Faith and Healing Counseling welcomes you to our practice.

This packet must be filled out completely prior to your initial appointment. Before beginning, You are required to verify your email address. Your security is important to us. Verifying your email address lets us know that you truly own your email address and allows us to better assist you. Additionally, your email address will be used to:

• Save your Client Intake Package progress ¹
• Used to send you a copy of the completed package

 

Thank you,
Faith and Healing Counseling

 

¹ Client Intake Package progress powered by JotForm, account required to save and view package.

Before advancing, please read the Terms, Conditions, Authorization, and Assignment before checking the box.

I {legalName} ({preferredName}),

agree to participate with FAITH AND HEALING COUNSELING, LLC. I understand that this treatment is for my mental health and physical welfare. I understand that I have the right to have any medication or prescription recommendations explained to me fully and that I have the right to review medications with my psychiatrist or nurse representative.

I understand that I have the right to ethical and fair treatment without regard to my race, religion, color, ethnic origin, or sexual orientation. I understand that I have the right to appeal any decision made in my treatment by first discussing it with my primary treating professional (therapist). I understand that if I am not satisfied with the determination of this appeal, I may then appeal to the treating psychiatrist (if applicable) or consult with another mental health professional for a second opinion.

In addition, I understand that I may refuse treatment within 48-hour notice. I understand that if I choose to interrupt refuse or termination treatment and/or rescind this consent for treatment, against medical advice, I will hold FAITH AND HEALING COUNSELING, LLC blameless for any pain or suffering I may incur because of my refusal or cessation of treatment.

I hereby agree that to release and hold harmless from any liability, FAITH AND HEALING COUNSELING, LLC, including its paid and volunteer staff, members or Chief Executive Officer, and their heirs, executors and administrators, and any other agents or representative of FAITH AND HEALING COUNSELING, LLC, for any claim or cause of action of any kind, including specifically, personal injury, which may occur while participating in any program or activity of any kind conducted, approved, organized, or sponsored by FAITH AND HEALING COUNSELING, LLC, or its representatives, these programs or activities including but not limited to field trips and transportation to and from said programs or activities.

Faith and Healing Counseling, LLC (FHC) wants to make your experience with us a positive one. Please take time to read this carefully before you sign it. This agreement defines both the therapist/client/policy holder’s expectations throughout the collaborative relationship. Please review the list of fees below, financial responsibility, cancellation policies, limits of confidentiality, and initial all sections, sign and date.

Hours of Operation/Appointments
Office hours are by Appointment Only

Crisis/Emergency Services
Should you experience a Mental Health Emergency outside of my regular office hours, I ask that you contact me on the number provided, if I am unreachable, you agree, you will call 911 and/or go to your nearest emergency room and have
them contact me.

Email Communications
Some of our therapists use email or texts for routine communication about appointments and other matters. If you communicate with your therapist via email or text, please be aware that privacy and security are a complex issue and
cannot be guaranteed at the same level as telephone or written messages. As such, emails can be received by unintended recipients, backup copies of email may exist even after email is deleted, email senders can easily type in the wrong email address, etc. For those therapists who use emails, emails will typically be used to discuss administrative issues such as appointments. Patients will receive emails about information on general practice news, groups, seminars, workshops, and satisfaction surveys if indicated on their patient questionnaire.

Insurance
Understand that it is your responsibility to contact your insurance company to determine if your insurance will cover outpatient mental health services and if pre-certification/authorization is required. Please make sure you are aware of any copays, coinsurances and deductibles. As a courtesy, we will verify benefits, obtain an estimate of coverage, file claims, and provide whatever reasonable information your insurance company requests from us. However, please be advised that working with your insurance company is a courtesy service provided by Faith and Healing Counseling, LLC, / Staff, and we cannot guarantee that your insurance company will pay. I will submit claims to your insurance company but make no guarantees as to what your insurance company will cover. Clients are ultimately responsible and aware of all fees for services rendered under private pay and through your health insurance coverage. Please be aware we utilize a billing company for billing purposes, therefore, from time to time you may receive a telephone call and/or email from them.

Please bring a copy of your medical insurance card to each appointment. It is also your responsibility to let us know if there is a change in your insurance coverage or changes in employment. We are happy to file your insurance claim for you, but you are responsible for all co-pays, deductibles, non-covered services, and co- insurance. If your insurance does not pay us for any reason, you will be responsible for your balance. Payments are due at the beginning of each session.

If we are not participating providers for your insurance plan, you will be considered SELF-PAY, payment is required in full and we will supply you with a detailed receipt of payment for the visit(s), which you can submit to your insurance company for reimbursement. Please note that not all insurance companies reimburse for out-of-network providers.

Opt Out of using Insurance/No Insurance/Self-Pay
For clients who participate in counseling and who choose not to use insurance, they are able to be a “self-pay/cash” for their sessions. However, if I am a participating provider with your insurance, you must sign an opt-out waiver, which allows me to bypass your insurance and you pay on your own. “Self-Pay/Cash” is generally used to keep counseling private – insurance companies maintain information in their computers about your problems and or diagnoses. Being “self-pay” is costlier but some find this worth the cost since their counseling is considerably more private. In addition, if I do not participate with your insurance company, you can still pay for services with me and file for reimbursement. I will assist with the information you need to file a claim.

Outstanding Balances
The person who signs below is agreeing to be the “financial guarantor,” which means this person agrees to pay any fees. If we determine there is a balance on your account (ex. Session fees, Missed Appointment, Returned Check, etc.), we will send you a statement. We ask that you complete payment within 30 days. If an outstanding balance exists on your account after 60 days, your account may be sent to a 3rd party collection agency, which can increase the amount you owe by 35%. You are responsible for all fees, court costs, and legal fees.

EAP Services (Employee Assistance Program)
There is no fee for use of your counseling services under your EAP. Services will be rendered according to contracts with your employer. No personal health information will ever be shared or disclosed to your employer without your written consent. Understand that certain EAPs may require their standardized paperwork to be submitted by the counselor for reimbursement, which may include the sessions and any progress. Only their standardized forms will be submitted. If I am an EAP client and am ever in need of a hard copy of my records, I understand that I am to contact the EAP Company directly.

Late Cancellation/No Show Policy
Your appointment time has been reserved specifically for you. Once your appointment is scheduled, you will be financially responsible for it unless you provide 24-hours’ notice of cancellation to your therapist via email or text (methods are time stamped). Please reach out to your therapist as soon as you can to discuss rescheduling options. No show appointments or Late cancelations not made within the 24-hour period assess a $35 fee. Payment for Late Cancellations and No Shows are due prior to your next appointment. This fee will be waived in the cases of an extreme emergency or inclement weather. Please note that NO insurance plans pay for this fee, so please do not ask me to bill this to your insurance company. This fee must be paid prior to your next scheduled appointment or within 2 weeks, whichever should come first.

FHC reserves the right to discontinue counseling if consecutive appointments are missed, if there are excessive cancellations and no shows and or if we do not believe you will make progress on your mental health condition because of no-shows or late cancellations. However, if scheduling permits and your provider agrees, you may contact us to set up an appointment to become active again. Although we make an effort to remind you about upcoming appointments by email or text reminders, it is ultimately your responsibility to remember and attend each scheduled appointment.

Confidentiality
Unless you authorize disclosure of communication and records of sessions outside this office, communication between you and your counselor are kept confidential, with the exceptions listed below. Your written consent is required for the disclosure of information outside this office. Healthcare providers are legally allowed to use or disclose records or information for treatment, payment and healthcare operations purposes. However, I do not routinely disclose information for purposes other than insurance reimbursement, so I will require your permission in advance, either through your consent at the onset of our relationship (by signing the attached general consent form), or through your written authorization at the time the need for disclosure arises. You may revoke your permission, in writing at any time, by contacting us.

In addition to your right to confidentiality, you have the right to end counseling services at any time, for whatever reason and without any obligation, with the exception of payment of fees for services already provided. You have the right to question any aspect of your treatment with your treatment provider. You also have the right to expect that your counselor will maintain professional and ethical boundaries by not entering other personal, financial, or professional relationships with you.

Limits of Confidentiality
Possible Uses and Disclosures of Mental Health Records without Consent or Authorization. There are some important exceptions to this rule of confidentiality. I may use or disclose records or other information about you without your consent or authorization in the following circumstances, either by policy or because legally required:

1. Emergency – If you are involved in a life-threatening emergency and I cannot ask your permission, I will share information if I believe you would have wanted me to do so, or if I believe it will be helpful to you;
2. Child/Adult Abuse – Where there is a reasonable suspicion of child abuse or elder adult physical abuse;
   
   
3. Danger to Others – Where there is reasonable suspicion that you my present a danger of violence to others;
   
   
4. Self-Harm – Where there is reasonable suspicion that you are likely to harm yourself unless protective measures are taken;
   
   
5. Prenatal Exposure to Controlled Substances – We are required to report admitted prenatal exposure to controlled substances that are potentially harmful;
   
   
6. Court Proceedings – If you are involved in court proceedings and a request is made for information about your diagnosis and treatment and the records thereof, such information is privileged under the state law, and I will not release information unless you provider written authorization or a judge issues a court order;
   
   
7. Minors/Guardianship – Parents or legal guardian of non-emancipated minor clients have the right to access the client’s records;
   
   
8. Insurance Companies (when applicable) – Insurance companies and other third-party payers are given information that they request regarding services to clients. Information that may be requested includes, but is not limited to types of services, dates/times of service, diagnosis, treatment plan, description of impairment, progress of therapy, case notes, and summaries.

Court Appearances, Letters and other Paperwork
All court-related services (preparation, consultation with attorneys, travel, court appearances, etc.) are billed at $300/hour with a minimum charge of eight (8) hours, for a total of two thousand four hundred ($2400) dollars. Due to the sensitive nature of the client-therapist relationship, it is often damaging to the therapeutic relationship for the therapist to be asked to present records to the court, testify whether factual or in an expert nature, in court or deposition. The therapist asks that clients only request a court appearance in extreme cases. In the event that it is necessary for the therapist to testify before any court, arbitrator, or other hearing officer to testify at a deposition, whether the testimony is factual or as an expert witness, or to present any or all records pertaining to the counseling relationship to a court official, the client agrees to pay the therapist for his or her services, including travel, preparation, and necessary expenditures at the rate of $300 per hour, rounded to the nearest half hour. These expenditures include but are not limited to copies, parking, meals, and the like. The client agrees to pay the $2400 two weeks prior to the appearance, presentation of records, or testimony requested.

In addition, we charge for copying records, telephone consultations, consulting with your other doctors, writing letters and reports, testimony or depositions about your services at our center, and any other service you request from us.

Supervision of Children
Faith and Healing Counseling, LLC does not provide childcare and is not responsible for children or adolescents left unsupervised in the waiting room. Minors must be picked up following their appointments on time. If you must leave your child in the waiting room during a session, it is your responsibility to provide appropriate supervision for that child. Children under the age of 10 (ten) may not be left without supervision in the waiting room.

 

I understand that, under the Health Insurance Portability & Accountability Act of 1996 (HIPAA), I have certain rights to privacy regarding my protected health information. I understand that this information can and will be used to:

• Conduct, plan and direct my treatment and follow-up care among the multiple healthcare providers who may be involved in that treatment directly or indirectly.
  
  
• Obtain payment from designated third-party payers.
  
  
• Conduct normal health care operations such as quality assessments or evaluations, and physician certifications.

I have been informed by Faith and Healing Counseling, LLC the Notice of Privacy Practices containing a more complete description of the uses and disclosures of my health information. I have been given the right to review such Notice of Privacy Practices prior to signing this consent. I understand that this therapist has the right to change its Notice of Privacy Practices from time to time and that I may contact this therapist at any time at the address(s) listed to obtain a current copy of the Notices of Privacy Practices. I understand that I may request in writing that this counselor restrict how my private information is used or disclosed to carry out treatment, payment or health care operations. I also understand the counselor is not required to agree to my requested restrictions, but if the therapist does agree, then it is bound to abide by such restrictions. I understand that I may revoke this consent in writing at any time, except to the extent that the organization has taken action relying on this consent.

I agree to the above statement of understanding and limits of confidentiality and understand their meanings and ramifications.

Faith and Healing Counseling, LLC, we provide professional mental health services for a fee. Our fees are considered a reasonable level of compensation for our professional time. We are confident with our fees and we ask that you pay your copay, coinsurance and any unpaid balances at the beginning of each visit. Our fees vary depending on the services offered. This varies depending on your insurance plan. As of May 1, 2021, our fees are as follows:

	Services	Fee
	Initial evaluation and assessment (50-60 min.)	$200.00
	Individual psychotherapy (50 min.)	$150.00 per session
	Couples therapy (50 min.)	$175 per sessio
	Clinical Supervision	$25.00 per session
	Missed Appointment/Late Cancellation	$35.00 per missed appointment
	Request for Copies	varies
	Reports for Court/Attorneys/General Reports	*$100.00 (request must be made 2 weeks in advance)

Assignment of Benefits & Release of Information
I authorize the release of medical information necessary to process this and all claims to my insurance company, including Medicare and Medicaid. I request benefits be made payable to Faith and Healing Counseling, LLC I acknowledge that I am financially responsible for this and all claims whether paid or not or covered by my insurance company or other organization. I also agree that if my account is referred to a third party for 60 days past due, I will be responsible for the collection agency fee of 35% plus 19% interest and the balance due.

You agree, for us to service your account or to collect any amounts you may owe, we may contact you by telephone at any telephone number associated with your account, including wireless telephone numbers. We may also contact you by sending text messages or emails, using any email address you provide us. Methods of contact may include using pre‐recorded or artificial voice messages and/or the use of an automatic dialing device, as applicable. I/We have read this disclosure and agree that Faith and Healing Counseling LLC or representative may contact me/us as described above.”