Integrative Counseling Solutions, Inc. has been selected to provide services to you and your family. No information identifying you or your family will be released or disclosed without written consent by a parent or other legally designated representative. The effective provision of services may require your consent to the exchange of information between Integrative Counseling Solutions, Inc. and the insurance company you are using as a payment agent. You may be asked to sign a specific release of information to any other individual or agencies which staff deems important to communicate with in the best interest of your family.
Integrative Counseling Solutions, Inc. will not knowingly utilize any treatment or procedure, which is experimental, controversial or carries intrinsic risk.
We/I, the undersigned, agree to accept services from Integrative Counseling Solutions, Inc. We agree to cooperate with the requirements for the services our child/family will be participating in during the next twelve months.
We/I, the undersigned, understand that with the proper release, when information needs to be shared quickly, it may be done via fax or computer e-mail. We/I also understand that individual client records may be kept on computer. We/I understand that there is no guarantee that information we disclose in a group or family setting will be held confidential by other members of the group or the family.
We/I understand that in the course of treatment, many subjects will be discussed. Some of these subjects may be, but are not limited to: age, educational achievement, family background, prior treatment efforts, family relationships, marital issues, sexuality, violence, leisure activities, drug/alcohol usage, medical involvement, housekeeping, shopping habits and hygiene.
We/I hereby authorize Integrative Counseling Solutions, Inc. and the identified insurance/funding agent to exchange (both receive and release) information concerning myself or my ward (child or dependent) for the purpose of providing effective treatment services.
We/I understand that it is my responsibility to keep insurance information updated with Integrative Counseling Solutions, Inc. We/I further understand that we need to provide a copy of our insurance card to Integrative Counseling Solutions, Inc. at the beginning/first appointment of each month.
We/I further agree to pay Integrative Counseling Solutions, Inc., the full balance of any account. I understand that I am responsible for any insurance co-pay, and will pay co-payment at each visit. I further understand that after my insurance company has finalized my claims and made payments to Integrative Counseling Solutions, Inc., I am responsible for any outstanding balances. I also understand that payment is due within 30 days of my receiving a billing statement from Integrative Counseling Solutions, Inc., and/or KASA Practice Solutions on behalf of Integrative Counseling Solutions, Inc. I understand that a 48 hours’ notice is required for change or cancellation of appointment. I understand that if I fail to give 48 hours notice, I will be charged for the cost of the session. If I am unable to pay the full balance, I will contact the billing department at (515) 267-1340 or will talk with my therapist to make acceptable payment arrangements. If this bill is not paid as agreed in full the balance of the bill for care rendered will be processed.
This agreement will remain in effect until one year after the involvement with Integrative Counseling Solutions, Inc. ends.