0257.  I will not retaliate against you for filing a complaint.