WordPress.com



[pic]

__________________________________________________________________________________________

This document is designed to inform you about my background and the counseling services I provide. I am happy to discuss any questions you might have about this document or the counseling process. I received a Master of Science in Couples and Family Therapy at the University of Oregon in Eugene. I am licensed by the state of Montana as a Licensed Clinical Professional Counselor. I do not testify in court, nor am I qualified to do psychological assessments for any purpose, such as child custody cases.

As we work together we both need to assess the process. Our first session will involve an evaluation of your needs. Together we will create goals to work toward in counseling. Counseling is not one-sided; it is important that you share your opinions, concerns and needs in session. I rely on multiple theoretical therapeutic approaches to best serve your needs. During counseling, you may have discussions about personal issues and I may challenge assumptions and choices you make bringing to the surface uncomfortable emotions. These are all opportunities in counseling. Furthermore, counseling involves a large commitment of time, money and energy so it is important that you decide for yourself if you think I am the right counselor for you. As a client you are in complete control and may end our counseling relationship at any point. It is impossible to guarantee any specific results regarding your counseling goals. However, I assure you my services will be rendered in a professional manner consistent with accepted ethical standards.

_______ APPOINTMENTS: Appointments are usually scheduled for the same time each week. Sessions are approximately 55 minutes in length. Your regular appointment time is reserved for you and you are financially responsible for the scheduled time. In the event you will not be able to keep an appointment, please notify me immediately. If you are more than 15 minutes late, or if an appointment is canceled, or missed without 24 hours notice, you will be responsible for paying a cancelation fee in the amount of $60 for the session you missed, as insurers will not reimburse for missed appointments. Emergencies or extenuating circumstances may be taken into consideration.

_______ CONFIDENTIALITY: I will keep confidential anything you say to me with the following exceptions: you authorize disclosure of your records through a signed release of information; I determine you are a danger to yourself or others; I become aware of suspected child or elder abuse; I am ordered by a court of law to disclose information; or you authorize release of your medical information to your insurance company as detailed on the Consent for Third Party Billing Form. I regularly consult with other professionals to enhance the services you receive. In the case consultation process, no identifying information is shared and professionals with whom I consult are bound by ethical and legal obligation to maintain confidentiality. An additional HIPPA (Health Insurance Portability and Accountability Act) Privacy Practices Information Form is included in the paperwork you will sign.

_______ DUTY TO WARN/DUTY TO PROTECT: If I believe that you (or your child, if child is the client) are in any physical or emotional danger to yourself or another human being, you hereby specifically give consent to contact any person who is in a position to prevent harm to you or another, including, but not limited to, the person in danger. You also give consent of contact to the following person(s):

Name Telephone Number

____________________________________________________________________ ___________________________________________

_______ PHONE CALLS/EMERGENCIES/THERAPIST ABSENCE: My phone number is 406-414-7552. I check my messages regularly; however I may be unavailable and will return your call when I am able. In case of an emergency that occurs outside of Monday through Thursday, 4pm to 7pm, you may contact the Help Center (a local, free, 24-hour crisis line) at 586-3333 or for immediate assistance or call 911. **From time to time, I may be unavailable for regular appointments, due to professional or personal obligations, or planned vacation. I may arrange for another therapist to be on-call in my absence and the Help Center will also be available. I may provide identifying information to these professionals in order to aid them in providing services to you if needed.

_______ LEVEL OF CARE: My services are not appropriate for clients requiring intensive care. If I determine that you require a more intensive level of care, I will refer you to an appropriate provider. I will only make such a referral after consulting with you. Under certain circumstance, I may determine that another professional may better serve your needs. I will discuss my concerns and provide referral information prior to terminating treatment.

_______ PAYMENT FOR SERVICE:

Free 30 minute consultation $0

Initial Meeting/Intake $155

Regular Office Visits, 55 minute sessions $140

Extended session (up to 90 minutes) $155

Inpatient Visits, Team Meetings (per hour) $120

Returned check fee per check $50

Payment of fees, including co-pays, are expected at each appointment. If you are using insurance benefits with BCBS, Allegiance, Cigna, or Pacific Source insurance claims will be filed for you and contractual agreements of specific reimbursement restrictions and claim requirements will be honored. If you use another insurance plan or are paying outright for sessions, payment is expected at each appointment. A statement for services will be provided upon request. Longer sessions are prorated according to the time we meet. Telephone conversations are prorated according to the time we talk, when such conversations are beyond the scheduling of appointments. You will be responsible for this fee, as insurance will not cover this type of support. I reserve the right to terminate services should your bill exceed $250. Defaulted accounts may be sent to collections. Please notify me if any problem arises during the course of your therapy regarding your ability to make timely payments.

_______ BILLING/PAYMENT: I understand that it is my responsibility of to obtain reimbursement for services rendered by Mallory Boich, LCPC/Bozeman Therapy PLLC. I understand that Mallory Boich, LCPC/Bozeman Therapy PLLC takes NO responsibility in understanding my insurance plan. It is my responsibility to gather the information on my own plan and accept full responsibility in the event that the costs are not covered by the insurance plan.

________ I UNDERSTAND THAT I am financially responsible for all charges, whether paid or not by my insurance company. I agree to pay the applicable co-pay or percentage of charges, determined through eligibility of my insurance, at the time of service. Furthermore, I acknowledge that, in the event my account balance for services rendered is sent to a third-party agency for collections, any and all costs or fees pertaining to collection of the outstanding balance will be added to my account and paid by me personally. I understand I will be responsible for all collections fees.

________ I UNDERSTAND THAT I authorize the use of my signature on all insurance submissions.

________ I UNDERSTAND THAT Mallory Boich, LCPC/Bozeman Therapy PLLC may use my health care information and may disclose such information to _____________________________________________ (named insurance company) and their agents for the purpose of obtaining payment for services and determining insurance benefits or the benefits payable for related services.

_______ CONSENT TO TREATMENT: By signing this Information and Consent Form, I acknowledge that I have read, understand and agree to the terms and conditions contained. I have been given appropriate opportunity for questions and clarification. I agree to receive mental health services for me (or my child if child is the client), and understand that I may stop services at any time. If you have any questions please feel free to ask.

Client/Guardian Signature:______________________________________________ Date:____________________

Client/Guardian Printed Name:_________________________________________ Date: ____________________

Counselor Signature:_____________________________________________________ Date:____________________

Insurance Subscriber/Member on Insurance plan, if different from above:

____________________________________________________________________________ Date: ______________________

Payment Agreement & Cancellation Policy For

Bozeman Therapy

Please provide a valid credit card number for billing purposes (all documentation is kept confidential and locked away). Please initial lines below and sign and date, showing you agree to pay the amount owed by allowing Mallory Boich, LCPC/Bozeman Therapy PLLC to charge your credit card and agree to the terms listed below.

**All patients are required to provide a valid credit card number, including

expiration date and billing zip code, in order to schedule an appointment

_______ If at any time your insurance company does not cover a balance, or you or Mallory Boich, LCPC/Bozeman Therapy PLLC become aware that you owe a co-pay that was not covered, the below signature states that Mallory Boich, LCPC/Bozeman Therapy PLLC has permission to charge the card listed below.

_______ Mallory Boich, LCPC/Bozeman Therapy PLLC has permission to charge the account listed the amount you owe Bozeman Therapy. Mallory Boich, LCPC/Bozeman Therapy PLLC will call to notify you before charges are made.

_______ If you cancel your appointment with less than 24 hours’ notice and choose not to reschedule

within the week or can not reschedule due to times being full, you credit card will be charged $60 for the missed session fee.

By signing this payment agreement & cancellation policy, you are indicating that you understand and agree to the terms of service explained above. You are also indicating that you have given permission to Mallory Boich, LCPC/Bozeman Therapy PLLC to charge your credit card if any of the above stipulations apply to you.

Name of Patient or Legal Guardian:_________________________________________

Signature:_________________________________ Date:________________________

Valid Credit Card Information:

Type of Card: ______________________ Card Number:_____________________________________

Expiration:____________ Security Code:_________ Billing Zip Code:______________

-----------------------

INFORMATION AND CONSENT FOR TREATMENT

................
................

In order to avoid copyright disputes, this page is only a partial summary.

Google Online Preview   Download