1 OF 4 INFORMED CONSENT (Patient/Guardian: keep pages 1-3. Office retains page 4
TIME COMMITMENT: Today's appointment will take approximately 1 hour. We realize that starting counseling is a major decision and you may have many questions. This document, along with the HIPPA Informa on form, strives to inform you of our policies, State and Federal Laws and your rights. If you have other questions or concerns, please ask and we will try our best to give you all the information you need. EMERGENCIES: If an emergency situation for which the client or their guardian feels immediate attention is necessary related to this office's services, please contact your counselor via their cell phone number. However, if your counselor is unavailable, you may call the office number to obtain contact info for Jodi (336-984-7591) or Kenneth Province (336-981-5938) If no contact can be made the client or guardian understands that they are seek a natural support, contact 911 or visit a local emergency room for services as a last resort, or contact Vaya Health MCO at 1-800-849-6127 or Partners MCO 1-888-235-HOPE, or mobile crisis at 877-492-2785 or 336-838-9936. This agency will follow those emergency services with standard counseling and support to the client or the client's family. For any grievance you may also contact the above MCO for your covered region. If you have any grievance you may call the number above. In the case of a medical emergency, while you or anyone in your party is present in our office, this agency will contact 911. RISKS AND BENEFITS: Please note there are risks and benefits to counseling. These will be discussed with you today as it relates to your case specifically. Alternative methods to treatment will also be discussed today. Each licensure board has a grievance process or system. If you wish to make a grievance, please contact the appropriate licensure board to file a complaint. CONFIDENTIALITY: Your verbal communication and clinical records are strictly confidential except for: a) information (diagnosis and dates of service) shared with your insurance company to process your claims, b) information you and/or your child or children report about physical or sexual abuse; then, by North Carolina State Law, your counselor is obligated to report this to the Department of Social Services, as well as any report that c) you the client have an infectious disease that you will intentionally spread to harm others d) where you sign a release of information to have specific information shared and e) if you provide information that informs your counselor that you are in danger of harming yourself or others f) information necessary for case supervision or consulta on and g) or when required by law. APPOINTMENTS, PROFESSIONAL FEES, AND CANCELLATIONS: Appointments are generally 45 to 60 minutes in length. Ini al intakes are $175.00, Counseling sessions are $150.00, *Psychological testing fees are dependent on the amount of me involved and are billed per hour. Because they vary we will discuss fees with you in advance. Other services including report writing, telephone conversations longer than 10 minutes, attendance and meetings with other professionals, court appearances/involvement, etc. canbe charged at hourly rates. A $100 up-front fee is charged for any court appearances. Letter/report fees: $45. As a courtesy we will bill your insurance company, HMO, responsible party or third party payer for you if you wish. We ask that at each session you pay your co-pay. In the event you have not met your deductible, the full fee is due at each session un 1 the deductible is satisfied. If your insurance company denies payment or does not cover counseling, we request that you pay the balance due at that me. If your account has not been paid for 60 days and arrangements for payment have not been agreed upon, we have the op on of using legal means to secure payment. This may involve but not be limited to hiring a collection agency or going through small claims court. If that were necessary you will be responsible for all cost of li ga on including attorney's fees. In most collection situations the only information released would be the client's name and address, nature of services provided, and the amount due. We sincerely appreciate your cooperation and at any me you have any questions regarding insurance, fees, balances or payments please feel free to ask. You should also be aware that most insurances companies require you to authorize us to provide them with confidential information such as clinical diagnoses, treatment plans/summaries, or copies of records. This information becomes part of the insurance company's files. All insurance companies claim to keep such information confidential, however we have no control over this information once received by the insurance companies. It is important to remember that you may always pay for services yourself to avoid the potential problems described
1260 College Ave #1, Wilkesboro, NC 28697336-818-0733 336-818-0734 (Fax)jodi.province@gmail.com