INFORMED CONSENT TO TREATMENT INFORMATION
Welcome to the Clinic for Christian Counseling, LLC (CCC). Thank you for choosing CCC to assist you. We pray that the matters you bring are resolved to the glory of our loving Lord.
CCC, founded in 2006, is a Christian counseling service committed to providing Christ-centered healing and helping services. It is our prayer that your relationship with your Christian therapist will help you and/or your family members to gain better insight into your daily living and to grow towards a healthier more satisfying Christian life. This requires mutual effort by both you and your therapist. Change does not happen by itself; we would fail without the strength of our gracious Lord. Living the Christian life is both a joy and a challenge for all of us.
The following is important information about our services and your treatment. Please read it carefully and feel free to ask questions about anything that is not understandable.
THE PROCESS OF THERAPY Depending on the personalities of the consumer and therapist and the particular issues that the consumer brings, psychotherapy may vary. There are different approaches to address different problems. The currently acceptable treatment modes to help you with your specific situation will be discussed with you. Be assured that the specific approach agreed upon to help you will be a God pleasing one. Unlike medical care, psychotherapy requires an active effort on your part. You have the right and responsibility to work together with the therapist to choose how to approach your concerns. To be successful you will have to work toward goals both during sessions and at home.
Psychotherapy has both benefits and risks. Psychotherapy has been shown to reduce feelings of distress, create better relationships and resolve specific problems. Risks include experiencing increased uncomfortable feelings such as sadness, guilt, anxiety, anger, loneliness and helplessness that may be part of the process of change. Relationships may also be affected. Side effects or risks of side effects from any psychotropic medications should be discussed with your physician.
There are two main steps in psychotherapy. The first step is assessment. You and your therapist will spend time evaluating your needs, goals, and gathering pertinent information. A treatment plan will be completed and will include an initial assessment, diagnosis (as appropriate), your treatment goals, and intervention techniques to accomplish these goals. You will then need to make a decision to continue the therapy process. If you choose not to work with your therapist, your therapist will refer you to another mental health professional in your area. Therapy involves a commitment of time, energy and money. Any questions you have about the process should be discussed whenever they arise. Should you choose to not pursue therapy or discontinue prematurely against your therapist’s advice, your symptoms may return and/or worsen. The second step is the actual therapy. While the first step usually takes 1 to 2 sessions, the actual number of sessions needed to accomplish goals for consumers will vary. Some matters are quite complex and considerable time is needed to accomplish the goals. Other situations take less time to resolve. Your therapist will make every effort to be as time and cost efficient as possible to help you resolve your concerns.
SCHEDULING APPOINTMENTS CCC business hours are 8:00 a.m. to 5:00 p.m., Monday through Friday. Please call during these hours especially when you are making or changing appointments, have questions regarding your bill, insurance, etc. Some evening hours are also available for therapy. Please call for availability.
Psychotherapy typically occurs in 45 minute blocks of time. A session usually occurs once per week or every other week to begin with and then, as progress toward your goal for therapy is being made, the time between your sessions is spread out. In cases of emergency or ‘after hours’ coverage, please call the office and the out-going voice-mail message will give you directions of who to contact for assistance.
Due to the nature of therapy, your commitment to the therapy process is important and includes keeping your scheduled appointments. Our cancellation policy requires a 24 hour notice of any cancellations (except for emergencies or other circumstances beyond your control). If such notice is not given, a $65.00 fee will be charged to you and not to your insurance. Also, any future appointments already scheduled will be cancelled. You will need to contact your therapist to discuss scheduling your next appointment. It is also important for you to be prompt for your sessions; the charge will not be reduced if you are late.
CONFIDENTIALITY The therapy relationship is confidential. Your therapist cannot release any information about the therapy process without your written permission. This includes even the fact that you are a consumer here. Confidentiality is governed by Federal and State law and CCC will abide by the law. When a couple seeks marital therapy, the therapy notes are ‘owned’ by the couple. The signature of both participants will be required to release information to third parties such as attorneys.
However, confidentiality does have its legal and ethical limitations. A therapist may break confidentiality if, in his/her judgment, it is necessary to protect the safety or welfare of you (the consumer) or another person. If you threaten to hurt yourself or someone else, or raise suspicion of child abuse, your therapist will report it to the proper authorities.
In addition, your therapist may discuss your case with other CCC professional staff and contracted consultants for purposes of providing effective treatment.
FEES AND INSURANCE The fees for a licensed master level therapist are as follows: first session - $225.00, individual sessions that follow - $150.00, and conjoint sessions (i.e. family, couple therapy) with / without client that follow - $175.00. Due to the additional time, training, and materials required to provide Sand Tray and Play Therapy there will be an additional fee charged of $20.00 per session. Your insurance may cover part or all of this additional fee. Please check. Marriage counseling (no diagnosis for either party or not billed to third party such as insurance) - $90.00. These fees are for a 45 minute session. The fees for a master level therapist in training are the same as that for a licensed therapist. A therapist in training works under the supervision of a qualified supervisor. There is no fee for a master level intern, that is, one who is completing the requirements for a master degree and works under the supervision of a qualified supervisor.
CCC billing is divided into two categories:
1. Non-insured services - Payment for services is due on the day of the scheduled appointment. Checks are to be made out to CCC.
2. Insured services - Your health insurance may cover all or a portion of the fee. We cannot guarantee payment from your insurance company. To avoid disappointment, we strongly suggest that consumers contact their insurance company to make certain that their mental health insurance assumptions are correct. As you know, most insurance companies pay only a portion of the provided services. Further, consumers must realize that professional services are rendered to a person, not to the insurance company. Hence, the insurance company is responsible to the consumer and the consumer is responsible to us. We cannot render services on the assumption that the charges will be paid by the insurance company. Should there be a dispute related to the service provided or the charge for that service, the settlement of that dispute is between you and your insurance carrier. Our office will not be involved in the settlement of such disputes. The final responsibility for the services provided to you is yours.
You will be asked to sign a form giving CCC your permission to release sufficient personal health care information to file the claim with your insurance company.
It is our practice to receive payment for co-pays, co-insurance, and deductibles at the time of your visit.
You will receive monthly statements that will notify you of any balance on your account. Unless prior arrangements are made, past due balances may be submitted to a third party, such as a collection agency or attorney, for collection. Past due is defined as being 30 days delinquent from the date of billing. CCC reserves the right to determine when a past due account is referred to a third party for collection.
EMERGENCY SERVICES When the Clinic is closed, an outgoing voice mail message will provide the consumer the options to call 911, contact their pastor, or go to the nearest hospital for help. For consumers currently being served by the Clinic and are at risk to hurt themselves, the consumer’s provider will work with the consumer to develop a specific action plan to follow when emergency services are needed by consumer.
LEGAL MATTERS In the event that a therapist is subpoenaed to testify in court and the consumer does not want their privileged and confidential information released to the court and will not sign a release of information form to allow this, all legal costs to prevent the release of information, including attorney's fees to represent the Clinic, will be the responsibility of the consumer. Also, all costs incurred for deposition and court testimony including travel time, cost for travel, preparation time including time spent with legal representation for the Clinic, time waiting to testify, and testifying time will be the responsibility of the consumer. Time spent in communicating with the consumer's attorney, either written (e.g. drafting a letter) or verbal, will be the responsibility of the consumer. Time will be billed at $180 per hour. Mileage will be billed at fifty cents per mile. Paper copies of records will be billed at the following rates: $1 per page for the first 25 pages; 75 cents per page for pages 26 - 50; 50 cents per page for pages 51 - 100; 30 cents per page for pages 101 and above. A retainer of $1200 is due in advance of giving testimony or communicating with an attorney regarding testimony. Minimum charge for a court appearance is $1200. If the case is rescheduled without a minimum of 72 hour notice, the client will be charged an additional $500 (in addition to the $1200). Any payment owed above and beyond the retainer is due within 30 days of service. Payment is due within 30 days of service.
ALCOHOL / DRUGS If, in the judgment of the consumer's therapist, the consumer appears intoxicated due to alcohol and/or drugs, the therapist may choose to discontinue the session. The normal fee for the session will be billed to the client and not to insurance, if applicable.
INVOLUNTARY DISCHARGE A consumer may be involuntarily discharged by the Clinic because of the consumer’s inability to pay for services or behavior that is a safety risk for staff or other consumers of the Clinic. Before the Clinic involuntarily discharges a consumer, the Clinic will do the following: notify the consumer in writing of the reasons for the discharge, the effective date of the discharge, sources for further treatment, and the consumer’s right to have the discharge reviewed by the subunit of the Department that certifies Clinics.
CONSUMER RIGHTS AND SATISFACTION If you consider the services you received are unsatisfactory or think your rights have been violated, you have the right to use a grievance procedure. Please contact the CCC office for an information packet on the procedures to follow. Include your name, address and phone number. Also, the State of Wisconsin has established a Patient Bill of Rights. (Statute Section 51.61). These rights are posted in our waiting room.
CONSUMER ACKNOWLEDGMENT This form will be provided at your initial appointment. Your signature on this form indicates that: 1) you have received the Informed Consent to Treatment Information document and you agree to abide by its stated terms regarding the cost/charges for care and treatment services during your professional relationship with your therapist; 2) you have received the Privacy Practice Notice, 3) you consent to enable us to use and disclose your personal health information for purposes of treatment, payment and health care operations; 4) you have received a brochure describing your rights and the grievance procedure; and 5) you have received the handout describing the Mission of CCC and Statement of beliefs.
The time period for this informed consent shall be one year. At the end of this time frame this material will be shared with you again and your informed consent obtained. You have the right to withdraw informed consent at any time, in writing. This will, in effect, terminate therapy.
10/01/2014
Welcome to the Clinic for Christian Counseling, LLC (CCC). Thank you for choosing CCC to assist you. We pray that the matters you bring are resolved to the glory of our loving Lord.
CCC, founded in 2006, is a Christian counseling service committed to providing Christ-centered healing and helping services. It is our prayer that your relationship with your Christian therapist will help you and/or your family members to gain better insight into your daily living and to grow towards a healthier more satisfying Christian life. This requires mutual effort by both you and your therapist. Change does not happen by itself; we would fail without the strength of our gracious Lord. Living the Christian life is both a joy and a challenge for all of us.
The following is important information about our services and your treatment. Please read it carefully and feel free to ask questions about anything that is not understandable.
THE PROCESS OF THERAPY Depending on the personalities of the consumer and therapist and the particular issues that the consumer brings, psychotherapy may vary. There are different approaches to address different problems. The currently acceptable treatment modes to help you with your specific situation will be discussed with you. Be assured that the specific approach agreed upon to help you will be a God pleasing one. Unlike medical care, psychotherapy requires an active effort on your part. You have the right and responsibility to work together with the therapist to choose how to approach your concerns. To be successful you will have to work toward goals both during sessions and at home.
Psychotherapy has both benefits and risks. Psychotherapy has been shown to reduce feelings of distress, create better relationships and resolve specific problems. Risks include experiencing increased uncomfortable feelings such as sadness, guilt, anxiety, anger, loneliness and helplessness that may be part of the process of change. Relationships may also be affected. Side effects or risks of side effects from any psychotropic medications should be discussed with your physician.
There are two main steps in psychotherapy. The first step is assessment. You and your therapist will spend time evaluating your needs, goals, and gathering pertinent information. A treatment plan will be completed and will include an initial assessment, diagnosis (as appropriate), your treatment goals, and intervention techniques to accomplish these goals. You will then need to make a decision to continue the therapy process. If you choose not to work with your therapist, your therapist will refer you to another mental health professional in your area. Therapy involves a commitment of time, energy and money. Any questions you have about the process should be discussed whenever they arise. Should you choose to not pursue therapy or discontinue prematurely against your therapist’s advice, your symptoms may return and/or worsen. The second step is the actual therapy. While the first step usually takes 1 to 2 sessions, the actual number of sessions needed to accomplish goals for consumers will vary. Some matters are quite complex and considerable time is needed to accomplish the goals. Other situations take less time to resolve. Your therapist will make every effort to be as time and cost efficient as possible to help you resolve your concerns.
SCHEDULING APPOINTMENTS CCC business hours are 8:00 a.m. to 5:00 p.m., Monday through Friday. Please call during these hours especially when you are making or changing appointments, have questions regarding your bill, insurance, etc. Some evening hours are also available for therapy. Please call for availability.
Psychotherapy typically occurs in 45 minute blocks of time. A session usually occurs once per week or every other week to begin with and then, as progress toward your goal for therapy is being made, the time between your sessions is spread out. In cases of emergency or ‘after hours’ coverage, please call the office and the out-going voice-mail message will give you directions of who to contact for assistance.
Due to the nature of therapy, your commitment to the therapy process is important and includes keeping your scheduled appointments. Our cancellation policy requires a 24 hour notice of any cancellations (except for emergencies or other circumstances beyond your control). If such notice is not given, a $65.00 fee will be charged to you and not to your insurance. Also, any future appointments already scheduled will be cancelled. You will need to contact your therapist to discuss scheduling your next appointment. It is also important for you to be prompt for your sessions; the charge will not be reduced if you are late.
CONFIDENTIALITY The therapy relationship is confidential. Your therapist cannot release any information about the therapy process without your written permission. This includes even the fact that you are a consumer here. Confidentiality is governed by Federal and State law and CCC will abide by the law. When a couple seeks marital therapy, the therapy notes are ‘owned’ by the couple. The signature of both participants will be required to release information to third parties such as attorneys.
However, confidentiality does have its legal and ethical limitations. A therapist may break confidentiality if, in his/her judgment, it is necessary to protect the safety or welfare of you (the consumer) or another person. If you threaten to hurt yourself or someone else, or raise suspicion of child abuse, your therapist will report it to the proper authorities.
In addition, your therapist may discuss your case with other CCC professional staff and contracted consultants for purposes of providing effective treatment.
FEES AND INSURANCE The fees for a licensed master level therapist are as follows: first session - $225.00, individual sessions that follow - $150.00, and conjoint sessions (i.e. family, couple therapy) with / without client that follow - $175.00. Due to the additional time, training, and materials required to provide Sand Tray and Play Therapy there will be an additional fee charged of $20.00 per session. Your insurance may cover part or all of this additional fee. Please check. Marriage counseling (no diagnosis for either party or not billed to third party such as insurance) - $90.00. These fees are for a 45 minute session. The fees for a master level therapist in training are the same as that for a licensed therapist. A therapist in training works under the supervision of a qualified supervisor. There is no fee for a master level intern, that is, one who is completing the requirements for a master degree and works under the supervision of a qualified supervisor.
CCC billing is divided into two categories:
1. Non-insured services - Payment for services is due on the day of the scheduled appointment. Checks are to be made out to CCC.
2. Insured services - Your health insurance may cover all or a portion of the fee. We cannot guarantee payment from your insurance company. To avoid disappointment, we strongly suggest that consumers contact their insurance company to make certain that their mental health insurance assumptions are correct. As you know, most insurance companies pay only a portion of the provided services. Further, consumers must realize that professional services are rendered to a person, not to the insurance company. Hence, the insurance company is responsible to the consumer and the consumer is responsible to us. We cannot render services on the assumption that the charges will be paid by the insurance company. Should there be a dispute related to the service provided or the charge for that service, the settlement of that dispute is between you and your insurance carrier. Our office will not be involved in the settlement of such disputes. The final responsibility for the services provided to you is yours.
You will be asked to sign a form giving CCC your permission to release sufficient personal health care information to file the claim with your insurance company.
It is our practice to receive payment for co-pays, co-insurance, and deductibles at the time of your visit.
You will receive monthly statements that will notify you of any balance on your account. Unless prior arrangements are made, past due balances may be submitted to a third party, such as a collection agency or attorney, for collection. Past due is defined as being 30 days delinquent from the date of billing. CCC reserves the right to determine when a past due account is referred to a third party for collection.
EMERGENCY SERVICES When the Clinic is closed, an outgoing voice mail message will provide the consumer the options to call 911, contact their pastor, or go to the nearest hospital for help. For consumers currently being served by the Clinic and are at risk to hurt themselves, the consumer’s provider will work with the consumer to develop a specific action plan to follow when emergency services are needed by consumer.
LEGAL MATTERS In the event that a therapist is subpoenaed to testify in court and the consumer does not want their privileged and confidential information released to the court and will not sign a release of information form to allow this, all legal costs to prevent the release of information, including attorney's fees to represent the Clinic, will be the responsibility of the consumer. Also, all costs incurred for deposition and court testimony including travel time, cost for travel, preparation time including time spent with legal representation for the Clinic, time waiting to testify, and testifying time will be the responsibility of the consumer. Time spent in communicating with the consumer's attorney, either written (e.g. drafting a letter) or verbal, will be the responsibility of the consumer. Time will be billed at $180 per hour. Mileage will be billed at fifty cents per mile. Paper copies of records will be billed at the following rates: $1 per page for the first 25 pages; 75 cents per page for pages 26 - 50; 50 cents per page for pages 51 - 100; 30 cents per page for pages 101 and above. A retainer of $1200 is due in advance of giving testimony or communicating with an attorney regarding testimony. Minimum charge for a court appearance is $1200. If the case is rescheduled without a minimum of 72 hour notice, the client will be charged an additional $500 (in addition to the $1200). Any payment owed above and beyond the retainer is due within 30 days of service. Payment is due within 30 days of service.
ALCOHOL / DRUGS If, in the judgment of the consumer's therapist, the consumer appears intoxicated due to alcohol and/or drugs, the therapist may choose to discontinue the session. The normal fee for the session will be billed to the client and not to insurance, if applicable.
INVOLUNTARY DISCHARGE A consumer may be involuntarily discharged by the Clinic because of the consumer’s inability to pay for services or behavior that is a safety risk for staff or other consumers of the Clinic. Before the Clinic involuntarily discharges a consumer, the Clinic will do the following: notify the consumer in writing of the reasons for the discharge, the effective date of the discharge, sources for further treatment, and the consumer’s right to have the discharge reviewed by the subunit of the Department that certifies Clinics.
CONSUMER RIGHTS AND SATISFACTION If you consider the services you received are unsatisfactory or think your rights have been violated, you have the right to use a grievance procedure. Please contact the CCC office for an information packet on the procedures to follow. Include your name, address and phone number. Also, the State of Wisconsin has established a Patient Bill of Rights. (Statute Section 51.61). These rights are posted in our waiting room.
CONSUMER ACKNOWLEDGMENT This form will be provided at your initial appointment. Your signature on this form indicates that: 1) you have received the Informed Consent to Treatment Information document and you agree to abide by its stated terms regarding the cost/charges for care and treatment services during your professional relationship with your therapist; 2) you have received the Privacy Practice Notice, 3) you consent to enable us to use and disclose your personal health information for purposes of treatment, payment and health care operations; 4) you have received a brochure describing your rights and the grievance procedure; and 5) you have received the handout describing the Mission of CCC and Statement of beliefs.
The time period for this informed consent shall be one year. At the end of this time frame this material will be shared with you again and your informed consent obtained. You have the right to withdraw informed consent at any time, in writing. This will, in effect, terminate therapy.
10/01/2014