Policies & Acknowledgements

Notice of Privacy Practices | All-Inclusive Consent & Acknowledgment/Service Agreement

Good Faith Estimate | Anti-Oppressive Practice Commitment | Land Acknowledgement | Creative Credits

Notice of Privacy Practices

Your privacy is important to us, and we take seriously the trust you place in us. We store your information securely, and routine releases for treatment, payment, and health care operations purposes are done in accordance with state and federal laws. If you have a any concerns or questions, please reach out to us at billing@JourneyPsychology.org or at 312-870-0330 if you have any questions or concerns related to privacy practices.

This notice describes how psychological/healthcare information about you may be used and disclosed, and how you can access this information. Please review this document carefully and save it for your records.

1) Uses and Disclosures for Treatment, Payment, and Health Care Operations

We may use or disclose your protected health information (PHI) for treatment, payment, and healthcare operations with your written authorization.

For Treatment:We use and disclose your health information internally in the course of your treatment at Journey Psychology Center.
For Payment:We may use and disclose your health information to obtain payment for services we provide to you as delineated in the Service Agreement/All Inclusive Consent.
For Health Care Operations:We may use and disclose your health information within Journey Psychology Center as part of our internal health care operations and to improve your care. We use health information to manage your treatment and services, including to contact you to remind you that you have an appointment or outstanding invoices or documents.

Helpful definitions:

“PHI” refers to information in your health record that can identify you.
“Treatment” is when we provide, coordinate, or manage your health care and other related services, such as consulting with another health care professional.
“Payment” is when we obtain reimbursement for your health care. Examples are when we disclose your PHI to your insurance company to obtain reimbursement or determine eligibility and coverage.
“Health Care Operations” are activities related to the performance and operation of my practice, such as quality assessment and improvement activities, business-related audits, administrative services, and case management.
“Use” applies only to activities within out office, such as sharing, employing, applying, utilizing, examining, and analyzing information that identifies you.
“Disclosure” applies to activities outside of our office, such as releasing, transferring, or providing access to information about you to other parties.
“Authorization” is your written permission to disclose confidential mental health information. All authorizations to disclose require a written form. Most uses and disclosures of psychotherapy notes, uses and disclosures of protected health information (PHI) for marketing purposes, and disclosures that constitute a sale of PHI require patient authorization.

2) Other Uses and Disclosures Requiring Authorization

We may use or disclose PHI for purposes outside of treatment, payment or health care operations when your authorization is obtained prior to the release of information. Uses and disclosures not described in this notice will be made only with authorization from the individual.

In most cases, we will not keep psychotherapy notes, but in the event that we do, we will also need to obtain your authorization before releasing these. Psychotherapy notes are notes made about our conversation during a private, group, joint, or family counseling session, which are kept separate from the rest of your record. These notes are given a greater degree of protection than PHI.

You may revoke all such authorizations at any time, in writing. You may not revoke an authorization to the extent that, (1) we have relied on that authorization; or (2) if the authorization was obtained as a condition of obtaining insurance coverage, as the law provides the insurer the right to contest the claim under the policy.

3) Uses and Disclosures Without Authorization

Under Illinois and federal law, information about you may be disclosed without your consent in the following circumstances.

Emergencies: Sufficient information may be shared at your clinician’s discretion to address an immediate emergency you are facing.
Child Abuse: If we have reasonable cause to suspect a child known to us in our professional capacity has been or is being abused or neglected, we must report this to the appropriate authorities and may disclose health information about you as indicated.
Adult and Domestic Abuse: If we have reason to believe that an individual (who is protected by State law) has been abused, neglected, or financially exploited, we must report this belief to the appropriate authorities and may disclose health information about you as indicated.
Judicial and Administrative Proceedings: If you are involved in a court proceeding and a request is made for information by any party about your evaluation, diagnosis and treatment and the records thereof, such information is privileged under State law, and we must not release such information without a court order. We can release the information directly to you on your request. Information about all other psychological services is also privileged and cannot be released without your authorization or a court order. The privilege does not apply when you are being evaluated for a third party or where the evaluation is court-ordered. You must be informed in advance if this is the case.
Criminal Activity: We may disclose your information if a crime is committed on our premises or against our personnel.
Serious Threat to Health or Safety: If you communicate to us a specific threat of imminent harm against another individual, or if we believe there is clear, imminent risk of physical or mental injury being inflicted against another individual, we may make disclosures that we believe are necessary to protect that individual from harm. If we believe that you present an imminent, serious risk of physical or mental injury or death to yourself, we may make disclosures we consider necessary to protect you from harm.
Health Oversight Activities: We may disclose health information to a health oversight agency for activities authorized by law, including licensure or disciplinary actions.
Worker’s Compensation: We may disclose PHI regarding you as authorized by and to the extent necessary to comply with laws relating to worker’s compensation or other similar programs, established by law, that provide benefits for work-related injuries or illness without regard to fault.
Business Associates: We may disclose the minimum necessary health information to our business associates that perform functions on our behalf or provide us with services related to our clinical work and business management if the information is necessary for such functions or services, including insurance claims processing and reimbursement.
Under certain circumstances, we may use and disclose health information for research. Before we do so, the project will go through a special approval process that includes a consent form for clients to sign if they are included in the research study.
The Journey Psychology Center may send you newsletters or information about services we provide in which we feel you might be interested. You may at any time request that your name be removed from our mailing list. We will not disclose any information to a third party for their use in telemarketing, direct mail marketing, or marketing through electronic mail.
Fundraising Activities: In the future, Journey Psychology Center may use certain client demographic information — such as your name and address — to contact you about fundraising to make our services accessible to everyone. If you do not wish to be contacted about fundraising, send a written request to connect@JourneyPsychology.org
Any other uses and disclosures not set out in the information above will be made only with your written authorization. You may revoke a written authorization for release of information at any time. The revocation must be in writing and will become effective when receipt has confirmed by Journey Psychology Center, and will only be for disclosures not already completed.

4) Patient Rights and Psychologist’s Duties

Right to Request Restrictions: You have the right to request restrictions on certain uses and disclosures of PHI. However, we are not required to agree to a restriction you request. Patients have the right to restrict certain disclosures of PHI to health plans/insurance companies if the patient pays out of pocket in full for the health care service and does not use insurance or receive superbills.
Right to Request Confidential Communications: You have the right to request and receive confidential communications of PHI by alternative means and at alternative locations. For example, you may ask that we contact you only by mail or at work. You must make this request in writing and it must specify the alternative means or location that you would like us to use to provide you information about your health care. We will make every attempt to accommodate reasonable requests.
Right to Inspect and Copy: You have the right to look at or get copies of your health information, with limited exceptions. Your request must be in writing. If you request a copy of the information, a reasonable charge may be made for the costs incurred.
Right to Amend: You have the right to request that we amend your health information for as long as the PHI is maintained in your record. Your request must be in writing, and it must explain why the information should be amended. We have the right to deny your request.
Right to an Accounting of Disclosures: You generally have the right to receive an accounting of disclosures of PHI for a purpose other than treatment, payment, or health care operations. To request an accounting of disclosures, you must submit your request in writing to billing@JourneyPsychology.org. Upon your request, we will discuss with you the details of the accounting process.
Right to Notification: You have the right to or will receive notifications of breaches of your unsecured PHI.
Right to a Paper Copy: You have the right to receive a paper copy of this notice and any amended notice upon request. You can print a copy from here or your client portal, or email billing@JourneyPsychology.org to request a paper copy to be mailed to you or provided at the clinic.
Clinician’s Duties: We are required by law to maintain the privacy of PHI and to provide you with a notice of our legal duties and privacy practices with respect to PHI. We reserve the right to change the privacy policies and practices described in this notice. Unless we notify you of such changes, however, we are required to abide by the terms currently in effect. If we revise our policies and procedures, we will notify you by providing you a revised notice.

5) Questions and Complaints:

If you believe your privacy rights have been violated, you may file a complaint with us, or the U. S. Department of Health & Human Services. To obtain additional information, or to file a complaint with us, contact our Executive Director, Dr. Irma Khelghati, at ikhelghati@JourneyPsychology.org or at 312-870-0330.

This Notice first became effective January 20, 2020 and was last revised April 20, 2026.

We reserve the right to change the terms of this notice and to make the new notice provisions effective for all PHI that we maintain. We will provide you with a revised notice by providing you with a copy of the changes.

Consent to Treatment: We encourage you to read this agreement in full before signing this binding consent. By signing this consent, you voluntarily agree that you, and/or your minor child as listed above, will receive mental health services, including assessment and treatment, and authorize Journey Psychology Center (JPC) and it’s clinicians to provide such care, treatment, and services as they consider clinically indicated. Services may be provided in person, virtually, or over the phone depending on situational factors and clinician determination of best fit. By proceeding, you acknowledge the potential risks and limitations of virtual and phone engagement and agree to make all reasonable efforts to ensure confidentiality. You understand and agree to participate in the planning of your, and/or your child’s, care, treatment, and assessment, and that you may stop such services at any time. Your agreement grants consent to Journey Psychology Center clinicians to use and disclose your protected health information for the purposes of treatment, payment, and healthcare operations, and confirms receipt or review of the HIPAA Notice of Privacy Practices. If the patient is a minor child, you certify that you are the parent and/or legal guardian and have legal custody of the above-named minor patient.

Financial Responsibility Agreement: By signing this agreement, you certify that you understand and agree that payment is due at the time services are rendered. If Journey Psychology Center (JPC) is contracted with your insurance carrier (“in-network”), claims will be submitted to the insurance company as a courtesy. However, you are responsible for payment of all applicable copayments, coinsurance, and deductible amounts based on the estimated insurance benefits available at the time of registration and/or service. These amounts are due at the time of service and may be charged to the credit or debit card maintained on file, even while insurance claims are pending. You acknowledge and agree that maintaining a valid credit or debit card on file is required for payment of services. Once insurance claims are processed, any additional amount determined to be the patient’s responsibility—including but not limited to adjustments, underpayments, or claim denials—will be charged to the card on file. You are responsible for ensuring that the card on file remains current, active, and able to process charges. If a payment method is declined, becomes invalid, or otherwise fails to process, you agree that JPC will, in line with clinical responsibility, suspend or postpone services until the outstanding balance is resolved and a valid payment method is provided. You remain responsible for all charges incurred prior to any suspension of services. A late payment fee will be assessed on any outstanding balance for each month the balance remains unpaid. If the patient is a minor child, you understand and agree that you, as the parent/guardian, are responsible for payment at the time services are rendered. You will be responsible for payment of the patient’s treatment regardless of any financial arrangement, whether oral or written, with the patient’s other parent or responsible party. You further certify that you understand Journey Psychology Center clinicians assume no responsibility for collecting payment from any other parent or responsible party with whom you may have financial arrangements for the patient’s medical care.

Cancellation and No-Show Policy: You understand and agree that when an appointment is scheduled, Journey Psychology Center (JPC) reserves that time specifically for you and/or your child. Late cancellations or missed appointments prevent other patients from being scheduled and result in unused clinical time. As a result, cancellations of scheduled appointments must be communicated at least forty-eight (48) hours prior to the scheduled session, directly to the treating clinician. Failure to provide timely notice, or failure to attend a scheduled appointment, will result in the assessment of a late cancellation fee equal to the full cost of one session per missed or late-canceled appointment.

Good Faith Estimate

If you are paying for services out of pocket and we are not billing your insurance, we will provide a good faith estimate of expected costs for your planned services upon scheduling. This is designed to give you predictability in how much you will be charged for the services you will be receiving, before starting therapy or assessment.

You have the right to receive a “Good Faith Estimate” explaining how much your medical care will cost. Under the law, health care providers need to give patients who don’t have insurance or who are not using insurance an estimate of the bill for medical items and services.

You have the right to receive a Good Faith Estimate for the total expected cost of any non-emergency items or services. This includes related costs like medical tests, prescription drugs, equipment, and hospital fees.
Make sure your health care provider gives you a Good Faith Estimate in writing at least 1 business day before your medical service or item. You can also ask your health care provider, and any other provider you choose, for a Good Faith Estimate before you schedule an item or service.
If you receive a bill that is at least $400 more than your Good Faith Estimate, you can dispute the bill.
Make sure to save a copy or picture of your Good Faith Estimate.

For questions or more information about your right to a Good Faith Estimate, visit www.cms.gov/nosurprises or reach out to us at billing@JourneyPsychology.org or at 312-870-0330 if you have any questions or concerns

Anti-Oppressive Practice Commitment

At Journey Psychology Center, we understand mental health within the full context of a person’s life—relationships, history, identity, and the broader systems in which they live and grow. Experiences of racism, oppression, and systemic inequity are not separate from mental health; they shape development, stress responses, access to care, and the ways individuals are seen and understood.

We are committed to anti-racist and anti-oppressive practice. This means we do not take a neutral stance on injustice. We actively examine how systems of power and bias influence the mental health field, our clinical work, and our clients’ experiences.

We approach this work with both intention and humility. We understand that anti-oppressive practice requires ongoing reflection, feedback, and growth. We remain committed to examining our own identities, biases, and positions of privilege, and to listening closely to the voices and experiences of those we serve.

Our work is relational at its core. We strive to create spaces where clients feel safe enough to explore their experiences fully—where their identities are affirmed, their stories are honored, and their healing is supported with care, curiosity, and respect.

Land Acknowledgement

In line with our commitment to issues of social responsibility and justice, we acknowledge that Journey Psychology Center is physically located on the native land of the Council of the Three Fires — the Potawatomi, Ojibwe, and Odawa Nations — to honor their enduring connection to the land and recognize the tragic legacy of colonization, genocide, and oppression that still impacts Native American lives today.

Creative Credits

Website development: Worksite LLC.

Logo & branding: TwentySix – a creative studio.

Website photos: Maija Martin Photography & amri photography