Signature Pages

Anonymous's picture

By signing the following document electronically, it is to be the legally binding equivalent of your individual handwritten signature. 

 

Consent for Purposes of Treatment, Payment, and Healthcare Operations:

I consent to the use or disclosure of my protected health information by Compassion Family Counseling for the purpose of diagnosing or providing treatment to me, obtaining payment for my health care bills or to conduct health care operations of Compassion Counseling. I understand and agree that no recording devices will be allowed in the counseling room unless agreed within a written document.  I understand that diagnosis or treatment of me by my counselor may be conditioned upon my consent as evidenced by my signature on this document.  I understand I have the right to request a restriction as to how my protected health information is used or disclosed to carry out treatment, payment or healthcare operations of the practice. Compassion Family Counseling is not required to agree to the restrictions that I may request. However, if Compassion Family Counseling agrees to a restriction that I request, the restriction is binding on Compassion Family Counseling and my counselor.  I have the right to revoke this consent, in writing, at any time, except to the extent that my counselor or Compassion Family Counseling has already taken action based on this consent.  My “protected health information” means health information, including my demographic information, collected from me and created or received by my physician, another health care provider, a health plan, my employer or a health care clearinghouse.  This protected health information relates to my past, present or future physical or mental health or condition and identifies me, or there is a reasonable basis to believe the information may identify me. I realize that it may be necessary for my counselor to converse with other counselors in the group practice to provide the best possible treatment for myself.  I understand that my counselor will not address me in public, unless I address him/her first.  I also acknowledge that in couples counseling confidentiality applies to the couple, not the individual, meaning information shared is between the counselor and couple. 

 

Confidentiality is extremely important to the client-therapist relationship.  All clients can trust in the confidentiality of Compassion Family Counseling with the following limits:

The limits to confidentiality in the state of Texas are:

1. Threatening to take one’s life/suicide

2. Threatening to take someone else’s life/homicide

3. Records/notes being subpoenaed by an attorney/court.

4. Abuse to a child or elderly.

5. If my therapist receives supervision or consultation in order to provide me with the best care.

6. If the therapy & or evaluation is court ordered.

 

I understand that my counselor may have a duty to warn if I am a danger to myself or others. Below is a list of people that can be contacted in an attempt to prevent harm to myself or others:

For after hours emergencies, call 911                       

Guidelines for Continued Care:

I understand the following fully:

1. The patient will only be considered an active patient if the patient keeps each appointment made.

2. If appointments are kept and made clients are able to schedule multiple appointments in advance.

3. If more than one appointment is canceled under 48 hours, or missed without canceling the client will not longer be able to schedule more than one week in advance. 

4. After the passage of 3 months without contact a patient will automatically be considered an inactive patient.

5. Inactive status may also be instituted if bills are not paid in a timely fashion.

Informed Consent:

I understand that counseling may involve discussing relationship, spiritual, psychological, and/or emotional issues that may at times be distressing.  However, I also understand that this process is intended to help personally and with relationships. It is important for you to understand that all identifying information about the clients counseling therapy/treatment is kept confidential.  Information regarding our case is only shared with those professionals who will confer with your service provider and thereby enhance the services you receive.  I am aware that there are alternative treatment facilities available to me.  My therapist has satisfactorily answered all of my questions about counseling at Compassion Family Counseling.  I understand that I may end therapy at any time, although I am aware that this is best accomplished in consultation with the therapist.  I understand that if I do not come to therapy as prescribed I may not receive the full benefits from counseling. I understand the confidentiality policies of Compassion Family Counseling and I agree to them.  I also understand that my role as a client is to be honest during counseling sessions, complete homework assignments, and demonstrate a willingness to change.    

Grievances:

I also acknowledge that I may submit a Grievance to the Provider at any time to register a complaint about any aspect of my care. If I am not satisfied with the responses I receive, I may submit the Grievance to the ad- dress below.

To report a rules violation by this licensee, contact:

Texas State Board of Examiners of Licensed Professional Counselors 1100 W. 49th Street Austin, Texas 78756-3183 (512) 834-6658

Notice of Privacy: (For Patient’s using insurance)

 

I have read and understand that Notice of Privacy. The Notice of Privacy Practices for Compassion Counseling is provided upon request. This Notice of Privacy Practices also describes my rights and the Compassion Counseling’s duties with respect to my protected health information. Compassion Counseling reserves the right to change the privacy practices that are described in the Notice of Privacy Practices. I may obtain a revised notice of privacy practices by calling the office and requesting a revised copy be sent in the mail, or by requesting one at the time of my next appointment.

Special Note:

If my counselor becomes incapacitated or dies, I give my consent for the person designated by them to become the custodian of my file and to access it for me. I understand I have a right to review Compassion Counseling’s Notice of Privacy Practices prior to signing this document. The Notice of Privacy Practices describes the types of uses and disclosures of my protected health information that will occur in my treatment, payment of my bills or in the performance of health care operations of Compassion Counseling. 

Our Fee Policies:

1.It is our policy to charge a $80.00 fee for a “no show” or appointments that are not cancelled at least 48 hours in advance. Your communication with our office about appointment cancellations allows us to offer that time to someone else who needs to be seen.  We sometimes send e-mail reminders, however it is your responsibility to remember your appointment, as we cannot always depend on proper functioning of the electronic reminders. Rates are subject to change in 6-month increments. 

2. If report/document preparation is requested documents related to history, background information, school behavior, or testing are billed at the rate of $2.00 per minute.

3. Phone Calls: Only emergency phone calls are returned on a regular basis by the therapist and only during office hours. These are billed at $2.00 per minute & will be charged to the credit card on file.

Review of Provided Documents and Phone Calls are not reimbursable by insurance.

4. Therapy sessions are 45 minutes long.  Time begins at your scheduled appointment time.  If you are late for your appointment, you are still responsible for the full fee for the session.

5. It is the responsibility of the client to notify Compassion Counseling’s office of any new or updated information regarding the client, including but not limited to, payment information, insurance, address, phone number, e-mail, marital status, etc.  

6. If the client has a past due balance over 30 days an interest rate of 3.5% will be added to the balance.

7. Professional Fees: Court appearances, depositions, and attorney consultations are $175.00 per hour (include all time involved in preparation, research, attorney fees incurred by the therapist, parking fees, mileage, travel time to and from the court house and all other expenses incurred in relation to testifying). Clients are discouraged from having their therapist subpoenaed.  A retainer deposit of $1,750.00 is to be paid in advance of, and clear the bank prior to the court date.  The minimum charge for a court appearance is $1,100. If a subpoena or notice to meet attorney(s) is received without a minimum of 48-hour notice there will be an additional $250 “express” charge. Also, if the case is reset with less than 72 business hours notice, then the client will be charged $500 (in addition to the retainer of $1750).  If the full amount of the retainer/deposit is not needed to complete the court testifying process, then the remainder of the funds will be refunded. If the costs for the court testifying process exceed the amount of the retainer/deposit then those fees will be immediately billed to you and are due upon receipt of the invoice. The party issuing the subpoena is responsible for the testifying fees.  NOTE: Even though you are responsible for the testimony fee, it does not mean that testimony will be solely in your favor. Only the facts of the cases and professional opinion of your counselor can be testified.6. Returned Checks: There is a $40.00 charge on all returned checks.  If check is returned counselor may ask for cash or credit card for future payments.

Please initial below:

I authorize Compassion Counseling to keep my signature on file and to charge my credit card account listed below for the following: You must initial 1-3, 4 is optional

1. Balances of charges not paid within 10 days, 30 days if on a payment plan.
2. Cancellation fee if an appointment is not cancelled within 48 hours.
3. I understand that there will be a 3.5% processing fee for each credit card payment.
4. I will be paying each appointment by credit card.

Credit Card Information

Filling out the credit card information on this webform is completely optional.  You can fill it out in our office upon your arrival.  Compassion Counseling is not responsible for the misuse of credit card information if you chose to fill it out on this webform.
 

This contract is an agreement between the interested parties that no party shall attempt to subpoena any testimony or records for a deposition or court hearing of any kind for any reason from Compassion Counseling.

All parties acknowledge that the goal of therapy is the amelioration of psychological distress and interpersonal conflict, and that the process of therapy depends on trust and openess during the therapy sessions.

Therefore it is understood by all parties that if they request my services as a therapist, they are expected not to use information given to me during the therapy process for their own legal purposes or against any of the other parties in a court or judicial setting of any kind. 

The following options do NOT have to be signed. 

Consent for Digital Communication

As a therapist, I am willing and able to hold therapy sessions  or communicate over digital forms of communication such as e mail, cell phone, Skype, and Face Time.  As the client, you should know that I cannot secure privacy when communicating with you digitally.  If you are willing to agree to communicating via technology as listed above, please sign the waiver below.

I understand that privacy and confidentiality cannot be guaranteed or secured when using digital forms of communication such as cell phones, texting, email, instant messaging, Skype, or Face Time.

In agreeing to communicate digitally, I waive my right to secured and guaranteed confidentiality. 

 

Consent to Record Counseling Sessions

These recordings will be used to aid the counseling process and to gain further understanding of important aspects of the treatment.  If my counselor is an intern I understand that the recording will be used for teaching/supervision purposes.  I have discussed this procedure with the counselor, including Compassion Family Counseling’s policy on confidentiality.

I, hereby give consent to my assigned counselor to: 

videotape (initial if Yes) and/or
audiotape (initial if Yes) our counseling sessions.

I understand that refusal to sign this form will not affect my eligibility for receiving services.

Employment

If you are a licensed counselor, a counselor intern or interested in individual or group supervision and would like to join our team, please contact us.

Meredith Akin-Ivey, is a Licensed Professional Counselor-Supervisor and a Registered Play Therapist- Supervisor.  Please E-mail or call her for more details.

Follow Us On:

Get in touch

Compassion Counseling
2214 Michigan Ave
Suite F
Arlington, Texas
76013

Phone: (817) 723-1210

Fax: (866) 776-5116

info@compassioncounseling.us

Our Specialities

At Compassion, our counselors have experience counseling a variety of issues including but not limited to: adoption, anxiety, abuse, body image, depression, couples, faith, families, grief, play therapy, parenting, teens, trauma, christian sex therapy, and self-esteem. Please call our office for more information regarding each counselor's specialty.