I hereby consent to receive mental health treatment from {clinician} (hereafter referred to as {clinician}). I understand that my consent is voluntary. I also understand that I do not have to accept any treatment option {clinician} offers and that I may withdraw my consent at any time.
POLICIES
Appointments: Individual sessions are 45 minutes in length. Couples sessions are typically 75 minutes in length. If you wish for an extended session, out of pocket arrangements can be made. Please be prompt to sessions as late arrivals mean shorter sessions.
Financial Obligation: I understand that I am responsible for full payment of all fees for services provided by {clinician} regardless of whether or not there is insurance coverage. If I have insurance, I understand that I am responsible for knowing the specific terms and limits of my insurance coverage, and that I am ultimately responsible for full payment of fees. Furthermore, unless prior arrangements have been made, I agree to pay any self-pay fees, copayments, and/or coinsurance amounts at the end of each session.
Changes to Benefits/Insurance: It is your responsibility to be aware and inform your providers of any changes to your mental health policies or benefits. If claims are rejected due to changes in policy, or if payment of claims go to deductible, you are responsible for these payments.
Billing Authorization and Release of Information: I hereby authorize {clinician} to bill my insurance company for their services and to release my individually identifiable health insurance information necessary to process insurance claims. I understand that my individually identifiable health insurance information will also be released to {clinician}'s billing service, Streamline. I understand that this authorization is voluntary. I understand that if the organization authorized to receive the information is not a health plan or healthcare provider, the released information may no longer be protected by federal privacy regulations.
Assignment of Benefits: I hereby authorize the payment of my insurance benefits directly to {clinician} for services performed.
Payments: Payments are expected at the time of the session.
Cancellation and Weather: 48 hour notice is required or the full fee for the session will be charged. In case of severe weather, please call to check. If roads become impassible or a state of emergency is called, no charge will be assessed for same day cancellation.
Collections of Overdue Payments: If payments are overdue after 15 days you will be sent a bill via email/snail mail which you must pay immediately. You will be warned via email or snail mail if the balance is not due after 30 days, and if after 45 days the debt is not paid, it will be sent to collections. CCPV will add 33% of the debt to your bill to cover collections costs.
Custody/Divorce: Despite the fact that I specialize in couples counseling, I am not qualified to conduct custody evaluations and I NEVER testify in court regarding custody or divorce matters.
Texting Policy: Text messages should only include scheduling information. No clinical information should be sent through text messages.
ACKNOWLEDGEMENT
My signature below acknowledges that I understand and accept the terms and conditions of this authorization and agreement.