Client Registration

I hereby voluntarily grant permission to EDGE Counseling Solutions to provide services to me. I understand that such permission may be revoked, in writing, at any time. I/We parent(s)/guardians of a minor child, hereby voluntarily grant permission to EDGE Counseling Solutions to provide services to our child. I/we understand that such permission may be revoked in writing at any time.

The intake, assessment and treatment planning process have been explained to me (us). I understand that I will be receiving services in an outpatient setting. As an EDGE Counseling Solutions client, I have the right to refuse treatment. If I choose to refuse treatment, the consequences of this refusal have been explained to me.

I acknowledge that I have been provided with the EDGE Counseling Solutions Notice of Privacy Practices on the date indicated.

EDGE Counseling Solutions is an outpatient counseling organization dedicated to providing the highest quality care for children, adolescents and adults who request our services. Our fees for services include $265.00 for an initial assessment, $150.00 for a 45 minute therapy session, $225.00 for a 60 minute therapy session, and $195.00 for a family therapy session. If the fees for our services change at any point during the treatment process, you will be notified in advance. In addition to regular therapeutic appointments, there are charges for other professional services you may need. If additional professional services are recommended, you will be informed of the fees for these services in advance.

If you have a health insurance policy, it is likely that your policy provides some form of coverage for mental health treatment. Our providers are in network with many health insurance companies, and our team will bill your insurance company for the services you receive provided we have your up-to-date insurance information available. Payment for services not billed to insurance, including all insurance copayments, are expected at the time services are provided. We accept cash, checks, and many types of credit cards for payment of services.

Credit Card Information:

A credit card is expected to be kept on file confidentially through SwervePay, LLC, whom we process our credit card payments. By signing below, you authorize EDGE Counseling Solutions to charge the card on file for any balance on your account that has been outstanding for greater than 30 days. If your insurance carrier subsequently makes payment for services after your card has been charged, those charges will be credited to the card on file in the amount received that exceeds the balance due. If payment is denied by your card company, then you agree to pay the entire amount within 10 days via another form of payment. If your account has not been paid, and repeated attempts have failed to collect an outstanding balance, EDGE Counseling Solutions reserves the right to utilize collections services to pursue payment of fees.

 

As a client of EDGE Counseling Solutions, you have the following rights. The following rights also apply to all those who participate in counseling services provided by EDGE Counseling Solutions:

1. Access to treatment will not be denied on the basis of race, ethnicity, disability, sexual orientation, HIV status, religion, a religious belief, refusal to hold a religious belief or a refusal to actively participate in a religious practice;

2. Treatment will be provided in the least restrictive environment;

3. Nondiscriminatory access to services will be provided if available, as specified in the Americans With Disabilities Act of 1990 (42 USC 12101);

4. The confidentiality of clinical records is protected by federal and state statutes as well

5. To give or withhold informed consent regarding treatment and regarding confidential information;

6. Each client has the right to be free of abuse/neglect;

7. The client has the right to refuse treatment or any specific treatment procedure, including completion of surveys and data sharing, without it resulting in a loss of services. Clients will be informed of the consequences resulting from a refusal of treatment or of the treatment procedure;

8. Upon request, access to a description of the route of appeal when a disagreement occurs with EDGE Counseling Solutions policies, practices, or procedures;

9. The identity of any person referred for HIV testing and results of HIV testing will be kept confidential, as consistent with the AIDS Confidentiality Act (410 ILCS 305) and the AIDS Confidentiality and Testing Code (77 IL Adm Code 697) (AIDS Code);

10. An HIV antibody or AIDS test cannot be required as a condition of treatment.

11. Client confidentiality:

a. The confidentiality of client records maintained by EDGE Counseling Solutions is protected by state law and federal regulations. Generally, the program may not say to a person outside the program that a client attends the program or disclose any information about the client unless:

i. the client consents in writing;

ii. the disclosure is allowed by court order; or

iii. the disclosure is made to medical personnel and medical emergency or to qualified personnel for research, audit, or program evaluation.

b. Violation of the federal law and regulation by program is a crime. Suspected violations may be reported to appropriate authorities in accordance with federal regulations.

c. Federal law and regulations do not protect any information about a crime committed by a client either a program or against any person who works for the program or about any threat to commit such a crime.

d. Federal laws and regulations do not protect any information about suspected child abuse or neglect from being reported under state law to appropriate state or local authorities.

e. Federal laws and regulations allow EDGE Counseling Solutions to take action with a court order in situations in which the client poses a serious threat of bodily injury or a threat of life to self or a third party. EDGE can also take action in the same situations without a court order if in the course of disclosure it is not revealed that the client is receiving alcohol or substance abuse treatment.

EDGE Counseling Solutions provides outpatient counseling services for adults, adolescents, and children. These services may include: crisis intervention, alcohol and drug treatment, family, individual, or group intervention, mediation services, urinalysis, indirect case management services such as paperwork and collateral, prevention services, service linkage, coordination of community service, mentoring programs that utilize volunteers, parent education and training group services, outdoor experiential therapy, home-based services, community outreach services, and youth development activities. Treatment is always provided in the least restrictive environment.

Outpatient counseling is providing intervention to individuals and families for a variety of presenting concerns. Outpatient counseling may be an important factor in your ongoing growth and development, and various presenting concerns create an opportunity for change. Outpatient counseling has the following risks: at times, the counseling process may intensify the symptoms that brought you and/or your child to treatment.

The alternatives to outpatient counseling are:

1. No counseling treatment intervention.

2. An alternative outpatient counseling program. If you would prefer to receive treatment fromanother provider, our professional staff members can provide a referral source of an alternative treatment program.

3. Inpatient treatment at a hospital, freestanding treatment center, or alcohol and drug treatment

EDGE Counseling Solutions involves a number of professionals with different roles which often overlap and build upon each other. In an effort to strengthen the intervention we are able to provide to a client, our clinicians may make use of the expertise provided by additional professionals through the utilization of peer consultation. Information regarding a client may be exchanged in the course of these meetings.

EDGE Counseling Solutions uses the electronic submission of data, including an electronic health record, our own data management system, email and other Internet-based systems. The organization places a high importance on keeping information safe and utilizes available tools in order to ensure this. There are risks inherent in these systems, including unauthorized access. EDGE Counseling Solutions minimizes these risks through the use of user IDs and passwords, equipment that limits the access to authorized users, encryption, and multiplatform security system. You may request a copy of our full MIS overview policy if you are interested.

Professional staff members are provided training in the utilization of behavior management techniques. This includes the use of de-escalation techniques as a means of calming situations. Copies of the de-escalation procedures are available at your request.

I have been offered a copy of the rights as stated above and I fully understand my rights as a client of EDGE Counseling Solutions.

TELETHERAPY SERVICES
Teletherapy is a method of providing traditional therapeutic services utilizing secure internet technology.  Instead of meeting with a clinician for each session face to face in our offices, meetings can take place using your computer from the comfort of your home or other private space. Like any other form of psychotherapy, teletherapy has both benefits and risks. Nevertheless, research has demonstrated that teletherapy sessions can have similar outcomes to face to face counseling for some people.

 

Because it does not involve traveling to an appointment, one common benefit of teletherapy is convenience. You can simply log onto your computer and initiate your counseling session. However, because information, including video and audio of your session is traveling through the internet, privacy is of the utmost importance. To best ensure your privacy, we have established a method of delivery utilizing software that conforms to privacy expectations. It is important, however, that you take steps to ensure your privacy as well. This includes ensuring that you only utilize the approved software for teletherapy sessions with your clinician, ensuring that you are in a private space throughout the session, and ensuring that you only participate in sessions from a private and secure internet connection.

 

Since therapy, including teletherapy, often involves discussing unpleasant aspects of your life, you may experience uncomfortable feelings like sadness, guilt, anger, frustration, loneliness, and helplessness. There are no guarantees of what you will experience, but it is important that you discuss these emotions with your clinician. While teletherapy offers a convenient and effective adjunct to traditional in person counseling, it is not designed to be a complete replacement for in person counseling sessions. Therefore, you will be expected to meet with your clinician in the office at an interval that you agree upon. Additionally, during the course of teletherapy, there may be times when your clinician will recommend that you meet in person for the next appointment. It will be important to follow the recommendations of your clinician to experience the therapeutic benefits expected.

 

PROFESSIONAL FEES AND SERVICES

In order for us to set realistic treatment goals and priorities, it is important to evaluate what resources you have available to pay for your treatment. If you have a health insurance policy, it will usually provide some coverage for mental health treatment but, in general, insurance policies do not provide coverage for teletherapy services. We will fill out forms and provide you with whatever assistance we can in helping you receive the benefits to which you are entitled; however, you (not your insurance company) are responsible for full payment of fees. Our fees for teletherapy services are $265.00 for an initial assessment, $115.00 for a 30 minute therapy session, $150.00 for a 45 minute therapy session, $225.00 for a 60 minute therapy session, and $195.00 for a family session. If these fees change for any reason at any point during the treatment process, you will be informed of this. In addition to scheduled appointments, we charge an amount for other professional services you may need, though we may prorate the hourly cost if work takes place for periods of less than one hour. You will be expected to pay for each session at the time it is held via a credit card on file, unless we agree otherwise.

 

 

 

 

DURING THE SESSION

You will be expected to login to the online service for teletherapy at least 5 minutes prior to the beginning of the scheduled session. To provide you with the best services possible, you will also need to have access to a telephone during the course of the session. In the case of extenuating circumstances or a failure in technology, your clinician will contact you via this telephone and will discuss how to proceed.

 

Prior to the initiation of teletherapy services you and your clinician will discuss a plan to follow if a crisis situation occurs. If a crisis situation develops during the course of the session, you agree to follow through with the procedures and instructions established. Your clinician will likely ask you to attend the next appointment in person, and you can discuss the continuation of teletherapy services at that time.

 

Your signature below indicates that you have read the information in this document and agree to abide by its terms during our professional relationship.