CLIENT INFORMATION AND INFORMED CONSENT Logo

  • CLIENT INFORMATION AND INFORMED CONSENT

  • The Genesis Therapy Center is a not-for-profit Counseling Center whose mission is to provide healing resources through therapy, education, and consultation. The staff is professionally trained and can work with both psychological issues and spiritual issues within the context of therapy. We know that therapy is a major investment of your time, energy, and money in improving your relationships and yourself as an individual. We, as therapists, commit ourselves to utilizing our professional skills to assist you in your therapy in the most effective way we know. It is important that you set goals for your therapy, discuss these with your therapist and regularly evaluate your progress towards these goals. You will be asked to identify your goals for treatment.

  • Supervision

    As a means of our continued development as therapists, we regularly participate in supervision. We may ask you for permission to audio or video tape the session for this purpose. We will not publish, communicate or otherwise disclose any of this material to anyone other than our staff and supervisors without your written consent.

  • Training

    We are a training site for Master's and Doctoral Graduate interns /externs in the field of psychology. Each intern/extern is supervised directly by one of our licensed therapists. If you are being assigned to an intern/extern for your therapy you will be told and given the option of asking for another therapist, although please know that this may not be financially feasible for you.

  • Confidentiality

    Confidentiality is a critical part of your therapy. We will respect and guard your right to maintain the confidentiality of any information you communicate to us, except for that information legally excluded from the therapy agreement (See Privacy Notice). Staff members/Interns/Supervisors will also maintain confidentiality.

     

     

     

    Legal Requests

    Please be aware that Genesis takes the protection of your Private Health Information and your confidentiality seriously and so it is our policy to not take part in court hearings at the request of our clients or their attorneys. If you do request that we become involved in legal matters, please understand that such legal issue involvement is outside your clinical contract with Genesis. Legal matter services are billed at a rate of $300/hour, billed by the tenth of an hour for our time in such activities as records review, report writing, giving depositions, consulting with attorneys, acting as professional witnesses to fact, transportation time, waiting time and other activities related to your legal needs request. Legal fees are not eligible for sliding scale reductions and cannot be billed to insurance. Genesis is not a forensic counseling agency and is not able to provide forensic assessments or evaluations. Genesis can provide clinical services only.

  • The Genesis Therapy Center is a not-for-profit Counseling Center whose mission is to provide healing resources through therapy, education, and consultation. The staff is professionally trained and can work with both psychological issues and spiritual issues within the context of therapy. We know that therapy is a major investment of your time, energy, and money in improving your relationships and yourself as an individual. We, as therapists, commit ourselves to utilizing our professional skills to assist you in your therapy in the most effective way we know. It is important that you set goals for your therapy, discuss these with your therapist and regularly evaluate your progress towards these goals. You will be asked to identify your goals for treatment.

    Supervision
    As a means of our continued development as therapists, we regularly participate in supervision. We may ask you for permission to audio or video tape the session for this purpose. We will not publish, communicate or otherwise disclose any of this material to anyone other than our staff and supervisors without your written consent.

    Training
    We are a training site for Master's and Doctoral Graduate interns /externs in the field of psychology. Each intern/extern is supervised directly by one of our licensed therapists. If you are being assigned to an intern/extern for your therapy you will be told and given the option of asking for another therapist, although please know that this may not be financially feasible for you.

    Confidentiality
    Confidentiality is a critical part of your therapy. We will respect and guard your right to maintain the confidentiality of any information you communicate to us, except for that information legally excluded from the therapy agreement (See Privacy Notice). Staff members/Interns/Supervisors will also maintain confidentiality.

    Legal Regnests
    Please be aware that Genesis takes the protection of your Private Health Information and your confidentiality seriously and so it is our policy to not take part in court hearings at the request of our clients or their attorneys. If you do request that we become involved in legal matters, please understand that such legal issue involvement is outside your clinical contract with Genesis. Legal matter services are billed at a rate of $300/hour, billed by the tenth of an hour for our time in such activities as records review, report writing, giving depositions, consulting with attorneys, acting as professional witnesses to fact, transportation time, waiting time and other activities related to your legal needs request. Legal fees are not eligible for sliding scale reductions and cannot be billed to insurance. Genesis is not a forensic counseling agency and is not able to provide forensic assessments or evaluations. Genesis can provide clinical services only.

  • Cancellations

    When you cancel a session, we expect you to give us a full 24 hours notice (not just the night before.) If you do not give us the 24 hours notice , we expect you to pay for the session , unless you are unexpectedly ill or prohibited from coming by circumstances beyond your control.

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  • My therapists and I have discussed an appropriate cancellation fee of
    $       .

  • If you otherwise fail to attend 50% of your scheduled therapy sessions in a month or are more than 15 minutes late to two of your scheduled sessions, Genesis will terminate you as a current client. We welcome you to apply for therapy at a point when you can attend and participate in therapy consistently.

  • Terminations

    In all terminations (whether as a result of meeting treatment goals, from dissatisfaction, or from not following your Treatment Plan), it is important that we have one additional appointment after you have informed your therapist about your intention to terminate (not following your Treatment Plan informs us that you do not wish to do therapy at this time). In this final session, your decision to terminate will not be reconsidered unless you wish to do so.

  • Sessions

    Psychotherapy sessions are 45 minutes in length with 15 minutes between sessions for the therapist to chart, return calls and review for the next patient. Arriving and exiting on time is greatly appreciated by other patients.

  • Phone calls

    It is sometimes necessary to contact your therapist in between sessions. A short call, lasting no more than 10 minutes will not be charged. Should a call last longer or take place in lieu of an appointment, the call will be charged at the prorated session fee.

  • Testing and Consultation

    We offer testing on a separate fee schedule. Consultation is charged at the regular session rate.

    Vacation

    When your therapist takes a vacation, you will be notified of the dates your therapist will be away and given a method of contacting a therapist in the event of an emergency (see emergency section).

    Emergencies

    We are not open 24 hours a day. Although we try to respond as promptly as possible to messages left on the answering machine or with staff members, if you are in an emergency and cannot reach your therapist, please call 911 or go to the emergency room.

    Fees

    You are to pay your therapist weekly at the time of each session and are to keep your account current. Genesis, as a not­ for-profit corporation, is committed to providing therapy at a fee that is related to your ability to pay. Gifts from churches, individuals and former clients are the sole income for the financial assistance fund, which allows us to provide therapy on a percentage of reduction of fees when needed. Fees are also charged for report writing and correspondence. (See Financial Assistance addendum.)

    The reduction in fee schedule is for those without insurance for mental health services. It is structured this way since we are not supported by the United Way, we receive no government funding and we are not a Medicaid provider. If you have extraordinary circumstances that would merit us considering you at a lower fee, please talk to your therapist. All clients see n by externs/interns will utilize an 8-session model that can be reviewed based on clinical and financial factors. (See Financial Assistance addendum)

    The full fee is appropriate for those who, through a combination of their income, assets and insurance, can either pay the full fee or use their insurance benefits. Insurance reimbursement for outpatient psychotherapy is a benefit of most major medical policies. We encourage you to find out your deductible and limits of coverage so that you have a realistic idea of your expected reimbursement. We will submit claims to your insurance company. If your plan is a Preferred Provider Organization (PPO) plan, please check with your insurance company to make sure your therapist is on your panel. We are preferred providers for several P PO's. If you have a Health Maintenance Organization (HMO) plan, please be aware that most of the HMO's require you to see a therapist on their staff, though so me do provide for reimbursement of other providers. If we are not in your network and you still wish to see one of our therapists, we can see you at a fee negotiated with us. 

    If your mental health insurance benefit is managed by a managed care company, we will discuss payment procedures as they are determined by your plan. Please be aware that all managed care plans involve direct clinical management by the company. This makes it necessary for us to work together with your company to determine the nature of your treatment and , therefore, does have some impact on confidentiality. We ask that a credit card be on file at the Ist session in order to cover any deductibles, co-pays or co-insurance. If you choose not to leave a credit card, you are responsible for full payment until insurance coverage is verified.

    Co-payments are due at the time services are rendered. Charges may be billed to your insurance company; however, any charges not covered by the insurance company are the responsibility of the client. Failure to pay co-pays, co-insurance and deductibles is considered insurance fraud and is reportable to your insurance company.


  • Emergencies

    We are not open 24 hours a day. Although we try to respond as promptly as possible to messages left on the answering machine or with staff members, if you are in an emergency and cannot reach your therapist, please call 911 or go to the emergency room.


    Fees
    You are to pay your therapist weekly at the time of each session and are to keep your account current. Genesis, as a not­ for-profit corporation, is committed to providing therapy at a fee that is related to your ability to pay. Gifts from churches, individuals and former clients are the sole income for the financial assistance fund, which allows us to provide therapy on a percentage of reduction of fees when needed. Fees are also charged for report writing and correspondence. (See Financial Assistance addendum.)

    The reduction in fee schedule is for those without insurance for mental health services. It is structured this way since we are not supported by the United Way, we receive no government funding and we are not a Medicaid provider. If you have extraordinary circumstances that would merit us considering you at a lower fee, please talk to your therapist. All clients see n by externs/interns will utilize an 8-session model that can be reviewed based on clinical and financial factors. (See Financial Assistance addendum)

    The full fee is appropriate for those who, through a combination of their income, assets and insurance, can either pay the full fee or use their insurance benefits. Insurance reimbursement for outpatient psychotherapy is a benefit of most major medical policies. We encourage you to find out your deductible and limits of coverage so that you have a realistic idea of your expected reimbursement. We will submit claims to your insurance company. If your plan is a Preferred Provider Organization (PPO) plan, please check with your insurance company to make sure your therapist is on your panel. We are preferred providers for several P PO's. If you have a Health Maintenance Organization (HMO) plan, please be aware that most of the HMO's require you to see a therapist on their staff, though so me do provide for reimbursement of other providers. If we are not in your network and you still wish to see one of our therapists, we can see you at a fee negotiated with us.

    If your mental health insurance benefit is managed by a managed care company, we will discuss payment procedures as they are determined by your plan. Please be aware that all managed care plans involve direct clinical management by the company. This makes it necessary for us to work together with your company to determine the nature of your treatment and , therefore, does have some impact on confidentiality. We ask that a credit card be on file at the Ist session in order to cover any deductibles, co-pays or co-insurance. If you choose not to leave a credit card, you are responsible for full payment until insurance coverage is verified.

    Co-payments are due at the time services are rendered. Charges may be billed to your insurance company; however, any charges not covered by the insurance company are the responsibility of the client. Failure to pay co-pays, co-insurance and deductibles is considered insurance fraud and is reportable to your insurance company.

  • Authorization of Services

    I acknowledge that per my insurance: 

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    1. I authorize my credit card may be used for deductibles, co-pays, co-insurance or unpaid balances   
    2. I have been given a copy of the privacy notice      


    I have read and agree with the terms and payment policies of the client informed consent.

    I have had all my questions answered, and my signature attests that I agree with this information. I am requesting that I/my child/my family receive diagnostic or therapy services and authorize the Genesis Therapy Center to provide those services.

          Pick a Date  

        Pick a Date   

  • I have read and agree with the terms and payment policies of the client informed consent. 

    I have had all my questions answered, and my signature attests that I agree with this information. I am requesting that I/my child/my family receive diagnostic or therapy services and authorize the Genesis Therapy Center to provide those services.

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