New Client Paperwork Packet

I hereby attest that the information provided on the Registration form is true, complete and accurate.

I hereby authorize A Healing Place, Complete Counseling Care to furnish my relevant personal health information to insurance carriers, payor sources and accrediting agencies, concerning myself or my dependent’s diagnosis and treatment (See Notice of Privacy Practices Form).

I hereby assign to A Healing Place, Complete Counseling Care all payments for services rendered to me, my dependents or the client named on the Registration form. I agree to be jointly and severally responsible for all charges incurred by myself, my spouse, my dependents or the client named on the Registration form.

I hereby authorize and consent to A Healing Place, Complete Counseling Care to provide behavioral health services for myself, or other identified client, for which I have legal authority to grant.

By indicating my consent, I am signing this agreement electronically. I agree my electronic signature is the legal equivalent of my manual signature on this agreement.

This document contains important information, which you should be aware of prior to your first appointment. Please discuss any questions or concerns you may have with your therapist.

Agreement for Mental Health Counseling Services

Services

A Healing Place provides individual, family, couple, and group counseling. Our therapists can only counsel within the scope of their practice. If it is determined that a client would be better served by a different provider, then appropriate referrals will be made.

Counseling Process

Mental Health counseling is a complicated process that offers benefits and can also pose risks. Counseling may elicit uncomfortable thoughts and feelings, or may lead to the recall of troubling memories. Counseling involves a signicant commitment and you should feel comfortable with the therapeutic relationship. If you feel that A Healing Place is not a good fit for you, a recommendation to another mental health professional can be made. It is encouraged that you address these concerns openly in session, as the exploration is often beneficial to treatment.

Confidentiality

Counseling involves the disclosure of sensitive, personal information. Communication between a client and mental health counselor is protected by law. Release of information to others about our work together is only done with your written permission. There are exceptions, to avert a serious threat to health and safety to self or others, abuse of a child or dependent adult and lawsuits or other legal disputes, the detail can be found in the Notice of Privacy Practices.

Consent for Release of Information

If any person or organization, other than you, contacts A Healing Place inquiring about attendance, diagnosis, and/or treatment progress, they will be given no information. If you would like information released to anyone, you must sign a release form specically indicating what you do and do not wish to be released and to whom. Once this information is released, A Healing Place cannot assume responsibility for how the information is handled and therefore cannot guarantee confidentiality.

Professional Records

In accordance with Federal law, all A Healing Place records are electronically stored/maintained. A Healing Place is the owner of all records. Records will not be released without your written permission except as mandated by law. You are entitled to receive a copy of your records at your written request, unless the counselor professionally believes seeing them could be emotionally harmful to you.

Communication

A Healing Place has sole access to records. All records of communication, written or verbal, between client and counselor remain the property of A Healing Place. Verbatim material from counseling sessions remain in the client record and should never be revealed publicly by the client or counselor unless both client and counselor agree. Voicemails, emails, faxes, instant messages, and text messages with A Healing Place staff/therapists are kept in the highest confidentiality within the limits of the technology, but confidentiality cannot be guaranteed.

Session length/Session Fees

All counseling sessions are 50 minutes and will start on the hour and end at 10 minutes to the next hour. If you are late for an appointment your session will still end at 10 minutes to the next hour. Clients who arrive later than 15 minutes after their start time will automatically have their appointment cancelled unless the clinic is notified and the late arrival time is approved by the clinician.

Therapist’s fees are $250 per session. You are responsible for any charges not covered by insurance, including copayments and deductibles.

Late Cancellation/No Show Fees/Terminations

Cancellations must be made at least 24-hours in advance of the scheduled session. You will be charged $75.00 if you cancel within 24 hours, or you do not show for your appointment.  

AHP has the right to terminate any client from the practice for any reasons, or after three no shows or late cancellations. No-showing or late cancellation of your initial appointment may lead to termination from our clinic. If the office is closed, you can leave a message with our voicemail or email info@healingplaceccc.org

Patient Payment Policy

A Healing Place is very fortunate to be growing and servicing so many more people for their mental health wellness. Due to the number of high deductible health plans and higher patient co-insurance benefits, all clients are required to have a credit card on file to see a provider at A Healing Place.

We recognize this can feel uncomfortable for some but we will only charge your card when there is a balance due, (except for co-pays which are due at the time of service) we only charge your card what your health insurance determines by your health plan.

Frequently Asked Questions Patient Payment Policy

Card Number:

(Please do not enter more than 4 numbers in each line)

Parent/Guardian Presence 

A Healing Place requires a parent or guardian's presence for clients that are under the age of 12 years old. This is required for safety purposes and for the therapist, who may want to discuss their treatment. A Healing Place does encourage parents/guardians presence for children 12 years and older, however it is not required. 

Emergency Services

A Healing Place does not provide emergency services. All phone messages and emails will be checked daily unless otherwise stated, but are not for use in an emergency. In an emergency please call 911, report to your local emergency room or call your local crisis number.

I have read, and affirmed by my signature, the above statements, and I consent to participate in the counseling process.

I have read and reviewed A Healing Places HIPAA Policy, and understand that I may request a printed copy of the above Notice of Mental Health Policies and Practices to Protect the Privacy of my Health Information.

By indicating my consent, I am signing this agreement electronically. I agree my electronic signature is the legal equivalent of my manual signature on this agreement.

Telehealth allows your therapist to diagnose, consult, treat, and educate, using interactive audio, video, or data communication regarding your treatment.

I hereby consent to participating in psychotherapy via telephone or the internet (hereinafter referred to as Telehealth).

I understand that I cannot be driving during my Telehealth session.

I understand that I must be physically present in the state of Wisonsin to be seen via Telehealth.

I understand I have the following rights under this agreement:

I have a right to confidentiality with Telehealth under the same laws that protect the confidentiality of my medical information for in-person psychotherapy.

Any information disclosed by me during my therapy, therefore, is generally confidential. There are, by law,exceptions to confidentiality, including mandatory reporting of child abuse harm to self or others, requestsfor records in a legal situation.

Further, I understand that the dissemination of any personally identifiable images or information from the Telehealth interaction to any other entities shall not occur without my written consent.

I understand that while psychotherapeutic treatment of all kinds has been found to be effective in treating a wide range of mental disorders, personal and relational issues, there is no guarantee that all treatment of all clients will be effective.

Thus, I understand that while I may benefit from Telehealth, results cannot beguaranteed or assured.

I further understand that there are risks unique and specific to Telehealth, including but not limited to, the possibility that our therapy sessions or other communication by my therapist to others regarding my treatment could be disrupted or distorted by technical failures or could be interrupted or could beaccessed by unauthorized persons.

In addition, I understand that Telehealth treatment is different from in-person therapy and that if my therapist believes I would be better served by another form of psychotherapeutic services, such as in-person treatment, I will be scheduled in person appointments only.

I understand that telehealth billing information is collected in the same manner as a regular office visit. My financial responsibility will be determined individually and governed by my insurance carrier(s), Medicare, or Medicaid, and it is my responsibility to check with my insurance plan to determine coverage.

I understand that electronic communication cannot be used for emergencies or time-sensitive matters.

I understand that electronic communication should never be used for emergency communications orurgent requests. Emergency communications should be made to the provider’s office or to the existing emergency 911 services in my community.

I have read and understand the information provided above. I have the right to discuss any of this information with my therapist, and to have any questions I may have regarding my treatment answered to my satisfaction.

I understand that I can withdraw my consent to Telehealth communications by providing written notification to Prepare to Change.

My signature below indicates that I have read this Agreement and agree to its terms.

By indicating my consent, I am signing this agreement electronically. I agree my electronic signature is the legal equivalent of my manual signature on this agreement.

A Healing Place, Complete Counseling Care is dedicated to taking the precautions necessary to protect your confidential information. Frequently email, text, or other forms of electronic messaging and document transferring can be helpful tools. This will be used for communication between sessions regarding non-clinical issues such as scheduling billing and other logistics. 

In an effort to make your experience at A Healing Place as helpful and efficient as possible, we employ the newest technology. While A Healing Place attempts to maintain privacy and security in all areas, it is important to understand the certain risks outlined below. You have the option of opting out. However, by opting out you will not receive appointment reminders or any of the below communication from A Healing Place via email or text alerts. 

If you provide us with your email/mobile phone number, it will only be used for:

• Appointment Reminders
• The ability to cancel appointments
• Invoices and Statements
• Credit Card Receipts
• Risks Associated with Email 

A Healing Place offers patients the opportunity to communicate with staff via email. However, transmitting client information by email has a number of risks that should be considered.

These include, and are not limited to: 

• Email can be circulated, forwarded and stored in numerous paper and electronic files
• Emails are not always encrypted and could theoretically be read by a malicious outside party with the technical skill to intercept emails.
• Email senders could misaddress an email
• Email is easier to falsify than handwritten or signed documents
• Backup copies of email may exist even after sender or recipients have deleted their copy
• Employer and on-line services may have a right to archive or inspect emails transmitted
• Email can be intercepted. Altered, forwarded, or used without authorization or detection
• Emails are part of the client file and therefore can be used as evidence in court 

Conditions for use of Communication for use with Electronics

A Healing Place will use reasonable means to protect the security and confidentiality of email information sent and received. However, because of the risks outlined above, A Healing Place cannot guarantee this security and confidentiality, and will not be liable for improper disclosure of confidential information that is not caused by our intentional misconduct. Thus, individuals must consent to the use of email for communication with the following conditions 

• Understand that clinical information sent via email is not secure.
• It is the client/guardians’ responsibility to notify A Healing Place of any change in email address 
• A Healing Place staff will do their best to respond promptly to an email, we cannot guarantee that any email will be read, received or responded to within any period.

No one shall use email for medical emergencies, or other time sensitive matters. Please call 911 for emergencies or go to the nearest hospital for urgent matters.

All emails received by or sent from A Healing Place may be made part of the client’s record. Other individuals authorized to access the medical record, such as, staff and billing personnel, will have access to email correspondence. 

A Healing Place may forward emails internally to the practice’s staff and agents as necessary for diagnosis, treatment, reimbursement, and other administrative handling. 

A Healing Place will not forward emails to independent third parties without the client’s prior written consent. 

A Healing Place also employs Facebook and other forms of social media as a means of marketing and connection with the community. It is your choice as to whether to connect with our business on these or other sites; again, we cannot guarantee your confidentiality on these sites. 

To maintain the professional nature of our relationships, the providers at A Healing Place do not accept requests from current or former clients on personal social networking sites. 

I have taken all precautions to eliminate others from accessing my email during my absence. I will not hold A Healing Place liable for others accessing my email sent by A Healing Place. 

By electronically signing below, I hereby agree to A Healing Place Electronic Communication and Technology Consent form. At any time, I understand that I have the right to revoke this consent in writing. I understand the risks associated with email communications between A Healing Place and me, and consent to the conditions outlined above. In addition, I agree to the instructions for communicating by email outlined here, as well as any other instruction A Healing Place may impose on email or technology communications. 

By indicating my consent, I am signing this agreement electronically. I agree my electronic signature is the legal equivalent of my manual signature on this agreement.

Thank you for choosing A Healing Place. Your treatment and care are especially important  to us. We believe it enhances the therapist patient relationship to have open communication regarding our financial expectations. 

We recommend that you contact your insurance to confirm that your therapist is an in-network provider prior to your first appointment. If you have any questions regarding the policies listed below, please contact A Healing Place at 920-725-1230.

Some insurance requires a referral to our service in order to pay claims. It is my responsibility to obtain the referral authorization for the appropriate source, if needed.

The parent who brings the child in the office for care is responsible for the payment at the time of service.

We designate accounts self-pay under the following circumstances:

1. Patient does not have health insurance coverage.

2. Patients are covered by an insurance plan that our providers do not participate in.

3. Patient does not have a current, valid insurance card on file.

4. Patient does not have a valid insurance referral on file Bill Payment and Refunds.

5. When you receive a statement, the balance is due in full within 30 days of the statement date. If you cannot pay the balance in full within 30 days, please contact our billing department with options.

6. It is your responsibility to notify the office of any change in address, phone, employment or insurance coverage.

7. We reserve the right to report delinquent accounts to credit bureaus, assess a collection fee, or take other collection action.

We accept all forms of payment including HSA cards. Returned checks are subject to a $35.00 return fee.

I have read, understand, and agree to the above Financial Policy. 

By indicating my consent, I am signing this agreement electronically. I agree my electronic signature is the legal equivalent of my manual signature on this agreement.

I have read, understand, and agree to the above New Client Paperwork Packet & Policies. 

By indicating my consent, I am signing this agreement electronically. I agree my electronic signature is the legal equivalent of my manual signature on this agreement.