HL COUNSELING AND CONSULTING SERVICES, INC.

HL COUNSELING AND CONSULTING SERVICES, INC.

5619 N. Figueroa St, Unit 216, Los Angeles, CA 90042 Counseling Services

INTRODUCTION TO SERVICES

To acquaint you further with the procedures and policies for counseling services, you are being provided the following information:

1. APPOINTMENTS: When a therapist sets an appointment with you, that time is yours and yours alone. Each appointment is based off of the standard 50-minute therapy hour. If you need to cancel your appointment, it is required to have a minimum of 24-hours notice; otherwise, you are subject to a charge for the missed appointment. Messages may be left on the voice mail which will accurately record the date and time you called. The therapist will do his/her best to be punctual for your appointment unless there is an emergency call. It is asked that you be punctual as well. If you are late, for any reason, you will receive the remainder of your scheduled time. This is necessary so therapists can see following clients at their scheduled times. You will, however, be required to pay the full fee. Of course, in the case of an emergency or illness, late cancellations are acceptable according to the therapist's discretion.

2. COUNSELING FEES: Counseling fees are set at the time of your first appointment. A standard counseling session lasts 50 minutes. The standard fee per session is $200.00, unless otherwise agreed upon by the person making your first appointment. Additional fees may be required for home-based sessions and/or standard mileage rates. This hourly fee applies to time spent on other professional services you may need, including telephone conversations lasting longer than 10 minutes, report writing, consultations and attendance to meetings with other professionals you have authorized, preparation of records or treatment summaries, travel time, and the time spent performing any other service you may request of the therapist. If time spent is less than an hour, I will bill you on a prorated basis. I also offer sliding scale based upon need and availability at the time of inquiry; therefore, professional fees will be discussed and agreed upon by the end of the first session.

3. BILLING AND PAYMENTS: You are fully responsible for all services rendered. Full payment is expected at the time of your service unless other contractual arrangements apply. Fees are to be paid directly to the therapist at the end of your session. You may pay by cash, check, money order, or cashier's check. Payments should be made out to "HL Counseling and Consulting Services, Inc". A receipt for payment is provided if requested.

Returned checks: A penalty fee of $25.00 will be assessed on all checks returned by the bank for any reason. Repayment of the returned check must be made by cash, cashier's check, or money order.

4. UNPAID BALANCES: Payments must be made by the 1st of the month or a late charge of $20.00 will be assessed. If your account has an unpaid balance at any time, it may be necessary to suspend counseling sessions until the account is paid. If there is a question regarding your bill, please do not hesitate to discuss this with me. I have the option of using legal means to secure the payment of delinquent accounts. This may involve hiring a collection agency or small claims court. In most situations, the only information I release regarding a patient's treatment is his/her name, the nature of services provided, and the amount due. Please notify me if any problems arise during the course of therapy regarding your ability to make timely payments.

HL COUNSELING AND CONSULTING SERVICES, INC.

5619 N. Figueroa St, Unit 216, Los Angeles, CA 90042 Counseling Services

5. HEALTH INSURANCE & CONFIDENTIALITY OF RECORDS: I do belong to a limited number of health insurance providers. If you have an insurance provider that I do not work with and you have out-of-network benefits through a PPO provider, you may submit my bills to your insurer and it may be reimbursed.

Please note that once you submit a claim for mental health treatment, disclosure of confidential information may be required by your health insurance carrier in order to process the claims. Please be aware that submitting a mental health invoice for reimbursement carries a certain amount of risk to confidentiality, privacy or future eligibility to obtain health or life insurance. While insurance companies claim to keep this information confidential, I have no control over the information once it leaves the office and once you submit a claim for reimbursement.

6. CHILDREN: Therapists do not provide care for your child(ren) while you are in a counseling session and are not responsible for any child that is left unsupervised. Young children can be disruptive to other clients, so the therapist can ask that you do not bring children to the center unless they are receiving counseling themselves. The therapist may request that you leave your counseling session to attend to unattended children.

7. EMAILS, COMPUTERS, AND FAXES: I do not use email or faxes to communicate with clients with the exception of scheduling and/or cancelling sessions. It is very important to be aware that computers and email communication can be relatively easily accessed by unauthorized people and hence can compromise the privacy and confidentiality of such communication. If you email me, you understand that you risk your privacy being breached.

8. PROFESSIONAL RECORDS: By both the law and standard practice of psychology, I keep appropriate treatment records. Both the law and professional practice require that I keep treatment records for at least 7 years. Unless otherwise agreed upon to be necessary, I will retain clinical records only as long as mandated by California law. If you have concerns regarding the treatment records, please discuss them with me. As a client, you have the right to review or receive a summary of your records at any time, except in limited legal or emergency circumstances or when I assess that releasing such information might be harmful in any way. When more than one client is involved in treatment, such as in cases of couples and family therapy, I will release records only with signed authorizations from all the adults (or all those who legally can authorize such a release) involved in the treatment.

9. AVAILABILITY: The therapist is available for regularly scheduled appointment times. If the therapist goes on vacation or is unavailable, he/she will have someone cover the practice and you will be provided with his/her name and phone number well in advance. This covering therapist will have access to your client information and is bound by the same laws and regulations as I am to protect your confidentiality.

Emergency services can be obtained at: by calling 911 if there is an emergency OR the Suicide Prevention and Survivor Hotline: (877) 727-4747.

HL COUNSELING AND CONSULTING SERVICES, INC.

5619 N. Figueroa St, Unit 216, Los Angeles, CA 90042 Counseling Services

10. TERMINATION OF TREATMENT: The therapist may terminate treatment in the following situations: 1) when it is mutually agreed upon that you have made improvements to your goals and that you no longer need professional therapeutic services; 2) you fail to pay the negotiated fee; 3) you are not cooperating with the therapist's treatment recommendations; 4) there is a discovered conflict of interest and/or multiple relationship that would make it difficult to maintain neutrality in the professional relationship (i.e. therapist later learns that you are close friends with a family member); 5) if some problem emerges that is not within the scope of competence of the therapist; or 6) therapist moves or closes the practice. The usual minimal termination for ongoing treatment process is four to ten sessions, but a satisfying termination for long-term work may take several months.

11. COMPLAINTS: If you are unhappy with services or what is happening in therapy, please do not hesitate to bring your concerns to me so that we can discuss them together. Sometimes, your experience can be part of the therapeutic process. If you believe that we are unable to work through these concerns together, you have the right to file a complaint with the California Board of Behavioral Sciences.

Board of Behavioral Sciences 1625 N. Market Blvd Sacramento, CA 95834 (916) 574-7830

Please sign below to indicate that "I have read the above policies, and I understand and agree to comply with them. I further agree that I am personally responsible for all financial obligations incurred. I also consent to receive treatment.

Signature: ________________________________________________ Date: ______________________ Please print your name: ______________________________________

Signature: ________________________________________________ Date: ______________________ (Parent/Guardian if client is less than 18 years old)

Please print your name: _____________________________________

Therapist/Witness: __________________________________________ Date: ______________________ Please print your name: ______________________________________

HL COUNSELING AND CONSULTING SERVICES, INC.

5619 N. Figueroa St, Unit 216, Los Angeles, CA 90042 Counseling Services

CONFIDENTIALITY POLICY

Informed Consent Statement

I offer private practice, consisting of individual, couples, or family therapy, under the fictitious business name "HL Counseling and Consulting Services, Inc." The therapist, Hannah Lee, LCSW 26041, provides psychotherapeutic services in accordance with California State Law. California law requires the therapeutic relationship to be both professional and confidential. What is revealed in the therapeutic setting is protected by legal, professional, and ethical standards, such that, with a few exceptions, all material is confidential and no information regarding clients is released to a third party outside of HL Counseling and Consulting Services, unless authorized by the client and/or his/her authorized representative. There are, however, exceptions, to confidentiality, which include the following:

1. Where there is reasonable suspicion that a client is in danger of inflicting physical harm to him/herself.

2. When there is reasonable suspicion that a client is in danger of inflicting physical harm to another person.

3. When there is reasonable suspicion that someone has been the victim of child abuse: sexual abuse, physical abuse and neglect.

4. When there is reasonable suspicion that the client has been the victim of elder/dependent adult abuse

5. When client information is subpoenaed by a court of law, requested by Victims of Crime Program, Desktop Services Incorporated, or requested by client's own health insurance.

It is important that you are aware of what to do in the event that you have a MENTAL HEALTH EMERGENCY during NONBUSINESS hours. A mental health emergency is when you feel that you are at risk of harming yourself or at risk of harming someone else. For example, if you are having suicidal thoughts or are making threats that you are going to kill or seriously injure someone, and then it is important that you seek help. Threatening serious damage to the property of another may also constitute a severe emergency, which requires attention.

If your concern is the "risk of being harmed" please call 911 immediately. Please be sure to communicate the seriousness of your emergency to the 911 operator. Usually it is a good idea to describe the behavior, any threats, and to state your fear about what will happen if you don't get immediate help. Other important information to include is: your name and age, location, known use of drugs/alcohol, access to dangerous objects/weapons (knife, scissors, gun, medications, etc.), any history of previous incidents like this one, and a description of the emergency situation.

Other Helpful Numbers:

Suicide Prevention and Survivor (877) 727-4747

Child Abuse Hotline (800) 540-4000

California Youth Crisis Hotline (800) 843-5400

Domestic Violence ? Sexual Assault Hotline (800) 399-3940

I have read the above confidentiality policy and understand the therapeutic relationship is private and confidential with exceptions noted above.

Signature of Client

Signature of Parent

Date

Therapist

Date

This was translated into ____________________ for the client and/or responsible adult.

A copy of this was given

declined on ______________ by __________

Date

Initial

NAME:

DOB#:

HL COUNSELING AND CONSULTING SERVICES, INC.

5619 N. Figueroa St, Unit 216, Los Angeles, CA 90042 Counseling Services

CONSENT FOR SERVICES

The undersigned client or responsible adult consents to and authorizes mental health service by this therapist,

I have been informed that HL Counseling and Consulting Services, Inc. is a mental health provider. I understand that the treating therapist who is a Licensed Mental Health therapist will see me for therapy. I have been informed of his/her title, training, and experience.

I understand that although the length of therapy is difficult to assess, I could be in therapy anywhere from a few weeks to several months.

I have discussed issues of confidentiality with this therapist, including Tarasoff, and child, elder, and dependent abuse. Further, I understand that if I am here under the Victims of Crime Program or any type of health insurance, certain information will be shared, such as a diagnosis, assessment, goals, and progress.

I understand that records are kept, both electronically and in writing regarding my services (e.g. such progress during each session): I have a right to have and view those records or have them shared with anyone I wish. I understand permission must be obtained from me to share this information with anyone.

I understand that there are alternative services that I can undertake to address whatever issues I have, and that I am free to terminate the therapy at any time for any reason. These services are voluntary and withdrawn this consent at any time.

I understand that there are certain risks I undertake if I refuse to proceed with these services, such as not resolving my presenting problem issues.

I understand that normal fees for services are set at $200.00 per session. Sliding Scale Fee is ____________

I understand that undertaking therapy can result in certain changes in my life, some results possibly being temporary disruptive in life, emotional stress, and even no improvement in my issues.

Signature of Client

Signature of Parent

Date

Therapist

Date

This consent was translated into ____________________ for the client and/or responsible adult.

A copy of this Consent was given

declined on ______________ by __________

Date

Initial

NAME:

DOB#:

HL COUNSELING AND CONSULTING SERVICES, INC.

5619 N. Figueroa St, Unit 216, Los Angeles, CA 90042 Counseling Services

NO SHOW / CANCELLATION POLICY

I understand that by signing below I agree to the following treatment services NO SHOW/ CANCELLATION POLICY:

If I am unable to keep my appointment due to an emergency or an unplanned circumstance, I will call within 24 hours (or as soon as possible) prior to my appointment to cancel and/or reschedule.

I understand that if I am more than 15 minutes late to my scheduled appointment, I may need to reschedule.

I understand that if I miss more than two sessions without calling to cancel, or if there is a pattern of missed appointments, or if I am regularly more than 15 minutes late, this may result I a change in the level of service provided, including termination of therapy.

I will bring relevant school, medical, and other treatment records related to the minor in treatment both at the time of intake and throughout the course of treatment if requested.

I will assume the responsibility to ensure that the minor will attend all scheduled appointments on time.

Signature of Client

Signature of Parent

Date

Therapist

Date

This consent was translated into ____________________ for the client and/or responsible adult.

A copy of this Consent was given

declined on ______________ by __________

Date

Initial

NAME:

DOB#:

HL COUNSELING AND CONSULTING SERVICES, INC.

5619 N. Figueroa St, Unit 216, Los Angeles, CA 90042 Counseling Services

ARBITRATION AGREEMENT

I agree to address any grievances I may have directly with the therapist immediately. If we cannot settle the matter between us, then a jointly agreed-upon outside consultation will be sought. If not, an arbitration process will be initiated which will be considered as a complete resolution and legally binding decision under state law which states as follows:

"NOTICE: BY SIGNING THIS CONTRACT, YOU ARE AGREEING TO HAVE ANY ISSUE OR MEDICAL MALPRACTICE DECIDED BY NEUTRAL ARBITRATION AND YOU ARE GIVING UP YOUR RIGHT TO A JURY OR COURT TRIAL. SEE ARTICLE ONE OF THIS CONTRACT."

Article 1: "It is understood that any dispute as to medical malpractice, that is as to whether any medical services rendered under this contract were unnecessary or unauthorized or were improperly, negligently or incompetently rendered, will be determined by submission to arbitration as provided by [state] law, and not by lawsuit or resort to court process except as [state] law provides for judicial review or arbitration proceedings.

Both parties to this contract, by entering into it, are giving up their constitutional right to have any such dispute decided in a court of law before a jury, and instead are accepting the use of arbitration." Any arbitration process will be considered as a complete resolution and legally binding decision. The client will be responsible for the cost of this process. In agreeing to treatment, you are consenting to the above identified grievance procedures.

This agreement constitutes the entirety of our professional contract. Any changes must be signed by both parties. I have a right to keep a copy of this contract.

__________________________________________________________ Client Signature

_____________________________ Date

__________________________________________________________ Parent/Guardian Signature

_____________________________ Date

__________________________________________________________ Therapist's Signature

_____________________________ Date

Verification Statement of the Therapist

This document was discussed with the client and questions regarding fees, diagnosis, and treatment plan were discussed. I have assessed the client or parent's/guardian's mental capacity and found him/her capable of giving an informed consent at this time.

Date and Initial of Therapist: _____________________________

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