Rights and Risks:
● I am aware that Dr. Atchison believes and has explained to me that counseling is a tool for teaching individuals about themselves and it will benefit me. I understand that no guarantees have been made to me as to the results of the treatment. I understand that it is my responsibility to inform my therapist of any changes in my physical, mental, emotional, spiritual condition.
● I understand that sometimes things get worse while in the process of change and acknowledge that some of the information discussed in session may cause significant distress or discomfort.
● I acknowledge that this is not a substitute for a physician and will not provide medical diagnosis, medical treatment, or any other type of medical advice. I give my consent to inform my physician of treatment and will review lifestyle suggestions with my physician before implementation.
Confidentiality:
● I have read and received a copy of the notice of Privacy Practice and Clients’ Rights documents.
● I understand that my information is confidential in most cases; however, there are other cases where information will be shared, and I give my consent, including: diagnosis and dates of services will be shared with insurance companies in order to collect payment, any case of safety (physical or sexual abuse, threats of suicide or homicide, basic needs not being met), cases where a release of information is signed, court mandates, case consultation, information released as outlined in the HIPAA Notice of Privacy Practices, and other cases as required by law.
● I understand that non-identifying information may be used for clinical research purposes.
● I understand that tele-sessions are conducted through HIPAA approved sites and I must ensure my confidentiality depending on who might be around during my sessions.
Appointments:
● All office visits are by appointment and can be scheduled through counselor or email.
● Tele-sessions will be conducted via video/audio and if there are technical struggles the therapist will call/text the client within that scheduled session.
● I agree to arrive on time for scheduled appointments. Late cancellation (less than 24 hours) will be billed to my credit card for $30. Insurance companies will not pay for missed appointments.
● I understand that I have the right to terminate my treatment at any time I choose to do so.
● Emergency services are not provided, and I will call 911 or go to my local emergency room.
Financial:
● I understand if I have insurance coverage, the contract is between me and my insurance company. I am responsible for the entire payment for counseling services. The client portion(co-pay/deductible) of fees will be determined after remittance from insurance.
● Rates for sessions are $155 per 50-60 minutes (which includes billing insurance). May be higher or initial sessions or planning sessions.
I acknowledge that I have read this consent for treatment and financial agreement (along with the contact and billing information form) and agree to abide by the provisions herein. I have been offered to take a copy of these policies with me if desired.