(Pattison Professional Counseling and Mediation Center offers paperless patient statements via email. Additionally, you will receive a monthly newsletter providing you with interesting articles and informative information pertaining to health and wellness. You may opt-out of receiving the newsletter at any time.)
Responsible Party Information (if client is a minor, please indicate parent information):
Thank you for choosing Pattison Professional Counseling and Mediation Center. We are interested in knowing how we were selected to serve you.
If you do not have insurance, we offer a sliding scale fee to help you afford treatment and counseling. To determine the appropriate fee, please enter your annual income below.
What do you consider to be the top three stressors in your life?
Please state which of the family members may have had any of the following:
The use of controlled medications may cause addiction and is only one part of the treatment for your condition. The goal of medicine is to work alongside therapy to treat your diagnosed conditions.
I have been told that:
1. If I drink alcohol or use street drugs, I may not be able to think clearly and I could become sleepy and risk personal injury.
2. I may get addicted to this medicine.
3. If I or anyone in my family has a history of drug or alcohol problems, there is a higher chance of addiction.
4. If I need to stop this medicine, I must do it slowly or I may get very sick.
I agree to the following:
I am responsible for my medicines. I will not share, sell, or trade my medicine. I will not take anyone else’s medicine.
I will not increase my medicine until I speak with my doctor or nurse.
My medicine may not be replaced if it is lost, stolen, or used up sooner than prescribed.
I will keep all appointments set up by my doctor (e.g., primary care, physical therapy, mental health, substance abuse treatment, pain management).
I agree to give a blood or urine sample, if asked, to test for drug use.
Refills will be made only during regular office hours—Monday through Friday, 8:00AM-4:30 PM. No refills on nights, holidays, or weekends. I must call at least three (3) working days ahead (M-F) to ask for a refill of my medicine. No exceptions will be made.
I must keep track of my medications. No early or emergency refills may be made.
I will only use one pharmacy to get my medicine. My provider may talk with the pharmacist about my medicines.
PRESCRIPTIONS FROM OTHER DOCTORS
If I see another doctor who gives me a controlled substance medicine (for example, a dentist, a doctor from the Emergency Room or another hospital, etc.) I must bring this medicine to Primary Care in the original bottle or clearly document the prescription on the bottle (via photograph), even if there are no pills left.
TERMINATION OF AGREEMENT
If I break any of the rules, or if my provider decides that this medicine is hurting me more than helping me, this medicine may be stopped by my provider in a safe way.
(To sign, please use your mouse, trackpad, or finger to provide your signature. You cannot continue with the form until your signature for this part of the agreement is received.)
I agree to make a commitment to the treatment process. I understand this means I agree to active involvement in all aspects of treatment, including:
I also understand that, to a large degree, my progress depends on the amount of energy and effort I make. If it is not working, I will discuss it with my provider.
This Consent form does not replace PPCC’s primary Informed Consent Form for “In Office” mental health services; it is in addition to.
The definition of Telehealth involves the use of electronic communications to enable PPCC, INC mental health professionals to connect with individuals using interactive video and audio communications. Telehealth includes the practice of psychological health care delivery, diagnosis, treatment, referral to resources, education, and the transfer of medical and clinical data. I understand:
By signing this document, I agree that certain situations, including emergencies and crises, are inappropriate for audio-/video-/computer-based psychotherapy services. If I am in crisis or in an emergency, I should immediately call 9-1-1 or seek help from a hospital or crisis-oriented health care facility in my immediate area.
I have read this document and understand the risks and benefits related to the use of telehealth services. I hereby give my informed consent to participate in the use of telehealth services for treatment under the terms described herein.
I hereby attest by signature that I have read, understood, and agree to the terms of this document.
In case of an emergency, please list the emergency contact person we should call:
Pattison Professional Counseling and Mediation Center (PPCC Inc.) is dedicated in protecting your protected health information (PHI). You agree to the following services to release specified information while being treated at PPCC Inc.
PPCC Inc. places reminder calls one business day prior to your appointment. Your first name, the appointment time at our facility, and the clinician that you will be seeing will be released via a phone message, text, email, or appointment verification for smartphones.
PPCC Inc. secures your medical records electronically utilizing a HIPAA HYTECH compliant service.
If you and your therapist and/or our support staff communicate via email or texting through a cell phone, you agree to and understand that your PHI may be released via your correspondence and communications. PPCC Inc. secures your PHI however, once communication is released via the internet or phone devices your information is no longer secure.
Thank you for choosing Pattison Professional Counseling Center. We are committed to your successful treatment. The following is our financial policy, which we request you read, understand, and sign prior to treatment.
Insurance: Your insurance policy is between you and your insurance company. We are not a party to that contract. If services are not covered by your insurance policy, you are responsible for all session fees. We do accept the assignment of benefits from insurance companies with which we are participating providers. All Tricare/Champus clients must obtain a doctor’s referral in order to file the insurance claims. If the client does not obtain a referral and insurance cannot be filed, the client is responsible for the entire session charge. We will file your insurance claims for you, either by paper claim or electronically, unless otherwise specified by you.
Assignment of Benefits: I assign my insurance benefits to Pattison Professional Counseling Center for the duration of my treatment.
Payments: Self-pay patients (those paying the total amount) need to pay over the phone, or when making the appointment (as opposed to on the actual day of the appointment), to hold their spot. This is a non-refundable payment for the time slot (New patient: $250; Follow-Up [30-minute session] $175).
Clients using insurance will be expected to pay their co-pay on the day of service. If your co-payment is not known on the first date of service, a co-payment of $20.00 will be collected at the time of each session until your correct co-payment can be determined. We accept cash, checks, money orders, Visa, MasterCard, and American Express for payments. We can also keep your credit card number on file and charge your card with your cost share after each visit.
Missed or Cancelled Appointments: More than 48 hours of notification is required if you need to cancel or reschedule your appointment. The entire fee will be charged to your account if you do not show up for your scheduled appointment or do not give us more than 48-hour notification. Self-pay patients will have to pay the full fee again if giving less than 48-hours notice or missing the appointment. Insurance patients will be charged the full rate as a no-show fee prior to rescheduling if giving less than 48-hours notice or failing to show. If calling to cancel or reschedule your appointment after business hours, please leave your name, appointment date and time, and a brief message on our voice mail. We appreciate your assistance in helping us serve you better by keeping scheduled appointments.
Billing: Payment for all client statements is due in full upon receipt. A divorce decree cannot assign responsibility for an adult or child’s account. Failure to pay your bill could result in your account being turned over to a collection agency. Only your name and account status will be discussed with the collection agency.
Returned Checks: A $30.00 service fee will be added to your account for each returned check from your bank. Only cash payments will be accepted if two NSF checks are received.
My signature acknowledges that I have read, understand, and agree to all parts of the financial policy of Pattison Professional Counseling and Mediation Center (PPCC Inc). I also understand that my account will be turned over to a collection agency if it becomes delinquent.
I have the right to efficient and effective care individualized to my needs. My treatment provider will work with me to develop a treatment plan best suited to me. We will use this plan to help us deal with my problems as quickly and effectively as possible.
I have the right to be treated with dignity and respect. I will be treated with respect at all times. I will report any misconduct by my treatment provider, including social invitations, suggestive remarks, or unwanted touching, to PPCC management. I may call PPCC any time with questions, comments, or complaints.
My treatment provider will make every effort to meet me at our scheduled appointment time. If my treatment provider is late, he or she will extend our session, if I am willing, or we will make other arrangements by mutual agreement.
I have a right to privacy and confidentiality. All records and communications will be treated with confidentiality in compliance with applicable state and federal laws. These laws may obligate PPCC to report suspected abuse or neglect, domestic violence, and those who pose a danger to themselves or others, or when ordered to by a court of law.
Scheduled appointments are commitments. I will make every effort to be on time for my appointment(s). I understand that time will be lost from my session if I am late for my appointment.
I am responsible to pay for services received. I am aware my insurance plan typically requires me to pay a co-payment (a dollar amount) or co-insurance (a percentage of my treatment provider's fee) at the time services are provided. My insurance plan may also have a deductible (an initial dollar amount) that is my responsibility. Additionally, certain services may be limited and/or not covered at all by my insurance plan. I understand I am financially responsible for co-payments, co-insurance, deductibles, and all services not covered by my insurance plan. My treatment provider and my insurance plan's representative will help me determine what services my insurance plan covers.
I have read this list of rights and responsibilities or had them read to me. I understand and agree to them.