Heads Up Guidance Services

Fee Schedule and Service Agreement

Heads-Up Guidance Services is a Non-Profit organization providing professional behavioral health counseling and addiction recovery services at a discounted rate for all motivated individuals in need. We are a Fee-For-Service Provider and do not accept Insurance or Medicaid. Initial Intake and all appointments must be paid (Cash, Check or Credit card) in advance to confirm appointments, cash and check payments must be made at least 48 hours in advance. There is a $2 service charge for all card payments (not for cash or check).

Initial Intake: Application/Needs Assessment - $40 Initial Paperwork includes Personal History Profile, Current Assessment of Functioning, Informed Consent for Services, Legal Consent to Treatment, Level of Care/Counseling Regimen and Recommendations.

Please check the type(s) of service below that you feel will be most appropriate for you.

If Client is a Minor (Under the age of 18), who has legal custody?

I, the undersigned, have provided accurate registration information (above) to the best of my knowledge. I agree to notify Heads-Up Guidance Services (HUGS) immediately if any changes occur to this information.

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We operate with 100% professional volunteers who all volunteer their time to serve our clients. Our professional volunteers all range from Master's Level Interns to Post-graduate and Associate Licensed clinicians, as well as fully licensed clinicians. Interns, Post-Graduate and Associate Licensed clinicians are all regularly supervised by fully licensed clinicians.

HUGS provides outpatient services to a motivated and high functioning population. In an outpatient setting, we are not available in case of emergency and/or crisis. We expect you to be able to go 24 hours without receiving a text or phone call response, as well as being able to go a week between sessions. If these things are not possible, you might need a higher level of care. Our clinical staff is trained to recognize and refer to higher levels of care as indicated or requested to ensure you can effectively meet your treatment goals. Therapeutic rapport is essential; and you may request a change in assigned counselor at any time. However, due to clinician scheduling and availability, you may need to be placed back on the waiting list temporarily.

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Informed Consent for Services

Confidentiality: The Health Insurance Portability and Accountability Act (HIPAA) has created new patient protections surrounding the use of protected health information. Commonly referred to as the "Medical Records Privacy Law," HIPAA provides patient protections related to the electronic transmission of data, the keeping and use of patient records, and storage and access to health care records. HIPAA applies to all healthcare providers, including mental health. Health care providers throughout the country are now required to provide patients a notification of their privacy rights as it relates to their health care records.

Be informed that the counselors and staff of Heads-Up Guidance Services guard your privacy to the fullest extent. All communications between the client and therapist are confidential and will not be revealed or released without your written authorization, unless required by law, such as in the case of child or elder abuse, or threats of physical harm to the client or others. I understand that it is NOT HUGS' policy to release client progress notes to the client or any public or private entities, even with a signed consent to release information.

Youth Considerations (clients under the age of 18) All information provided in confidence between the youth and their service provider will remain strictly confidential with a few exceptions. These include, but are not limited to; if the client presents as high-risk regarding suicidal ideation or homicidal ideation, if the client presents or reports safety concerns or risky acting out behaviors that could lead to self-injury or death, if the youth reports evidence or knowledge of child abuse, elder abuse, or animal cruelty. We will disclose this information to the responsible adult party before reporting as we are mandated reporters. It is required in these circumstances that such information be disclosed to the guardian and will be done so as part of a collaborative session/therapeutic process. All efforts possible will be made to contact the guardian within 24 hours of this information being disclosed and then discussed in the next collaborative session. It is our policy that collaborative sessions be offered to guardians/caregivers on a monthly basis to update them on youth's progress, treatment goals, needs/recommendations, concerns, and any issues with attendance/compliance. It is encouraged that beyond the collaborative meetings, youth are allowed to keep private what is disclosed between themselves and their counselor. Guardians are encouraged to use collaborative sessions to explore any questions or concerns, or request 15 minutes at the beginning or end of the youth's scheduled

Legal Issues: HUGS' clinicians do not participate in legal proceedings. If they receive a subpoena to appear in court, the client or the legal representative must agree to pay HUGS $250 per hour plus travel time. Please understand that a subpoena for a counselor to witness in court is always against therapeutic/clinical advice, as it is likely to harm the client's case and therapeutic rapport. In lieu of a court appearance, the counselor can provide a written Treatment Summary for a fee of $50.

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While your therapist will take reasonable precautions to protect your confidential information, email, texting & social networking are not completely secure methods of communication. Email and other forms of electronic communications may be used for convenience in regards to scheduling, appointment reminders, homework assignments, follow-up care, or information concerning payment status. It is NOT a way of communicating therapeutic information regarding care or emergency treatment.

I acknowledge that if I use electronic mail to initiate contact with my therapist, that he/she and/or his/her representative has my permission to respond via the originally initiated communication (i.e. text, email, etc

Emergencies: While our clinical staff strives to be available when needed, please note that they are not on call for emergencies. I understand that, if I have an emergency, I should contact the nearest hospital emergency

Since Weapons of any kind are NOT allowed in the HUGS' Building, I understand that law enforcement officers required to carry a loaded weapon while on duty must sign a special waiver and it will be kept in their client file.

Appointments and Payments Insurance is not accepted as our service rate is lower than most insurance co-pays. If there is a financial hardship that impacts payment, HUGS' staff is willing to hear concerns and help clients work out an alternative method of

I understand the fee schedule and payment agreement for HUGS' Counseling Services. I know that I will be expected to pay for missed appointments that are not canceled 24 hours in advance, except in the event of a documented emergency.

In order to maintain your confidentiality, your therapist will NOT acknowledge you in the event you encounter him/her in public. This ensures that you will never be put in an awkward position, not knowing how to respond. If you would like to initiate an acknowledgment, your therapist will be delighted to respond. He/she will not be offended if you choose not to do so. While our counselors do not view therapy as shameful or something to be concealed, they understand that discretion is important and your right to privacy will be respected.

I understand that information about therapy sessions will always be kept confidential, even if I choose to engage in a social conversation in public.

I agree to have a counseling session recorded for educational/supervision purposes. This would only be done with my written permission, and no names, images or identifying information would be revealed to protect my privacy.

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The fees listed may be adjusted annually. However, clients will be notified prior to any changes. All Payments are processed on Mondays at 8AM for that week. If appointments are canceled or rescheduled due to documented emergencies, your payment will be credited to your next appointment. There is a $20 charge for all declined payments due to insufficient funds. Returned checks will result in a "cash or credit only" payment from that time forward. A $2.00 surcharge is required for each credit card payment to cover processing costs.

A Credit Card Authorization form must be completed for your personal file. If someone else is paying for your services, there must be a Release of Information on file for that person.

I understand that I must PREPAY for all appointments and my card will be charged before my session. The office will run your credit card payment the Monday before your scheduled session - when observed holidays fall on a

Monday, payments will be run the previous Friday.

If I choose to pay with a credit or debit card, I understand that I will be charged a $20 penalty if my card is declined due to insufficient funds. Our office will run your credit card payment the Monday before your scheduled session - when observed holidays fall on a Monday, payments will be run on the previous Friday.

I understand that if my credit card is declined, I will receive an email notification/call/tex and I will not be seen for a session until this issue has been resolved. We encourage you to still come to the scheduled session, as long as you can pay prior to being seen ($20 penalty fee + $20 session fee + processing fee if paying via card Failure to rectify this situation could result in an automatic discharge for non-compliance.

I understand that it is my responsibility to keep my credit card information updated in HUGS' office records. I will inform the office and my counselor when I get a new card or of any change in payment information to avoid any

I understand that recurring credit card penalties and/or delinquent cash payments will result in my discharge from

I understand that if I wish to have a debit card on file, I must also provide either a backup credit card or provide a $40 ($20 session, and $20 declined card penalty) cash deposit to be used in the event of a declined payment.

I understand if the primary debit card is declined, the backup credit card will automatically be charged with the declined payment penalty fee of $20

I understand that if my primary debit card is declined, my primary payment method moving forward will be the

I understand that if the cash deposit has to be used, I will not be rescheduled until the cash deposit is replaced, orI provide a backup credit card for payments.

 

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This form must be filled out even though you may choose not to pay with a card for your appointments. (This form will be kept confidential & secure.)

Please provide your credit card information below. All billing is processed on Mondays. If you reschedule with more than 24 hours notice, but after Monday at 8AM, your payment will move to the next session. Your card will be on file in our square billing system. Your acceptance of this policy ensures your payment will always be up-to-date and will be made in a timely manner. There is a $20 declined card penalty for any declined payments.

If you choose to make your payments by Credit or Debit Card instead of cash, we must charge an additional $2.00 fee per payment for processing costs. If you choose to pay by debit card, there must be a backup credit card on file, or a cash deposit of $40. There is a $20 declined card penalty for any declined payments.

Please Note: Your signature gives Heads-Up Guidance Services permission to bill your card for services provided and for scheduled appointments not met. This includes "no shows" or cancellations not made within 24 hours of your scheduled appointment time. 

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Appointment Policies Counselors schedule all client appointments. When you confirm an appointment with your counselor, you are confirming payment for services. HUGS', therefore, requires that participants provide at least 24-hour notice when canceling an appointment. Cancellations are NOT refundable because you are paying for the counselor's time. Clients who do not show up for appointments, and have failed to call to cancel, will be charged the full fee for those appointments. If you must cancel, please contact your counselor directly, then the office at 912-417-4320 or text 912-800-5701. If the office is closed, you may leave a message on the answering machine.

Keeping Scheduled Appointments

Our staff at HUGS, in order to make counseling available to all motivated individuals, must strictly adhere to regulations concerning missed and rescheduled appointments. Please understand that we have a list of clients waiting to be seen, and that clients who have habitual cancellations and/no shows are preventing other clients from scheduling during that time slot.

Not showing up for 2 scheduled sessions in a row (without a call or reschedule request), is considered "non-compliant" and a reason for Discharge.

Habitual cancellations and reschedules (2 times in a row) and/or a pattern of non-compliance are considered

If I cannot be reached after 3 attempts to contact within a 2-Week period, I will automatically be discharged.

Gift Giving Policy: We encourage and acknowledge the desire of our clients to express gratitude. However, due to our ACA and NASW Code of Ethics, counselors are not able to accept gifts of any kind from their clients. (Counselors are required to decline any gifts beyond a cup of coffee If you feel inclined to contribute more, please make your tax-deductible donation to the HUGS' organization.

I have reviewed the fee and payment guidelines listed above. I agree to accept financial responsibility for services provided, as well as for missed appointments that have not been canceled 24 hours in advance.

Our commitment to serve you must be matched by your commitment to keep appointments and actively participate in treatment recommendations.

Please know that counselors will make every effort to reach you before removing you from their caseloads. You may be assured that any messages left at the front desk concerning emergency cancellations will be relayed to your counselor.

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HUGS' Counselors Do NOT Evaluate Custody Cases and cannot make any recommendations on custody.

We may elect to see children whose parents are in the process of custody litigation. Due to the sensitive nature of divorce and all potential issues that may arise in such cases, we have very specific policies to which you MUST agree before we enter a counseling relationship.

1. Provided all proceedings have come to a close, we require a copy of the current,    standing court order demonstrating custodial rights of each parent and/or the parenting agreement that is signed by both parents and the judge. We will need to have contact with the parent who has legal custodial decision-making for medical concerns/needs before we see the child for counseling, and will need to obtain written consent for the child to participate in counseling from the legal custodian(s We prefer to have contact with both parents prior to seeing the child.

2. We ask all clients to waive their right to subpoena our counselors to testify in court. This policy is set in order that we can preserve the efficacy and integrity of the therapeutic process and relationship with you and/or your child. It is our experience that a counselor's appearance in court often damages the therapist-client relationship, and it is our ethical duty to make every reasonable effort to promote the welfare, autonomy and best interests of our clients. By signing this agreement, you waive the right to subpoena a HUGS' counselor and client records. If you prefer, we will recommend a referral to a therapist(s) who are willing to appear in court.

3. In the event that we are subpoenaed to appear in court despite this waiver-whether we testify or not - we charge the full standard Court Related fee. A retainer of $1,000 is billed and drawn on during the court process. Professional time is billed at $250 an hour. All time dedicated to any court-mandated appearance including but not limited to: preparing documentation, discussions with lawyers and/or a guardian ad litem, affidavits, depositions, wait time spent at the courthouse, time on the stand, and travel will be billed at $250 per hour. Food and lodging will be billed if expenses are incurred in relation to the court

I understand these policies and I, and any of my representatives now and in the future, hereby waive any and all rights to subpoena Andrea M. Epting or any of HUGS' Clinical Volunteers, Student Interns, Counselors. Clinicians, Supervisors, or Directors, within the HUGS' organization.

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Legal Consent to Treatment

(You will initial these with your counselor in the intake session)

I have had confidentiality explained clearly to me by a HUGS' Service Provider, and I fully understand that will be protected and respected by the HUGS' Organization.

I have had the "limits of confidentiality" explained to me by a HUGS' Service Provider, and I fully that (as mandated reporters) Heads Up Guidance Services, Inc. is ethically obligated to breach my and report to the proper authorities any active intent to harm myself or others, and active/current of child abuse or elder neglect.

I have been informed about the HUGS' Client Rights Advocate, and I understand that I have an to schedule a meeting to discuss concerns involving any event in which I feel that my rights may have violated.

I have read the Client Bill of Rights and HUGS' Crisis Procedure.

I have had HUGS' program policies, regulations, and expectations explained clearly to me by a HUGS' Provider, and I understand the consequences of non compliance. I agree to abide by/comply with all their and safety regulations, and to respect the professional opinions of HUGS' counselors and staff. 

I understand that if there is suspicion or confirmation of intoxication upon arrival for my appointment, be seen, and will be charged for my session.

I have read the above information and voluntarily request counseling services from Heads-Up Guidance Services (HUGS I agree with their terms and conditions, and I give my formal consent willingly and without force for HUGS to provide any psychotherapy and/or psycho-educational services that their staff recommends and deems necessary for my treatment. I affirm my understanding of "Informed Consent" and "Limits of Confidentiality."

 

For Clients Under the Age of 18: I am seeking services for this minor child to engage in a professional relationship with the counseling staff of Heads-Up Guidance Services, and I agree to their terms and conditions.

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Introduction to TeleMental Health Services:

TeleMental health services involve the use of electronic communications (telephone, written, text, email, video conference, etc to enable therapists to provide services to individuals who may otherwise not have adequate access to care. TMH may be used for services such as individual, couples, or family therapy, follow-ups, and trainings/education in a group setting. TMH is a relatively recent approach to delivering care and there are some limitations compared with seeing a therapist in person. These limitations can be addressed and are fairly minor depending on the needs of the client and the care with which the technology (cell phone, computer, etc is utilized. It is important that both the client and the counselor be located in a private place during their sessions, and that the security of their technology be up-to-date with appropriate security protection.

Initial Intake will also apply to TMH services. I understand that HUGS' TMH is a scheduled service is NOT an Emergency Service, and in the event of an emergency, I will use a phone to call 911. Emergency Plan: I understand that in case of serious threat or plan to harm self or others during a TMH session, my counselor will have the police or an ambulance sent to my location and call the following Emergency Contacts:

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I understand the information provided above regarding HUGS' TeleMental health Services. I hereby give my informed consent for the use of TeleMental health in my care.

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Authorization for Release of Information

I sign this form voluntarily knowing that I am authorizing the use or disclosure of my individual identifiable health information as described below. I understand that reports and/or medical records to be released may contain information pertaining to social, educational, psychiatric, drug and/or alcohol abuse diagnoses and treatment, and may also contain confidential HIV/AIDS related information. I understand that if the organization authorized to receive the information is not a health plan or health-care provider, the released information may no longer be protected by federal privacy regulations.

This form must be comlpeted for anyone paying for services, other than the client.

Organization Authorized to Release Information: Heads -Up Guidance Services, Inc. dba HUGS 912-417-4320 I info@headsupsavannah.org

 

Collaborating Individual or Organization to Which Release is Authorized:

This authorization will expire within one year of my discharge from Heads-Up Guidance Services, Inc. (HUGS).

I understand that my health-care and payment for my health-care will not be affected by my signing this form. I understand that I may see and copy the information described on this form. I understand that information disclosed in this request about substance abuse treatment is disclosed from records protected by Federal Confidentiality rules (42 CFR Part 2 Federal rules prohibit further disclosure of this information unless such disclosure is permitted by the written consent of the person to whom it pertains, or as otherwise permitted by (42 CFR Part 2 A general authorization for release of information is not sufficient for this purpose. Federal rules restrict any use of the information to criminally investigate or prosecute any alcohol or drug abuse patient. I understand that I may revoke this authorization at any time by notifying HUGS in writing, but that it will not affect my actions taken before the revocation.

I have read and understand the above statement and do hereby voluntarily consent to the disclosure of the information and/or medical records (including alcohol/drug abuse records) to those persons/agencies named above. I hereby release HUGS of liability arising from the release of this information. If this release concerns a minor, I certify that I am legally authorized to provide consent.

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Note the year of that you received any of the following services: