Welcome Letter Form

Welcome to the Central DuPage Pastoral Counseling Center!

The Central DuPage Pastoral Counseling Center provides a unique counseling service to DuPage County and the surrounding areas. Our pastoral counselors have both theological training and mental health degrees and consider their clinical work a ministry within the church community. In the course of counseling, your faith experience and religious values will be taken seriously as genuine expressions of yourself. Our counselors, however, are not your spiritual advisors – that is the function of your pastor. You will be equally respected if religious faith is not part of your personal values.

APPOINTMENTS

Counseling sessions are approximately 38-60 minutes long within the scheduled appointment hour. If you are unable to keep an appointment at the time arranged, please notify the office at least 24 hours in advance, by telephone (630-752-9750). You should expect to be charged for the session if you fail to notify the Center within the 24-hour advance. Emergencies are always considered and no charge incurred, but canceling a session without advance notice can disadvantage other people who could be scheduled at that hour.

INSURANCE (Release of Information):

I hereby give permission to the Central DuPage Pastoral Counseling Center to release Protected Health Information (PHI) to my insurance carrier for reimbursement of fees. This may include data from office notes or psychology notes.

NAME of PERSON INSURED:*

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Signature*

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Note: The Central DuPage Pastoral Counseling Center is a Medicare provider but not Medicaid.

INFORMED CONSENT

In order to help establish a foundation of mutual trust between client and counselor, we request that you read and sign the following informed consent form, which summarizes the responsibilities of both the counselor and the client.

I, {your first and last name}, affirm that I have read and understand the information stated in this agreement.** I will discuss the goals, objectives, methods, and time frame of my treatment with my counselor, understanding that these may be modified as therapy progresses. I am aware that I have the right to refuse treatment or to terminate counseling should I choose. I understand I can discuss the nature of the treatment to be employed along with the risks and alternatives. Furthermore, I limit my counselor’s use of any information which can in any way identify me to others, unless I have given my specific written permission.

I understand that therapists at Central DuPage Pastoral Counseling Center are mandated reporters. The limits of confidentiality do not include discussion of homicide, suicide, child abuse/neglect (past or present), elderly abuse/neglect, abuse/neglect to any other vulnerable population, supervision or consultation with colleagues, responses to court-ordered subpoenas, other exceptions identifiers in the HIPAA information. Further, I understand that according to the Patriot Act, federal officials conducting national security investigations may access my records without my knowledge. The law supersedes the ethic of confidentiality.

I agree to pay for the session (or insurance co-pay) at the time of service. I agree to pay for any outstanding balances which may be billed to me or charged to my credit card, understanding that failure to do so may result in collection action or credit bureau reporting.

At this time I consent to work toward the achievement of the objectives with my counselor. I have read and understand the HIPAA psychotherapist/client services agreement. It is without any pressure or coercion that I sign this consent.

Your Initials*

By initialing here, I agree to the use of a digital signature

Client Signature (including minors (12-17):*

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Dated:*

Date

Parent Signature (if client is a minor)

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Dated:

Date

Therapist's Name*

Your Email Address*

example@example.com

* Denotes a required field

**The HIPAA Psychotherapist/Client services agreement was made available to me.

** The Illinois Notice Form was made available to me.