I understand that I am responsible for all amounts that the insurance company does not cover. I authorize the release of any medical information necessary to process any claims for services that I receive from Mrs. Keenum. In consideration of services rendered, or to be rendered, I hereby irrevocably assign and transfer to Mrs. Keenum all rights, title and interest in the benefits payable by my health insurance company(ies) for services rendered by Mrs. Keenum. Said irrevocable assignment and transfer shall be for the recovery on said policy(ies) of insurance, but shall not be construed to be an obligation of Mrs. Keenum to pursue any such right of recovery provided. However, this assignment and transfer shall not take away my standing to make claim or sue for benefits should coverage be denied by any insurance carrier(s). I hereby authorize the insurance company(ies) herein listed above to pay directly to Gabrielle Keenum, MA, LPC, NCC all benefits due under said policy(ies) by reason of services rendered therein. A photostatic copy of this authorization shall be considered as effective and valid as the original.
Your time is respected and Mrs. Keenum endeavors to be on time to give you your full 50 minute session. Please give mutual respect for her professional time. A scheduled appointment reserves that time only for you.
If you need to change your appointment time, please allow 24 hours prior notification. The full session fee is charged for missed appointments and one half the full session fee is charged for late cancellations (within 24 hours of the scheduled appointment time). Insurance will not pay for these fees. These fees are the client’s responsibility
The standard fee for an individual session is $130 per session. The standard fee for couples is $165 per session. The intake fee is $145 for individuals and $180 for couples.
Payment is due when services are rendered. Accounts are to be kept current. If payment is not made, another appointment cannot be scheduled.• A fee of $25 is charged for returned checks.
I understand that if my counselor is subpoenaed to court on my behalf or requested by me to appear:• The fee is $300 per hour for my counselor’s time, with a four hour minimum charge plus additional hours as requested by the court or your attorney.• This fee is non-refundable for my counselor’s scheduled time if court is cancelled or rescheduled and Mrs. Keenum is given less than a three business day notice.• If travel is required out of city limits, time charged will commence at departure from city limits and continue until return to city limits.• The fee is for the entire time spent at the court house, whether or not Mrs. Keenum testifies.
I understand that all information shared with my counselor and any of her associates will remain strictly confidential and will not be released to others without my written consent, except in the following circumstances: a) the information I share pertains to the physical, sexual or emotional abuse of a minor, elderly person, or an adult who is mentally or physically unable to protect his/her own rights; b)the information I share suggests that I represent a significant danger to myself or to others; c)the records of my care are subpoenaed by a court of law, and the judge in the matter rules that the client/therapist privilege of confidentiality does not apply; d) if it is disclosed you have committed a crime or; e) defense of claims brought by a client against Mrs. Keenum.
Audio and/or video recording of sessions by either the client or the counselor is expressly prohibited without written consent.
The following informs you of the policies and practices of Gabrielle K. Keenum, MA, LPC, NCC. Please read the information carefully and if you have questions, please ask.
I have read and fully understand the statements in this document and the policies stated regarding counseling. I am giving my consent to Gabrielle K. Keenum, MA, LPC, NCC to provide professional counseling services, including assessment and treatment. I will be provided a copy of this form at my request.
Parental Consent: (To be completed by a legal guardian with rights of decision-making authority for clients under the age of 18. If the right for decision-making authority for mental health treatment has been granted by a court, a copy of the court order must be provided.) I give my authorization for Gabrielle K. Keenum, MA, LPC, NCC to provide professional counseling services for the minor child named in this intake form.