INSURANCE INFORMATION - Fill out if you are using your Medicaid for counseling. Otherwise, skip to the Private Pay and Insurance section below.

Private Pay & Insurance: I authorize the release of any information necessary to expedite insurance claims. I agree to be responsible for all charges regardless of insurance coverage. I agree to pay any bank charges if my checks are returned.

Medicaid: I authorize the release of any information necessary to coordinate services between Family Counseling Services and my primary care physician, and to file for Medicaid benefits.

I understand that me fee will be $60 per session with a LPC, $20 per session with a LPC-A, or $20 for 8 sessions with a Master's level counselor.

A.     CONFIDENTIALITY: The counselor cannot reveal information concerning the client

Except:

1. If life or safety is seriously threatened, in which case the counselor may contact the victim or authorities who can help prevent harm.

2. If the counselor's records are subpoenaed by the court, they shall be surrendered.

3. If it is suspected that a child, elder, or disabled person is suffering abuse, or is in danger of abuse, that shall be reported.

4. If the licensing agency for your counselor asks to see a client's records, those records shall be made available for the purpose of insuring professionalism.

B.     Except as noted in A above, no information concerning a client shall be released without the written consent of the client, or in the case of a minor, the minor's legal guardian.

C.     Any suspected violations of counselor ethics may be reported to:

TX Board of Examiners of Professional Counselors

1100 West 49th St

Austin, TX 78756-3183

TX Board of Marriage & Family Therapists

1100 West 49th St

Austin, TX 78756-3183

TX Board of Social Work

P.O. Box 141369

Austin, TX 78714-6718

I have read and understand the limits of confidentiality.

You may expect...

...a counselor to listen to you in a confidential setting.

...a counselor who is knowledgeable in the application of the threapeutic counseling process.

...a counselor who is willing to assist you in developing a treatment plan to deal effectively and ethically with your issues.

...a counselor who will provide appropriate referrals to other individuals, groups, or agencies if necessary.

...a fee for service that will accommodate your budget and current financial situation.

We expect you...

...to work on your issues during each session.

...to understand that 50 minutes of counselor time is set aside just for you and your issues.

...to be on time for your counseling sessions If you are unable to make a session, or you find you will be late to a session, please call and let your counselor know. Please give 24 hours notice if you plan to cancel a session.

Length of therapy will be determined by you and your therapist.

Please be aware that the therapeutic process may involve personal awareness that may be emotionally painful, may cause anxiety, tension, or stress, and may cause some disruption and turmoil in your life and/or the lives of your significant others.

In the event of a subpoena or lawsuit, Family Counseling Services reserves the right to charge you its regular fee for time in court, preparation, travel, and consultation.

I fully understand the above statements, and I consent to treatment.

Our agency has a commitment to you as a client to provide affordable counseling services. The counselors only come to this location if they have appointments scheduled. They only show up FOR SCHEDULED CLIENTS. Otherwise, they have other employment outside of this agency.

I will make every effort to come for each counseling appointment. If it is necessary to cancel an appointment, I understand that this should be done 24 hours in advance. If I fail to make an appointment without notifying my counselor at the number provided by my counselor, this appointment time may be given to someone else.

WE DO NOT HAVE A CONTRACT WITH CPS TO PROVIDE MANDATORY COUNSELING SESSIONS. OUR COUNSELORS WILL NOT COMMUNCATE IN ANY WAY WITH A CPS CASEWORKER REGARDING YOUR COUNSELING. IF THIS is A SERVICE YOU NEED, CONTACT YOUR CASEWORKER. He or she can direct you to an agency who has a contract with CPS. The office manager can ONLY provide verification of attendance.

Clients are discouraged from having their therapist subpoenaed. Even though you are responsible for the testimony fee, it does not mean your counselor's testimony will be solely in your favor. He/she can only testify to the facts of the case and the his/her professional opinion. For those who fail to heed the counselor's discouragement of court appearances, the following fees are in effect:

All attorney fees and costs incurred by the therapist as a result of the legal action to include small claims court should the client not make payment of these fees are the responsibility of the client. The minimal charge for court appearance is $1,500 (this is only the minimum. Additional fees may apply A retainer of $1,500 is due in advance. If a subpoena or notice to meet an attorney is received without a minimum of a 48 hour notice, there will be an additional $250 "express" charge. Also, if the case is reset with less than 72 business hours' notice, then the client will be charged $500 (in addition to $1,500 retainer). Finally, all fees are doubled if the counselor had scheduled plans to go out of town/take vacation time prior to the court summons.

By signing you are acknowledging that these fees have been discussed with you and that should your counselor be required to appear in court or testify in court for a case related to you and the services provided to you by your counselor you will be billed the above listed fees with a minimum payment of $1,500 due but may also include additional fees outlined above.

NOTICE OF PRIVACY PRACTICES (NPP)

This notice describes how psychological and medical information about you may be used and disclosed and how you can get access to this information Please review it carefully.

Your health record contains personal information about you and your health. This information that may identify you and relates to your past, present, or future physical or mental health or condition and related health care services is referred to as Protected Health Information (PHI), and to provide you with notice of our legal duties and privacy practices with respect to PHI. We are required to abide by the terms of this Notice of Privacy Practices. We reserve the right to change the terms of our Notice of Privacy Practices at any time. Any revised Notice will be effective for all PHI that we maintain at that time. We will provide you with a revised copy by posting it on our website, sending a copy via mail upon request, or providing one at your next appointment. This form is a shorter version of the full, legally required NPP and you may have a copy of this if you prefer.

How we may use and disclose your protected health information

• For Treatment: Your PHI may be used and disclosed by those who are involved in your care for the purpose of providing coordinating or managing your health care treatment and related services, including consultation with clinical supervisors or other treatment team members.
• For Payment: We may use and disclose PHI so that we can receive payment for the treatment services provided you. Examples of payment-related activities are: making a determination of eligibility or coverage for insurance benefits, and processing claims.
• For Health Care Operations: We may use or disclose, as needed your PHI in order to support our business activities, including but not limited to, quality assessment employee review activities, and conducting or arranging other business activities. 
• Required by Law: Under the law. we must make disclosures of your PHI to you upon your request In addition, we must make disclosures to the Secretary of the Department of Health and Human Services for the purpose of investigating or determining our compliance with the requirements of the Privacy Rule.  

Uses and Disclosures Requiring Authorization

Uses and disclosures not specifically permitted by applicable law will be made only with your written authorization In those instances, we will obtain an authorization from you before releasing the information You may revoke all such authorizations at any time, provided you do so in writing.

Uses and Disclosures Requiring Neither Consent or Authorization

Applicable law and ethical standards permits us to disclose information about you without your authorization only in a limited number of situations:

• Abuse and Neglect: Reporting of child abuse or neglect or the abuse, neglect or exploitation of an elderly or disabled person is mandatory to the Texas Department of Protective and Regulatory Service or to any local or state law enforcement agency.
• Health Oversight: If a complaint is filed against a clinical staff member with their respective state licensing board, that board can subpoena PHI relevant to the complaint
• Judicial and Administrative Proceedings: We may disclose information when it is required by a court order.
• Serious Threat to Health or Safety: We may disclose information to prevent or lessen a serious and imminent threat to the health or safety of a person or the public. Information will only be disclosed to person(s) reasonably able to prevent or lessen the threat
• Worker's Compensation: If you file a worker's compensation claim, information related to your diagnosis and treatment may be disclosed to your employer's insurance carrier.
• Verbal Permission: We may use or disclose your information to family members that are directly involved in treatment with your verbal permission

Your Rights Regarding Your rotected Health Information (PHI)

• Right to Amend: If you feel that the PHI we have about you is incorrect or incomplete you may ask us to amend the information although we are riot required to agree to the amendment.
• Right of Access to Inspect and Copy: You have the right to inspect and copy PHI that may be used to make decisions about your care. Your right to inspect and copy PHI will be restricted only where there is compelling evidence that access would cause serious harm to you We may charge a reasonable cost-based fee for copies.
• Right to an Accounting of Disclosures: You have the right to request an accounting of certain of the disclosures that we make of your PHI. We may charge you a reasonable fee you request more than one accounting in any 12-month period.
• Right to Request Restrictions: You have the right to request a restriction or limitation on the use or disclosure of your PHI for treatment payment or health care operations. We are not required to agree to your request.
• Right to Request Confidential Communication : You have the right to request that we communicate with you about medical matters in a certain way or at a certain location that is more private for you. For example, you may wish billing statements to be mailed to an address other than your home address.
• Right to a Copy of This Notice: You have the right to obtain a copy of this notice.

Complaints or Questions

To exercise any of your rights, or if you wish to file a complaint please do so in writing and submit it to our Privacy Officer, Bryan Moffitt, 5701 Avenue P: Lubbock TX 79412. You also have the right to file a complaint with the Secretary of Health and Human Services. We will not retaliate against you for filing a complaint.

I hereby acknowledge that have received and have been given an opportunity to read a copy of Family Counseling Services' Notice or Privacy Practices. I understand that if have any questions regarding the Notice of my privacy rights I can contact

Bryan Moffitt, Privacy Officer

Family Counseling Services

5701 Avenue P Lubbock TX, 79412

The counselors at FCS are primarily volunteers who hold employment elsewhere. They are paid either nothing or next to nothing. As volunteers, they set their own schedule and DO NOT come to the office unless they have scheduled an appointment with you. That's right! They come here to see you and for no other reason.

So, please be considerate. You could save your counselor a trip over here if you will communicate with them well in advance any time you cannot meet for your session. If you decide you do not want to come to counseling anymore, that is fine. We understand. Please let your counselor know. That is far preferable to them driving over here only to be stood up.

After 2 no-shows with no communication prior to the session, your spot will be given to another client. IF you decide you still want counseling, you may communicate that to your counselor and they will either try to find a new appointment time or refer you to sign up on the website once more (fcslubbock.org) to meet with a new counselor.