*If requesting counseling sessions to be held in-school, a team member will be reaching out to have a Release of Information form signed before in-school service can begin.

1. I seek and consent to participate in services at Family Service Agency's programs.

2. I understand that developing a treatment plan with my counselor and regularly reviewing progress towards my treatment goals is in my best interest.

3. I understand that I may stop program services at any time and that I am responsible for any consequences of terminating counseling.

4. I understand that when services terminate Agreement to Pay for Professional Services continues to apply until my bill is fully paid.

5. I understand that my insurance company or third-party payer may receive information about the services I receive.

6. I understand and have discussed with my counselor: a.) my condition, problem and/or diagnosis, b.) the planned course of treatment, c.) alternatives to treatment, including no treatment and d.) confidentiality and the limits or exceptions of confidentiality.

7. I understand as the parent or guardian of a recipient of services who is at least 12 but under 18 years of age that my child has rights to confidentiality that are different than for a child under 12 years of age. I understand the following provisions: a.) Any minor 12 years of age or older may request counseling services without the consent of the parent or guardian. b.) Sessions provided to a minor age 12-17 without parent or guardian consent shall be limited to not more than 7 sessions, lasting no more than 45 minutes each. c.) If a minor child age 12-17 chooses to consent to counseling without parent or guardian consent, then the parents will not be informed unless required by law. d.) If a minor child age 12-17 chooses to consent to counseling without parent or guardian consent then the parents are not financially responsible for those sessions. e.) Parent or guardian is not entitled access to protected health information of a child age 12-17 without the child's consent, unless required by law.

8. If the person to receive services is a minor (under the age of 18 years of age), I give permission to the program services to provide services to him or her.

9. I understand that a child age 17 or under who has been a victim of criminal sexual assault or abuse may consent to program services without parent or guardian consent.

10. I give consent for Family Service Agency to contact me for evaluative purposes.

Charges that may apply:

• The fee for intake or diagnostic assessment is $150.
• An individual session costs up to $150 depending on the type of session and time frame of session.
• Sessions extended more than 10 minutes are charged on a pro-rated basis for the additional time.
• If I seek additional services (i.e. requesting materials for court, seeking a counselor in court), I will be charged the hourly rate of $90 for those services.
• The fee for medication is $125 per hour which is divided equally between each party.
• The fee for phone consultation with a counselor is pro-rated based on the hourly rate of $90.
• The fee for checks returned for insufficient funds is $25 per occurrence, plus any applicable collection fees.
• If I fail to cancel an appointment less than 24 hours in advance or no show I will be charged a $25 fee.

Additional billing policies:

• I am responsible for knowing my insurance benefits and for providing accurate and timely insurance information, including completion of any authorization or approval process required by my insurance company. Any fees not covered by my insurance company resulting from not knowing benefits or providing accurate or timely information is my responsibility.
• There are some services that insurance may not cover and I am responsible for these fees or any fees denied for coverage by my insurance.
• If my insurance or other third party payer has not paid for services after two billing or denies coverage, I am fully responsible for the remaining bill for services.
• If a bill is not paid it, it may be sent to collections and I will be responsible for the additional 35% charged by the collection agency to collect the bill.
• I am responsible to give Family Service Agency updated address information. Failure to do so may result in any unpaid bill being sent to collections.
• Lack of payment of the co-pay for two consecutive sessions or lack of timely payment on a pre-arranged payment plan may result in being unable to schedule another appointment with a counselor until payment is received on the account.
• Any billing questions should be directed to the Family Service Agency Business Office.
• All balances are due upon termination of services, unpaid balances will be sent to collections.

If you have additional concerns, please contact the Agency for assistance 815-758-8616.

I understand and agree to the information contained in this Agreement to Pay for Professional Services. If applicable, my signature below authorizes my insurance to make payment directly to Family Service Agency's Center for Counseling.

• My behavioral health professional wishes me to engage in a telehealth consultation using Zoom.
• My behavioral health professional has provided information needed to make an informed decision about engaging in Zoom technology.
• I understand there are potential risks to this technology, including interruptions, unauthorized access, and technical difficulties.
• I understand that my behavioral health professional or I can discontinue the telehealth consult/visit if it is felt that the Zoom videoconferencing connections are not adequate for the situation.
• I understand that if others are present during the consultation other than my behavioral health professional, they will maintain confidentiality of the information obtained. I further understand that I will be informed of their presence in the consultation and thus will have the right to request the following: 1.) omit specific details of my medical history/physical examination that are personally sensitive to me; 2.) ask non-medical personnel to leave the telehealth session/room: and or 3.) terminate the consultation at any time.
• In an emergency, I understand that the responsibility of my behavioral health to contact my listed emergency contact or the local first responders if there is a termination of the Zoom video conference connection.
• I have had a direct conversation with my behavioral health professional, during which I had the opportunity to ask questions regarding this procedure. My questions have been answered and the risks, benefits, and any practical alternatives have been discussed with me in a language in which I understand.

By signing this form I certify:

• I have read or have had this form read/explained to me.
• I fully understand its contents including the risks and benefits of the procedure(s).
• I have been given ample opportunity to ask questions and that my questions have been answered to my satisfaction.