Please note: If you have scheduled a Couples or Marriage counseling appointment, this is NOT the correct paperwork. Please go back to the webpage and find the correct form under the section labeled "Couples Counseling Clients" - Thank you.

I understand that all email messages are sent over the Internet and are not encrypted, are not secure, and may be read by others. I understand that my email communications with my therapist will NOT be encrypted and, therefore, my therapist can NOT guarantee the confidentiality and security of any information we send via e-mail. I understand that SMS/phone messages are even less secure than email, and the same conditions apply. I understand that for this reason, my therapist has advised me not to send sensitive​ information via email or SMS message. This includes information about current or past symptoms, conditions, or treatment, as well as identifying information such as social security numbers or insurance identification information. ​Reminder and voicemail services will only be used for scheduling or billing purposes.

I am signing to agree that I was able to review the disclosure statement for the above therapist, whom, I will receive services from A Better Way Counseling Services, LLC. I acknowledge that a copy of this document is always available to me upon request. I agree to all the sections of the disclosure statement, including:

Please fill out the below information if there is anybody you would like your therapist to have permission to speak to (example: a past therapist, a partner that you want to be able to schedule appointments or pay on your behalf, etc.).

If there is not, please move on to the next page. 

 

I authorize the following information to be exchanged between the below party and A Better Way Counseling Service, LLC:

This release is valid for one year after completion or termination of designated treatment. A patient may revoke in writing a disclosure authorization to a health care provider at any time unless disclosure is required to effectuate payments for health care that has been provided or another substantial action has been taken in reliance on the authorization. A patient may not maintain an action against the health care provider for disclosures made in good-faith reliance on an authorization if the health care provider had no actual notice of the revocation of the authorization.

Thank you for choosing us as your mental health provider. We are committed to your treatment being successful. Our goal is to provide quality, individualized mental health care. We would like to remind you of our policy concerning appointments. It is required for us to make appointments in order to see our clients as efficiently as possible.

You will receive an automated appointment reminder email 48 hours before your appointment. In order to be respectful of the needs of other clients, please be courteous and call our office promptly if you are unable to show for an appointment. The time will be reallocated to someone who is in need of treatment.

If it is necessary to cancel your scheduled appointment, we require that you call at least 24 hours in advance and email us at cancelabwcs@gmail.com. Appointments are in high demand and your early cancellation will allow another client access to timely mental health care. No-shows and late-cancellations cause problems that go beyond a financial impact on our practice. When an appointment is made, it takes an available time slot away from another client. No-shows and late cancellations delay the delivery of mental health care to other clients, some of which are in great need of our services. A no-show is missing a scheduled appointment. A late cancellation is canceling an appointment without calling us to cancel 24 hours in advance. Arriving too late to an appointment will be treated the same as a no-show or late cancellation. If you do not provide adequate notice, you will be charged the full session fee. 

To cancel your appointment, please call 360-281-6824 AND email us at cancelabwcs@gmail.com. If you do not reach one of our office staff, you may leave a detailed message on our voicemail. We encourage you to ask any questions you may have regarding our attendance policy so that you may have a clear understanding. We value you as a client and look forward to serving you. If you cancel a session with less than 24 hours notice, the full session fee will be charged to the client. This fee can be waived in the case of an emergency, with permission from the counselor. By signing below you acknowledge that you have read and understand this appointment policy and accept the above-mentioned terms.

If you cancel a session with less than 24 hours notice, the full session fee will be charged to the client. This fee can be waived in the case of a documented emergency, or at your counselor’s discretion.

By signing below you acknowledge that you have read and understand this appointment policy and accept the above mentioned terms.

Thank you for choosing us as your mental health provider. We are dedicated to providing the best possible care and service to you and regard your complete understanding of your financial responsibilities as an essential element of your
care and treatment. In order to reduce confusion and misunderstanding between our clients and our practice, we have adopted the following financial policy.

If at any time you are eligible for insurance or your insurance plan changes, please notify the office immediately. Without doing so there may be a lapse in reimbursement that you could be responsible for. 

We do not under any circumstances accept Cobra insurance coverage. If we are alerted you are using Cobra you will be responsible for all fees. If your insurance is ending and you now have Cobra, please call the office to discuss what the cash rate would look like for your provider. 

Whether you are paying fully out of pocket or have mental health coverage with your insurance, our staff is prepared to answer your questions and concerns. We understand that even with insurance, most clients will experience at least some out-of-pocket expenses. The amount insurance pays varies from one policy to another. As a courtesy service to you, we will call to verify the extent of your coverage and review the results with you. However, the final extent of your coverage and the exact amount of your liability can only be determined after your claims have been processed by your insurance carrier. We recommend all of our clients take the time to verify their own coverage for mental health care before beginning treatment at our office. The benefits quoted to us by your insurance company are not a guarantee of payment. Your insurance policy is a contract between you and your insurance company. If for any reason your insurance company does not pay for services or deems certain procedures as non-covered, you will be responsible for the complete charge. Any balance due is your responsibility and payment is due upon receipt of a statement from our office.

A bill for services rendered will be sent to you in the event there is a difference between what was paid at the time of service and what insurance has placed towards your responsibility. If you have a dispute concerning an account balance, we advise you to contact your insurance company first and then
contact our office.

We require a credit card to be stored in your file. This card number is stored in a secure and HIPPA-compliant system. It will only be charged in the instances stated below. All transactions will include a processing fee of 3.5%. The regular fee for your attended session will be automatically charged to this card on the business day following your appointment. Late cancellations (less than 24 hours notice) and no-show fees will automatically be charged to your card. 

If you are a client who is using insurance, then the late cancellation fee charged will be the rate contracted with the insurance company for sessions. Please inquire with the office if you have questions about what the fee would be, based on your insurance. If you are a cash-paying client, then the cancellation fee is the full amount you pay for each session.

If your credit card payment does not go through, we will attempt to contact you before your upcoming appointment. If we cannot reach you, future appointments may be canceled until payment is received. 

Please call our office at 360-281-6824 AND email us at cancelabwcs@gmail.com if you need to cancel or reschedule. Both are necessary to cancel your appointment. Please also indicate if you will attend your next scheduled appointment, in your email. Thank you for your cooperation.

We encourage you to ask any questions you may have regarding our financial policy so that you may have a clear understanding. If financial hardship exists, please speak with a member of our staff concerning your treatment options. Our goal is to concentrate on returning you to optimal health and to establish overall well-being. We value you as a client and look forward to serving you.

By signing below you acknowledge that you have read and understand this financial policy and accept the above mentioned terms.

I authorize the following information to be exchanged between the below party and A Better Way Counseling Service, LLC:

 

This release is valid for one year after completion or termination of designated treatment. A patient may revoke in writing a disclosure authorization to a health care provider at any time unless disclosure is required to effectuate payments for health care that has been provided or another substantial action has been taken in reliance on the authorization. A patient may not maintain an action against the health care provider for disclosures made in good-faith reliance on an authorization if the health care provider had no actual notice of the revocation of the authorization.

Communication between Behavioral Health providers and your Primary Care Physician (PCP) is important to ensure that you receive comprehensive and quality health care. There are circumstances when your Behavioral Health condition and/or medications will influence the treatment of your physical conditions. Many times behavioral health and physical health share a connection. This form will allow your Behavioral Health Provider to share Protected Health Information (PHI) with your PCP. This information will not be released without your signed authorization. This PHI will only include diagnosis, treatment plan, and medication, if necessary. Information relating to any psychotherapy notes or conversations will not be shared.

 

I, the undersigned, understand that I may revoke this consent at any time. I have read and understood the information and given my authorization.

If you agree to release any applicable mental health/substance abuse information to your PCP, then please proceed filling out the following: