Consent to Treat: I authorize and give voluntary consent to participate in psychiatric and/or medical testing, evaluation, procedures, and treatment including group and/or individual services, and as appropriate to my presenting condition and as recommended by professionals. This could encompass ongoing diagnostic procedures, examination, and treatment including but not limited to, laboratory work (i.e. blood, urine, other), x-rays, and administration of medications as prescribed to me.
Healthcare Pledge: I understand that I will be encouraged to take primary responsibility, to the fullest extent possible, for my own health, including hygiene, medical, dental, and psychiatric care, including adherence to prescribed medication regime and/or treatment. This includes an at least annual physical examination and other specialty exams, tests, or procedures as recommended by professionals.
Right for Refusal: I understand that, at any time, I have the right to refuse medications, treatments, or services offered and I also understand that staff will continue to encourage and educate me about the importance of maintaining the medication, treatment plan and routine care for my physical and mental health that have been specified. I further understand that refusal of medications, treatments, or services might result in a decline in my health, thereby requiring emergency care or crisis intervention.
Payment for Services: If insured, COUNSELING CHOICES, PLLC can bill my insurance for the services I have elected; however, I understand that I am ultimately responsible for ensuring payment of these services. I also understand that COUNSELING CHOICES, PLLC will work with me to obtain the benefits and entitlements I need to pay for services. While registered as an COUNSELING CHOICES, PLLC individual, there will be no discontinuation of services while staff works with me to obtain the benefits and entitlements. If it is determined that I have no insurance coverage, I understand that COUNSELING CHOICES, PLLC offers a sliding fee schedule, in which the cost of these services may be reduced based on my personal data.
Co-payments: All co-payments, co-insurance, and deductibles are due and payable at the time services are rendered and are required by your insurance to be paid at each visit. There is a $25.00 charge on all returned checks. After receiving a returned check, COUNSELING CHOICES, PLLC can only accept cash, money order or credit card.
Cancellation/No Show Policy: While understanding there may be times an appointment is missed due to emergencies or obligations, COUNSELING CHOICES, PLLC requires at least 24 hours’ notice on all cancelled appointments. There is a $50.00 charge for failing to notify within 24 hours.
Rates and Changes: I understand that rates for services, or for any other financial item noted in this contract, may be subject to change at any time.
Part III: Discharge
Circumstances for Discharge: I understand that I am a voluntarily receiving services from COUNSELING CHOICES, PLLC and I may, at any time, discontinue services as I choose or be discharged from services when: