Consent For Services

TREATMENT CHOICE/INVOLVEMENT

I acknowledge that I have made a voluntary choice to engage in treatment. I understand that therapy is a collaborative effort between my Provider and me. I agree to keep my Provider informed of my needs and work together to address any challenges that may arise during our therapeutic journey. Successful therapy is often the result of a strong client-provider relationship. To establish the best possible partnership, it is essential that you have a thorough understanding of the process.

The therapeutic journey commences with the intake process. First, we will review my Provider’s policies and procedures, discuss fees, identify emergency contacts, and explore whether health insurance can cover my fees based on my plan's benefits. Second, we will delve into what to expect during therapy, including the type of therapy, the duration of treatment, and the associated risks and benefits. If my Provider practices under the supervision of another professional, they will inform me about their supervision and provide the name of the supervising professional. Third, we will craft a treatment plan, encompassing the type of therapy, session frequency, my short- and long-term goals, and the steps to attain them. Over time, we may revise the treatment plan to ensure it aligns with my goals and progress. Following the intake, I will attend regular therapy sessions either at my Provider's office or via telehealth. When I have achieved my goals, we will assess my progress, identify support systems to maintain my gains, and discuss the option of returning to therapy if necessary. At the time of termination, the client and Provider will collaboratively determine the most suitable way to conclude the therapeutic relationship. However, it's important to note that participation in therapy is voluntary, and I may choose to terminate it at any time.

TELEHEALTH SERVICES

To utilize telehealth services, I will require an internet connection and a device equipped with a camera for video sessions. My Provider will provide guidance on how to log in and navigate the telehealth platform. If telehealth is not suitable for my needs, my Provider will suggest alternative options. The use of telehealth comes with certain benefits and risks:

Benefits:

- Privacy and Confidentiality: I may be required to share personal information with the telehealth platform for account creation, such as my name, date of birth, location, and contact details. My Provider ensures that any telehealth platform used adheres to appropriate security standards to safeguard my information.

- Technology: Technical issues with internet, video, or sound may occasionally occur. In such cases, my Provider will follow the backup plan agreed upon before sessions.

- Crisis Management: During emergencies or crises, it may be challenging for my Provider to provide immediate support through telehealth. Together with my Provider, we will devise a crisis plan, which may involve designating a local emergency contact, establishing a communication plan, and compiling a list of local support, emergency, and crisis services.

FEES AND PAYMENT FOR SERVICES

Full payment is expected at the time of each session. In the event that I am unable to make the payment, I am encouraged to communicate this with my Provider. My Provider may offer payment plans or a sliding scale, should they be feasible. Any outstanding balance remains due until paid in full and may be sent to a collections service if necessary. Further, any future services may be paused until payment is received. Please note that in addition to therapy sessions, there may be circumstances where additional services are required, leading to additional charges beyond the scope of typical therapy practices. These additional services may include writing contracts, letters, or reports; consulting with other healthcare providers or professionals outside of typical case management practices; communication via telephone/email beyond the standard correspondence related to therapy sessions (scheduling & billing); and preparation, travel, and attendance at a court appearance. These services are subject to additional administrative fees. Legal-related services, including matters related to court appearances, consultations, document preparation, and any associated administrative tasks, are billed at a rate of $400 per hour, charged in 10-minute increments. Payment is to be made in advance. I am required to maintain a valid credit or debit card on file, which will be charged for the amount due at the time of service and for any incurred fees, unless alternative arrangements are made with the practice in advance. It is my responsibility to keep this information up to date, including promptly updating it if my card information changes or if my account has insufficient funds to cover the charges.

NOTICE OF CANCELLATION

I acknowledge that scheduling an appointment establishes a contract between KPI and me. The reserved appointment time is intended for my convenience and to provide adequate time for discussions. Late cancellations require a minimum 24-hour notice. I understand that my Provider may charge a fee, which can be up to 100% of the hourly rate, at their discretion, for late cancellations or no-shows. These fees are not covered by insurance. Certain exceptions may apply. Repeated no-shows may result in the forfeiture of future appointments, with payment required before scheduling any additional sessions.

INSURANCE AUTHORIZATION

I authorize the release of all information necessary for insurance and payment purposes. Should I opt to use insurance benefits to cover services, I will need to share personal information with my insurance company. Insurance companies typically maintain the confidentiality of personal information, disclosing it only as required by law, to act on my behalf, comply with federal or state regulations, or fulfill administrative requirements. Before commencing therapy, I am responsible for verifying with my insurance company:

- Whether my benefits cover the type of therapy I will receive

- Whether my benefits cover in-person and telehealth sessions

- Whether I may have any financial responsibility

- Whether my Provider is in-network or out-of-network. If my Provider is out-of-network, I can still choose to see them, but all fees will be due at the time of my session. My Provider will inform me if they can assist with filing for reimbursement from my insurance company. If my insurance company denies reimbursement, I remain responsible for the full amount.

FAILURE TO PROVIDE INFORMATION

I understand that if I fail to release information or provide the information requested by a payer source, I will be responsible for payment at the full fee. My treatment will be maintained with the utmost confidentiality, with the release of information occurring solely with my informed, signed, and witnessed consent. The only exceptions to this are those required by law, including concerns related to sexual abuse, danger to oneself or others, or the treatment of minors. While we routinely consult with other professionals to enhance the quality of your care, we never disclose names or other identifying information, ensuring complete anonymity while maintaining your confidentiality.

RELEASE OF MEDICAL INFORMATION

I authorize KPI to release the necessary medical information to appropriate third parties for reimbursement purposes and/or to the person authorized to conduct service utilization reviews.

PRIVACY PRACTICES

I have received a copy of KPI's Privacy Practices or have waived my right to receive them.

PSYCHOLOGICAL REPORTS

Upon completion of a feedback session and payment of services, the parent/client will receive the original copy of the psychological report. It is the responsibility of the parent/client to distribute any additional copies to other requesting providers. 

RECORD KEEPING

Your Provider is required to keep records about your treatment. These records help ensure the quality and continuity of your care, as well as provide evidence that the services you receive meet the appropriate standards of care. Your records are maintained in an electronic health record provided by TherapyNotes. TherapyNotes has several safety features to protect your personal information, including advanced encryption techniques to make your personal information difficult to decode, firewalls to prevent unauthorized access, and a team of professionals monitoring the system for suspicious activity. TherapyNotes keeps records of all logins and actions within the system.

TELEPHONE/EMAIL CONSULTATION

I understand that telephone/email consultation may result in a charge at a prorated rate for that time. Please keep in mind that emails should only be used to inform a Provider of information. If you need feedback or have questions, you must schedule an appointment.

ELECTRONIC TRANSMISSIONS

I gave permission to exchange text messages and emails for scheduling and canceling appointments. 

COURT APPEARANCE

A separate contract agreement will need to be signed. Upon request, we will agree to write up a summary or statement for the purpose of court, however, our hourly rate of $400 will be charged. For subpoenaed court appearances, the fee is 250% of our hourly rate. Payment is required to retain our services.