Mind Body Soul Therapy, LLC Registration Form

Consent for Treatment

I agree to take part in counseling services at Mind Body Soul Therapy, LLC. I understand that counseling has potential risks and benefits. I understand that no promises or guarantees have been made to me as to the results or success of treatment. I understand that I may withdraw consent for treatment at any time. If I withdraw consent, I will be responsible for paying for the services that I have already received. Withdrawal of consent for treatment can be in the form of any of the following:

• Verbal
• Written
• Lack of communication after two attempts by the counselor to reach out via phone call, email, text, or secure messaging
• Refusal or continual inability to pay for services
• Failure to show up for two consecutive appointments, without providing a 24-hour notice.
• Being consistently late for sessions (more than 7 minutes)
• Any other unwillingness to continue participating in treatment.

I understand that the counselor has the ethical and legal responsibility to break the limits of confidentiality
and notify proper authorities or outside sources if any of the following were to occur:

• I hurt/threaten to hurt myself and/or others, or if someone hurts/threatens to hurt me
• There is abuse or neglect of a child or vulnerable adult
• There is a court order for the release of information/documentation

I understand that it is within my rights as a client to report any ethical or legal complaints about Danielle Osborne, LPC (license no. 9754) to South Carolina Labor Licensing Regulation by going online to https://llr.sc.gov/ and selecting the option for filing a complaint, or by selecting Licensee Lookup and filing a complaint through that venue.

I understand that services rendered will be solely virtual through Psychology Today’s HIPAA-compliant telehealth portal.

As an active client of Mind Body Soul Therapy, LLC, if I am experiencing an urgent, clinical, or life-threatening emergency, I agree to contact one or more of the following:

• The National Suicide Prevention Hotline at 1-800-273-8255
• Call or text 988 to be connected to a crisis center
• Call 1-843-414-2350 to be connected to South Carolina Mobile Crisis
• My emergency contact

My signature below shows that I understand and agree with all of the above statements. The risks, benefits, side effects, and  alternatives of treatment as well as the consequences of non-compliance with treatment have been discussed with me and I have had the opportunity to ask questions.

 

Financial Policy

Payment is expected at the date of service, unless previously agreed upon with the counselor. All therapy sessions are expected to be approximately 53 minutes. Rates are subject to change based on socioeconomic factors of both client and counselor. The client will be notified of any increases at least 30 days before they are applied. Sliding scale fees or decreased session fees are also accepted based on the need of the client and discretion of the counselor.

Session payments are expected to be made the day of session. Mind Body Soul Therapy, LLC accepts payments through IvyPay and Headway, confidential credit card processing systems specifically created for therapists and clients.

Clients are expected to give 24 hours notice of cancellation; anything less means the client will be charged the late cancellation fee, which is equal to the amount of the session fee. If the counselor can get the client rescheduled in the next 48 hours (on the condition that the counselor has the availability to do so), client will not be charged the late-cancellation fee.

If the client does not show for session at the session time, the session will be counted as a no-show and the counselor will charge the session fee. 

Mind Body Soul, LLC has a 10 minute wait policy. If a client is not present in the session after 10 minutes, the counselor will log off and count it as no-show, and will charge the session fee.

Mind Body Soul, LLC allows for one waived late-cancellation fee per year. A client may use this waived fee opportunity at the time of their choosing, and an email receipt will be sent to the client.

My signature below shows that I understand and agree with all of the above statements:

 

 

Consent for Electronic Means of Communication

Mind Body Soul Therapy, LLC takes your privacy and right to confidentiality seriously. Although it is convenient, email and other formats of electronic communication are not secure mediums because third parties can view and store confidential information. Therefore, email and other formats of electronic
communication are not to be considered completely confidential forms of communication. Mind Body Soul Therapy, LLC does not conduct therapeutic services via email or text.