Consent and Patient Information

Consent and Patient Information
Name*

First NameLast Name
Birthday*
Age*
Relationship status:

MarriedDivorcedSingleOther
Address*
City*
State*
Zip*
Only list numbers and email addresses that you approve us to call, text, or email, identifying our self to whomever receives this communication as "Oklahoma Christian Counseling"
Phone Number*
Please enter a valid phone number.
Email*
example@example.com
Employer
Occupation
Primary Care Physician
Psychiatrist
How did you hear about us? (be specific)*
Parent/Legal Guardian

First NameLast Name
Parent Occupation
Parent Employer
School
Patient's Grade
initialsIf UNDER 18 years old: I attest that I am the custodial parent or legal guardian of patient stated above and consent that he/she may be treated as a client by Duncan Counseling/Oklahoma Christian Counseling.
Insurance Company*
Insurance ID#
Group#
PRIMARY Insured's Name
PRIMARY Insured's DOB
Insured's Employer
** We will need a copy of your insurance card. Please take a picture of it and text it to 918-319-2935 or email it to info@oklahomacc.com **
Signature*

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Signature*

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Agreements
Welcome to Oklahoma Christian Counseling, PC. Please read over our policies. If you have any questions, feel free to ask our staff. We will always work with patients to keep their out-of-pocket expenses as affordable as possible.

Fees: Counseling sessions are typically 50 minutes long. The fee for a typical session is $95-$250 (fees vary based on service). Payment is collected before your session at the reception desk or we can automatically run your credit/debit card at each session.

INITIAL each paragraph to indicate you have been fully informed, understand, and agree:
initials* FINANCIAL RESPONSIBILITY: I understand that I am ultimately responsible for all counseling fees, whether I file insurance or not.
initials* INSURANCE: I understand that because my insurance is accepted is no guarantee my insurance will pay for my session. I will contact my insurance if I have questions about their payment or the amount of payment I am responsible for.
initials* DEDUCTIBLES & CO-PAYS: I understand my insurance may have a deductible. I understand my insurance will not pay anything until I have paid my deductible amount for medical expenses. I understand a co-pay is the amount I owe After my deductible is met. I understand that I can not pay less than the amount my insurance requires for a counseling session, as this would violate the contract between OCC & my insurance company.
initials* CREDIT/DEBIT CARD GUARANTEE: I understand that I am required to keep a credit card on file with Oklahoma Christian Counseling, PC whether I am using insurance or not. I give Oklahoma Christian Counseling, PC permission to charge my credit/debit card for any owed or unpaid fees. I understand that all known fees are due before each session and will be charged to my card the morning of my appointment. I understand that if I pay out of pocket and my insurance also pays I will have an overpayment that will be refunded to me promptly or applied to future visits.
COLLECTIONS: After 60 days any owed or unpaid balance will be charged 1.5% interest a month (18% APR). In the event that my account is overdue and turned over to our collection agency, the client or responsible party will be held liable for any fee charged to our office to collect the debt owed.

ADVANCED PAYMENT DISCOUNT: You may be eligible for an Advanced Payment Discount if you self-pay. You may pay up to 20 sessions(10 sessions minimum) in advance and receive a 20% discount. Payment must be made before the prepaid visits. Let the scheduler or your therapist know you are interested in this discount.

METHODS OF PAYMENT: Oklahoma Christian Counseling, PC accepts cash, check, debit cards, and major credit cards.
initials* 24-HOUR CANCELLATION AGREEMENT: I understand that counseling appointments are limited and another client may be on a waiting list for a session to open. I understand that if I do not cancel more than 24-hours before my appointment I will be charged and pay the full fee of the session. If we are filing insurance for you, your insurance carrier will not pay for your missed session and you will be charged the full fee, not just the deductible. Your charge will be applied to your debit/credit card on file or to your prepaid balance.
initials* CONFIDENTIALITY: I understand my verbal communication and clinical records are strictly confidential except for: a) information you and/or your child or children report about physical or sexual abuse; then, by Oklahoma State Law, this office is required to report this information to the Oklahoma Department of Children and Family Services, b) information shared with your insurance company to process your claims, c) where you sign a release to have specific information shared, d) if you provide information that informs your therapist that you are in danger of harming yourself or others, e) if you provide information that informs your therapist of elder abuse.
initials* COMMUNICATION: I give my permission to receive phone calls, text messages, or emails to confirm appointments and communicate with Oklahoma Christian Counseling staff.
initials NEWSLETTER: I consent to receive Oklahoma Christian Counseling's newsletter, containing encouragements, news, mental health information, links to our site, links to external sites, and promotions by email, text or standard mail. You can unsubscribe at any time.
initials* EMERGENCY SITUATIONS: If an emergency arises for which the client or their guardian feels immediate attention is necessary, the client or the guardian agrees that they will contact the emergency services in the community for emergency services (i.e. dial 911). I release Joel Duncan, LPC and Oklahoma Christian Counseling, PC of any liability for emergencies outside of my counseling session. I understand that Oklahoma Christian Counseling, PC does not take emergency or after-hours call. Oklahoma Christian Counseling, PC will follow any emergency services with standard counseling and support to the client or the client's family in a timely manner. ODMH 24-hour Crisis Assistance: (800) 273-8255
Signature(s)*

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Signature

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Agreement Not To Seek Testimony
I hereby acknowledge that Oklahoma Christian Counseling, PC ("OCC") and my Therapist have informed me how involving a treating psychotherapist as a non-party witness in legal proceedings can create conflicts of interest and negatively impact therapy, reducing the possibility of a successful treatment outcome.
I also acknowledge that involving OCC and/or Therapist as a non-party witness in legal proceedings would be disruptive to his/her practice and unfairly impose upon him/her.

It is with this understanding that I hereby agree, as a condition upon which OCC and Therapist has consented to provide therapy, that I (or my legal representative) will not call, subpoena, or otherwise seek to compel OCC or Therapist to provide oral or written testimony as a non-party witness in a legal proceeding with respect to his/her assessment, evaluation, or treatment of me, my partner, or my child.

I agree that such attempts to seek OCC or Therapist's testimony as a non-party witness shall constitute a basis upon which a court should quash any subpoena or issue a protective order, and I agree to be responsible for and to pay for any attorney fees and costs incurred by OCC or Therapist in attempting to secure enforcement of, and compliance with, this agreement.

I also agree that Therapist, whether in the role of fact or expert witness, is entitled to recover from me his/her current professional rate of $500 per hour for any time he/she spends providing, preparing to provide, or traveling to provide oral or written testimony as a non-party witness in a legal proceeding in which I or my representative seek his/her testimony. This includes testimony compelled by a court

Finally, I agree to deliver to OCC or Therapist a retainer of $2,000 before he/ she provides any oral or written testimony as a non-party witness in any legal proceeding in which I or my representative seek his/her testimony.
Client Signature*

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Acknowledgement of Receipt of Note of Privacy Practices
We are required to provide you with a copy of our Notice of Privacy Practices. The notice states how we may use and/or disclose your health information.

Please sign this form to acknowledge receipt of the Notice.

I acknowledge that I have received a copy of this office's Notice of Privacy Practices.
Please print your name here*
Signature*

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Should be Empty:

Consent and Patient Information

Agreements

Agreement Not To Seek Testimony

Acknowledgement of Receipt of Note of Privacy Practices