Cornita Mental Health Services, LLC 1800 Town Center Drive, Suite 420 Reston, VA 20190 When you book an appointment, a specific time slot is allocated to you. Cornita Mental Health Services does not overbook appointments. If you fail to show up for your appointment or fail to cancel your appointment in a timely manner, your clinician and other patients are directly affected. Every effort is made to see you on time. Your clinician loses that income and cannot effectively fill that appointment time. All appointments must be canceled or rescheduled before 48 hours prior to the scheduled appointment time. Failure to do so will result in a missed appointment charge of $65.00 I understand that if I arrive 30 or more minutes late for an appointment, I will be charged for a missed appointment. I understand that if I arrive for an appointment without the proper co-pay, I will be assessed a $10.00 administrative fee to cover the additional administrative cost to the practice. I understand that it is my responsibility to check the appointment at the time that is issued and verify that the proper date and time are listed. Cornita Mental Health Services, LLC will not waive a missed appointment fee because of an error on the appointment. Cornita Mental Health Services will send a courtesy reminder text, email or phone call 2-3 days prior to the appointment day. I understand that it is my responsibility to remember my appointment. I understand that in the event of snow or inclement weather, I may cancel an appointment with less than the required notice if FairFax County Government (not the school) is closed and if I call to cancel my appointment PRIOR to the appointment time. With my signature below, I acknowledge that I have read Cornita Mental Health Services, LLC cancellation policy and that I agree to adhere to the missed appointment, cancellation policy and fee schedule as set forth in this policy. _________________________________ Printed Name over Signature

We strive to make scheduling an appointment as easy as possible for our clients. Here are our scheduling policies: Initial Appointment: To schedule your first appointment, please call our office during our regular business hours. Our receptionist will ask you for some basic information and help you schedule a convenient time to meet with one of our mental health professionals. Subsequent Appointments: After your initial appointment, you can schedule subsequent appointments with your therapist directly. You may discuss the frequency of your appointments during your initial visit, and your therapist will work with you to create a treatment plan that meets your needs. Cancellation Policy: We understand that unforeseen circumstances may arise, and you may need to cancel or reschedule your appointment. Please refer to our cancellation policy for more information. Late Arrivals: If you arrive late for your appointment, we will make every effort to accommodate you. However, please note that your session may need to be shortened if there is another client scheduled after you. No-Show Policy: If you do not show up for your scheduled appointment and do not provide us with any notice, you will be considered a no-show. Please refer to our cancellation policy for more information. Waitlist: If your preferred therapist is not available at a time that is convenient for you, we may be able to add you to our waitlist. If an appointment becomes available, we will contact you as soon as possible. We are committed to providing our clients with high-quality mental health services, and our scheduling policies are designed to ensure that our clients receive the care they need in a timely and efficient manner. If you have any questions or concerns about scheduling, please do not hesitate to contact us.

As a mental health service clinic, we are committed to protecting the privacy and confidentiality of our patients' health information in compliance with the Health Insurance Portability and Accountability Act (HIPAA). This policy outlines our approach to maintaining HIPAA compliance and protecting patient privacy. 1. Purpose and Scope: This policy applies to all employees, contractors, volunteers, and other individuals who handle patient health information on behalf of our clinic. The purpose of this policy is to ensure that patient health information is kept confidential, secure, and protected from unauthorized access or disclosure. 2. Patient Rights: Our clinic respects the rights of our patients regarding their health information. Patients have the right to access their health information, request amendments, and receive an accounting of disclosures. Patients also have the right to file a complaint if they believe their rights have been violated. 3. Notice of Privacy Practices: Our clinic provides patients with a Notice of Privacy Practices that outlines their rights and our responsibilities under HIPAA. The notice is provided to patients is available upon request. 4. Use and Disclosure of Patient Health Information: Our clinic will only use and disclose patient health information for treatment, payment, and healthcare operations purposes, as permitted by HIPAA regulations. We will obtain written consent from patients before using or disclosing their health information for any other purpose. 5. Safeguards: Our clinic has implemented appropriate safeguards to protect patient health information from unauthorized access, disclosure, and misuse. These safeguards include physical, administrative, and technical measures, such as secure storage, access controls, encryption, and employee training. 6. Business Associates: Our clinic may disclose patient health information to business associates who provide services on our behalf, such as billing or IT support. We will ensure that our business associates also comply with HIPAA regulations and have signed a Business Associate Agreement that outlines their responsibilities regarding patient health information. 7. Training: Our clinic provides regular training to employees on HIPAA policies and procedures, including the proper handling and safeguarding of patient health information. Employees who violate HIPAA policies will be subject to disciplinary action, up to and including termination. 8. Breach Notification: In the event of a breach of unsecured patient health information, our clinic will promptly notify affected individuals, the Department of Health and Human Services, and, if necessary, the media. We will also take appropriate corrective action to prevent future breaches. 9. Policy Review: This policy will be reviewed and updated as necessary to ensure ongoing compliance with HIPAA regulations and to reflect changes in our clinic's operations or technology. By following these policies and procedures, our clinic is committed to maintaining HIPAA compliance and protecting the privacy and confidentiality of our patients' health information.

These are the following insurances that our clinic accept: Cigna United Health Care - Optum MediCare TriCare CareFirst Anthem (BlueCross and BlueShield) Aetna Self Pay