Patient Agreement and Authorization for Treatment/Consult

Guided Path Counseling, LLC

641 Monroe St., Suite 111, Sheboygan Falls, WI  53085

Tele 920-286-2203  Fax 920-927-9011

www.guidedpathcounseling.com 

Informed Consent for Psychotherapy

General Information

The therapeutic relationship is unique in that it is a highly personal, and at the same time, a contractual agreement. Given this, it is important for us to reach a clear understanding about how our relationship will work, and what each of us can expect. This consent will provide a clear framework for our work together. Feel free to discuss any of this with me. Please read and indicate you have reviewed this information by signing below.

The Therapeutic Process

You have taken a very positive step by deciding to seek therapy. The outcome of your treatment depends largely on your willingness to engage in this process, which may, at times, result in considerable discomfort.  Remembering unpleasant events and becoming aware of feelings attached to those events can bring on strong feelings of anger, depression, anxiety, etc. There are no miracle cures. I cannot promise that your behavior or circumstances will change.  I can promise to support you and do my very best to help you understand your repeating patterns, clarify what it is that you want for yourself, and work toward relief of your symptoms.

Confidentiality

The session content and all relevant materials to the client’s treatment will be held confidential unless the client requests in writing to have all or portions of such content released to a specific named person(s). Limitations of such client held privilege of confidentiality exist and are itemized below:

1.  If a client threatens or attempts to commit suicide or otherwise conducts him/herself in a manner in which there is substantial risk of incurring serious bodily harm.

2. If a client threatens grave bodily harm or death to another person.

3. If the therapist has a reasonable suspicion that a client or other named victim is the perpetrator, observer of, or actual victim of physical, emotional, or sexual abuse of a child under the age of 18 years.

4. Suspicions as stated above in the case of an elderly person who may be subjected to these abuses.

5. Suspected neglect of the parties named in items #3 and #4.

6. If a court of law issues a legitimate subpoena for information stated on the subpoena.

7. If a client is in therapy or being treated by order of a court of law, or if information is obtained for the purpose of rendering an expert’s report to an attorney.

Occasionally I may need to consult with other professionals in their areas of expertise in order to provide the best treatment for you. Information about you may be shared in this context without using your name or other identifying information.

If we see each other incidentally outside of the therapy office, I will not acknowledge you first. Your right to privacy and confidentiality is of the utmost importance to me, therefore I do not wish to jeopardize your privacy. However, if you acknowledge me first, I will be more than happy to speak briefly with you, but feel it appropriate not to engage in any lengthy discussions in public or outside of the therapy office.

By signing I agree that I have read and agree to the items contained in this document.

2. Payment Guarantee-Collection Fee:  If I decide to use insurance for payment of services, I will make payment directly to Guided Path Counseling, LLC, both prior to insurance payment and if I am provided any payments from my insurance carrier directly, and I will be responsible for obtaining reimbursement for services rendered from Guided Path Counseling, LLC.  I understand Guided Path Counseling, LLC will assist me and bill my insurance carrier through National Billing Company.  I understand I am financially responsible to Guided Path Counseling, LLC for any covered or non-covered services, as defined by my insurer. 

3. Non-Medicaid clients: I understand I am required to provide 24-hour notice if I am unable to attend an appointment or I will be responsible to pay a $80 (+3% credit card fee) no call no show/inadequate notice fee billed to the card on file below.

4. As the Payee, I authorize GPC to charge the card on file for no call no show/inadequate notice, agreed upon services, and/or unpaid balances due. 

Credit Card

5. Medicaid Clients who do not provide adequate notice (24-hours prior to scheduled session) and/or “no call no show” 3 times may be terminated by the provider.  Should the provider terminate services, appropriate referrals for further treatment will be provided.

6. I understand I/we will be seen as a: Individual, Family, or on a Consultation basis (Circle One).  The fee for the initial appointment (psychiatric evaluation-90791) is $150. The fee for follow up appointments (Individual therapy or Family therapy) is $120 per session or as dictated by insurance plan or referral contract. The length of the therapy session length will be approximately 45 minutes.  60-minute therapy sessions will be charged $150. Additional services such as report writing, will be billed a rate of $2 per minute, minimum of $120 fee.  I understand that payment must be in full prior to the time of court and/or report writing, and there are no refunds if a client is displeased with a court ruling or work performed.

7. I understand if I choose to use my debit card/credit card I will be charged a 3% card services fee per transaction.  If you decide to pay by check, please make out check to: “Guided Path Counseling.” Any check that is returned for insufficient funds will be subject to a $70 fee.  

8. I understand if I do owe money for services rendered and do not make payment arrangements within one month of billing, a third-party collection agency will be notified to collect payment for services.

9. (a) I understand if I do decide to use my insurance, Guided Path Counseling, LLC uses National Billing Company to submit to insurance carrier. Thus, necessary information, including diagnostic information, is shared with them for billing purposes.  (b) I understand Guided Path Counseling, LLC will only bill the primary insurance. If the client wishes to use a secondary insurance as well, the client is responsible for submitting to their secondary insurance (unless client has governmental insurance).  (c) The therapist will not submit insurance claims to out of network insurance companies. However, upon request, therapist will provide a superbill, which the client can submit to their insurance company. 

10. If I choose  to receive a copy of my client file, or an agency requests the file on my behalf, I will be charged $2.00/page.

I understand that signing below indicates I have read and or been informed of the above information.