**Quick note before you complete this form.**

If you are seeking services forthe following, one of our friendly staff can provide you with contact information for an office or practictioner who specialize in these areas. These services are currently outside our scope of expertise. We apologize for any inconvenience.

Office hours

Monday - Thursday 8:00am - 5:00pm

Fridays 8:00am - 3:00pm Phone: 210-209-0642 CALL OR TEXT!!

Services We do NOT provide

^Services pertaining to legal matters or requesting service to aid in obtaining disability paperwork

^Same day appointments or is actively in a crisis situation

^Eating Disorders

^Court ordered counseling or custody evaluations

^Letters for therapy animal

^Evaluation or testing for diagnosis

Your out-of-pocket estimate is estimated before the initial session. If using insurance, your benefits will be verified, however, the estimate is not a guarantee of how your insurance plan will pay for your services. You will be financially responsible for any amount not covered by your insurance plan or if your insurance plan information has expired or new plan information or the proper authorization(s) were not provided to Counseling4Life at the time services were rendered. To make changes to your insurance plan information you can contact our office directly. We also encourage you to reach out to your insurance provider to learn more about your Mental Health Benefits.

Counseling4life requires you provide an active Credit or Debit card before we can proceed with scheduling any "new clients" appointments.

.** Credit cards are the only acceptable form of payment due to COVID health crisis and will be processed automatically from the credit card noted as the "Default" card, saved in your client portal, under "My Saved Cards." We do not accept AMEX

** Payments are typically collected the day following an appointment. Our office does NOT reschedule initial appointments that are "no show" or canceled with less than 24-hour notice from the time of your appointment unless a one-time allowance with a cancellation fee of $50 is collected.

**Reasons to Pay Privately** Private paying clients choose not to involve insurance companies in their mental health care. Their counseling is not limited by a diagnosis, treatment plan or session limits that health insurance companies mandate. Often, insurance companies limit the number of sessions and even the type of therapy they will cover. In order to obtain reimbursement from your insurance company, a mental health diagnosis must be made. This becomes a part of your permanent health care record, and the insurance company can review all of your records at their discretion. By paying privately or out of pocket, we can assure private pay clients the highest degree of privacy, flexibility and control of their mental health and records that is allowed by Texas state law. We will work collaboratively to decide how often you would like to attend therapy and you decide what you want to focus on. You have the control over your mental health care. 

**Choosing to use your insurance** if you work with a fully licensed therapist, we can provide you with a receipt to turn in to your insurance carrier for reimbursement as an out-of-network provider. Medicare Part B helps cover mental health services you generally get outside of a hospital, including visits with a clinical psychologist or clinical social worker. Health insurance plans and benefits vary, so please consult your insurance provider about reimbursement for your counseling services. Unfortunately, insurance companies will not recognize and reimburse for services provided by LPC-Associates. However, if you have an FSA (flexible spending account) or health savings account, any counselor you receive services from at COUNSELING4LIFE LLC, can be paid for with these accounts as they are paid to COUNSELING4LIFE LLC and not individual counselors.

If your child is the client and is named in a custody agreement, please know your counselor's license requires them to receive an official (judge signed), most recent, and complete electronic copy of the divorce decree, naming custody for the client or custody agreement naming the client, be sent in BEFORE the counselor has their first session with the child. Conservatorship rights are required to be reviewed according to mental health laws before a minor client can receive treatment. Please also note, our office DOESN'T see a child or adolescent under the age of 18 during the 1st session. The first scheduled appointment is with the Parent/Legal Guardian and the therapist. The second session is when the child will be seen. If you wish to provide documents for clients named in a custody agreement in advance you can attach those documents Directly to this form or email them to our scheduling team at scheduling@counseling4lifellc.com.

**Private Pay Session Rates and Fees**

Licensed Therapists: $120 for a 50-minute session

​LPC Associate/LMFT Associates/LMSWs* $60 for a 50-minute session

​Graduate Therapy Student Interns**: $30 for a 50-minute session**

If your child is the client and is named in a custody agreement, please know your counselor's license requires them to receive an official (judge signed), most recent, and complete electronic copy of the divorce decree, naming custody for the client or custody agreement naming the client, be sent in BEFORE the counselor has their first session with the child. Conservatorship rights are required to be reviewed according to mental health laws before a minor client can receive treatment. Please also note, our office DOESN'T see a child or adolescent under the age of 18 during the 1st session. The first scheduled appointment is with the Parent/Legal Guardian and the therapist. The second session is when the child will be seen as long as all necessary legal documents are on file with COUNSELING4LIFE.

If you wish to provide documents for clients named in a custody agreement in advance you can attach those documents Directly to this form or email them to our scheduling team. Counseling involving Client named in Custody Situations Counseling Involving Minor Clients of Divorced Parents or Minor Clients Named in Court Order According to the provisions made to Tex. Admin. Code Ann. tit. 22, part 30, §681.41 (2004), “(aa) Prior to the commencement of counseling services to a minor client who is named in a custody agreement or court order, a licensee shall obtain and review a current copy of the custody agreement or court order, as well as any applicable divorce decree. A licensee shall maintain these documents in the client's record.” Be advised, without sufficient documentation, a minor client cannot enter treatment.

It is also important to note that licensed mental health professionals do not possess the authority to make custody recommendations or provide evaluations or expert testimony for any purpose and will refuse any prompting to do so, as it is out of the counselor’s scope of practice.

In the event, a minor client is named in a custody agreement, and when it is deemed therapeutically necessary, counselor must obtain permission from all parties named as Managing Conservators of the minor client named in the custody agreement that has any of the following before treatment of the minor client can occur, unless consenting Managing Conservator affirms otherwise below in Non-Participating Managing Conservators in Custody Situations section:

● Right to access the psychological records of the minor client

● Right to consult with the psychologist/mental health professional of the minor client

● Right to consent to psychiatric and psychological treatment for the minor client