The following practice policies have been updated-2025
(a) I acknowledge that my informed consent and HIPAA agreement are ongoing unless I choose to withdraw my consent from treatment.
(b) In the event of an outstanding balance, it is mandatory to provide an updated card on file for all future appointments to maintain active patient status. It is the responsibility of the patient to ensure their card information is kept current.
(c) If a therapist believes that another therapist may be a more suitable fit, the client will be referred to another therapist, either within or outside The Teal Door Counseling Center. The assessment process continues beyond the first session, and a referral may be deemed in the best interest of the client.
(d) While I have the right to access my records, I understand that I shall not attempt to subpoena the therapist's testimony or my documents for deposition or court hearings, including divorce proceedings.
(e) I acknowledge responsibility for remitting payment for professional services at the end of each session. Weekly reviews of my account will occur, and any outstanding balances will be processed to my card on file, unless alternative arrangements have been previously agreed upon.
(f) The therapist will communicate any increase in rates, and I have the right to terminate treatment due to fee increases.
(g) I am aware of the $75 no-show policy. Failure to cancel or reschedule within a 24-hour notice will result in a no-show fee. I understand that the $75 fee could potentially increase over time, and I will be notified of any changes.
(h) I am familiar with the "No Surprise Act" for patients paying a sliding scale fee. I will sign the no surprise act form if I am paying a sliding scale fee.
(i) My credit card information is current with the Billing Department, enabling me to schedule appointments.
(j) My insurance information is up to date with the Billing Department, allowing me to continue scheduling appointments.
I certify by my signature below that I have read, fully understand, and agree to abide by the stated policies.