Child / Adolescent Intake Form

FINANCIAL RESPONSIBILITY

I accept full responsibility for all costs associated with the services I receive from The Wellness Centre.

I accept that I may utilize my health insurance benefits and that The Wellness Centre will verify my benefits as a courtesy however, The Wellness Centre cannot be held responsible or liable for inaccurate information provided by myself or my insurance provider.

I accept responsibility to confirm coverage with my insurance provider and communicate to The Wellness Centre any changes in my insurance coverage or policy immediately so that claims can be filed within the insurance provider’s deadlines.

I accept responsibility for the full fee(s) for services rendered but not covered by my insurance provider.

I accept that any co-pay, coinsurance, deductible, and/or service not covered by my insurance plan must be paid at the time of service.

I accept that The Wellness Centre and/or therapist(s) may release any information as necessary to process claims to my health insurance company.

I accept that I am responsible for obtaining and providing any required medical referrals. It is my responsibility to meet the referral requirements of my insurance provider.

I accept full responsibility for the payment due on services that are provided during any period when a referral is not active and/or expired.

I accept full responsibility for the fees associated with missed appointments and/or late cancellations. 

I accept that Corporate Wellness benefits and health insurance benefits cannot be utilized to cover the fees associated with no show appointments or late cancellations.

I accept full financial responsibility for any additional services such as phone calls, letter writing, completion of forms, and administrative meetings in or out of the office. These services will be billed at the usual rate and will remain the client’s obligation to pay.

I accept the responsibility to immediately update The Wellness Centre of any changes in physical/billing address and contact information.

I accept the responsibility to ensure that any direct bank transfers are made accurately and in a timely manner, to ensure The Wellness Centre is in receipt of funds on their respective due date.

I accept that The Wellness Centre reserves the right to charge interest and/or pursue delinquent accounts via third-party collection agencies or attorneys at the client’s cost. I further accept that I expressly waiving privileges concerning disclosure of any information necessary to proceed with collection activities and acknowledge an itemized account history, showing services rendered, fees charged, and payments received may be filed as an exhibit.

I accept that this Financial Responsibility Agreement is valid for all sessions and/or services rendered by The Wellness Centre, a copy of which may be used in place of the original agreement signed.

All invoices/receipts are presented in Cayman Islands Dollars and payments by USD cash, credit/debit cards, and wire transfers are accepted at the exchange rate of 0.80. Services may be suspended if your account is more than 30 days in arrears.

PAYMENT DETAILS

DIRECT DEPOSIT / ELECTRONIC FUND TRANSFER: When making an online or direct deposit please ensure the CLIENT's name is noted in the narration/memo so that the deposit can be accurately applied to the account.

Bank: Cayman National Bank | Branch: Elgin Avenue
Account Name: The Wellness Centre Ltd.
Account Type: KYD Chequing
Account Number: 011-09070

Your rights to information about us

All our mental health professionals are registered, certified, or licensed as required by law and are held to the highest of legal and ethical standards. We are committed to your rights of information regarding office policy, non-discrimination, confidentiality, consent, and competent service.

If you have any questions or concerns, please do not hesitate to tell us. For further information please visit our website www.wellnesscentre.ky or call us at 949-9355.

1. Child Safety Policy
The Wellness Centre Ltd operates an open-door policy as it relates to the service of children under the age of 18 years. Although most therapeutic services are conducted behind closed doors between a child and their primary therapist, if at any time a parent wishes to do so, they may enter their child’s therapy session without knocking or advanced notice.

2. Confidentiality
Unless you grant us permission to do so in writing, we will not inform anyone that you are receiving therapy, nor will we disclose the content of your treatment. Additional consent will be required for The Wellness Centre to provide treatment to minors and to exchange information with a third party.

Family matters will also require consent from all primary adults involved before treatment materials will be released. You may revoke your permissions in writing at any time.

Please note client records will remain property of The Wellness Centre for a period of 10 years, after which time they will be destroyed. We function as a clinical team at The Wellness Centre and therefore utilize internal peer supervision and consultation regularly as well as professional external consultation and supervision as needed.

Any para-professionals, administrators, or interns are also bound by our strict ethical code of confidentiality; they are bound by a written declaration of fidelity to confidentiality and required to maintain HIPAA certification. 

However, there are a few circumstances when we have a legal obligation to disclose information without your written permission:

• Harm to a Child/Elderly Person/the Disabled: If we are made aware that a vulnerable person is in direct danger, we are legally obligated to make our concerns known to the appropriate authorities;
• Harm to Self or Others: If at any time it is our clinical assessment that your actions or intentions are of a threatening nature to yourself or others, we have a legal obligation to make these concerns known to the appropriate authorities.
• Order of the Court: The Court of the Cayman Islands may at any time request information regarding your treatment where it is applicable to current or pending criminal case proceedings.
• Professional Supervision: The Wellness Centre operates as a team structure and performs professional best practices such as clinical meetings, supervision, and consultations to ensure the most beneficial care in collaboration with internal practitioners. No outside professionals will be involved. Any conflicts of interest will be identified and may be avoided upon request.

3. Corporate Partners
All employees of our Corporate Partners receive individual, family, and couples counselling at no cost to them. Family members of employees may also receive free services or a Corporate Partner discount depending on the company. Corporate Partner employees also receive a discount for specialized services. Please identify yourself as an employee of one of our Corporate Partners at the time of booking.

4. Complaints
If at any time you believe your rights have been violated or you have concerns about the quality of service received, you are encouraged to speak to your therapist. If you are not able to resolve your concerns, you may contact the Director, Dr. Shannon Seymour, in writing.

Client Satisfaction Surveys are available at your request. If no course of action has been helpful to you, you have the right to speak to a member of the Health Practice Commission www.dhrs.ky/hpc/contact.php

The Cayman Islands Council for Professionals Allied with Medicine has set out a code of practice and guidelines for the provision of counselling services for your protection.

By signing below, you indicate you are fully informed and agree to the preceding information and consent to treatment. By signing below, you also agree that if you or someone in therapy with you makes an allegation against this agency, or any employee acting in the capacity of the agency for a legal or ethical violation, we have the right to release information sufficient to our own defense against the charges made.