Practice Policy & Procedures

(General and Electronic)


If you would like to schedule an additional appointment during a crisis-situation or difficult period, please call and leave a confidential voicemail indicating your request (734-837-5423). I will return your call as soon as possible to schedule an additional appointment (usually returning your call within 24 hours during the regular work week). On occasion, however, there may be times when I am unable to receive or respond to messages, such as when out of cellular range or out of town.

Please be aware, however, that I am not on call and do not have or offer a 24 hour emergency answering service. Therefore, in the event of an emergency, you should not wait for my response. If an emergency arises, please call 911 or go to the nearest emergency room. Crises lines include: 1-800-273-TALK (8255) or 1-800-784-2433.

Please refrain from making contact with me using social media messaging systems including, but not limited to, Facebook, Instant Messenger, or Twitter. I do not use social media to communicate with my patients. These methods have very poor and limited security, and I cannot ensure the confidentiality of any information transacted over the internet or web-based system.

Email or text is not a secure method of contact, and I ask that you refrain from using email or text to communicate clinical material and personal matters. Also, I may not regularly check my email nor be able to respond immediately, so these methods should not be used for an emergency (see emergency procedures above).

I do not conduct therapy via email or text nor do I use email or text to provide advice, discuss problems, or comment on our work together. All clinical matters should be discussed during session or over the phone at an agreed upon time. It is important that we be able to communicate in ways that maintain confidentiality (to the best of our knowledge and ability) and promote a safe therapeutic space.

Please speak with me about any concerns you may have regarding my preferred communication methods. If you feel you need to send me specific documents or forms pertinent to your treatment, please bring this to my attention so we may discuss appropriate delivery options (ex: in-person, U.S. Postal Service, or HIPAA compliant/secure email). If in-person delivery is not an option, for example, we will discuss using the U.S. Postal Service or my HIPAA compliant/secure email that may be provided and utilized on certain, agreed upon occasions when both parties (therapist and client) approve its use and acknowledge security risks specific to all internet transactions.


As of 2019, I will be offering online video therapy (virtual therapy or teletherapy) for patients who are unable to attend in-person appointments for various reasons. We will discuss your needs to determine if the online video therapy platform is an appropriate option for our work together and your clinical needs, as some differences exist when considering the relational experience of being together in-person versus online. Most research shows that teletherapy is about as effective as in-person therapy, but more time is needed to gather robust information regarding efficacy. Nonverbal communication, for example, and the “feel” of sitting down together do present differently when meeting in virtual therapeutic space versus physical therapeutic space.

If online therapy is determined to be an appropriate modality, I will provide you with specific information about how to set up a secure account and create a password. You will find the initial link to the online therapy portal on my website for your convenience. The online video therapy platform that I use is from the same company that manages my website. It is a company specifically designed for therapists, and as such, Therapysites (WeCounsel) now offers what they advertise as “a completely secure and HIPAA compliant software” so that therapists can “interact with clients from virtually anywhere” (Retrieved June 13, 2019, from

All confidentiality and privacy practices still apply to teletherapy services. Please note that, while I have taken precaution to maintain all aspects of confidentiality and privacy by selecting a HIPAA compliant software system, all online transactions carry an inherent risk in security breaches given the nature of the internet. As such, it is important to use a secure internet connection rather than public or free Wi-Fi. Likewise, it is important for you to find a private and secure location when meeting for online therapy, minimizing the risks of interruption and safeguarding the confidentiality of sessions. At no time, and under no circumstance, will either party (therapist or client) be permitted to record any session to uphold the privacy provisions of this practice.

If, as your psychologist, I determine that teletherapy is no longer appropriate for reasons I will specify and explain, specific recommendations will be made (example: resume in-person meeting if possible or make appropriate referral for face to face, in-person treatment).

As your therapist, I will treat all the information you share with me with great care and respect. In all, but a few rare situations, your confidentiality is protected by state law, HIPAA, and the rules of my profession. In most cases, it is your absolute legal right that our sessions remain private and protected. This is why I will ask you to sign an “authorization form” before I can talk about you (e.g. consult with your psychiatrist) or send any records about you to anyone else. In general, I will tell no one what you tell me. I will not even reveal that you are receiving treatment from me.

Please note that I do not use electronic health records or electronic medical records to store information about you, as I do not feel confident in the type of security that such electronic systems afford given the inherent security risks specific to electronic or “cloud” storage (ex: breaches). Your clinical, psychological information should be afforded the upmost protection, and thus, I prefer to utilize traditional, paper record keeping practices and store any such material in a locked file cabinet located in my locked office.

Here are the most common cases in which confidentiality is not protected:

1. If you were sent to me by a court or an employer for evaluation or treatment, the court or employer expects a report from me. If this is your situation, please talk with me before you tell me anything you do not want the court or your employer to know. You have a right to tell me only what you are comfortable with telling.

2. Are you suing someone or being sued? Are you being charged with a crime? If so, and you tell the court that you are seeing me, I may be ordered to show the court records which have been subpoenaed. Please consult your lawyer about these issues.

3. If you make a serious threat to harm another person, the law requires me to try to protect that other person by informing others about the threat (such as the police and/or the person in danger).

4. If you seriously threaten (or act in a way that is very likely) to harm yourself, I may have to seek a hospital for you or call your family members or others who can help protect you. If such a situation does arise, I will discuss the situation with you in attempts to arrive at an agreed upon solution that keeps you safe from harming yourself. However, in an emergency situation where your life or health is in danger, and I cannot get your consent, I may give other professionals (such as hospital staff and the police) some information to protect your life.

5. If I believe or suspect that a child, an elderly person, or a disabled person has been or will be abused or neglected, I am legally required to report this to the authorities.

6. If I am being compensated for providing treatment to you as a result of your having filed a worker’s compensation claim, I may, upon appropriate request, provide information necessary for utilization review purposes.

7. Insurance companies request certain information about your treatment (e.g. diagnosis, treatment plan, progress notes, etc.) in order to authorize psychotherapy services and disburse payment for such services. You have a right to know what type of information your insurance company may be seeking about your treatment. Please note: I do not take insurance of any kind nor do I work with insurance companies (including their policies or procedures); therefore, it is my general policy to not disclose clinical information to insurance companies.

8. If you chose to correspond via email or text (e.g. rescheduling an appointment or writing about an emotional event), I cannot ensure the confidentiality of any information transacted over the internet or web-based system. Please be aware of the security risk posed with any internet transaction and non-secure method of communication. Email or text is not a secure way to contact me. I also do not conduct therapy via email (or text) nor do I use email to provide advice, discuss problems, or comment on our work together.

Notice of Privacy Practices

If you have any questions or concerns about this Privacy Notice, please contact Dr. Sarah Pouliot for clarification. This Notice of Privacy Practices is a requirement for the Health Insurance Portability and Accountability Act (HIPAA). This Privacy Notice describes how psychologists or providers may “utilize” and/or “disclose” your health information to carry out treatment, payment, or heath care operations in addition to other purposes that are permitted or required by law. It also describes your rights to access and control your protected health information in some cases.



II. IT IS MY LEGAL DUTY TO SAFEGUARD YOUR PROTECTED HEALTH INFORMATION (PHI). By law, I am required to ensure that your PHI is kept private. With some exceptions (delineated below), no information of any kind will be released without your written consent or explicit permission. The PHI constitutes information created or noted by me that can be used to identify you. It may contain data about your past, present, or future health or condition, the provision of healthcare services to you, or the payment for such healthcare. I am required to provide you with this Privacy Notice about the privacy procedures specific to my practice. This Privacy Notice explains when, why, and how your PHI may be used and/or disclosed. Utilization or use of PHI means when I may share, apply, utilize, examine, or analyze information within my practice; PHI is disclosed when I may release, transfer, give, or otherwise reveal such information to a third party outside my practice. If you have signed an authorization to disclose your PHI, you have the right to revoke that authorization, in writing, to stop any future uses or disclosures (assuming I have not taken any action subsequent to the original authorization). With certain exceptions, I will not use nor disclose more of your PHI than is minimally necessary to accomplish the purpose for which the use or disclosure is made; however, I legally am required to follow the privacy practices described in this Privacy Notice. I will never disclose your PHI for marketing purposes nor will I sell your PHI to third parties.

III. POTENTIAL PHI USES AND DISCLOSURES PHI may be utilized and/or disclosed for many different reasons. Some of the uses or disclosures will require your prior written authorization; others, however, will not. Written authorization involves signing a consent form that permits a specified disclosure that you have requested. Below you will find the different categories of uses and disclosures, with some examples.

1. For treatment: “Treatment” is when I provide, coordinate, or manage your health care and other services related to your health care. Under certain circumstances, I may disclose your PHI to physicians, psychiatrists, psychologists, and other licensed healthcare providers who provide you with healthcare services or are otherwise involved in your care. Example: If a psychiatrist is treating you, I may disclose your PHI in order to coordinate care. However, it is my practice only to do so if you directly have authorized me in writing, unless a threat to personal safety is involved.      

2. For healthcare operations: “Healthcare Operations” are activities related to the performance, function, and operation of my practice. Examples of such operations include quality assessment or improvement activities and other business-related matters such as audits and administrative services as well as case management and care coordination. I also may provide minimal PHI to attorneys, accountants, consultants, business associates, and/or other professionals to make sure that I am in compliance with applicable laws. Additionally, I have a BAA (Business Associates Agreement) with Therapysites (WeCounsel), the company I currently use to provide HIPAA compliant teletherapy services. If consenting to use this teletherapy service for online sessions, you are providing limited PHI to Therapysites and their teletherapy system (ex: Name, phone number, email address).     

3. To obtain payment for treatment: I may use and disclose PHI to bill and collect payment for the treatment and services provided to you. I may provide limited PHI to certain business associates for payment collection purposes, such as billing companies, claims processing companies, and others that process healthcare claims for my office. All my business associates are obligated to protect the privacy of your information and are not allowed to use or disclose any information other than as specified in our contract. Please note: I do not take insurance or work with insurance companies at the present time, and therefore, I will not be disclosing your PHI for billing purposes to insurance companies.      

4. Disclosures to designated person(s) when requested by you: When appropriate for your treatment and with your specific written consent, I may provide limited PHI to a family member or designated individual who is responsible for the payment for services provided to you and/or who is involved in your healthcare. You have a right to revoke any prior authorization and not permit any PHI or contact between my office and your family or designated others. Retroactive consent may be obtained in emergency situations.      

5. For research purposes if applicable: If I were to engage in a clinical research project, I may provide limited PHI in order to conduct the clinical study. However, this type of clinical research would require your written consent and interest in participating. Please note: I generally do not participate in clinical research directly involving my patients.      

6. Appointment reminders and health related benefits or services: Examples: I, or Therapysites (WeCounsel) if utilizing teletherapy services, may use limited PHI to provide appointment reminders (ex: email reminders). I also may use PHI to give you information about alternative treatment options or other healthcare services.

PHI may be used or disclosed without your consent or authorization in the following circumstances:

7. As required by federal, state, or local law; judicial, board, or administrative proceedings; or law enforcement: Example: I may make a disclosure to the appropriate officials when a law requires me to report information to government agencies, law enforcement personnel, and/or in an administrative or judicial proceeding. Example: If I receive a subpoena or other lawful request from the Department of Health or the Michigan Board of Psychology, I must disclose the relevant PHI pursuant to that subpoena or lawful request. Please note: If you are involved in a court proceeding, and a request is made for information specific to your diagnosis and treatment or the records thereof, such information is privileged under state law, and I will not release information without your written consent or a court order. This privilege, however, does not apply to court orders.      

8. To avoid serious harm to self and/or other(s) and/or the public: I may provide PHI to law enforcement personnel or persons able to prevent or mitigate a serious threat to the health or safety of you, another person, or the public. If I believe that there is an imminent risk that you will inflict serious physical harm on yourself, I may disclose information in order to protect you. Disclosure is compelled or permitted if you are in such a psychological condition as to be dangerous to yourself, and I determine that disclosure is necessary to prevent or minimize the threatened danger (e.g., seeking hospitalization for you if you need emergency treatment to ensure your safety). Disclosure also is compelled or permitted when I learn of a serious or imminent threat of physical violence by you against a reasonably identifiable victim or victims.      

9. To report abuse and/or neglect or domestic violence: Disclosure is mandated by the child abuse and neglect reporting laws if I have a reasonable suspicion of child abuse or neglect. Similarly, disclosure is mandated by law if I have a reasonable suspicion of elder abuse or dependent adult abuse. Additionally, if you are being criminally abused, I might be required to report such abuse to the appropriate authorities when required by law.      

10. For workers’ compensation: I may provide PHI in order to comply with Workers’ Compensation Laws.      

11. For public health risks or activities and purposes relating to disease or FDA-regulated products.     

12. For health oversight activities involving HHS or a state department of health.     

13. For specific government functions such as fitness for military duties, eligibility for VA benefits, and national security and intelligence.      

14. If disclosure is otherwise specifically required by law.

IV. YOUR RIGHTS WITH RESPECT TO YOUR PHI Right to a Paper Copy of this Policy Notice: Upon request, I will provide you with a paper copy of this notice, even if you already have received a previous copy or have agreed to accept this notice electronically.

Right to Request Restrictions or Limits on Uses and Disclosures of PHI

You have the right to request restrictions on certain uses and disclosures of PHI. All requests must be in writing and specify the nature of the requested restriction (as well as to whom it may apply). However, I am not required to agree to a restriction you request. For example, you may not limit the uses and disclosures that I am legally required or permitted to make as delineated in this Privacy Notice. 

Right to Inspect and Copy PHI

You have the right to inspect and/or obtain a copy of your PHI for as long as the PHI is maintained in the record. Such a request must be made in writing. You will receive a response from me in a manner that is timely and reasonable (current standard being 30 days), but if I am delayed, I will notify you in writing of the reasons for the delay, including the date when the PHI will be provided. I also may see fit to provide you with a summary or explanation of the PHI, but only if you agree to that format. Under certain circumstances, I may deny your access to PHI but will provide you with the reasons for the denial in writing. In some cases, you may have this decision reviewed. On your request, I will discuss with you the details of the review and denial process. Psychotherapy notes, if taken, are not part of your PHI and remain separate from the medical record. Under the privacy rule, you are not permitted access to psychotherapy notes or have the right to inspect or obtain a copy of such notes. Please note: a reasonable fee may be charged for the costs of copying PHI materials and delivering them in compliance with your request.

Right to Amend If you believe that there is some error in your PHI or that important information has been omitted, it is your right to request that I correct the existing information or add the missing information. Your request and the reason(s) for the request must be made in writing. I may deny your request, in writing, if I find that: the PHI is (a) correct and complete, (b) forbidden to be disclosed, (c) not part of my records, or (d) written by someone else. My denial must be in writing and must state the reasons for the denial. It also must explain your right to file a written statement objecting to the denial. If you do not file a written objection, you still have the right to ask that your request and my denial be attached to any future disclosures of your PHI. If I approve your request, I will make the change(s) to your PHI. Additionally, I will tell you that the changes have been made, and I will advise all others who need to know about the change(s) to your PHI.

Right to Choose How You Receive PHI It is your right to ask that requested PHI be sent to you at an alternate address or email address (other than your home address, for example). I am obliged to agree to your request providing that I can give you the PHI, in the format you requested, without undue inconvenience. You also have the right to receive a copy of your PHI in electronic form if readily producible. You are not entitled to direct access to any electronic health record system or record keeping system.

Right to Obtain an Accounting of PHI Disclosures You generally have the right to receive an accounting of PHI disclosures. This right applies to disclosures for purposes other than treatment and payment of health care operations as described in this Privacy Notice. The list will not include uses or disclosures to which you already have consented (i.e., those for treatment, payment, or healthcare operations, sent directly to you, or to your family) or requested (i.e., disclosures that have been made to you) or previously authorized (i.e., pursuant to a signed release or authorization form). Neither will the list include disclosures made for national security purposes, to corrections or law enforcement personnel, or when permitted without your authorization under certain circumstances. The list will include the date of the disclosure, to whom PHI was disclosed (including their address, if known), a description of the information disclosed, and the reason for the disclosure. I will provide the list to you at no cost, unless you make more than one request in the same year, in which case I will charge you a reasonable sum based on a set fee for each additional request. On your request, I will discuss with you the details of the accounting process.

Right to Get Notice of Breach. You have the right to be notified upon a security breach specific to your PHI. I am required to notify each affected individual whose information has been compromised.

Psychologist’s Responsibilities: I am required by law to maintain the privacy of PHI and to provide you with a notice of my legal duties and privacy practices with respect to PHI.

I reserve the right to change or amend the privacy policies and practices described in this Privacy Notice. I will notify you if any such changes are made during the course of treatment or if any such changes will result in additional PHI disclosure. Unless I notify you of such changes, however, I am required to abide by the terms currently in effect.

If I revise my policies and procedures, I will post a new, updated Privacy Notice in my office to alert you to the revisions. It also will be posted to my website for your convenience and instant accessibility. You may request a paper copy of any revised notice, or you can view a copy of it in my office.

I will not use nor disclose your PHI without your authorization, except as described in this Privacy Notice.

V. COMPLAINTS Please notify me, Dr. Sarah Pouliot (designated and sole contact person for Pouliot Psychological Services PLLC), if you have any questions, concerns, or complaints about my privacy practices. If, in your opinion, I may have violated your privacy rights, or if you object to a decision I have made about access to your PHI, you may contact me at my office address listed below. You may also file a complaint with the Department of Health and Human Services. If you file a complaint about my privacy practices, I will take no retaliatory action against you.


Pouliot Psychological Services PLLC Dr. Sarah Pouliot 4000 Portage Street Suite 105 Kalamazoo MI 49001

U.S. Department of Health and Human Services 200 Independence Ave, S.W., Washington D.C. 20201

VII. EFFECTIVE DATE OF THIS NOTICE: This Notice went into effect on November 5th, 2013.

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