Informed Consent for Mental Health Services
This document provides you with important information regarding your mental health treatment including costs, privacy policies, limits of service, etcetera. Please have each adult participating in therapy read & sign a separate electronic or paper form. If you have any questions regarding its content or our policies, please immediately ask your clinician or someone on our administrative team. The informed consent for mental health services must be signed by the client and or guardian of the client to receive services and will be reviewed and resigned annually.
The Mental Health Process
Milestones Counseling Center PLLC is a team where professionals of diverse training and backgrounds collaborate to help you in reaching your stated mental health goals. Our goal is to serve as your partner in the therapeutic process. As such, it is crucial that you provide ongoing feedback to our team regarding the process, your changing needs, and the effectiveness of our services. You always have the right to disagree with your clinicians’ recommendations and refuse any recommendations that are made.
Due to the varying nature and severity of presenting issues as well as unique personality of each client we are unable to predict the length of your therapy or guarantee specific outcomes. We believe it can take months or years for clients to reach their goals and that consistent appointment attendance is crucial to that process.
Termination, or the process of ending your mental health treatment with our practice, is a collaborative process between you and your clinician. When you and your clinician feel that your goals have been reached, we will encourage you to decrease the frequency of care to a minimum of one appointment every three to six months. If you decide to completely end care your clinician will still encourage you to schedule a follow up appointment for some point in the next year to ensure that you maintain your therapeutic progress without needing to restart regular therapy.
If you ever feel like your therapist is not a good fit for your needs, we encourage you to ask that therapist for a referral or contact our scheduling team (708-880-7747). You can also e-mail our scheduling team at admin@milestonescounselingcenter.com.
As a client of Milestones Counseling Center PLLC, you have the right to service is free from abuse, financial or other exploitation, retaliation, humiliation, or neglect. If you believe you are experiencing one of these things, even if you are not fully certain, please contact us at info@milestonescounselingcenter.com. If you ever have any complaints about your therapist or our practice, please do not hesitate to contact our practice owner, Michelle Adams, at 708 880 7747 x2, or at info@milestonescounselingcenter.com.
Contacting Employees
You may find the need to contact your clinician, or another employee, in-between sessions. Please note that we are often not available to answer the phone. All employees aim to respond to contact attempts within 24 hours.
Communicating via the client portal is, not only he most secure, but usually the most efficient. Employees can respond 24/7 and can often respond in-between therapy sessions. This is not something that can be done with phone calls.
You may contact Milestones Counseling Center PLLC employees in any of the following ways:
· Log into your client portal and use the messaging feature. This is the most secure and efficient way of communicating with employees.
· Call/text the office and/or leave a message on the voicemail @ 708-880-7747
· E-mail us at admin at milestonescounselingcenter.com
Medication Management
To better meet the mental health needs of our clients, our clinicians will often recommend medication management services from independent physicians or nurses outside of our practice. By your request, your clinician may communicate with this individual to help coordinate care and help you reach your goals. A release of information must be completed for this individual before any contact can be made. In addition, you may always research your own medication management services by contacting your insurance company directly.
Psychological Testing
Currently Milestones Counseling Center PLLC does not do psychological testing. If you are interested in psychological testing in addition to therapy services, please notify your clinician to obtain referrals. You may also contact your insurance company’s customer service center.
Client Emergencies
Milestones Counseling Center PLLC does not currently offer on call, after hours, or emergency services. We are solely an outpatient clinic providing services by appointment only. In the event of a medical emergency (including side effects from prescribed medications) or an emergency involving a threat to your safety or the safety of others, please call 911, go to your nearest emergency room, or call 988 for the mental health hotline.
Our clinicians do not travel to see clients or make house calls. All meetings with our clinicians must take place in our established place of business or via telehealth, unless previously scheduled to occur at another location and approved by Milestones Counseling Center PLLC practice owner.
Client Communications, Public Contact, and Social Media
To facilitate communication, we require all clients provide us with a valid home address, telephone number and e-mail that we may use to contact you. We encourage you to avoid providing contact information associated with your place of employment to help protect your privacy, as Milestones Counseling Center PLLC is not liable for breaches of privacy associated with the contact information you provide.
E-mail communication will be sent through an encrypted e-mail whenever possible but some systems in use may not have this option.
By signing the last page of this document, you give our clinical and administrative personnel authorization to contact you for scheduling and billing purposes at the addresses provided. By signing this client agreement, you also acknowledge and give permission for Milestones Counseling Center PLLC to include private health information in these communications.
Our team wishes to be sensitive to your confidentiality in public settings. If we encounter you in public, we will do our best to avoid contact or conversation with you and encourage you to do the same. At no point will we discuss the details of your mental health treatment outside of offices.
All of Milestones Counseling Center PLLC staff and clinicians are prohibited from engaging in anything besides a therapeutic relationship with our clients. This includes, but is not limited to, accepting relationship requests on social media, exchanging gifts, entering business and personal relationships with clients, or similar activities with close or immediate family members of clients.
Fees and Insurance Policies (subject to change without notice)
Our standard fees for all insurance billing, are your payers’ allowable amount or the amounts listed below, whichever is less. In most cases your responsibility will be far less than the either of those amounts and will be limited to your insurance copay if applicable.
Clients with insurance, but not wishing to utilize their insurance, may request a negotiated “cash discount” rate that is less than the ones below and reflect our cost savings associated with paying your bill in full at the time services are rendered. This “cash discount” will be equal to the negotiated rate of your insurance plan. Offering a rate lower than this would put us in breach of the contracts we hold with your insurance company.
The clients needing pro bono or low clock cost therapy services, these are available upon request through Milestones Counseling Center PLLC’s graduate level interns. These services are exempt from therapy rates below. A limited number of these spaces are available. Fees for records, court appearances, etcetera still apply.
$175- Initial individual counseling appointment and family therapy
$150- each subsequent 55-minute counseling/therapy session
$99- Late cancel (less than 24 hours), No shows, Late Arrival/Early Departures (10 minutes)
$100- written treatment summary (1 to 2 pages)
$50- group therapy (lasting 60 to 90 minutes) for unrelated parties
$25- insufficient funds/bounced check fees
$25/15 minutes- Any phone conversation over 7 minutes will be charged at a prorated fee based on $100/hour. This will be billed in 15-minute increments. Phone calls are not covered by your insurance company.
$25/15 minutes- Any paperwork completion over 7 minutes will be charged at a prorated fee based on $100/hour. This will be billed in 15-minute increments. Paperwork completion is not covered by your insurance company.
In accordance with the standards set by the Illinois medical board, fees for all records releases are as follows:
$15 labor fee on all records, plus $1.00 per page for the first 25 pages, then $0.79 for pages 26-50, then $0.39 for each additional page.
If records are mailed, client will be responsible for all postage. Records may be picked up at a mutually convenient time at Milestones Counseling Center PLLC’s Crete, IL office for no additional cost. In addition, there will be a $50 rush fee assessed for anyone wanting documents in less than our standard 5 to 10 business days. Cost of records is payable prior to the pickup or mailing of requested records.
If a third-party request records on your behalf, you will be responsible for paying the records fee if payment is not received from them within 60 days of the release. If they pay a maximum fee or failed to remit our full fee, the difference will also be charged to your card on file. Records may be requested by sending an e-mail to info@milestonescounselingcenter.com.
Sessions that last longer than their allotted time, as well as Telehealth sessions, will be prorated into 15-minute increments and charged to your credit card on file (if required). Counseling or therapy sessions involving crises or technical complexity may be billed to insurance at higher rates than those listed above.
In the event a client request that any member of our staff complete paperwork of any kind on their behalf (FMLA, disability, etcetera), the client will be charged their clinicians hourly fee, prorated into 15-minute increments. Completion of such paperwork is not covered by insurance and will be billed at the clinician’s hourly rate to the credit card a client placed on file (if required).
Completion of Legal and Disability Forms
Milestones Counseling Center PLLC clinicians and staff do not provide evaluations regarding the scope, nature, duration, or accommodations related to a disability or other medical conditions. Instead, our clinicians will only provide their diagnosis and clinical observations of their clients. Further, no such evaluations will be completed by our clinicians until a minimum of five clinical visits have occurred. Questions regarding the scope, nature, duration, severity, or accommodations related with any medical or mental health condition will be answered with “No opinion- outside the clinician’s scope of practice”.
Milestones Counseling Center PLLC and its clinicians will not provide letters recommending emotional support animals, medical marijuana, or any matters regarding employment, immigration, or fitness to serve matters.
Collection of Fees
Copays, coinsurance, and session fees for non-insurance clients are due at the time services are rendered. The credit or debit card you have placed on file, if required, will be charged the day of your scheduled session. If your card is declined, our office will continue to attempt to process your card including partial amounts at our discretion for up to 180 days after your appointment. We are not responsible for fees associated with the bank account, including overdraft fees, or delayed processing of your credit card.
In the event the client contests a valid charge resulting in a reversal or chargeback initiated by their card issuer, Milestone Counseling Center PLLC will assess a clients account $50 to cover the cost charged by our credit card processor and the additional labor involved with collecting their outstanding balance.
Failure to pay any fees within 60 days of the date of service will result in your private information being turned over to the law firm or collection agency of our choice for collection actions, including the possible filing of a public lawsuit for collections. This may result in the disclosure of some aspects of your private health information. Fees associated with collections will be added to the balance you owe to our practice.
Timeliness / Cancellation / No Show Fee
Due to the nature of our business, it is essential that sessions start and end on time. We appreciate your cooperation in arriving on time for your appointments. While therapists make all attempts to arrive on time, we do, on occasion, run over time to provide the best care for the client before you. Please allow your therapist 10 minutes past your scheduled appointment to arrive. If your therapist’s timeliness becomes an issue, please contact Michelle at info@milestonescounselingcenter.com.
All clients will be charged a $99 fee per therapy hour that they fail to show up for, cancel with less than 24 business hours’ notice, or show up more than ten minutes late or leave more than ten minutes early. This is due to our inability to properly bill insurance for the time you reserve that cannot be recouped.
Monday appointments are required to be cancelled / rescheduled by the Friday prior to the appointment.
This fee is charged regardless of the reason for your no show, later arrival, late cancellation (including illness, family emergency, vehicle difficulties etcetera. This fee is also charged to non-insurance clients whose agreed session fee is at least $99 per hour.
Any non-insurance clients with a negotiated rate of less than $99 dollars per booked hour of therapy will be charged their entire session rate for no shows or late cancellations.
This fee will be charged to your credit card on file within 24 hours and is not covered by your insurance provider or EAP.
Please do not rely on voicemails to cancel your session. You may cancel your appointment in any of the following ways:
· Cancel during a prior session
· Log into your client portal and cancel your appointment before 24 hours.
· Message your clinician, Michelle, or Melissa in the client portal
· Text the office @ 708-880-7747
· E-mail us at admin at milestonescounselingcenter.com
The $99 fee will be charged unless specifically prohibited by a third-party payer (insurance company, government program, etcetera).
Inclement Weather Policies
Snow/ice days- Cancellation / no show fee is only waived if Crete-Monee School District 201-U is closed for the day. Telehealth is always a possibility if clients do not want to leave home, but schools are still in session.
Tornado sirens- If a tornado siren goes off during a session, please end the session and go to the safest place near you. You are welcome to move to a safe space with a Milestones Counseling Center PLLC clinician but are always free to leave the office if you so choose.
No Unaccompanied Minors
Children under age 14 may not be left unattended in our waiting areas. If our therapist realizes that a minor is unaccompanied, they will terminate the session and apply the no show fee. Additionally, children under 14 that are receiving therapy are required to have a parent or guardian seated in the waiting room at all times. Failure to remain on site may result in a call to DCFS. Waiting outside or in the car is not sufficient.
Legal Retainer
Milestones Counseling Center PLLC does not get involved in court proceedings. The agency will not provide documentation, aside from a treatment summary, for court purposes. If a clinician is subpoenaed, by a judge, to attend court, the client and/or their guardian is responsible to pay the court fees.
By signing this document, you agree in advance to pay our $2500 legal retainer fee (per day, per staff person) should we be asked to testify in any type of court proceeding. This includes, but is not limited to, any type of court trials (include divorce or custody cases), depositions, mediations, etcetera. You agree to pay this fee even if another attorney, without your authorization, subpoenas any of our staff regarding your records.
Additional court related fees, not included in the daily retainer: Client is responsible for $300/hour for preparation time, any incurred legal costs for consultation required to prepare for court, and any additional fees that may be incurred due to the court participation.
This fee must be paid prior to our appearance in court and will be billed to your credit card if one is on file. If a credit card is not on file payment must be submitted in full by credit or debit card, check, or cashier’s check. Failure to pay this fee will result in our normal collection procedures. Unless specifically contracted to do so, in writing prior to your first appointment, Milestones Counseling Center PLLC’s clinical staff will not make custody recommendations regarding children, even if we have provided therapy service to all parties involved in the divorce.
Please note that provisionally licensed clinicians may require, per Milestones Counseling Center PLLC, supervisory support for any and/or all these tasks. If that support is required, fees will be doubled.
Recording Fee
Milestones Counseling Center PLLC strictly prohibits audio or video recording of any therapy or other interaction without all parties expressed written consent. By signing this document, you also agree to pay a fee of $2500 for each session in which you record all or part of the session, without our clinicians expressed written consent.
In-Network Insurance Billing
Not every clinician at Milestones Counseling Center PLLC works with every insurance company. If one of our providers can provide you with in network care and you wish to use that coverage, we will collect your estimated copay or cost share the day of the session. This fee may be collected prior to your appointment.
It is your responsibility to know your insurance coverage and notify Milestones Counseling Center PLLC of any changes to your insurance, coverage, or policy. If your insurance coverage has changed, you must notify Milestones Counseling Center PLLC prior to your next visit. Any services provided that are not covered by your insurance company are your financial responsibility and are subject to our standard collection procedures.
Out of Network Insurance Billing
If your clinician is not contracted with your insurance company, your insurance is considered “Out of Network.” This means that it may be subject to a different set of deductibles, copay formulas, and limits on coverage and we cannot guarantee your insurer will reimburse you for your care. Clients wishing to use out of network insurance coverage must pay their therapist negotiated cash discount rate (written in at the beginning of the fees section of this document) at the time of service.
We do not submit claims on an out of network basis for our clients. If you want your claims submitted on an out of network basis, you need to contact our billing coordinator at info@milestonescounselingcenter.com and request a super bill that you can personally submit to your insurer.
If you’re out of network insurance coverage fails to cover your care, you will be held liable for our standard rate for cash pay clients.
Fees Not Covered by Insurance
Insurance companies will not cover mental health services where a valid diagnostic code is not provided and or there is no evidence of medical necessity. Milestones Counseling Center PLLC defines medical necessity as a condition that impairs your relational, vocational, emotional, physical, or spiritual functioning. For families and coupling couples seeking counseling, at least one individual must be assigned an individual diagnosis code and treatment must be appropriately focused on treating the individual’s diagnosis. Additionally, insurance companies do not cover no show fees, cancellation fees, record fees, or fees associated with our legal retainer. These fees are your sole responsibility.
Confidentiality and Privacy
As part of providing therapeutic services, various Milestones Counseling Center PLLC staff beyond your clinician will have access to your private information as needed to perform their job duties. Your rights to privacy and explanations of how your information are used are more fully explained in a separate document entitled Notice of Privacy Practices. If you have not received this document or would like another copy you can request one by emailing us at admin@milestonescounselingcenter.com
Confidentiality and Complaints
By signing this agreement, you give Milestones Counseling Center PLLC permission to break confidentiality in order to properly address or answer any complaints or lawsuits you bring against our practice, or any individual staff member or contractor associated with our practice, whether you bring them in a public or regulatory setting.
Release of Records and Documentation
Milestones Counseling Center PLLC has a very strict records release policy, even if documentation or records are being released directly to you the client. In all case cases, written permission is required to release any written documentation of any kind or to communicate with any parties besides those under our care. Further, the identities of all parties authorizing release must be verified by one of our staff using your government issued photo identification or by providing us with a notarized copy of our release form. If you participate in marital or family therapy, Milestones Counseling Center PLLC will not disclose confidential information about your treatment to unrelated parties, unless all adults who participated in therapy with you provide their written authorization for release of said information. Release of records may take up to 10 business days from the time we received a signed consent form and are subject to the fees outlined above. If needed sooner than five to 10 days, records are subject to an additional $50 fee for rush service. All fees and postage will be billed to the credit card on file, if required, on the date the records are released or mailed. Records may be requested by sending an e-mail to info@milestonescounselingcenter.com.
Your Privacy and 3rd Party Payers
By signing this form, you consent that all submissions for reimbursement sent to insurance companies, employment assistance plans, and other third parties may include private health information such as your diagnosis, identifying information, dates of service, and amounts paid to our practice. If a family member or other acquaintance agrees to pay for your services, we reserved the right to communicate to them about session attendance, no shows / cancellation fees and the expected duration and effectiveness of therapy.
Call Recording
All phone calls to our administrative staff and clinicians may be recorded and be archived for up to six months for quality control and training purposes.
Supervision and Consultation
All clinicians at Milestones Counseling Center PLLC are subject to the full supervision of our clinical directors. This means that your case and private health information may be discussed with your clinician supervisory chain of command or supervision group. Additionally, notes for every session performed by unlicensed graduate interns and provisionally licensed clinicians, are reviewed by their clinical supervisor. Graduate level interns may also discuss cases in their class at their university as part of their graduate training program. This discussion will take place with as little identifying information as possible.
From time to time, our clinicians will also seek outside consultation from other industry professionals regarding their clients. Additionally, our therapist may use anecdotes from therapy as part of writing, speaking, teaching or being interviewed in public settings. In these instances, all reasonable efforts will be made to ensure client confidentiality.
No Secrets Policy
When working with multiple persons within the same family, Milestones Counseling Center PLLC adheres to a no secrets policy. This means that we cannot and will not guarantee confidentiality between the multiple parties engaged in marital, couples, or family therapy. Further, our clinicians reserve the right to break confidentiality when they encounter information that any party involved in treatment might feel betrayed or aligned against if the information remains secret. Your clinician may attempt to notify you prior to disclosing material facts to another adult involved in conjoint therapy with you but does not guarantee this.
Treatment of Minors and Confidentiality
Communications between clinicians and clients who are minors (under the age of 18) are confidential. However, in the exercise of their professional judgment, your clinician may discuss the treatment progress of a minor client with the parent or legal guardian as is beneficial to the child. We strongly discourage parents from using their right to a child’s medical records to violate this confidentiality. We believe it destroys a child’s trust in their clinician and the mental health process.
If you are a minor, your parents/guardians may be legally entitled to some information about your therapy. We will discuss with you and your guardians what information is appropriate for them to receive and which issues are more appropriately kept confidential.
Right to Respond to Complaints, Reviews, and Media
If you exercise your right to create an online review, file a complaint with any regulatory body, or engage in commentary in the media about our practice, clinicians, or your treatment, you also waive your right to confidentiality. By signing this agreement, you give Milestones Counseling Center PLLC permission to respond publicly and privately to any such complaints while protecting its reputation, defending its ethics, or clarifying facts related to your treatment.
Tobacco, Alcohol, and Illegal Substance Usage
Policy- smoking or vaping of any kind (tobacco, marijuana, etcetera), possession or consumption of alcohol, or use of any other illicit, illegal, or mind-altering substance, is strictly prohibited by both staff and clients within our facilities.
Procedure for Tobacco, Alcohol, and Illegal Substance Usage
In the event that an individual engages in any of these behaviors, they will be asked immediately to cease, and a critical incident form will be completed and added to the client or employees file for management review and action. Failure to cease and or repeat violations may result in termination of services or dismissal from employment.
If a client arrives to session and use is suspected by the clinician, the session will be ended immediately, and the client will be charged $99 for an early terminated session. In addition, if the clinician feels that the client is unable to safely drive home, the clinician has the right to notify the local police department. You agree to waiving your confidentiality.
Lost and Found Policy
Milestones Counseling Center PLLC is not responsible for the safety and security of items brought by clients, staff, and visitors onto its premises. If an item is left behind by a client, staff or visitor and is found by one of our staff, we will make our best attempt to secure those items in the office to be claimed later. Illegal or illicit items will be disposed or turned over to law enforcement, as safety dictates. Medications left behind will be transported to the nearest pharmacy and are turned over to law enforcement.
Mandated Reporting
Milestones Counseling Center PLLC may, without notice, break client confidentiality and contact the appropriate authorities with all pertinent information when we suspect:
1. Child, elder, or dependent adult abuse is revealed about any party, including those not in therapy.
2. A client poses a serious physical threat to themselves or others.
Additionally, by signing this document, you give Milestones Counseling Center PLLC permission to release information when ordered by a judge or court of law under threat of sanction to our practice or staff.
Use of Third-party Software, Applications, and Electronic Communication
Milestones Counseling Center PLLC uses several software, web-based, and electronic applications created and administered by third party providers. These include but are not limited to Simple Practice, iPlum phone and fax service, Google Gmail, and business applications, Paubox, and various cell phone providers. Additionally, third party applications may be implemented by our practice without any additional disclosure to you as the client at any point in the future.
While Milestones Counseling Center PLLC has secured a business associate agreement from each of these service providers, we cannot ultimately guarantee their compliance with HIPAA and other regulations. As part of signing this document and receiving service from us, you exempt Milestones Counseling Center PLLC from liability or blame for any privacy violations that occur due to any action on the part of these vendors.
Agreement to Mediation
All complaints and disputes, except for collection actions initiated by Milestones Counseling Center PLLC, will be handled through a certified mediator. The mediator will be chosen by Milestones Counseling Center PLLC and paid for by the party initiating the complaint.
Technology Assisted Counseling / Online Counseling / Telehealth
1. Potential risks and concerns with phone and video counseling
Due to certain limitations, technology assistant counseling should be used only when face to face counseling is not available or practical given the client’s life circumstances. Specifically, you as the client should be aware of the following limitations associated with counseling over the phone, e-mail, or video counseling: Possible misunderstandings due to the lack of nonverbal cues normally present with in-person counseling. Technology assisted counseling is prone to possible misunderstandings between the therapist and client. If you’re having trouble understanding your therapist’s communications or feel misunderstood, you should immediately tell your therapist or e-mail them these thoughts after your session.
2. Turnaround time
Technology assisted counseling involves a longer lag time between when you communicate with your therapist and when he or she communicates back. Our counselors make every effort to respond to your communications, within a 12-to-24-hour period of your request. It is important to realize that the use of these services does not mean that your therapist is on call or available to you in a crisis or emergency situation. If such a situation arises, you should call 911, go to your nearest hospital emergency room, or contact 988.
3. By signing this agreement, you acknowledge that Milestones Counseling Center PLLC is not your emergency care provider and exonerate them from liability arising from delayed responses.
4. Privacy breaches
Technology assisted counseling utilizes many outside resources and companies (internet and software providers, Public Utilities, etcetera). All these entities are prone to their own security risks. By signing this agreement, you agree to evaluate and establish your own technological safeguards (strong passwords, secure networks, virus protection) and indemnify Milestones Counseling Center PLLC for any blame or liability associated with the hardware, software and third-party technology providers use select.
5. Safeguards employed by Milestones Counseling Center PLLC
Milestones Counseling Center PLLC uses Simple Practice for video-based communications. All personal health information acquired and stored by Milestones Counseling Center PLLC is encrypted and utilizes HIPAA compliant cloud-based services. Please discuss any such concerns with your counselor early in your first session to develop strategies to limit risk.
6. Records and recordings
In addition to our normal clinical records, Milestones Counseling Center PLLC maintains records of when online counseling services were provided and to who. NO AUDIO OR VIDEO RECORDING of any kind is permitted by either the client or the therapist. Without expressed, written consent by both all parties involved. By signing this agreement, you agreed to pay $2500 per session that you record without our permission.
7. Emergency contact services
If there is ever a disruption of services on the Internet, then the client will need to notify our main office at 708-880-7747.
By signing this document, I certify that I understand the limitations of technology assisted counseling/telehealth and consent to the use of these measures, if agreed upon with my clinician.
Progress Note Taking Software
Milestones Counseling Center PLLC uses external providers to enhance services including the Upheal platform. Upheal empowers counselors to concentrate on their services by offering automated notes and analytics for client conversations. As a part of this process, Upheal handles protected health information for counselors, adhering to HIPAA regulations as a Business Associate.
Milestones Counseling Center PLLC has signed a Business Associate Agreement (BAA) to protect data that is shared with Upheal. Under the BAA, Upheal adheres to regulations such as the HIPAA Security Rule and Privacy Rule. This ensures that electronic health information (ePHI) is safeguarded through appropriate administrative, physical, and technical measures, ensuring its confidentiality, integrity, and security. You can learn more about Upheal and its privacy practices at www.upheal.io/privacy.
Weapons
No weapons of any kind may be brought into any Milestones Counseling Center PLLC building or office, even if otherwise allowed under state concealed carry laws, unless in the possession of a bona fide law enforcement officer. Failure to abide by this policy will result in immediate termination of services.
Termination of Services
Ending relationships can be difficult. Therefore, it is important to have a termination process to achieve closure. The appropriate length of time for termination to take place depends on many factors. Termination may take place after your goals have been achieved, progress is not being made, or a more appropriate level of care is found. Should you fail to schedule an appointment for three consecutive weeks, unless other arrangements have been made in advance, for legal and ethical reasons, we must consider the professional relationship discontinued. You may be eligible to re-engage in services later, however appointment times/days and therapist assignments are not guaranteed.
Compliance or Ethics Concern
Quality and integrity are core values that Milestones Counseling Center PLLC. Should you ever have concerns or complaints about the quality of your care, the integrity of our billing procedures, the protection of your privacy, or our commitment to uphold the dignity and protect against the discrimination of every individual we serve, you can contact our business owner at 708-880-7747 or e-mail them at info@milestonescounselingcenter.com. All calls are confidential, may be made anonymously, and will be responded to if requested.
Agency Newsletter Participation
As part of our commitment to keeping clients informed, you will be automatically added to our agency’s email newsletter, which includes updates, resources, and wellness tips. If at any time you prefer not to receive these communications, you may opt out easily by clicking the “unsubscribe” link included in each email.
Acknowledgement of All Terms and Receipt of Privacy Practices
Your signature below indicates that you have carefully read all pages of this client agreement for services, as well as receive a separate copy of our Notice of Privacy Practices.
By signing, you agree to all conditions set forth in it. Please ask your therapist to address any questions or concerns that you have about this information before you sign this form.