ASPIRE COUNSELING 127C SICHLER RD SW, LOS LUNAS, NM 87031 PHONE: (505)235-9723 FAX: (505)212-0198

I CERTIFY THAT THE ABOVE INFORMATION is ACCURATE

ITHE UNDERSIGNED, CERTIFY THAT (OR MY DEPENDENT) HAVE INSURANCE COVERAGE WITH THE INSURANCE COMPANY(IES) USTED ABOVE AND ASSIGN DIRECTLY TO ASPIRE COUNSELING ALL INSURANCE BENEFITS - UNDERSTAND THATI AMI FINANCIALLY RESPONSIBLE FOR.ALL CHARGES, WHETHER OR NOT PAID BY INSURANCE. AGREE TO PAY $100FOR LATE CANCELLATIONS OR NO SHOWS W/OUT 24 NOTICES IAUTHORIZE THE USE OF THIS SIGNATURE ON ALL INSURANCE SUBMISSIONS

THERAPEUTIC COUNSELOR-CLIENT SERVICE AGREEMENT

This document contains important information about the professional services and business policies. Confidentiality/HIPPA is addressed in a separate document. Aspire Counseling does not support disability claims. We support doing the work to get better. If you have a copay or deductible it is collected at the start of the session; if you don't have the payment, you agree to cancel your appointment with at least 24 hours' notice or be charged the last-minute cancellation fee.

Appointments ordinarily will be 45-50 minutes in duration at a time we schedule in advance. Your appointment time is for you alone. If you need to cancel or reschedule, please provide at least 24 hours' notice. If you miss a session without cancelling, or cancel with less than 24 hours' notice, you will be charged a $100 fee (unless you and your provider both agree that you were unable to attend due to emergency circumstances beyond your control Note: Insurance companies do not reimburse for cancelled or missed appointments; therefore, you are responsible and accountable for the fee. Your credit card will be kept on file to cover these potential expenses. Also, we can attempt to find another time to reschedule the appointment You are responsible for attending your appointment on time; if you are late, your appointment will still end on time, and you will be charged for the full time. There is a zero-tolerance policy for no shows/no calls. A No Show is counted at 20 minutes after the start of your appointment if you have not contacted Aspire Counseling by that time. Therapy will be terminated if there is a no show/no call or a pattern of last-minute cancellations. Your appointment is part ofa contractual service agreement bound by your signature.

The standard fee for the initial intake is $150.00 and each subsequent session is $125.00. There is no sliding scale. Payment must be made in full at the time of your appointment. Checks returned for insufficient funds will accrue an additional $50 inconvenience fee. Court appearances are $125/hour non-refundable, including travel time, even if not called to the stand.

Often, we are not immediately available. We do not answer the phone when with clients or otherwise unavailable. At these times, you may leave a message on the confidential voicemail and your call will be

Your signature below indicates that you have read this contractual agreement and agree to their terms.

Limits of Confidentiality As a rule, Aspire Counseling will disclose no information about you, or the fact that you are a patient, without your written consent (Release of Information Health care providers are legally allowed to use or disclose records or information for treatment, payment, and health care operations purposes. You may revoke your permission, in writing, at any time, by contacting Aspire Counseling. There are some important exceptions to this rule of confidentiality: mandated reporting of child abuse or adult abuse, misconduct by another healthcare provider, court proceedings wherein a request is made by subpoena for information about your diagnosis and treatment, and a serious threat to health/safety of yourself or another person or persons (Duty to Warn

Please sign, print your name, and date this acknowledgement form.

Los Lunas, NM 87031 505-235-9723 www.aspirenm.com

If am a no-show for my scheduled appointment or cancel my appointment without giving at least 24- hour notice, I accept that I may be charged a $100 no-show/late-cancellation fee. If have provided credit card or debit card information on file, I allow Aspire Counseling LLC to bill this account for the last- minute cancellation or no-show fee. Also, should I subpoena or otherwise request my Aspire Counseling provider to be available for or testify in court, I accept that I will be charged in advance of the court date for the lost-income hourly rate of my provider set at $125 per hour, including travel time, for all hours my provider misses from work; I understand I must pay this fee in advance of my court date and that this payment is regardless of whether or not the provider actually is called to testify.

Credit Card Information (Required):

Consent for the Release and Exchange of Confidential Information

I request and authorize Aspire Counseling LLC, Los Lunas, NM 87031, (505) 235-9723, to release and

(Name, address, contact information of person/agency) Information pertinent to medical and/or psychological status and treatment, including but not limited to attendance, level of participation, diagnosis, and treatment plan and progress notes, and completion or

Purpose of the Request: Coordination of Care

This release of information is subject to revocation in writing by the undersigned at any time. This authorization will expire, if not revoked by the undersigned, one year from effective date. I understand that this information will be used only for the purposes noted above. A photocopy or fax copy of this authorization, which contains my signature, shall be considered as effective and valid as the original.