CONSENT FOR TREATMENT, PAYMENT, AND HEALTHCARE OPERATIONS

ADULT

Please correct the errors described below.

Professional Disclosure: I understand that my counselor is a Master’s level mental health clinician, practicing with a license issued from the State of Arkansas and not a medical doctor, or a doctor of Psychology. My counselor’s primary role is to provide professional counseling services. If I have questions, I am welcome to ask for clarification of my counselor’s credentials, specializations, and training.

Risks and Benefits: I am aware that there are both risks and benefits to counseling. While most people experience some level of distress that leads them to seek counseling, it should be understood that when a counselor and client are working towards the goals of counseling, distress, problems in relationships, and other unforeseen circumstances may arise. It is also understood that a goal of counseling will be to alleviate or manage these potential stressors, but an exacerbation of problems may occur. The benefits of therapy may include, but are not limited to, the diminishing of symptoms, distress, relationship growth and a general sense of well-being. However, individual results are not predictable and may vary.

Limits of Confidentiality: I understand that confidentiality is not absolute, that in some circumstances my counselor may be required by law or by the ethical standards of the American Counseling Association to share information about my case. Information may be released without my consent in situations where there is reason to believe I might harm myself or others, in the case of actual or suspected abuse of a child, elder or handicapped person. For the purpose of case consultation, my information may also be discussed with others associated with Still Waters Family Counseling and/or with supervisors/other supervisee.

Emergency Notification: My counselor can be called in the case of psychological emergencies. However, he will not always be available by phone or in the evenings. If I cannot reach my counselor I can call 911 or go to the nearest emergency room.

I have read and understand the above information and agree to receive counseling for myself or for my child. I also give consent for my mental health clinician to leave a voicemail, text my phone, or contact me via email, as needed.

CLIENT DEMOGRAPHICS

EMERGENCY CONTACT

EMPLOYMENT INFORMATION (OPTIONAL)

CONSENT TO FILE INSURANCE ON YOUR BEHALF

Please provide copy of insurance card with paperwork

Primary Insurance Information:

If you know…

Secondary Insurance Information (If applicable)

If you know…

I consent to have Still Waters Family Counseling file insurance on my behalf.

Please Note: Any insurance coverage quoted by our staff is not a guarantee until your insurance company reviews the claim to determine actual coverage.

FEE SCHEDULE AND AGREEMENT

  • Initial Intake Session: $165.00 (60 minutes)
  • Individual/Family Counseling: $165.00 (60 minutes)
  • Professional Consultation $110.00 (45 minutes)
  • Paper Work for 3rd Party: $50.00
  • Court Appearance: $2,500.00 (per day includes all prep work)
  • Document Creation: $50.00
  • Coping/ Mailing/ Faxing of Records: $20.00
  • Late Cancellation/ No Show Fee: $75.00
  • Assessment: $15.00 (per assessment)

Prices subject to change. Clients are responsible for payment of all fees. We will be happy to submit an insurance claim for you or provide you with a receipt for submitting your insurance claim. However, clients are ultimately responsible for payment of their bill. Fees are payable at the time of service.

Your appointment time is reserved for you alone. Due to the nature of the services provided filling an appointment time on short notice is nearly impossible. So, we ask that (expect in cases of actual emergencies) you give us at least 24-hour notice for appointment cancelation or rescheduling. The missed appointment fee will be charged for any appointment canceled or rescheduled without a 24-hour notice or if the appointment is missed without notice. Habitual canceling, rescheduling or not keeping of appointments may result in loss of services.

If payment becomes problematic for you, we are willing to work with you on an individualized payment agreement.

I have read and agree to the terms of the above fee policy.

I would like to use the following credit/debit cared for the purposes of making automatic payments. (optional)

Miscellaneous Information

A reminder does not replace your responsibility to keep your appointment. Our cancellation policy still applies. Since your appoint time is for you alone we ask that you give us 24-hour notice for cancellation or rescheduling. Chronic canceling or rescheduling, even with 24-hour notice, may result in application of the missed appointment fee or loss of future service. Please make every effort to keep your appointment.

INCLEMENT WEATHER POLICY

We understand that weather my affect your ability to make your appointment. Still Waters Family Counseling will not be opened when Fayetteville Public Schools are closed for inclement weather. Every effort will be made to give rescheduling priority if the clinic needs to close. If inclement weather affects you differently, please contact us. You will not be charged the broken appointment fee.

CHILDREN IN THE LOBBY

We understand that childcare may not be available or may fall through at the last minute. If needed infants and toddlers may stay in the session with you. We asked that you keep in mind that our staff members have duties they need to perform and may not be able to give your child supervision. We do offer a Lego table and books for older children.

PERSONAL INFORMATION

Marriage Information:

List all others living in your home:

History of the Presenting Problem or Complaint

Medical History

Recent Weight Changes:

Medication(s) taken for anxiety, nervousness, depression, or related types of problems

Primary Care Physician

Consent:

I give my counselor Consent to Release Information to my Primary Care Physician.

Crisis Information:

Religious Background

Still Waters Family Counseling
3980 W. Wedington Dr. # 9 Fayetteville, AR 72704
Phone (479) 263-7602
stillwatersfamilycounseling@gmail.com
Fax (479) 443-2892

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