Body Doubling Registration Form

MBST Registration Form
Identity*

Legal First NameLegal Last Name
Preferred Name
GenderPronouns
Address*

Street Address

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E-mail Address*
example@example.com
Phone Number*
Date of Birth*

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Date

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 therapist to reach out via phone or email
- Refusal or Inability to pay for services
- Failure to show up for two consecutive appointments, without providing a 24-hour notice.
- Being consistently late for sessions
- Any other unwillingness to continue participating in treatment.
I understand that the therapist 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.
Client/Guardian Signature*

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Financial Policy

Payment is expected at the date of service, unless previously agreed upon with therapist. All therapy sessions are expected to be approximately 50 minutes. Rates are subject to change based on socioeconomic factors of both client and therapist. The client will be notified of any changes before they are applied. Sliding scale fees are also accepted based on the need of the client.

Session payments are expected to be made the day of. Clients are permitted two (2) late payments (i.e. waiting until payday, or the following session), and must otherwise be capable of payment the day of session. Mind Body Soul Therapy, LLC accepts payments through IvyPay and Therasoft, confidential credit card processing systems specifically created for therapists and clients.

Clients are expected to give 24 hours notice of cancellation; anything less may mean the client is subject to the session fee.

If the client no-calls and/or no-shows, the session will be counted as a no-show and the therapist may charge the session fee.

Mind Body Soul, LLC has a 15 minute wait policy. If the client is not present in the session after 15 minutes, the therapist will log off and count it as no-show, and may charge the session fee. If the client reaches out the same day for a session within 48 business hours, the no-show fee will be applied to the rescheduled session.

My signature below shows that I understand and agree with all of the above statements:
Client/Guardian Signature*

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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 forms of electronic communication are not secure mediums because third parties can view and store confidential information. Therefore, email and other forms of electronic
communication are not to be considered completely confidential forms of communication.
Please indicate which method(s) Mind Body Soul Therapy, LLC can contact you:*

EmailText MessagePhone CallVoicemail
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MBST Registration Form