Subscription Informed Consent Disclosure
By signing this form, you agree to receive mental health services provided by Kentucky Counseling Center, LLC DBA Counseling Now and its independent contractors. We know that starting counseling is a big decision and you may have many questions. We will do our best to answer any questions or concerns. This form explains information about KCC policy, State and Federal Laws, and your rights about counseling. All KCC employees and contractors have met the highest level of education, certification, and licensing requirements set forth by state law related to their license. Counseling practices, philosophy and plan limitations and risks will be discussed with you today.
TREATMENT PROCESS AND DOCUMENTATION
It is the mental health professional’s responsibility to keep accurate records including Evaluations, Treatment Plans, and Progress Notes. By signing this document, you are consenting to the Treatment Plan that your provider creates and agree to any goals, objectives, and therapy techniques that may be used in your therapy process.
Your card will be collected, saved on file and charged before starting the subscription package and each month after on a date agreed upon until cancellation notice is received. If your card is declined for any reason in the middle of services, you will be denied treatment until payment is settled and a valid card is obtained. If balances remain unpaid for 60 days, client information will be sent to a collection agency.
Appointments will be cancelled and will be counted towards your package if client "no-call, no-shows" or is 15 minutes late without notice. If a client cancels an appointment with a notice greater than 24 hours, KCC will not count the missed appointment towards the package. If the appointment cannot be rescheduled within the 30 day cycle, you may add it to your next monthly appointment allotment, carry over appointments are good for 60 days.
CREDIT CARD PAYMENTS
You will be required by KCC to store your credit card information in your chart for future bills you may incur not covered by insurance. KCC will automatically process your balance one time per month and will not provide any additional warning other than what is written in this section of the Informed Consent form. Please be aware that if your balance is not paid in full after 3 statement cycles your account will be sent to collections with GLA. Please note that once your debt is filed with GLA you will then be liable for an additional charge of 30% of your total balance. We will not permit you to be seen until you have satisfied your outstanding balance in full with GLA.
CONFIDENTIALITY AND EMERGENCY SITUATIONS:
Confidential information discussed in session is not discussed with anyone without your written permission except for:
1. Diagnosis and dates of service shared with your insurance company to process your claims
2. Information you tell KCC about physical, sexual or elder abuse; then, by Kentucky State Law, I have to report this to the Kentucky Department of Children and Family Services
3. Where you sign a release of information to have specific information shared
4. If you tell KCC you are in danger of harming yourself or others
5. Information shared with therapist’s clinical supervisor if applicable
6. When required by law.
If you need to contact us between counseling sessions were available at kentuckycounselingcenter. com and counselingnow.com via live chat. Text messages and social networking sites are not confidential and we may not be able to respond. In the event of an emergency please call 911.
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