Thank you for taking the time to complete this information. Your intake will include four parts.

PART ONE: collecting general information about you and financial information for billing purposes
PART TWO: gathering biopsychosocial information (e.g., ranging from how you’re feeling today to habits and history)
PART THREE: reviewing Kizaur Counseling privacy practices
PART FOUR: consenting to being treated by Kizaur Counseling

After you complete each part of your intake and click the "SUBMIT" button, you will then be taken to the next part.

All the information you share during this process remains completely confidential and helps me better help you.




Applicable state and federal laws require me to establish privacy practices, maintain the privacy of your health information, and provide this Notice regarding these practices. These are designed to safeguard your health information and inform you of your rights. I reserve the right to change these privacy practices and the terms of this Notice at any time, as permitted by applicable law. You may request a copy of this Notice at any time.

For further information about your privacy and rights, please feel free to contact me or visit the State of Ohio Department of Administrative Services and review the Guide To HIPAA Privacy Rule 

You have the following rights with respect to your health information: 

  • The right to request restrictions on certain uses of your health information, however we are not required to agree with your request.
  • The right to request, in writing, the manner or method by which we contact you to furnish confidential communications about your health information (e.g., email, voicemail, messaging, etc.). You are obligated to notify us of any changes to your request in writing.
  • The right to receive an accounting of health information disclosures, except those disclosures related to treatment, payment or health operations, disclosures that are made to you, disclosures made for national security purposes or to correctional facilities or law enforcement officials, or disclosures that were made prior to compliance date.
  • The right to receive a copy of this Notice in writing.

We have the following obligations:

  • We are required by law to maintain the privacy of your health information, and we are required to provide you with a notice of our legal duties and private practices.
  • We are required to abide by the terms of this Notice.
  • We are required to advise you of any changes we make in the terms of this Notice. If any changes are made to this Notice we will post a revised Notice and make a copy available upon request.



I will use and disclose your health information for the purposes of treatment, payment, and healthcare operations. For example:

Treatment: means the provision, coordination or management of health care and related services by one or more health care providers, including the coordination or management of health care by a health care provider with a third party, consultation among healthcare providers as necessary for treatment relating to the patient, or the referral of a patient for health care from one provider to another.  For example, I may use or disclose your health information to a physician or other healthcare provider providing treatment to you or for the management of healthcare and related services. I may contact a provider on your behalf to facilitate your access to mental health treatment.

Payment: means activities undertaken by a covered health care provider or plan to obtain or provide reimbursement for services.  For example, I may use and disclose your health information to obtain payment for services provided to you. I may contact a benefit plan (your insurance company or employee benefit plan) to obtain information concerning billing for services, copay information, etc.

Healthcare Operations: include certain activities of this practice, as well as activities of an organized health care arrangement in which we participate like: quality assessment and improvement activities, case management, reviewing the competence or qualification of healthcare professionals, evaluating practitioner and provider performance, conducting training programs, accreditation, certification, licensing or credentialing activities. For example, from time to time, hospitals and insurance companies will review physicians' clinical skills in order to assure that quality health care is being provided.  When such reviews are conducted, it is often necessary for the reviewer to randomly select and examine patients’ medical records.

Your Authorization: In addition to my use of your health information for treatment, payment or healthcare operations, you might provide written authorization to use your health information or to disclose it to anyone for any purpose. If you give me an authorization, you may revoke it in writing at any time. Your revocation will not affect any use or disclosures permitted by your authorization while it was in effect. Unless you give me a written authorization, I cannot use or disclose your health information for any reason, except those described in this Notice.

To Your Family and Friends: I must disclose your health information to you, as described in the Client Rights section of this Notice. I may disclose your health information to a family member, friend or other person to the extent necessary to help with your healthcare or with payment for healthcare, but only if you agree that I may do so.

Persons Involved In Care: I may use or disclose health information to notify, or assist in the notification of (including identifying or locating) a family member, your personal representative or another person responsible for your care, of your location, your general condition, or death. If you are present, then prior to use of disclosures of your health information, I will provide you with an opportunity to object to such uses or disclosures. In the event of your incapacity or emergency circumstances, I will disclose health information based on a determination using my professional judgment disclosing only health information that is directly relevant to the person’s involvement in your healthcare. I will also use my professional judgment and mental health community standards to make reasonable inferences regarding your best interest in allowing another person to pick up health information.

 Marketing Health-Related Services: I will not use your health information for marketing communications without your written authorization, but may for the purposes of appointment reminders, treatment alternatives, or other related benefits and services that may interest you.

Required by Law: I may use or disclose your health information when I am required to do so by law, for example, when ordered to do so by a court having jurisdiction of an appropriate matter.

Health Oversight Activities: including audits, civil, criminal, or administrative investigations, proceedings, or actions; inspections; licensure or disciplinary actions or judicial/administrative proceedings in response to court orders.

Abuse or Neglect: I may disclose your health information to appropriate authorities if I reasonably believe that you are a possible victim of abuse, neglect or domestic violence or the possible victim of other crimes.

National Security/Law Enforcement/Specialized Government Functions: I may disclose to military authorities the health information of Armed Forces personnel under certain circumstances. I may disclose to authorized federal officials health information required for lawful intelligence, counterintelligence, and other national security activities. I may disclose to correctional institutions or law enforcement officials, having lawful custody of protected health information of an inmate or client under certain circumstances.

Appointment Reminders: I may use or disclose your health information to provide you with appointment reminders (such as voicemail messages).

To Avert Serious Threats: in the case of health or safety of you or others.

Worker’s Compensation: to the extent necessary to comply with applicable laws.

Coroners, medical examiners, funeral directors: for the purposes of identifying deceased persons or identifying cause of death.

Public Health Activities: including the prevention or control of disease, vital statistics, and public health investigations.


Questions and Complaints:

If you are concerned that I may have violated your privacy rights, or you disagree with a decision I made about access to your health information or in response to a request you made to amend or restrict the use or disclosure of your health information or to have me communicate with you by alternative means or an alternative locations, you may issue a complaint using the contact information listed below. You also may submit a written complaint to the U.S. Department of Health and Human Services (200 Independence Ave, SW HHS Building, Washington DC 20201). I fully support your right to the privacy of your health information. I will not retaliate in any way should you choose to file a complaint with me or the U.S. Department of Health and Human Services.

Contact Information:
Matthew Kizaur, MA, LPC, MEd, LPSC
3454 Oak Alley Court, Suite 400, Toledo, OH 43606
Phone: 419.367.9646  Email:

Printing my name in the signature field below and providing the date, indicates that I have carefully reviewed the “Notice of Privacy Practices” information above and have received proper explanation from my service provider including clarification of the content listed. My signature serves as a waiver to hold me, or any of my associates, legally responsible should I choose not to take steps to ensure my own safety and confidentiality.

I understand I can REFUSE TO SIGN this acknowledgment, and if I refuse I will fill out the appropriate field below.

If you checked Emergency Contact, please provide your contact's name,
relationship to you, and contact number(s)
If you refuse to acknowledge the privacy policy,
please type "I REFUSE" in the field below