PLEASE READ THE FOLLOWING. YOU WILL SIGN THIS DOCUMENT DURING YOUR VISIT TO OUR CLIENT PORTAL.
PRACTICE POLICIES/COUNSELING AGREEMENT
Your counselor has a responsibility to safeguard information about you obtained during counseling. All identifying information about your assessment and treatment is kept confidential, except as mandated by law. A release will be obtained from you for release to sources not mandated by law.
In some circumstances, mental health professionals are required by law to reveal information obtained during therapy to other persons or agencies without your written consent. In such situations, your counselor is not required to inform you of this release. Please note the following exceptions to confidentiality:
•Confidentiality does not apply to cases of suspected abuse/neglect of children or the elderly.
•Confidentiality does not apply to cases of potential harm to self or others.
•A mental health professional may disclose confidential information in proceedings brought by a client against a professional.
•Confidentiality does not apply to cases involving criminal proceedings, except communications by a person voluntarily involved in a substance abuse program.
•Confidentiality may not apply in cases involving legal proceedings affecting the parent-child relationship.
•Confidentiality may not apply to cases involving a minor child. In such cases, the mental health professional may advise a parent, managing conservator or guardian of a minor, with or without minor’s consent, of the treatment needed by or given to the minor. Insurance and managed care companies require personal identification information, diagnosis, symptoms, treatment goals, prognosis, evaluation of progress, and other information before reimbursement is considered. Such companies may also maintain the right to have a copy of your records. Information regarding such releases is covered in the Health Insurance Portability and Accountability Act (HIPAA) information you have received.
One major benefit that may be gained from participating in counseling is the resolution of the concerns brought to therapy. Other possible benefits may be a better ability to cope with marital, family and other interpersonal relationships, and /or a greater understanding of personal goals and values. There are certain risks involved in counseling. You may experience a variety of negative emotions during therapy as you remember and therapeutically resolve unpleasant events. Seeking to resolve concerns between family members, marital partners, and other persons can similarly lead to discomfort as well as relationship changes that may not be originally intended. The greatest risk of counseling is that it may not by itself resolve your concerns. Psychotherapy is a collaborative process and the progress you make will depend in large measure upon your investment in the process.
APPOINTMENTS AND CANCELLATIONS
Please remember to cancel or reschedule 24 hours in advance. You will be responsible for the entire fee if cancellation is less than 24 hours.
The standard meeting time for psychotherapy is 50 minutes. It is up to you, however, to determine the length of time of your sessions. Requests to change the 50-minute session needs to be discussed with the therapist in order for time to be scheduled in advance.
A $25.00 service charge will be charged for any checks returned for any reason or for Credit Card rejections.
Cancellations and re-scheduled session will be subject to a full charge if NOT RECEIVED AT LEAST 24 HOURS IN ADVANCE. This is necessary because a time commitment is made to you and is held exclusively for you. IMPORTANT NOTE: If you are going to be more than 10 minutes late for a scheduled session, you must "TEXT" our office to rescheduled the session. If the session can be rescheduled within the same week, no cancellation fee will be assessed.
If you need to contact me between sessions, please leave a message on my voice mail. I am often not immediately available; however, I will attempt to return your call within 24 hours. Please note that Face- to-face sessions are highly preferable to phone sessions. However, in the event that you are out of town, sick or need additional support, phone sessions are available. If a true emergency situation arises, please call 911 or any local emergency room.
SOCIAL MEDIA AND TELECOMMUNICATION
Due to the importance of your confidentiality and the importance of minimizing dual relationships, I do not accept friend or contact requests from current or former clients on any social networking site (Facebook, LinkedIn, etc). I believe that adding clients as friends or contacts on these sites can compromise your confidentiality and our respective privacy. It may also blur the boundaries of our therapeutic relationship. If you have questions about this, please bring them up when we meet and we can talk more about it.
PROFESSIONAL FEE SCHEDULE:
Initial Intake: $160.00 (typically 55-60 minutes).
Client counseling sessions:
Individual (adult or child) $140.00 per 55-60 minutes.
Family (adult and child) $160.00 per 55-60 minutes.
Counseling sessions will be scheduled in advance.
Other counseling related administrative services: (i.e., document preparation or review, communications and/or coordination with client approved sources, administrative requests/services, etc.). Minimum cost per service $50.00.
PAYMENT OF FEES:
All fees shall be paid at the time the service is rendered. Cash, personal check, major credit/debit cards and some insurance plans are accepted. Credit or Debit cards will be processed prior to the start of session. Other counseling-related administrative services shall be paid upon completion or delivery of service.
CRISIS POLICY AND TELEPHONE/INTERNET COMMUNICATIONS:
Counselor will see clients based on an agreed appointment date and time. If the client has a crisis or wish to see the counselor during normal business hours (9:30a-5:00p), please call and make an appointment - the counselor will make every effort to fit you in. If for any reason the counselor is unavailable or you experience a crisis outside of business hours, call 911 for assistance.
Whether in crisis or not, a client may occasionally want to discuss an issue on the phone or by Internet with the counselor. For this service the counselor charges a minimum $40.00 fee, which includes up to 15 minutes of Internet or telephone counseling. If the internet session or call goes beyond 15 minutes, the client will continue to be billed at a rate of $40.00 per 15-minute increments. Health insurance companies do not reimburse for this type of contact, therefore the client will be personally responsible for the fee.
I cannot ensure the confidentiality of any form of communication through electronic media, including text messages. If you prefer to communicate via email or text messaging for issues regarding scheduling or cancellations, I will do so. While I may try to return messages in a timely manner, I cannot guarantee immediate response and request that you do not use these methods of communication to discuss therapeutic content and/or request assistance for emergencies.
The Client or Parent/Guardian are responsible for payment of all fees, whether or not your health insurance provides reimbursement. Counselor can provide receipts of sessions for your submission to your insurance.
If you have secondary insurance (more than one active insurance policy), you must provide that information so that all your claims can be filed correctly. When claims are filed without complete and accurate insurance information, substantial administrative time and penalties are incurred, as every claim must be corrected and re-processed.
As the Client, Parent or Guardian, I understand and agree that if I have a secondary insurance policy that the secondary insurance information will be disclosed during client portal processing or updated as necessary, during subsequent client care. I also understand that if any insurance information (primary and/or secondary) is not disclosed completely and accurately, I will be charged a reprocessing fee of $80 per claim.
Failure to disclose all insurance information, that results in reprocessing of claims, may delay or interrupt client care until insurance matters are resolved.
If you are a minor, your parents may be legally entitled to some information about your therapy. I will discuss with you and your parents what information is appropriate for them to receive and which issues are more appropriately kept confidential.
Ending relationships can be difficult. Therefore, it is important to have a termination process in order to achieve some closure. The appropriate length of the termination depends on the length and intensity of the treatment. I may terminate treatment after appropriate discussion with you and a termination process if I determine that the psychotherapy is not being effectively used or if you are in default on payment. I will not terminate the therapeutic relationship without first discussing and exploring the reasons and purpose of terminating. If therapy is terminated for any reason or you request another therapist, I will provide you with a list of qualified psychotherapists to treat you. You may also choose someone on your own or from another referral source.
Should you fail attend or to schedule an appointment for three consecutive sessions, unless other arrangements have been made in advance, for legal and ethical reasons, I must consider the professional relationship discontinued.
NOTICE TO CLIENTS:
The Texas Behavioral Health Executive Council investigates and prosecutes professional misconduct committed by marriage and family therapists, 61 professional counselors, psychologists, psychological associates, social workers, and licensed specialists in school psychology. Although not every complaint against or dispute with a licensee involves professional misconduct, the Executive Council will provide you with information about how to file a complaint. Please call 1-800-821-3205 for more information.
ACKNOWLEDGEMENT AND CONSENT TO COUNSELING: (This document will be signed by you in the Client Portal)
I have read and accept this agreement and herewith consent to counseling/psychotherapy with San Antonio Compassionate Counseling and Behavioral Center, Cori Callahan, MA, RBT, LPC.