We know this process takes a bit of time and we truly appreciate your effort.
By completing everything online, you're actually saving time in the long run. This helps you avoid waiting for office hours, playing phone tag, or going back and forth by email.

While it may feel like a lot upfront, this is the fastest and most streamlined way to get you scheduled and connected with the right therapist as quickly as possible. 

Please know that you can save your work at any point and return later to finish. Your progress is saved so you can go at your own pace. We're here if you need support along the way!

Select "SAVE" Below. Then "NEXT". This will save your work. Clicking "NEXT" by itself does not save it. 

Select "SAVE" Below. Then "NEXT". This will save your work. Clicking "NEXT" by itself does not save it.

Select "SAVE" Below. Then "NEXT". This will save your work. Clicking "NEXT" by itself does not save it.

Select "SAVE" Below. Then "NEXT". This will save your work. Clicking "NEXT" by itself does not save it.

Select "SAVE" Below. Then "NEXT". This will save your work. Clicking "NEXT" by itself does not save it.

Select "SAVE" Below. Then "NEXT". This will save your work. Clicking "NEXT" by itself does not save it.

Select "SAVE" Below. Then "NEXT". This will save your work. Clicking "NEXT" by itself does not save it.

Select "SAVE" Below. Then "NEXT". This will save your work. Clicking "NEXT" by itself does not save it.

Select "SAVE" Below. Then "NEXT". This will save your work. Clicking "NEXT" by itself does not save it.

Select "SAVE" Below. Then "NEXT". This will save your work. Clicking "NEXT" by itself does not save it.

Select "SAVE" Below. Then "NEXT". This will save your work. Clicking "NEXT" by itself does not save it.

Select "SAVE" Below. Then "NEXT". This will save your work. Clicking "NEXT" by itself does not save it.

Select "SAVE" Below. Then "NEXT". This will save your work. Clicking "NEXT" by itself does not save it.

You are almost there! We truly appreciate your effort and care. These final consent forms ensure we have everything we need to move forward with your services.

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.
• 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.

 

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 admin staff in the client portal
• 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 Milestones Counseling Center PLLC's 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 supervisor and 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:

• Child, elder, or dependent adult abuse is revealed about any party, including those not in therapy.
• 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.

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.

Consistent attendance is essential to achieving meaningful and lasting progress in therapy. Each session builds upon the last, and repeated missed or late-canceled appointments disrupt treatment, delay progress toward your goals, and limit access to care for other clients.

By signing this intake paperwork, you acknowledge and understand the following:

• A late cancellation is defined as canceling an appointment less than 24 hours before the scheduled time.
• A no-show is defined as failing to attend a scheduled appointment without notice.

Repeated attendance concerns interfere with the therapeutic process and may result in:

• Late cancellation or no-show fees
• Loss of a standing or recurring appointment time
• Placement on same-day scheduling status

If you accumulate three (3) late cancellations and/or no-shows within a six (6) month period, you may be discharged from services.

If discharged due to attendance concerns, you will be provided with referrals to outside providers to ensure continuity of care.

This policy is not intended to be punitive. It exists to maintain clinical effectiveness, fairness, and responsible use of scheduled appointment times. If circumstances arise that make attendance difficult, we strongly encourage you to communicate with us as early as possible so we can discuss options.

Your signature indicates that you understand and agree to these expectations and the potential consequences of repeated missed or late-canceled appointments.

• All payments are ultimately the responsibility of the client. If insurance is not paying within 90 days, you will be responsible for full payment.
   
• All co-payments and deductible payments are due at the time of service.
   
• Adjustments to payment amounts from the insurance company will be applied upon receipt of the insurer’s report, without prior notification to the client.
•  
• Full fee and sliding scale payments are due at the time of service.
   
• Reasonable efforts are made to verify benefits on your behalf. Please know that these benefits are subject to final approval by the insurance companies. Milestones encourages you to speak to a benefits counselor at your insurance company to fully understand your benefits.
   
• Insurance policies are contracts between you and your insurance company. Milestones files these claims and will assist, to a reasonable degree, with solving problems. If these attempts do not result in the completion of payment you will be asked to follow up with the insurance company.
   
• 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.
   
• 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.
   
• Any appointments scheduled but not kept, as well as any appointments cancelled within 24 hours of scheduled time will be charged at the rate of $99. This is not covered by your insurance company.
   
• 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. Fees for court as follows: $2500 per clinician/per day, $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. Please note that provisionally licensed clinicians may require, per Milestones Counseling Center PLLC, supervisory support for any and/or all of these tasks. If that support is required, fees will be doubled.
   
• 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. In the event that 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.
   
• I authorize Milestones Counseling Center LLC to keep my credit card information on file and charge it for incurred costs including cancelled appointments, co-pays, telephone calls, etc.
   
• I understand that if my credit card does not accept the charge, I will immediately make the payment to the practice.
   
• I understand that I may cancel this authorization at any time, but by doing so, I acknowledge that the balance owing will be due & paid in full.
   
• I acknowledge that credit card transactions could be linked to Protected Health Information.
   
• I acknowledge that it is my responsibility to keep Milestones updated on any change to my credit card information.
   
• I acknowledge that some payment methods such as Health Savings Accounts will not allow charges for cancelled fees, paperwork, phone calls, etc. and I will still be responsible for these charges.
   
• I acknowledge that this is not a complete list of fees that may be incurred during my treatment. For a more complete list see the Informed Consent. Any additional services required by the clinician or client will be discussed and a price agreed upon before rendering the services. If at any time a service is rendered without being agreed upon, it will be billed at $150/hour.

 

By signing below, I waive my right to use EAP services.

I understand that EAP services are meant to be short-term, problem-solving interventions, while therapy is a more comprehensive treatment modality.

I understand that it is my responsibility to know whether I have access to EAP services or not and that Milestones Counseling Center PLLC does not check to see if these benefits are available.

I understand that if I wish to use EAP services, all necessary information including, but not limited to, authorization number, number of sessions, and beginning and end dates of the service must be provided to Milestones Counseling Center PLLC before my initial session.

I understand that I am responsible for paying all charges incurred during treatment that are not covered by my insurance or EAP company.

* BY CLICKING ON THE CHECKBOX BELOW I AM AGREEING THAT I HAVE READ, UNDERSTOOD AND AGREE TO THE ITEMS CONTAINED IN THIS DOCUMENT.

• I authorize the release of any medical information necessary to process my claim and payment of benefits. 

• I acknowledge that it is my responsibility to inform Milestones Counseling Center (MCC) of all health insurance plans covering the client. I confirm that I have provided accurate and complete insurance information. If there are more than two insurance plans, I understand that I must contact the office to provide the additional details.

• I attest that I am only covered by the insurance plan or plans that I have listed in my intake documents. I understand that if I don’t disclose all plans under which I am covered, faulty claim filing may occur and I may end up being financially responsible for large sums of money at a later date.

• I understand that if my insurance plan recoups fees paid to Milestones Counseling Center LLC because of unpaid insurance premiums, undisclosed secondary insurance, gaps in coverage, or other reasons that are not the fault of the practice, I am financially responsible for paying Milestones Counseling Center LLC for all money recouped. Further, I understand that Milestones Counseling Center LLC may take legal action, including collections and small claims court, if I refuse to pay.

• 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. In the event that your card is declined, our office will continue to attempt to process your card including partial amounts at our discretion 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.

• I understand that I am financially responsible for co-pays and deductible payments for my sessions. I understand and agree that these charges will be posted to the credit card on file and that I must call my insurance plan, not Milestones Counseling Center LLC, if I do not understand or agree with what my plan has and has not covered.

 

BY CLICKING ON THE CHECKBOX BELOW I AM AGREEING THAT I HAVE READ, UNDERSTOOD AND AGREE TO THE ITEMS CONTAINED IN THIS DOCUMENT.

Model Notice of Privacy Practices for HIPAA Covered Health Care Provider

Your Information. Your Rights. Our Responsibilities.

This notice describes how medical information about you may be used and disclosed and how you can get access to this information. Please review it carefully.

Your Rights
You have the right to:

• Get a copy of your paper or electronic medical record
• Correct your paper or electronic medical record
• Request confidential communication
• Ask us to limit the information we share
• Get a list of those with whom we’ve shared your information
• Get a copy of this privacy notice
• Choose someone to act for you
• File a complaint if you believe your privacy rights have been violated

Your Choices
You have some choices in the way that we use and share information as we:

• Tell family and friends about your condition
• Provide disaster relief
• Include you in a hospital directory
• Provide mental health care
• Market our services and sell your information
• Raise funds

Our Uses and Disclosures
We may use and share your information as we:

• Treat you
• Run our organization
• Bill for your services
• Help with public health and safety issues
• Do research
• Comply with the law
• Respond to organ and tissue donation requests
• Work with a medical examiner or funeral director
• Address workers’ compensation, law enforcement, and other government requests
• Respond to lawsuits and legal actions

To the extent that we have your substance use disorder patient records, subject to 42 CFR part 2, we will not share that information for investigations or legal proceedings against you without (1) your written consent or (2) a court order and a subpoena.

Your Rights
When it comes to your health information, you have certain rights. This section explains your rights and some of our responsibilities to help you.

Get an electronic or paper copy of your medical record

• You can ask to see or get an electronic or paper copy of your medical record and other health information we have about you. Ask us how to do this.
• We will provide a copy or a summary of your health information, usually within 30 days of your request. We may charge a reasonable, cost-based fee.

Ask us to correct your medical record

• You can ask us to correct health information about you that you think is incorrect or incomplete. Ask us how to do this.
• We may say “no” to your request, but we’ll tell you why in writing within 60 days.

Request confidential communications

• You can ask us to contact you in a specific way (for example, home, office, or cell phone) or to send mail to a different address.
• We will say “yes” to all reasonable requests.

Ask us to limit what we use or share

• You can ask us not to use or share certain health information for treatment, payment, or our operations. We are not required to agree to your request, and we may say “no,” for example, if it could affect your care. If we agree to your request, we may still share this information in the event that you need emergency treatment.
• If you pay for a service or health care item out-of-pocket in full, you can ask us not to share that information for the purpose of payment or our operations with your health insurer. We will say “yes” unless a law requires us to share that information.

Get a list of those with whom we’ve shared information

• You can ask for a list (accounting) of the times we’ve shared your health information for six years prior to the date you ask, who we shared it with, and why.
• We will include all the disclosures except for those about treatment, payment, and health care operations, and certain other disclosures (such as any you asked us to make). We’ll provide one accounting a year for free but will charge a reasonable, cost-based fee if you ask for another one within 12 months.

Get a copy of this privacy notice

You can ask for a paper copy of this notice at any time, even if you have agreed to receive the notice electronically. We will provide you with a paper copy promptly.

Choose someone to act for you

• If someone has authority to act as your personal representative, such as if someone has your medical power of attorney or if someone is your legal guardian, that person can exercise your rights and make choices about your health information.
• We will make sure the person has this authority and can act for you before we take any action.

File a complaint if you feel your rights are violated

• You can complain if you feel we have violated your rights by contacting us using the information on page 1.
• You can file a complaint with the U.S. Department of Health and Human Services Office for Civil Rights by sending a letter to 200 Independence Avenue, S.W., Washington, D.C. 20201, calling 1-877-696-6775, or visiting https://www.hhs.gov/hipaa/filing-a-complaint/index.html.
• We will not retaliate against you for filing a complaint.

Your Choices
For certain health information, you can tell us your choices about what we share. If you have a clear preference for how we share your information in the situations described below, talk to us. Tell us what you want us to do, and we will follow your instructions.

In these cases, you have both the right and choice to tell us to:

• Share information with your family, close friends, or others involved in your care or payment for your care
• Share information in a disaster relief situation
• Include your information in a hospital directory

If you are not able to tell us your preference, for example if you are unconscious, we may go ahead and share your information if we believe it is in your best interest. We may also share your information when needed to lessen a serious and imminent threat to health or safety.

In these cases we never share your information unless you give us written permission:

• Marketing purposes
• Sale of your information
• Most sharing of psychotherapy notes

In the case of fundraising:

We may contact you for fundraising efforts, but you can tell us not to contact you again.

If we have your substance use disorder patient records, subject to 42 CFR part 2, we will give you clear and obvious notice in advance and a choice about whether to receive fundraising communications that use your Part 2 information.

Our Uses and Disclosures
How do we typically use or share your health information?

We typically use or share your health information in the following ways.

Treat you

We can use your health information and share it with other professionals who are treating you.

Example: A doctor treating you for an injury asks another doctor about your overall health condition.

Run our organization

We can use and share your health information to run our practice, improve your care, and contact you when necessary.

Example: We use health information about you to manage your treatment and services.

Bill for your services

We can use and share your health information to bill and get payment from health plans or other entities.

Example: We give information about you to your health insurance plan so it will pay for your services.

How else can we use or share your health information?

We are allowed or required to share your information in other ways – usually in ways that contribute to the public good, such as public health and research. We have to meet many conditions in the law before we can share your information for these purposes.

In all cases, including those listed below, if we have substance use disorder patient records about you, subject to 42 CFR part 2, we cannot use or share information in those records in civil, criminal, administrative, or legislative investigations or proceedings against you without (1) your consent or (2) a court order and a subpoena.

Help with public health and safety issues

We can share health information about you for certain situations such as:

• Preventing disease
• Helping with product recalls
• Reporting adverse reactions to medications
• Reporting suspected abuse, neglect, or domestic violence
• Preventing or reducing a serious threat to anyone’s health or safety

Do research

We can use or share your information for health research.

Comply with the law

We will share information about you if state or federal laws require it, including with the Department of Health and Human Services if it wants to see that we’re complying with federal privacy law.

Respond to organ and tissue donation requests

We can share health information about you with organ procurement organizations.

Work with a medical examiner or funeral director

We can share health information with a coroner, medical examiner, or funeral director when an individual dies.

Address workers’ compensation, law enforcement, and other government requests

We can use or share health information about you:

• For workers’ compensation claims
• For law enforcement purposes or with a law enforcement official
• With health oversight agencies for activities authorized by law
• For special government functions such as military, national security, and presidential protective services

Respond to lawsuits and legal actions

We can share health information about you in response to a court or administrative order, or in response to a subpoena.

Our Responsibilities

• We are required by law to maintain the privacy and security of your protected health information.
• We will let you know promptly if a breach occurs that may have compromised the privacy or security of your information.
• We must follow the duties and privacy practices described in this notice and give you a copy of it.
• We will not use or share your information other than as described in this notice unless you tell us we can in writing. If you tell us we can, you may change your mind at any time. Let us know in writing if you change your mind.

For more information see: www.hhs.gov/ocr/privacy/hipaa/understanding/consumers/noticepp.html.

Changes to the Terms of this Notice

We can change the terms of this notice, and the changes will apply to all information we have about you. The new notice will be available upon request, in our office, and on our web site.

Other Instructions for Notice

• Effective Date of this Notice: February 16, 2026
• For questions or concerns contact Michelle Adams at 708-880-7747
• We will not share your mental health treatment records without your written consent unless it is for treatment or another law requires us to share the information.

By signing below, I acknowledge that I have received, or have been offered the opportunity to receive, a copy of the Notice of Privacy Practices for Milestones Counseling Center PLLC.

I understand that this Notice explains:

• How my Protected Health Information (PHI) may be used and disclosed
• My rights regarding my health information
• The practice’s legal duties to maintain the privacy of my health information

I understand that I may request a copy of the Notice at any time.

 

Becoming a fully licensed clinical professional (LCSW, LCPC, LMFT) is a long process. While each license has specific requirements, a general process is completed by all. Future clinicians obtain a master’s degree in a clinically related field. During this process they complete at least one year of internship/practicum, resulting in several hundred hours of client contact and education. After graduation, they apply for a provisional license (LSW, LPC, etc.). After obtaining this license, provisionally licensed clinicians are required to work under and be supervised by a fully licensed clinician for several years. Clinical interns are currently enrolled in a master’s program and working towards their master’s degree in a counseling related field.

At Milestones Counseling Center PLLC, we have several provisionally licensed clinicians and interns providing services. All the following individuals receive direct supervision from Milestones Counseling Center PLLC’s owner Michelle L. Adams, MSW, LCSW, CADC, CODP I or Emily Page, MSW, LCSW.

 

Patricia Burton is a Licensed Social Worker (LSW) in the State of Illinois. Patricia received her Master of Social Work from Governors State University and is receiving supervision to obtain her LCSW (Licensed Clinical Social Worker) license.

Nerissa Vogt is a Licensed Social Worker (LSW) in the State of Illinois. Nerissa received her Master of Social Work from University of Wisconsin-Madison and is receiving supervision to obtain her LCSW (Licensed Clinical Social Worker) license.

Danielle White is a Licensed Professional Counselor (LPC) in the State of Illinois. Danielle received her Master of Arts in Clinical Psychology from Governors State University and is receiving supervision to obtain her LCPC (Licensed Clinical Professional Counselor) license.

Kyle Meers is currently a master's level student at Governor's State University. He will be graduating in 2026 with a Master's Degree in Clinical Psychology.

Courtney Kodat is currently a master's level student at Governor's State University. She will be graduating in 2026 with a Master's Degree in Social Work.

Confidentiality: Information gathered in the sessions will be held with the same confidentiality laws of all clients at Milestones Counseling Center PLLC. Session details will be discussed with the clinician’s supervision team for the purpose of feedback and support. Exceptions to this confidentiality occur when there is suspected child/elder abuse, imminent danger to the client or others, a court order, or when a client signs a release of information.

Code of Conduct: If for any reason you have questions about counseling or are dissatisfied, you have the right to meet with your therapist and their supervisor, Emily Page, MSW, LCSW. Emily can be reached at 708-880-7747 or via e-mail at emily@milestonescounselingcenter.com.

Emergency Situations: You may leave a message at 708-880-7747, and your call will be returned within 48 business hours. In an emergency situation when an immediate response is necessary, please call 911 or go to the nearest emergency room for attention.

I ACKNOWLEDGE THAT IF I AM SEEING A CLINICIAN LISTED ABOVE, I UNDERSTAND WHERE THEY ARE IN THEIR JOURNEY TO BECOME A FULLY LICENSED CLINCIAN AND CONSENT TO RECEIVE CARE FROM THIS CLINCIAN.

Introduction
To ensure we can fully focus on you during sessions and provide the highest quality care possible, MCC uses a secure virtual scribe to assist with clinical documentation. This helps your clinician generate required clinical notes so we do not need to take notes during sessions. As a result, our time together can flow more naturally, allowing us to stay present and engaged with you without interruptions.

Privacy and Confidentiality
The documents created by the virtual scribe are generated from a brief written record. Sessions are not recorded or stored. The text exists only long enough to create clinical documentation and is automatically deleted once the note is completed.

The virtual scribe is fully HIPAA-compliant, and all information is fully encrypted. Documentation can also be manually deleted at any time or automatically removed according to established retention settings.

Benefits
Enhanced Focus
We are able to concentrate fully on you and your experience without dividing attention between conversation and note-taking.

Accurate and Efficient Documentation
The system supports timely and thorough documentation, helping ensure important clinical information is captured accurately.

Improved Quality of Care
By reducing administrative burden and clinician fatigue, this process allows us to devote more energy and attention to providing thoughtful, high-quality care.

Your Choice
The use of a virtual scribe is intended to enhance the therapy experience; however, participation is completely optional. Choosing not to use this technology will not negatively impact your treatment or the therapeutic process. Your comfort, privacy, and autonomy remain our highest priorities.

By signing below, I confirm my consent to the use of the virtual scribe during my sessions. I acknowledge that the virtual scribe may use an artificial intelligence tool the purpose of which is to reduce to written form recordings of my sessions, and I consent to the use of artificial intelligence for this purpose.

 

Help Us Train the Next Generation of Mental Health Clinicians

Milestones Counseling Center PLLC is proud to be a training facility for master’s-level graduate students pursuing careers in counseling, social work, and marriage and family therapy. These unlicensed clinicians—often referred to as "interns"—are completing the final, supervised stage of their education.

To provide our clients with the highest standard of care and prepare future professionals with meaningful experience, we offer a variety of training opportunities within our practice. Interns are supervised by fully licensed clinicians, and your participation is completely voluntary.

 

How Intern Supervision Works

All interns are supervised by a fully licensed professional and receive weekly individual and group clinical supervision.
If you work directly with an intern, their supervisor will introduce themselves within the first three sessions, and you’ll be given their direct contact information.
You are encouraged to share any concerns with your assigned clinician or their supervisor at any time. Your comfort and care always come first.
We invite you to support our mission by consenting to one or more of the following learning options:

 

Working With a Master's Level Intern

Working With a Licensed Clinician

At Milestones Counseling Center, we believe in supporting your well-being both in and out of sessions. From time to time, we send out optional email updates designed to be helpful, supportive, and informative.

By opting in, you may receive communications that include:

• Mental health tips, tools, and seasonal self-care ideas
• Agency updates including new services, staff, events, or expanded hours
• Notices about open appointment slots or clinician availability
• Emergency closures, weather-related delays, or telehealth transitions
• Announcements for groups, workshops, or events at Milestones
• Information about local or community-based resources, events, or services that may benefit your mental health and well-being (e.g., support groups, wellness fairs, nonprofit workshops, free giveaways)

These messages will never include personal health information and are sent only occasionally. Your contact information is kept confidential and never sold or shared with outside parties. You can unsubscribe at any time.

PAYING FOR SERVICES
I understand that if Milestones Counseling Center PLLC provides me with information regarding my verification of benefits, this information has been obtained, as a courtesy, from my insurance company. Milestones Counseling Center PLLC has no control over the accuracy or completeness of the information provided by my insurance provider. I acknowledge that if the information is inaccurate or incomplete, I am still fully responsible for any charges incurred.

I acknowledge that it is my responsibility to know my insurance coverage and notify Milestones Counseling Center PLLC of any changes to my insurance before the change takes place.

If my insurance lapses or later says that a service is not covered, I agree to pay the full fee for that service.

I understand that all payments are ultimately my responsibility. If insurance does not cover sessions, I will be responsible for the full session fees outlined below.

INSURANCE PROCESSING
Insurance claims are processed every day, and the amount I owe might change because of things like deductibles, co-pays, or updates to my insurance plan. I will be charged for the remaining balance that my insurance company says I owe. This charge may happen on the day of my session or when the insurance notification is received.

These rate changes are decided by my insurance company, not by Milestones Counseling Center PLLC.

HOW & WHEN TO PAY
I must pay my copay, coinsurance, or session fee the day of my appointment.

My debit or credit card on file will be charged on the day the insurance claim comes back from the insurance company. Milestones Counseling Center PLLC has no way of knowing when this may occur.

Milestones Counseling Center PLLC is not responsible for any bank fees I may get. (Overdraft fees, etc.)

FAILURE TO PAY
Per the contract that Milestones Counseling Center PLLC has with health insurance companies, they MUST make reasonable attempts to collect any unpaid fees from me. This may include sending my account to collections if not paid, in full, within 60 days.

I understand that if legal or collections actions are required, some of my health information may be shared.

Any additional fees incurred due to sending my account to collections or involving a lawyer, will be added to my balance.

 

SESSION COSTS
$175 - First session (or family/couples therapy)

$150 - Regular 55-minute sessions

$99 - Late cancel (less than 24 hours), No-shows, Late Arrival/Early Departures (10 minutes).

*If my insurance lapses or later says that a service is not covered, I agree to pay the full fee for that service.

 

APPOINTMENT CANCELLATION POLICY
If I cancel or reschedule an appointment less than 24 hours in advance, I will be charged a $99 fee.

If I do not arrive for a scheduled session, I will be charged the $99 fee.

If I am more than 10 minutes late, my session may be canceled, and I will be charged the $99 fee.

 

HOW TO CANCEL OR RESCHEDULE
I understand that I may cancel/reschedule my appointment in the following ways and SHOULD NOT rely on voicemails to cancel/reschedule sessions:

Cancel during a prior session.

Log into my client portal and cancel my appointment at least 24 hours in advance.

Message my clinician through the client portal.

THERAPIST FIT & REFERRALS
If I feel that my therapist is not a good fit for my needs, I may request a referral from my therapist or contact the scheduling team at 708-880-7747 or admin@milestonescounselingcenter.com.

Admin staff may reach out to me, throughout treatment, to assure that my therapist is a good fit and that therapy is meeting my needs.

I acknowledge that I have read, understand, and agree to the policies outlined above. I accept responsibility for all financial obligations and communication expectations.

I authorize Milestones Counseling Center LLC to contact the below mentioned individual(s) via any means necessary in case of a crisis. Crises can include, but are not limited to, instances in which myself or another person/people are at imminent risk of harm. This contact is not to be used for any purpose other than to keep myself or another person safe. Only information required for safety purposes will be released.

The following information may be released, if necessary: Current mental status Plans for harming self or others Physical location Contact information Other pertinent information required to assist in keeping all parties safe

The information provided above may be used for crisis intervention, safety planning, or any other situation considered an emergency by Milestones Counseling Center PLLC staff; including, but not limited to, reports of self-harm, harm to others, abuse or neglect, severe emotional distress, medical situations, or inability to care for oneself.

I understand that this information may be protected by Title 42 (Code of Federal Rules of Privacy of Individually Identifiable Health Information, Parts 160 and 164) and Title 45 (Federal Rules of Confidentiality of Alcohol and Drug Abuse Patient Records, Chapter 1, Part 2), plus applicable state laws. I further understand that the information disclosed to the recipient may not be protected under these guidelines if they are not a health care provider covered by state or federal rules. I understand that this authorization is voluntary, and I may revoke this consent at any time by providing written notice, and after (some states vary, usually 1 year) this consent automatically expires. I have been informed what information will be given, its purpose, and who will receive the information. I understand that I have a right to receive a copy of this authorization. I understand that I have a right to refuse to sign this authorization. If you are the legal guardian or representative appointed by the court for the client, please attach a copy of this authorization to receive this protected health information.

By signing below, I consent to and acknowledge the information outlined in this document.

If you are here to work on relationship concerns, it’s important for you to understand what your therapist will believe about relationships and marriage.

Your therapist will not have preconceived notions about whether you should stay together or part ways. We believe it is important to explore such questions openly, honestly, and thoroughly. Once your goals are established, we will work diligently to support you in achieving them, whatever they may be. You are entrusting your therapist to use their professional judgment as it relates to individual confidences.

By signing this form, you are acknowledging that anything you communicate to your therapist individually by phone, email, or any other means may be important to bring up and work on in a couple therapy session, and we reserve the right (but not the obligation) to do so.

Please note that this extends to conversations that are discussed during individual sessions regardless of who the couple may see for couple's therapy.

Select "SAVE" Below. Then "NEXT". This will save your work. Clicking "NEXT" by itself does not save it.

Two More Quick Steps and You Will Have Your Appointment!

 

1. Submit this form.There are TWO MORE BUTTONS TO PUSH before the form is submitted. 

 

2. REQUEST A SESSION- When you sign the documents, you will be redirected to our electronic health record, Simple Practice, where you will select a clinician and a date/time for your appointment. Secure that appointment with a credit or debit card and you are all set! Our staff will be in touch soon to confirm your appointment. 

When you get to the Simple Practice page, select "I'm a New Client".