Living Well Counseling and Wellness Policy and Procedures
It is important to go over a few policies and procedures. Please read carefully the following information. You will be required to acknowledge your reading and understanding of the policies and procedures of Living Well Counseling and Wellness before submitting this form.
As the financial responsible person for the account, I understand my initial appointment for
I understand I will be financial responsible for any charges. I acknowledge that I accept these terms for services for mental health treatment, marriage and family therapy or other wellness services.
I understand I will be charged and am required to pay for phone consults with the therapist which last longer than 15 minutes or longer unless the call is a free initial 30-minute consultation. Fees are based on the 50-minute psychotherapy clinical hour and are prorated accordingly.
I understand I shall keep all scheduled appointments, unless a personal emergency occurs. In this situation, I will give at least 24 hours notice of my intention to cancel my appointment.
I understand if I do not cancel my appointment at least 24 hours notice or fail to show for my scheduled appointment, the FIRST time this occurs, I will NOT be charged. However, if this should occur a second time, I understand I will be charged. I understand I will be required to pay for the psychotherapist’s full fee for service missed.
I understand and agree that I am ultimately financially responsible for all fees described in this agreement.
Insurance Reimbursement Information
At this time, we do not accept insurance. However, we will provide you with a “superbill”. You can submit this form to your insurance company for reimbursement. We would be considered an out of network provider. If you are unsure about whether your policy covers mental health care (some do not), please contact your personnel/HR department or by calling your insurance company directly.
Most PPO plans will reimburse you for some portion of the cost of your sessions, as long as you or your spouse meet the clinical criteria for a reimbursable disorder. Upon your request, our office will provide you with a receipt to file with your insurer. To determine your coverage, you may contact your insurer and ask the following questions:
90801 (initial visit)
90806 (1 hr. individual counseling)
90847 (1 hr. couples counseling)
In order to use your insurance benefits, you will need to meet the reimbursable diagnosis (e.g. dysthymia, generalized anxiety disorder, depression, etc.). We can discuss this further at your initial session.
As a result of the lack of respect demonstrated by most insurers related to client privacy and confidentiality, I have minimized participation on managed care provider panels.
All fees are due at the time of your session. Please sign below to indicate that you understand our office policy regarding insurance and payment.
Notice of Privacy Practices
As required by the Privacy Regulations Created as a Result of Health Insurance Portability and Accountability Act of 1996 (HIPPA)
Notice of Privacy Practices Receipt and Acknowledgement of Notice
I hereby acknowledge that I have received and have been given an opportunity to read a copy of the “Notice of Privacy Practices” of Living Well Counseling and Wellness. I understand that if I have any questions regarding the Notice of my privacy of rights, I can contact Living Well Counseling and Wellness.
This document is intended to clarify in writing some of the issue we may have already discussed verbally that need to be brought to your attention regarding our professional relationship. I have found it is best to specify the content of our therapy relationship by making a mutual agreement in order for you to receive the service you desire. Be assured that I am aware and respectful of your basic rights as a consumer and that I will respond to your needs in the most highly ethical manner, according to the standards of care for my profession. I remain personally and professionally committed to providing you with the highest quality of service.
As a client of Living Well Counseling and Wellness, I have certain rights which are:
To participate voluntarily in treatment with your therapist and to terminate at any time without penalty.
To understand that “treatment” could include individual or conjoint therapy for up to 60 minutes (a therapy hour) conducted by your licensed therapist with no absolute guarantee of your desired results by your therapist.
To participate with your therapist in exploring and setting your treatment goals and discussing possible benefits and risks.
To have reasonable access to your therapist.
To have information available to you regarding your therapist’s professional license and credentials as well as access to the ethical guidelines or “Standards of Practice” in Mental Health Counseling. Your counselor is licensed under Florida Statute 491 of the Board of Clinical Social Work, Marriage and Family Therapy, and Mental Health Counseling of the Agency for Health Care Administration in Tallahassee, Florida.
To be aware that your therapist works in private practice at 7334 Berry Ave., Jacksonville, Florida 32211.
To have all records and other information concerning your involvement with this office held in strict confidence and all communication with your therapist privileged, which means that no information is ever to be released to a third party without your written permission. Certain exceptions are: if you are in clear and imminent danger to yourself and others, in child abuse and neglect cases, therapist’s subpoena or court order, or if there is a medical emergency.
As a client/consumer, I have carefully read over and signed all of the policies regarding financial responsibilities, making, keeping and cancelling appointments with this therapist and this agreement.
Consent and Authorization for Treatment
I consent to and authorize the assessment and/or treatment I will receive as a client/patient of Living Well Counseling and Wellness. I have read the policies of this office and received a copy of them. I understand these rules and policies and agree to follow them.
Please type your name below to indicate consent to treatment.
If the patient is a minor, the parent or guardian must sign below to consent to the minor receiving treatment.