Consent Form

Consent to Treat and Notice of Privacy Practices
Client/Patient Information

We may need to communicate with you through telephone (including leaving messages on your voicemail), mail, and email. Communications may include appointment reminders and account billing notifications; we will not communicate clinical information through these channels unless authorized/requested by you.
Patient Name*

First NameLast Name
Date of Birth*

MonthDayYear
Date
Administrative Sex*
This is needed for billing purposes and must match what is listed with the insurance company
Gender
Phone Number*
Email*
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
I consent to the following forms of communication from Creekside Counseling Group:*

TextsCalls/voicemailEmailSurveysPromotions
Emergency Contact

An emergency contact is required. Entering an email is optional.
Emergency Contact *

First NameLast Name
Phone Number*
Email
example@example.com
Relationship to Patient*

Parent/guardianFamilySpouse/significant otherFriendOther
Relationship to Patient Parent/Guardian Family Spouse/Significant Other Friend Other _____________*
Additional Contacts

Please list any persons you would like to have access to your billing or appointment information, such as your spouse, caretaker or other family member. We will ask for additional consent prior to releasing information related to mental health services and/or test results.
Contact Name (1)

First NameLast Name
Phone Number (1)
Email (1)
example@example.com
Relationship to Patient (1)

Parent/guardianFamilySpouse/significant otherFriendOther
Contact Name (2)

First NameLast Name
Phone Number (2)
Email (2)
example@example.com
Relationship to Patient (2)

Parent/guardianFamilySpouse/significant otherFriendOther
Contact Name (3)

First NameLast Name
Phone Number (3)
Email (3)
example@example.com
Relationship to Patient (3)

Parent/guardianFamilySpouse/significant otherFriendOther
Relationship to Patient Parent /Guardian Family Spouse/Significant Other Friend Other _____________
Is treatment required by the court of law?*

NoYes, briefly explain
Is there an active custody agreement in place for the patient?*

NoYes, briefly explain
If yes, do both parents consent to treatment?

YesNo
If yes, please upload a copy of the custody agreement/court order here or bring with you to the intake/first appointment:

Cancelof
Please check the items that you believe are affecting you

Alcohol or drug problemsAnger or hostile feelingsAnxiety, nervousness, fearsSadness or DepressionEating or appetite problemsFamily issuesProcrastinationPhysical distressRelationship/marital concernsSexual concernsTraumatic experiencesSocial conflictsSuicidal feelings or behaviorsStressSelf-controlSelf-esteem or confidenceWork or career concernsOther
Client's Rights

The client may ask questions on what to expect during and end result of the therapy. The client may decline to proceed the therapy as to the techniques which may be conducted by the therapist. The client may cease to continue therapy anytime, without any impediment and may return to therapy anytime. The therapist has the right to dismiss the client from the course of therapy. The client has the right to review his or her records from the therapist. Right to confidentiality: Within limits provided for by law, all records and information acquired by the therapist shall be kept strictly confidential in accordance to the principles of a doctor-patient relationship. All information will not be shared or revealed to any person, agency, or organization without the prior written consent of the client. The client can raise any concerns and to speak with the therapist immediately of any concerns provided that the therapist is likewise available to discuss matters with the client. More information regarding your rights as a client can be found here. By signing this form, you acknowledge that you have received the HIPAA Rights Policy and Service Agreement and agree to the terms.
Initial Here* to acknowledge that you understand the client's rights and give consent to treat. Additionally, you authorize the release of any and all protected health information necessary for the billing of insurance on your behalf.
COVID-19 Disclaimer

Due to the COVID-19 pandemic, we are taking additional precautions to keep our clients safe. This includes regularly sanitizing shared spaces and maintaining social distancing guidelines according to the CDC. We ask that you do not visit our practice if you have tested positive in the past 5 days or if you are experiencing any of the following symptoms of COVID-19:
- Fever
- Fatigue
- Dry Cough
- Difficulty Breathing
If you are experiencing any of these symptoms, we do offer virtual appointments. By signing this agreement, you acknowledge the risk associated with attending in-person appointments during the COVID-19 pandemic and do not hold Creekside Counseling Group responsible for any and all unintentional exposure to COVID-19.
Initial Here* to acknowledge that you have reviewed the COVID-19 guidelines and accept this agreement.
Late Cancellation and No-Show Policy

Cancellation Window: Please be advised that all cancellations must be made at least 24 hours in advance of your scheduled appointment time. This allows us to offer the appointment slot to another client in need of services.

No-Show Fee: A $50 fee may be charged for any missed appointments or cancellations made within the 24-hour period. This fee is not covered by insurance and is the responsibility of the client.

Exceptions: We understand that emergencies and unexpected illnesses may occur. In such cases, please contact us as soon as possible to discuss your situation, and we will work with you to find a suitable solution.

Communication: If you need to cancel or reschedule your appointment, please contact our office at (810) 771-4074 or info@creeksidecounselingllc.com. If you are unable to reach us directly, please leave a voicemail, send a text, or send an email with your name, appointment date, and a brief explanation.

Repeated Offenses: Clients who accumulate three or more late cancellations or no-shows may be subject to discharge from our practice. We value our clients and want to ensure that our services are accessible to those in need.

Outstanding Balances - Billing Policy

Copays and Deductibles: All copayments and deductibles are due at the time of service. We accept various forms of payment, including credit/debit cards, cash, HSA/FSA cards, and checks. Your balance may be paid automatically with a credit/debit card store securely on our server, in office at the time of service, through our patient portal, or directly on our website.

Card on File: Should a patient late cancel/no show more than two appointments, we require that a valid credit or debit card be kept on file to keep future appointments. This card will be securely stored, and charges will be processed for copays, deductibles, and any outstanding balances.

Authorization: By providing your credit/debit card information, you authorize us to charge your card for any outstanding balances, copays, or deductibles accumulated over the course of your care.

Outstanding Balance: If your account accumulates an outstanding balance of $200 or more, your next scheduled session may be subject to cancellation until the balance is reduced to less than $200. We understand that financial situations may change, and we encourage open communication to address any concerns regarding payments.

Notification: You will be notified in advance if your account approaches the $200 threshold, giving you an opportunity to address any outstanding balances and avoid session cancellations.

Receipts: A receipt for each transaction, including copayments and charges to the card on file, will be provided upon request.

Payment Plans: Please reach out to administrative staff if you are interested in setting up a payment plan. Payment plans are available under certain conditions. Additionally, you may apply for a sliding scale and reduce payment liability under eligibility specific criteria.

Lapsed Insurance Policies: It is the client’s responsibility to understand their health plan benefits. Should you lose or change health care coverage for any reason, it is the patient’s responsibility to inform administrative staff of the change. Should a valid insurance policy not be effective for a completed date of service, the patient will be billed the private pay out-of-pocket cost for that date of service.
Initial Here* to acknowledge that you have read and understand the Cancellation and Billing Policies.
Initial Here* Disability Paperwork: It's up to clinician discretion to fill out disability paperwork. Furthermore, paperwork will not be filled out after the intake due to insufficient information to process.
Out-of-Office Policies

Occasionally, clients may ask for or require their therapist to attend a meeting or appointment outside of the office. While our clinicans are willing to do what is needed, it is important to remember that insurance will not cover such claims. Below are the policies and fees regarding attnding out-of-office appointments and attendance/testimony at court hearings/proceedings.

**Please note that we must receive a subpoena. Issuing party is responsible for payment.**

**A reatiner of $1,000 must be received at least 48 hours prior to the court/proceeding.**

Fee: $250/hour (Partial hour billed at the 15-minute increment.)

Minimum billing of $1,000 and emcompasses:
- Case preparation (min. 1 hour)
- Travel time to court from office
- Attendance at court hearing/proceeding (min. 1 hour)
- Travel time from court to office
- Other professional services as agreed
- Parking fees
Initial Here* to acknowledge that you understand the out-of-office appointments policy and agree to any and all fees associated with this policy.
Agreement of Financial Responsibility

MY SIGNATURE SERVES AS ACKNOWLEDGEMENT OF A CLEAR UNDERSTANDING OF MY FINANCIAL RESPONSIBILITY FOR SERVICES RENDERED. I UNDERSTAND THAT IF I USE MY INSURANCE AND THE INSURANCE COMPANY DENIES COVERAGE AND OR PAYMENT IN FULL FOR SERVICES PROVIDED TO ME, I ASSUME FINANCIAL RESPONSIBILITY FOR ANY REMAINING ACCOUNT BALANCE AND WILL PAY ALL SUCH CHARGES IN FULL.

MY SIGNATURE ALSO INDICATES THAT I UNDERSTAND AND AGREE TO THE TERMS OF THE SERVICE AGREEMENT REVISED 7/21 AND ACKNOWLEDGES THAT I HAVE RECEIVED THE HIPAA NOTICE DESCRIBED THEREIN.
Patient or Parent/Guardian Signature*

Clear
Printed Name*

First NameLast Name
Date Signed*

MonthDayYear
Should be Empty:

Consent to Treat and Notice of Privacy Practices

Client/Patient Information