• Services regardless of race, sex, color, creed, age, sexual orientation, disability, or national origin.
• Contact NC Disability Rights.
• Consent to or refuse treatment of your own free will and seek medical care.
• Confidentiality which means that your therapist is obligated to keep details which could disclose a client’s identity private. Confidentiality may be broken if one of the following happens:
1. When a release of confidentiality is signed by all (18 and over) who will be discussed.
2. Whenitismandatedbylawtoreportsuchasabuseorneglectofchildren,theelderlyordisabled,domestic violence, or when a client is a danger to him or herself or to others.
3. When a therapist is sued by a client formal practice or when a client uses his/her mental health as a defense in a court of law.
4. When the therapist is ordered by a court judge to surrender records or to testify in court. Note: A subpoena for records or testimony is not sufficient for disclosure of confidential information. Although, a response is required, the order to break confidentiality must be given by a judge.
• Be informed of one’s own condition, of proposed or current services, treatment, and alternatives.
• A summary of personal records or the records of children under the age of 18 for whom you have legal custody of. The provider may limit access to a child’s records if there is reasonable belief that the parent is either not acting in the best interest of the patient, or that such disclosure would be detrimental to the patient. Requests must be made in writing and 30 days given to produce such documentation. Appropriate fees apply.
• Understand that third party payers (insurance companies) may have access to otherwise confidential information. Understand that telephone messages, calls, faxes, email, and other forms of electronic communication may be accessed by others and are therefore not guaranteed confidential. Please let your provider know if you wish to minimize use of any electronic and other forms of communication. You agree to assume the security risk for the transmission and reception of such information.
By signing this contract, you (the client) agree to the following:
• I consent to receive therapy services.
• I agree to a fee of $150* for initial session and $120* for subsequent sessions (other insurance rates may apply). *Rates are subject to change. $25 fee for returned check.
• I accept that my chart will be closed after 30 days of inactivity unless other arrangements have been made.
• I consent to the exchange of any necessary information to third parties including my insurance company, billing company, paypal credit card merchant, and/or an attorney for the purpose of collecting all fees.
• I authorize payment of medical benefits to the undersigned physician for all services to be rendered.
• I am the legal guardian and have the legal right to admit any child or children being admitted for therapy without any limitations from a court of law to do so.