Peaceful Path Counseling, LLC Amy Kay, LPC

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1 Revision VII, Effective January 15, 2015 Please Keep This for Your Records INTRODUCTION Welcome to my counseling practice. The decision to pursue counseling is an important one, often filled with questions. This document is known as an informed consent. It describes my policies and procedures, as well as your risks, rights, and responsibilities. It is designed to help you make an informed decision about whether or not to proceed with counseling. The law requires I obtain your signature, acknowledging that I provided you with this information. It is important that you read this carefully, as your signature represents an agreement between you and me. You will not be considered a client until this is signed. If you have any questions about what is in this document, or something that is not covered, please ask me so we can discuss it. You may revoke this agreement in writing at any time. Please note, you will need to sign a new informed consent form every two years. Minors will need to sign one when they become an adult, thus becoming responsible for their own sessions. ABOUT ME I am a Licensed Professional Counselor in the state of Georgia, license LPC I received a Master s of Science in Professional Counseling from Georgia State University. I received a Bachelor s of Science in Public and Social Services, with a minor in Human Services, from Kennesaw State University. I am also certified in dating, premarital, and marriage counseling by Prepare/Enrich, and I am working towards a certification in PTSD through Light University. I have been practicing Professional Counseling in a variety of settings since I offer private counseling for adults, adolescents 16 and up, couples, families, and groups. I specialize in Christian counseling, couples, families, parenting, and grief and loss. I also offer solution-focused brief counseling, as I believe counseling is not meant to last forever; rather to equip you with the necessary tools to go out and live life. I am the sole owner and independent practitioner of Peaceful Path Counseling, LLC. I intentionally keep a small caseload so you have my full attention. You should find your entire experience to be private and quiet. I tend to look at things rationally, and believe in living life passionately. I also believe in finding contentment, regardless the circumstances. Every client is met with unconditional positive regard. Please note that as a Licensed Professional Counselor, I am unable to prescribe medication. Medication should be managed by your treating Physician, or by a Psychiatrist. I am happy to provide you with the name of a Physiatrist, should you feel this is something you need. APPOINTMENTS The first session costs $ for 60 minutes. Subsequent sessions are $90.00 for 45 minutes. All couples and families are $ for 60 minutes. Please see the Informed Consent for Collaterals if you are interested in couple or family counseling. Also, please carefully read the section marked for couples and/or parents. I offer a $20.00 discount for any appointments made for 2:00 pm and earlier, Monday through Friday. Payment in full is required at the beginning of each session. I offer a sliding scale rate based upon your family s gross income and size, on an as needed basis. I do not want you to be discouraged from seeking counseling due to financial concerns. If you would like to discuss my sliding scale rate, please let me know. Please be advised, I cannot bill insurance when accepting a reduced rate. Telephone calls lasting longer than 10 minutes are $2.00 per minute. Completion of paperwork is $ Court appearances are $1, per day of appearance. Completion of paperwork and court appearances is not reimbursable by insurance, and is billed directly to you. Please allow 24 hours notice if you are unable to keep an appointment. If you cancel an appointment without sufficient notice, or are a no-show for an appointment, you will be billed for that appointment. I understand things come up, and will work with you to the best of my ability. The first appointment not canceled in a timely manner, and not having to do with an emergency, will be overlooked. The second appointment will result in a cancellation fee that is one half of my appointment rate of $ Any additional late cancellations will result in a cancellation fee that is my full appointment rate of $ No-shows are automatically billed at my full appointment rate of $ You will be considered a no-show after 20 minutes into your scheduled appointment time, as someone may be scheduled directly after you. All fees must be paid before a missed appointment may be rescheduled. Missing appointments keeps others from seeing me, as you have contracted for that time and it cannot be billed to insurance providers. Exceptions to this rule are emergencies, such as; unexpected illness, the death or illness of a loved one, or inclement 1

2 weather. You may call, , or text me to let me know that you will not be able to make your scheduled appointment. Please note, arriving late may cause your session to be shorter, as someone may be scheduled directly after you. Also, please arrange childcare for any children under the age of 14 in advance of your appointment. There is no set amount of time a person should be in counseling. I ask that you commit to at least three sessions, as it can take the first two sessions to determine the goals or direction needed. Counseling will continue until goals are met, there is a mutual decision that counseling is complete, if you decide to stop coming, if I feel that I am unable to help you, if there are excessive cancellations, if there is a continued nonpayment of services, or if you threaten or act violent towards me or my family in any way. I reserve the right to terminate counseling and refer you to someone else at any time. EMERGENCIES Due to the fact that I am usually in session, I am not always immediately available by telephone. However, I check messages from my confidential voic on a daily basis, and make every effort to return phone calls within one to two business days, between the hours of 9:00 am and 5:00 pm. You may reach me sooner by filling out a form on my website at by ing me at or by texting me at If you are unable to reach me and need to speak with someone immediately, please call your treating physician, go to your local emergency room, or dial 911. You may also call the Georgia Crisis and Access Line. This is a free service, available day or night, in which they will send a Licensed Professional Counselor to you. They can be reached at CLIENT INVOLVEMENT, BENEFITS, AND RISKS Research has shown that a positive outcome from counseling typically depends on a good working relationship between the Counselor and the client. In this partnership, we will explore what led you to seek counseling at this point in your life, define any problem areas that need to be addressed, and utilize techniques to help you make the changes you would like to see. Counseling is a growth process. While some changes may occur rapidly, typically growth takes time. Effort on your part as the client is essential for growth to occur. In order for counseling to be successful, you will need to work on any topics and/or assignments we discuss during sessions. Both the benefits and risks of counseling should be considered before entering into counseling. Regarding the risks, counseling often involves discussing unpleasant aspects of your life. As a result, you may experience uncomfortable feelings associated with these discussions; such as, anger, fear, frustration, guilt, helplessness, loneliness, sadness, or simply feeling tired. Also, clients entering into counseling may gradually disclose new information that may create stress or discomfort for the client s family members and/or friends. As the client experiences growth throughout the counseling process and begins to implement changes in his or her life, family and/or friends may need time to adjust to the positive changes being made. Most of these risks are to be expected when people are making important changes in their lives. There is no guarantee of what you will experience. As you consider the above mentioned risks, you should also be aware that research supports the counseling process, as counseling can help improve relationships, reduce stress, and resolve specific problems. If you have any questions or concerns regarding your counseling, I encourage you to express them freely. It is essential that we discuss them, explore them, and work together to resolve them. CONFIDENTIALITY The confidentiality of any information in a client s file is protected by both state and federal law. It can only be released if you, the client, specifically authorize me to do so. There are a few exceptions to that rule: If I believe that you are a danger to yourself, I will take action to protect your life, even if I must reveal your identity to do so. If you threaten serious bodily harm to someone else, I will take action to protect that person, even if I must reveal your identity to do so. If I suspect the abuse or neglect of a child or vulnerable adult, I am required to file a report with the appropriate agency. If I suspect sexual exploitation has been placed upon you by another Counselor, I am required to file a report with the appropriate agency. If you are involved in a lawsuit and the court requires I submit information or testify, I must comply. If you dispute credit card charges, or file a complaint or lawsuit against me, I am permitted to disclose any information necessary for my defense. 2

3 If insurance is being used to pay for counseling, your insurance provider may require me to submit information about the counseling for claims processing purposes, utilization review, or to ensure proper care. Subpoenas and court appearances are highly discouraged to protect the confidentiality of our sessions, as well as to respect the counseling relationship and process. A release of information form must be signed prior to any court appearances. The Notice of Privacy Practices form, that you have also been given, explains confidentiality in detail. Please let me know if you have any questions. Please note that while this office is in a shared space, every effort is being made to protect your privacy. Please also note that should I see you in public, I will not acknowledge you unless you first acknowledge me, nor will I befriend you on any social media sites. ELECTRONIC TRANSMISSIONS Please know that any information expressed in an or text cannot be guaranteed as secure. While I do send appointment reminders via , no identifying information will be contained therein. Anything you put in an or text is your responsibility. I will respond to s or texts; however, I will make every effort to not divulge anything pertinent in doing so. In addition to s or texts, I maintain all files electronically. These file are not kept online, and are encrypted and password protected. Please note, most insurance providers are now online. Authorization, billing, payment, and records necessary to counseling are typically handled in this way or via fax. You have the right to refuse to have anything handled electronically. If you wish to refuse, you will be given a receipt to file with your insurance provider, yourself. Payment for counseling services will be expected upfront. CONSULTATION The competent and ethical practice of counseling requires regular case consultation with other licensed professionals. Should I obtain consultation regarding aspects of your case, I will omit identifying information so your confidentiality is maintained. My goal is to assist you in making the changes you are seeking, whether working with me or another Counselor. If I think you would benefit from working with someone else, I will provide you with a referral to another Counselor. You have the right to ask me for a referral at any time, should you feel I am not the best Counselor to meet your needs. You or I may choose to transfer your case at any time. In order to transfer your case, or simply have me consult with another professional you have worked with in the past, please sign a release of information form. RECORDS Please be aware that, pursuant of HIPAA, I will keep a written record of our work together. This record may include any correspondence, the dates of our sessions, your reason for seeking counseling, how your problem affects your life, any goals established during counseling, billing records, and any forms you have signed. You have a right to request a summary of the information in your file for yourself, or for someone else designated by you. This request must be made in writing at least five business days prior to when it is needed, and accompany $30.00 to cover administrative costs. I reserve the right to change this amount at any time. You will not be given access to your entire file, or notes often referred to as Psychotherapy notes, as this could hinder the counseling process. Also, you will not be given your record until you pay any outstanding charges you are responsible for. BILLING AND INSURANCE Acceptable forms of payment are cash (exact change), check (made out to Peaceful Path Counseling or I can stamp it for you), or credit card (Flex Spending cards must bare a major credit card logo). There is a $30.00 fee for any returned checks, due at the beginning of our next session, along with payment in full for that session. I reserve the right to change this amount at any time. If I receive two returned checks, I will require that you pay using cash from that point on. Credit cards are processed via the Square credit card processing company and device. Peaceful Path Counseling, LLC will appear on all credit card statements. Please note, paying by credit card cannot be guaranteed as private. Should you pay for counseling services in advance and then need to cancel or reschedule your appointment, a refund will be issued to you ten business days from the date of your cancellation. If you have health insurance, it will usually provide some coverage for behavioral health services. The services I provide are considered outpatient. As a courtesy to you, I am happy to bill your insurance provider for you. This does not release you from the responsibility of any charges they do not cover. You, the client, are ultimately responsible. I will notify you in writing if they have not paid me within 60 days from the date of service. I will send you a bill if they have not paid me within 90 days from the date of service. If I am listed as in-network with your insurance provider, this means I have contracted with that provider for a specific rate. I will not charge you the difference between that contracted rate and my customary rate. Copays, coinsurance, and/or deductibles are due at the time of your appointment. Please note, deductibles for behavioral health services are often separate from medical. If you have insurance coverage paid for through the Affordable Care Act rather than an employer, I will provide you with a receipt, known as a Superbill, to submit to your insurance provider for reimbursement to you after each session. You will be responsible for payment in 3

4 full in advance. Due to identity theft and the fraudulent use of health insurance coverage, I will need to photocopy your insurance card and photo ID at the beginning our first session. If you have not already done so, please call your insurance provider to see if you need an authorization number. If so, they will give you an authorization number, the number of sessions for which you are approved, and a date for when the sessions must be used by. Please verify that I am in-network, if you are allowed to see a Licensed Professional Counselor, if you need a Physician s referral, if you have a behavioral health deductible, and what your copay or coinsurance is. It is your responsibility to inform me of any changes to your insurance. We will review this at the start of each calendar year. Please inform me of any changes to your address and/or employment, as well. Please note that I do not accept Medicare, Medicaid, PeachCare for Kids, or secondary insurance plans. If I am listed as out-of-network, I am happy to provide you with a receipt, known as a Superbill, to submit to your insurance provider for reimbursement to you after each session. You will be responsible for payment in full in advance. Often times you are reimbursed more, or come out better, than if you were to pay your copay. If you have Medicaid or Medicare, you will need to contact them to see if you are allowed to pay out-of-pocket. Please be aware that insurance providers often require an update on how counseling is going, any concerns or stressors you may have, as well as your general level of functioning. They also require a diagnosis for reimbursement of any counseling services. A diagnosis is a term used to describe the nature of your problem, and indicates if the problem is considered long-term or short-term. All diagnoses come from the DSM V. I am happy to show you a copy of this book, and discuss any diagnostic impressions I have made. Paying out-of-pocket helps avoid a diagnosis altogether, thus further ensuring your privacy. There are many benefits to paying outof-pocket for counseling services. Confidentiality is lessened when protected health information (PHI) must be reported to your insurance provider. When this information is reported, it becomes a part of your mental health record and a national databank. Certain diagnoses may hinder your ability to receive disability, health insurance, life insurance, or even certain employment opportunities. Furthermore, insurance providers often dictate who you may see, the number of sessions you may have, and the length sessions may be. Struggling with one of life s many challenges, such as divorce or grief, may not meet your insurance provider s criteria as being medically necessary to receive counseling services. For example, most insurance providers do not recognize couples counseling. Such struggles are common, and do not necessarily mean you are suffering from a mental illness. Additional benefits to paying out-of-pocket are the ability to keep costs down. Insurance providers contract with Counselors for a percentage of their customary rates, causing Counselors to have higher rates in order to keep their practices open and services flowing. Paying out-ofpocket means less paperwork is required of the Counselor, thus freeing up their resources, time, and energy to devote to the direct care of each client. Overall, care is more personalized, treatment options are more flexible, sudden rate increases are prevented, certain costs may be waived should you face a hardship, labels may be avoided, any stigma associated with counseling may be removed, and true privacy may be maintained. The costs of this practice are kept below fair market value for the area, as I do not want anyone to be discouraged from seeking counseling due to financial concerns. If you wish to decline, and thus forego the use of insurance, please let me know. You may make this decision at any time, making you responsible for payment in full at the beginning of each session. SUMMARY If you have any questions about counseling, my procedures, or your role in this process, please discuss them with me. The best way to ensure the quality and ethical treatment of the counseling process is to keep communication open and direct. 4

5 Revision VII, Effective January 15, 2015 Please Sign and Return This for My Records By signing below, I indicate I have read, understand, and will abide by this document and the policies therein. Signing this also authorizes counseling services to begin. CONFIDENTIALTY By signing below, I understand and agree to the terms of confidentiality, and any limitations therein. ELECTRONIC TRANSMISSIONS By signing below, I authorize electronic transmissions may be sent and received on my behalf, as well as electronic record keeping. BILLING AND INSURANCE By signing below, I authorize the billing of my insurance and/or EAP for any services rendered. Billing may be done on my behalf, or I may request a receipt to submit to my insurance provider for reimbursement. I understand that I am responsible for any unpaid charges. I also understand that this may require I am given a diagnosis. FOREGOING INSURANCE By signing below, I choose to forego the use of my insurance and/or EAP and will pay out-of-pocket. I understand that I am responsible for payment in full at the beginning of each session. NOTICE OF PRIVACY PRACTICES By signing below, I acknowledge I received a copy of the Notice of Privacy Practices. I have read and understand it. 5

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