Village Counseling Services
CLIENT SERVICES CONTRACT
This document conta=
ins
important information about our professional services and business
policies. Please read it care=
fully
and jot down any questions that you might have so that we can discuss them =
at
our next meeting. Once you si=
gn
this, it will constitute a binding agreement between us.
Psychotherapy
is not easily described in general statements. It varies depending on the persona=
lity
of both the therapist and the patient and the particular problems that the
patient brings. There are a n=
umber
of different approaches that can be utilized to address the problems you ho=
pe
to address. It is not like vi=
siting
a medical doctor, in that it requires a very active effort on your part.
Psychotherapy
has both benefits and risks. =
Risks
sometimes include experiencing uncomfortable levels of feelings like sadnes=
s,
guilt, anxiety, anger and frustration, loneliness and helplessness. Psychotherapy often requires recal=
ling
unpleasant aspects of your history.
Psychotherapy has also been shown to have benefits for people who
undertake it. It often leads =
to a
significant reduction of feelings of distress, and better relationships and
resolutions of specific problems.
But there are no guarantees about what will happen.
By
the end of the evaluation, your therapist will be able to offer you some
initial impressions of what the work will include and an initial treatment
plan, if you decide to continue.
You should evaluate this information along with your own assessment
about whether you feel comfortable working with your selected therapist.
Our normal practice=
is to
conduct an evaluation that will last from 2 to 4 sessions. During this time, you and your the=
rapist
can decide together whether he/she is the best person to provide the servic=
es
that you need in order to meet your treatment objectives. If psychotherapy is initiated, we =
will
usually schedule one forty-five to fifty-minute session (one appointment ho=
ur
of 45-50 minutes duration) per week at a mutually agreed time, although
sometimes sessions will be longer or more frequent.
The regular hourly rate for psychotherapy servic=
es is
$125.00 for LPCs and $75.00 for LPC Interns, however, for clients without
insurance or who are experiencing financial hardship, we may be willing to
prorate our fee, at your request, according to a predetermined sliding scal=
e,
such fee to be determined by completion of the SLIDING SCALE FEE AGREEMENT.
Village Counseling Services uses two sliding scales:
<=
span
style=3D'font-size:10.0pt'>1) =
For clients in therapy with a fully licensed and
experienced professional counselor.
<=
span
style=3D'font-size:10.0pt'>2) =
For clients in therapy with a licensed counseling
intern being actively supervised by a fully licensed professional counselor=
.
In addition to weekly appointments, it is our pr=
actice
to charge this amount on a prorated basis for other professional services y=
ou
may require such as
report writing, telephone
conversations that last longer than 5=
minutes, attendance at meetings or consultations with other
professionals which you have authorized, preparation of records or treatment
summaries or the time required to perform any other service that you may
request of me. In unusual
circumstances, you may become involved in a litigation that may require your
therapist’s participation.
You will be expected to pay for the professional time even if he/she=
is
compelled to testify by another party.
_____ APPOINTMENT SCHEDULING AND CANCELL=
ATION
Cancellation
of scheduled appointments is required 24 hours in advance. If you do not ap=
pear
for a scheduled appointment, you will be charged the full hourly fee ($125.=
00
for LPCs and $75.00 for LPC Interns), unless you provide 24 hours advance
notice of cancellation [or unless we both agree that you were unable to att=
end
due to circumstances beyond your control].
If you do not appear for a scheduled appointment=
, you
will be charged the full hourly fee for two reasons:
<=
span
style=3D'font-size:10.0pt'>1) =
We maintain a waiting list of clients who require
appointments. If you cancel 24 hours in advance, we will be able to fill yo=
ur
appointment with another client.
<=
span
style=3D'font-size:10.0pt'>2) =
Insurance companies do not reimburse therapists =
or
clients for missed appointments; therefore you will be liable for our full =
fee,
not your standard co-pay amount.
_____ BIL=
LING AND
PAYMENTS
You will be expected to pay for each session at =
the
time it is held, unless we agree otherwise. Payment schedules for other profes=
sional
services will be agreed to at the time these services are requested.
If you did not pay at the time of service and yo=
ur
account is more than 60 days in arrears, a service charge of 1.5% of the ba=
lance
per month will be charged to your account.=
If your account is more than 60 days past due and suitable arrangeme=
nts
for payment have not been agreed to, we have the option of using legal mean=
s to
secure payment, including collection agencies or small claims court. If such legal action is necessary,=
the
costs of bringing that proceeding will be included in the claim. In most cases, the only informatio=
n that
is release about a client’s treatment would be the client’s nam=
e,
the nature of the services provided, and the amount due.
If your therapist is a network provider with your
mental health insurance carrier, our office will submit claims for payment =
on
your behalf. You are responsi=
ble
for any co-payments, co-insurance, and deductibles required by your health
plan.
If your therapist is not a network provider with=
your
mental health insurance carrier, our office will assist you by completing o=
ur
portion of a claim form. You =
are
responsible for completing your portion as well as mailing it to the insura=
nce
company and tracking your reimbursement.&n=
bsp;
We do not accept assignment of benefits from insurance carriers whose
panels we are not affiliated with.
Your therapist will gladly discuss your proposed treatment with your
insurance company if they call us and
you provide us with a signed release.
We will not call to request
authorizations. You are
responsible for the full fee regardless of your insurance company’s
reimbursement policies.
In general, the confidentiality of all communica=
tions
between a client and a licensed professional counselor is protected by law,=
and
your therapist can only release information about your work to others with =
your
written permission. However, =
there
are a number of exceptions.
In some judicial proceedings, you may have the r=
ight
to prevent information about your treatment being provided. However, in some circumstances, su=
ch as
child custody proceedings and proceedings in which your emotional condition=
is
an important element, a judge may require my testimony if he/she determines
that resolution of the issues before him/her demands it.
There are some situations in which your therapist
would be legally required to take action to protect others from harm, even
though that requires revealing some information about a client’s
treatment:
=
· =
If he/she
believes that a child, an elderly person, or a disabled person is being abu=
sed,
he/she must file a report with the appropriate state agency.
=
· =
If he/she
believes that a client is threatening serious bodily harm to another, he/sh=
e is
required to take protective actions, which may include notifying the potent=
ial
victim, notifying the police, or seeking appropriate hospitalization.
=
· =
If a client
threatens to harm him/herself, he/she may be required to seek hospitalizati=
on
for the client, or to contact family members or others who can help provide
protection.
Should such situations occur, your therapist wou=
ld
make every effort to fully discuss it with you before taking any action.
Your
therapist may occasionally find it helpful to consult about a case with oth=
er
professionals. In these
consultations, he/she will make every effort to avoid revealing the identit=
y of
his/her client. The consultan=
t is,
of course, also legally bound to keep the information confidential. Unless =
you
object, your therapist will not tell you about these consultations unless
he/she feels that it is important to your work together.
If
you are being treated by a Licensed Professional Counselor Intern, your
therapist is required to discuss your case on a regularly scheduled basis w=
ith
his/her LPC Supervisor. The L=
PC
Supervisor is also required by law to maintain the confidentiality outlined
above. Nancy Baker-Brown is t=
he
licensed LPC Supervisor on staff at Village Counseling Services. It is important to note that when =
you
are in treatment by an LPC Intern, you are legally a client of his/her LPC
Supervisor. If you have any q=
uestions,
comments, or complaints, please contact
While this written summary of exceptions to
confidentiality should prove helpful in informing you about potential probl=
ems,
it is important that you discuss any questions or concerns that you may have
with your therapist at your next meeting.&=
nbsp;
As you might suspect, the laws governing these issues are quite comp=
lex
and your therapist is not an attorney.&nbs=
p;
While he/she will be happy to discuss these issues with you, should =
you
need specific advice, formal legal consultation may be desirable. If you request, your therapist will
provide you with relevant portions or summaries of the applicable state laws
governing these issues.
Your
therapist is often not immediately available by telephone. Anytime you need to speak to your
therapist, you may call our main line at 713-533-9811. During business hours you may eith=
er
leave a message with our office manager, or you may leave a voicemail
message. If you call outside =
of
business hours, you will be able to leave a confidential voicemail message =
for
your therapist. Listen carefu=
lly to
the message to ensure you are selecting the correct voicemail box for your
therapist. Please note that v=
oicemail
messages will result in your therapist being paged. If you cannot reach your therapist=
, and
you feel that you cannot wait for your call to be returned, you should call
your family physician or the emergency room at the nearest hospital and ask=
for
the psychologist or psychiatrist on call.&=
nbsp;
If your therapist will be unavailable for an extended time, he/she w=
ill
provide you with the name of a trusted colleague whom you can contact if
necessary.
Both
law and the standards of my profession require that we keep appropriate
treatment records. You are en=
titled
to receive a copy of the records at our discretion, but if you wish, your
therapist can prepare an appropriate summary. Because these are professional rec=
ords,
they can be misinterpreted and/or can be upsetting. If you wish to see your records, we
recommend that you review them in your therapist’s presence so that y=
ou
may discuss what they contain.
Clients will be charged an appropriate fee for any preparation time
required to comply with an information request.
If
you are under eighteen years of age, please be aware that the law may provi=
de
your parents with the right to examine your treatment records. It is our policy to request an agr=
eement
from parents that they consent to give up access to your records. If they agree, your therapist will
provide them only with general information on how your treatment is proceed=
ing
unless he/she feels that there is a high risk that you will seriously harm
yourself or another, in which case, your parents will be notified. Your parents will also be provided=
a
summary of your treatment when it is complete. Before giving them any information=
, your
therapist will discuss the matter with you and will do the best he/she can =
to
resolve any objections you may have about what has been prepared to discuss=
.
_________=
___________________________________________________________________________=
_
Client Name(s)
I,
____________________=
__________________,
have read and agree to the conditions of this contract.
(Print full name(s). If client is a minor, name of pare=
nt or
legal guardian. For couples/f=
amily
counseling, names of all individuals.)
_________=
___________________________________ =
__________________________=
_____
Signature (If
client is a minor, signature of parent or legal guardian) =
Date
_________=
___________________________________ =
__________________________=
_____
Signature (For
couples/family counseling, signatures of all individuals.) =
Date
Check
one of the following statements:
____I am covered by mental health insurance for whic=
h my
selected therapist is an in-network provider. I understand that he/she will seek
reimbursement from my mental health insurance carrier and will track
reimbursement. I hereby autho=
rize
the release of any information necessary to process health insurance claims=
and
assign payment of such benefits to my selected therapist.
____I am covered by mental health insurance for whic=
h my
selected therapist is an out-of-network provider, will be seeking reimburse=
ment
for services, and am requesting services at the regular hourly rate. I understand that my therapist or
his/her office manager will complete the provider’s portion of a heal=
th
insurance claim form at least once every four visits and at my request and =
will
provide such form to me. If f=
or any
reason I have not paid in full for services received, I hereby authorize the
release of any information necessary to process the necessary health insura=
nce
claim and assign payment of such benefits to my selected therapist.
____My visit was arranged and will be paid for by on=
e of
the following third parties:
=
· =
DARS
= · = METRO lift<= o:p>
=
· =
IBC Bank
____I
do not have insurance covering mental health treatment.
____I am receiving services from an LPC intern and
understand that insurance cannot be used for my sessions.
HOURLY RATES:
$125 for LPCs
$75 for LPC Interns
I, _______________________________________, understand that the
regular hourly rate for psychotherapy services is $125.00 for LPCs and $75 =
for
LPC Interns. I agree to pay t=
he
above hourly rate for any professional services performed (as outlined under
PROFESSIONAL FEES on page 1 of the Client Services Contract) during the cou=
rse
of my treatment. If my treatm=
ent is
covered by my mental health insurance, I agree to pay my portion of the fees
for service as outlined by my insurance company.
_________=
______________________________ =
&nb=
sp; __________________________=
______
Client Signature (if minor, parent or legal guardian) &n=
bsp; =
; &n=
bsp; Date
_________=
______________________________ =
&nb=
sp; __________________________=
______
2nd Client Signature (for family or couples counseling) =
&nb=
sp; Date
Village Counseling Services
Villa=
ge
Counseling Services