Enrollment Application

Authorization to Release Confidential Information
Will you need us at any point to send an enrollment / progress report or in any way inform a Court, agency, social worker, attorney or other individual of your participation in counseling? (if No, you do not need complete this form. Navigate to bottom and click Next)*

YesNo
I,
Client's Name
, hereby authorize and request Advantage Counseling Services to release and obtain from the person or organization listed below any and all necessary confidential information, including, but not limited to, personal records, progress in treatment, summary of treatment, dates of treatment, diagnosis, summary and results of psychological testing, summary and results of psychiatric evaluations, medical records, school records, results of investigations, and court and police reports to/from:
Name of Person or Organization
Person or Organization we are reporting to or obtaining information from
Telephone Number
Telephone Number of the Person or Organization we are reporting to or obtaining information from
Address
Full Address of the Person or Organization we are reporting to or obtaining information from
I authorize the release of the information described above for the purpose of managing services, coordinating services, and verifying compliance with any orders or recommendations for counseling.

The recipient may use the information described above solely for the purpose of managing services, coordinating services, and verifying compliance with any orders or recommendations for counseling.

I understand that I can revoke or modify this authorization, with written notice, at any time, except to the extent that action has already been taken in reliance upon it. Unless revoked earlier, this authorization shall expire 90 days after the termination of services.

I understand that this authorization is voluntary and that I may not be denied services for refusing to sign this authorization. I also understand that any cancellation or modification of this authorization must be in writing, and that I have the right to receive a copy of this authorization upon my request.

I understand that my signature below authorizes the release of the confidential information described above and that this information may not be re-released to any other entity or individual without my additional signed consent unless otherwise provided by law. I further understand that if I authorize the disclosure of confidential health information to someone who is not legally required to keep it confidential, it may no longer be protected by federal or state confidentiality laws. I authorize the use of a duplicate copy of this authorization as having the same legal effect and validity as the original. I furthermore release Advantage Counseling Services, Corp. of all liability resulting from the release of information while this authorization is in effect.
(*) Electronic Signature Consent

By checking here, you are consenting to the use of your electronic signature in lieu of an original signature on paper. You have the right to request that you sign a paper copy instead. By checking here, you are waiving that right. After consent, you may, upon written request to us, obtain a paper copy of an electronic record. No fee will be charged for such copy and no special hardware or software is required to view it. Your agreement to use an electronic signature with us for any documents will continue until such time as you notify us in writing that you no longer wish to use an electronic signature. There is no penalty for withdrawing your consent. You should always make sure that we have a current email address in order to contact you regarding any changes, if necessary.
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Date of Signature

MonthDayYear
Date
Advantage Counseling Services - 6205 Laurel Canyon Blvd., North Hollywood, CA 91606 – Ph. (818) 763-6615

Online Program Rules
In order to participate in our on-line programs, you are responsible to secure the appropriate hardware, software, and means of reliably connecting to the internet in order to access the meetings.

To protect the confidentiality of all members, the place where you plan to join the meeting must be and remain private for the entire duration of the session.

Payments for services can be made online using any debit/credit card. If you provided us with an email address or cellular phone number, we will send you an invoice by email or text after every session. Alternatively, you can make payments in cash at the office.

Payments must be current to join a session. Carrying a balance in any program will automatically block you from entering future meetings. If you need to make payment arrangements, you must call the administration in advance.

Payments must be received no later than 15 minutes prior to the start of a meeting in order to allow time for processing and to clear any access restriction on the account. Payments received after this time will not allow you to join the meeting.

You must log in within the first 10 minutes of the meeting scheduled time to be admitted. When logging in you must use your first and last name so that you can be easily identified by the counselor in order to be admitted.

Your camera must remain on for the entire meeting.

You must remain in front of the camera for the entire meeting and actively participate.

You must remain logged in for the entire duration of the meeting in order to receive credit for a session. If for technical reasons you lose your connection, you can try to reconnect within a 5-minute window. Reconnection attempts after this time will not be allowed and you will not receive credit for the session regardless of the time your connection was lost. If you are removed from the session by your counselor, you will not be able to reconnect that day.

Situations that will get you removed from the group:

·         not having your camera on.

·         not being in front of the camera.

·         not participating appropriately, being distracted or engaged in other tasks.

·         not answering when called on by the counselor.

·         not being in a private setting.

·         the indication of the presence of any additional person/s around you.

·         being disrespectful toward the counselor or other members.

You may call the office and leave a message for your counselor at any time. Counselors are not available to answer calls while the group is in progress.

You must attend meetings regularly. You will be discontinued from the program if you missed 3 consecutive sessions without contacting our office. If you were discontinued and would like to return, you will need to contact our office and pay a re-enrollment fee to be reinstated.

If you need a progress report, you must provide the court date or report due date with at least 3 business days of advance notice. Progress reports are normally available for pick up at the office after the last scheduled session before they are due. If this does not fit your schedule, please make alternative arrangements with your counselor or administration in advance.
I have read and understood the above online program rules and agree with all of the terms.*

Clear

Service Agreement - Group
ATTENDANCE TERMS
Once enrolled, you are required to attend weekly sessions until the completion of the number of sessions required for your program. You will be dismissed from the program if you miss three (3) consecutive sessions. You may temporarily or permanently discontinue the program at any time by contacting our office or notifying your counselor. In that event, the referring agency, if any, will be notified of your termination.

You are responsible for being on time for every meeting. You may arrive UP TO 10 MINUTES late after which time you WILL NOT be allowed to join the group and you will be marked absent and charged for the missed session. This will be determined only by the time of your arrival and not by the reason for which you are late. Work, traffic or any other reasons will not excuse you for being late. Calling will not relieve you of this responsibility.

Once session begins, you may not leave your meeting until your counselor dismisses the group for the day. There are no breaks in between. If, for any reason, you step out of your meeting for over 5 minutes, you leave or are asked to leave your meeting before its conclusion, you will be marked “Absent.” You may not attend any other group other than the one assigned to you, unless authorized to do so by the administration.
FINANCIAL TERMS
Fees for services are due and payable at the time services are rendered. Enrollment and re-enrollment fees are administrative processing dues and are non-refundable. The fee for service is indicated below.

While enrolled in the program, you are responsible for paying said fee every week for your scheduled day and time, WHETHER YOU ATTEND OR NOT. Group sessions cannot be cancelled or rescheduled. When absent, payment for the day/s you were absent must be made in full upon returning to session.

Your counselor will issue up to one (1) standard progress report per month free of charge. You will be billed for any additional work at a prorated rate of $120 per hour, this includes but is not limited to additional reports during a month, and phone calls in excess of 5 minutes in one (1) week, whether initiated by you or a third- party involved in your case.

Payment for in-person sessions must be received at the beginning of each meeting in the form of cash only. Payments for telehealth sessions can be made with credit / debit card through electronic invoices sent to you by email or by text. Additionally, you may mail a check / money order, or pay cash at our office during our normal business hours. There will be a $25 additional administrative charge for any check returned unpaid by the bank.

If at any time your balance exceeds the equivalent of two (2) unpaid sessions, you will not be allowed to continue attending further sessions until your balance is paid. Additionally, you will be charged for any sessions missed as a result of nonpayment.

If you are unable to continue to make payments, you can call the office to make financial arrangements or to discontinue the program to avoid further charges to your account. Completion reports or transfers will not be issued until any outstanding debt has been paid in full. In the presence of a balance, one session will be deducted from your attendance for each unpaid week on any progress report. If your account becomes delinquent and is not paid after 120 days and arrangements for payment have not been agreed upon, Advantage Counseling Services may use legal means to secure payment.
CONFIDENTIALITY
All communications between you and your counselor will be held in strict confidence unless you provide written permission to release information about all or part of the information about your counseling to a specific person or agency.

There are, however, certain legal exceptions to confidentiality. For example, therapists are required to report instances of suspected child or elder/dependent adult abuse. Therapists may be required to break confidentiality when they have determined that a client presents a serious danger of physical violence to another person or when a client is dangerous to him or herself.

You may not disclose any information obtained through participation in the program or during group session regarding other participants in the program.

Your counselor may not be subpoenaed to testify in any court proceedings.
CONDUCT TERMS
While enrolled in the program, you are required to comply with all court/DCFS orders, probation/parole terms, and restraining orders, if any. You are responsible to notify our office of changes in regards to: your current case, future court hearings, protective orders, new arrests, new/pending charges, and personal information such as name, phone number, email, and address changes.

You are required to attend sessions free of chemical influence. You will be asked to leave your meeting if you are thought to be under the influence of drugs or alcohol. Smoking is not allowed. Drinks, snacks and gum chewing are not allowed in session. If you carry a cellular phone, you are required to turn the ringer off.

Physical contact and the use of improper, obscene, threatening, racist, or sexist language are not allowed during session or while dealing with the agency staff. You are required to follow the instructions given by counselors or staff members and actively participate during group discussions.

Administrative issues will not be discussed during group time. If you have questions about fees/balance, attendance, schedule conflicts, or any other concerns, call or visit the office during our business hours outside your session time.

If you are found in violation of any of the terms of this agreement or if it is determined that you are disruptive, uncooperative, or not benefiting from counseling you will be asked to leave the meeting and may be terminated from the program. If, at any time during your participation in the program, you become unable to comply with any of the terms of this agreement, it is your responsibility to notify the administration to make arrangements or request termination from the program.
Client Name*
Your Full Name
I agree with the financial terms and assume the responsibility of paying the following fee per week at the beginning of each meeting.*
Fee
I have read and understood the above policies, agree with all of its terms, and I agree to enroll in a ____ - week program.*
Number or weeks or sessions required (if unknown, type 12)
I will attend weekly meetings every*
Day of the week (ex. Tuesday)
From*
Time group begins
To*
Time group ends
Starting on*

MonthDayYear
Date you will begin attending group
(*) Electronic Signature Consent*

By checking here, you are consenting to the use of your electronic signature in lieu of an original signature on paper. You have the right to request that you sign a paper copy instead. By checking here, you are waiving that right. After consent, you may, upon written request to us, obtain a paper copy of an electronic record. No fee will be charged for such copy and no special hardware or software is required to view it. Your agreement to use an electronic signature with us for any documents will continue until such time as you notify us in writing that you no longer wish to use an electronic signature. There is no penalty for withdrawing your consent. You should always make sure that we have a current email address in order to contact you regarding any changes, if necessary.
Signature*

Clear
Date Signed*

MonthDayYear
Date

My Products

Enrollment - Group Counseling

$25.00

Total

$0.00

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Advantage Counseling Services - 6205 Laurel Canyon Blvd., North Hollywood, CA 91606 – Ph. (818) 763-6615
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ATTENDANCE TERMS

FINANCIAL TERMS

CONFIDENTIALITY

CONDUCT TERMS

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