SIgn my Informed Consent For Treatment

Informed Consent for Treatment

Welcome to our practice and thank you for entrusting us with your care. At PPG we provide psychotherapy services to children, adolescents, and adults. Our clinicians are licensed to provide behavioral health services by the state of North Carolina. This document contains important information about our professional services and business policies. To avoid misunderstandings, it is important that you read these policies carefully, ask for clarification when needed and after reading this, sign and date this form.

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Name *

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Last

Address *

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City

State

Zip Code

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In case of an emergency who can we contact? *

First

Last

Date of Birth *

Email *

Is it okay to contact via email for billing or other issues? *

Yes No

If Minor (Name of Legal Guardian) *

First

Last

Cell Number *

Other Number *

Is it okay to leave a message? *

Yes No

Relationship to client *

May we contact your medical provider? *

Yes No

Emergency Contact Phone Number *

Name and phone no. of your medical provider *

Current Areas of Concern:
Please rate how the issue(s) below are affecting the following areas of the client’s life.
1= No Effect to Seldom Effect 2= Moderate Effect 3= Significant Effect

Depression &/or Anxiety *

WHAT TO EXPECT: Our first few sessions will involve an evaluation of your needs. During this time, we can both decide if I am the best person to provide the services you need in order to meet your treatment goals. Once psychotherapy has begun, we will usually schedule weekly or bi-weekly sessions. If, at any time, you feel dissatisfied with our sessions, please let me know, so we can discuss your needs and modify our approach as needed or direct you to alternate resources that may be helpful. We would like to offer support and guidance in all the phases of our work together, including when you decide to leave counseling. Ending treatment will work best if you give several weeks’ notice prior to actually leaving. The notice allows you to highlight your progress, review useful concepts and tools, and have a positive experience of completion.

SECTION 1 (FEES & COPAYS)
FEES AND PAYMENT:
Initial Intake Interview (Evaluation) - $175.00
Individual Therapy Session- $165.00
Family & Couples Therapy Session- $130.00
Late Cancellation Fee- $60.00
Returned Check Fee- $25.00
Documentation/Communication Letter or Form- $25 for 2 pages or less$125/hr for 3+ pages
Record Requests- $.50/page, 13-100 pages. (First 12 pages free)Court/Legal Appearances- $125/hr(Please refer to Court/Legal Appearances section for details)

Co-Payment and/or payment of services are due at the time of service. We accept checks, payable to "Peak Professional Group, LLC," cash and major credit cards including MasterCard, Visa, Discover, American Express & Flex Cards. We may file your insurance for you. Receipts for our services are made upon request. Please note that during the course of therapy, it may become necessary to increase fees to compensate for our overhead expenses. (Please type your name in the box below).

Initials *

SECTION 2 (INSURANCE)
I have read and understand that my insurance (if using insurance) may or may not cover the full session fees as described above and I agree to be timely (within 10 days of notice) in making payment arrangements if this is necessary. (Please type your initials in the box)

Initials *

INSURANCE: If you have a health insurance policy, it will usually provide some coverage for mental health treatment. With your permission, PPG will assist you as a courtesy to the extent possible in filing claims and ascertaining information about your coverage, but you are responsible for knowing your coverage and for letting PPG know if/when your coverage changes.
I understand I am responsible for knowing my insurance policy information and notifying Peak Professional Group, LLC of any policy/coverage changes. You should also be aware that most insurance companies require you to authorize PPG to provide them with a clinical diagnosis. Sometimes we may have to provide additional clinical information which will become part of the insurance company files. By signing this Agreement, you agree that PPG can provide requested information to your carrier if you plan to pay with insurance, including diagnosis and treatment provided. If you plan to use your insurance, authorization from the insurance company may be required before they will cover counseling fees. If you did not obtain authorization and it is required, you may be responsible for full payment of the fee. Many policies leave a percentage of the fee to be covered by the patient. Either amount is to be paid at the time of the visit by check, cash or credit card. In addition, some insurance companies also have a deductible, which is an out-of-pocket amount that must be paid by the patient before the insurance companies are willing to begin paying any amount for services. If we are not a participating provider for your insurance plan, we will supply you with a receipt of payment for services, which you can submit to your insurance company for reimbursement. Please note that not all insurance companies reimburse for out-of-network providers. If you prefer to use a participating provider, we can provide a referral for you.

I understand and consent to the release of information for the purposes of filing insurance claims and I understand that this information will include a diagnosis. I also understand that further information may be requested by the insurance company to make a determination regarding medical necessity. (Please type your initials on the line below)

Initials *

CANCELLATION POLICY: Once an appointment is scheduled, that time is reserved exclusively for you. If you are unable to make the appointment, please provide at least 24-hour notice so that you will not be charged the $60.00 cancellation fee and that time can be made available to someone else. We will waive that fee in the case of emergencies (e.g.) death in the family, contagious illness, unsafe driving conditions). Please note that we will not make exceptions for situations such as lack of babysitter, forgotten appointment or a sudden business meeting or time conflict.

I have read and understand that missed appointments or appointments not canceled at least 24 hours in advance will be charged the $60.00 fee (excluding Medicaid). (Please type/print your initials in the box).

Initials *

SECTION 4 (CONTACTING THE OFFICE)
CONTACTING THE OFFICE: Office Phone: (919) 335-3105 Fax : (919) 355-5694 Addresses: 800 W. Williams Street, Suite 280, Apex NC, 27502 Email- sarah@peakprofessionalgroup.com. Please note that email is not a secure form of communication and should not be used to discuss important issues that would best be discussed directly during our sessions. Please keep email correspondence limited to scheduling and administrative purposes. If we are unavailable for your immediate attention, please leave a message on our voicemail and we will make every effort to return your call by the next business day. For mental health emergencies, contact our after-hours crisis coverage line at (919) 412-5685 or proceed to your local emergency room. If your therapist will be unavailable for an extended period of time, we will notify you and provide therapeutic coverage with another PPG clinician, as needed.

Initials *

SECTION 5 (CONFIDENTIALITY)
CONFIDENTIALITY: In general, the law protects the privacy of all communications between a client and a therapist. In most situations, we can only release information about your treatment to others with written permission, but please note the exceptions listed below: If we have cause to suspect abuse and/or neglect of a minor child or an elderly or disabled adult, we are required to file a report with the appropriate state agency. If we believe you present an imminent danger to the health and safety of yourself or another, we may be required to disclose information in order to take protective actions, including initiating hospitalization, warning the potential victim, if identifiable, and/or calling the police. In response to a court order or where otherwise required by law. If a client files a complaint or lawsuit against us, we may disclose relevant information regarding that client in order to defend our practice. To the extent necessary for emergency medical care to be rendered. Finally, there are times when we find it beneficial to consult with colleagues as part of our practice for mutually professional consultation. The consultant is also legally bound to keep the information confidential. Some clients may choose to use technology in their counseling sessions. This includes but is not limited to online counseling via a HIPAA compliant video conferencing software/program, telephone, email, text or chat. Due to the nature of online counseling, there is always the possibility that unauthorized persons may attempt to discover your personal information. PPG will take every precaution to safeguard your information but cannot guarantee that unauthorized access to electronic communications could not occur. Please be advised to take precautions with regard to authorized and unauthorized access to any technology used in counseling sessions. Be aware of any friends, family members, significant others or co-workers who may have access to your computer, phone or other technology used in your counseling sessions. Should a client have concerns about the safety of their email, we can arrange to encrypt email communication with you.*Please note that if you are also seeing another provider in the practice, we have the right to discuss pertinent information that you may disclose with that provider to coordinate the best possible care. I have read and understand the exceptions to my confidentiality. (Please type/print your initials in the box)

Initials *

SECTION 6 (PROFESSIONAL RECORDS)
PROFESSIONAL RECORDS: The laws and standards of our profession require that our clinicians (behavioral health practitioners) keep Protected Health Information (PHI) about you in your confidential clinical record. It includes information about your reasons for seeking therapy, your diagnosis, the goals that we set for treatment, your progress towards those goals, your medical and social history, your treatment history, any past treatment records that we receive from other providers, reports of any professional consultations, your billing records, and any reports that have been sent to anyone, including reports to your insurance carrier. Except in unusual circumstances that involve danger to yourself and/or others or the record makes reference to another person (unless such other person is a health care provider) and your therapist believes that access is reasonably likely to cause substantial harm to such other person, you may examine and/or receive a copy of your clinical record, if you request it in writing.

Because these are professional records, they can be misinterpreted and/or upsetting to untrained readers. For this reason, we recommend that you initially review them in the presence of your therapist, or have them forwarded to another mental health professional so you can discuss the contents.
A separate consent form to release medical records must be authorized by the client before we can release any records. If your therapist refuses your request for access to your records, you have a right of review, which your therapist will discuss with you upon request.

Initials *

SECTION 7 (COURT/LEGAL APPEARANCES)
COURT/LEGAL APPEARANCES: Your clinician’s role at PPG is not intended to gather information for custody decisions, to determine parental capacity for the courts, or provide testimony in court cases. However, we understand that on rare occasions these situations may be unavoidable. If you anticipate needing court/legal appearances and would like a recommendation of someone who may be able to more easily participate, we can provide a referral to you.

I agree that I will make every possible effort to avoid calling upon my therapist to provide treatment records or to testify in a future divorce, custody or parental capacity action unless extenuating circumstances make such request unavoidable.
Should a court or legal appearance be required, the following fee schedule applies: clinician will be compensated for their time at a rate of $125/hr, to begin when clinician leaves office, includes all travel time to and from appearance location, and includes all duration of time present at appearance location regardless of time clinician is an active participant in proceedings. A $500 deposit is required to obtain these services, to be paid in full on the date clinician agrees to participate. If the total cost including all portions of time aforementioned totals less than the $500 already paid for deposit, the remaining funds will be refunded back to client in the form of a check. If time spent exceeds the $500 deposit, client agrees to make payment in full on remaining balance within 3 business days of the clinician’s appearance.

I understand that the outcome of the proceedings with my clinician’s involvement does not alter the fee schedule in any way, and all monies are to be paid in full regardless of proceedings being ruled in my favor or the opposing party’s favor. I understand that courts can appoint professionals who have had no prior contact with my family to conduct independent evaluations and make recommendations to the court. If such evaluation is required, your therapist can assist you in locating a clinician who is qualified to conduct such assessments. (Please type/print your initials on the line).

Initials *

SIGNATURES
I give my consent for Peak Professional Group, LLC to provide assessment, treatment and/or other services for the above named client. I reserve the right to withdraw consent at any time. I also reserve the right to refuse, at any time, any services offered to me. Additionally, in an emergency, I grant Peak Professional Group, LLC permission to seek emergency medical care from a hospital or physician.

Client/Parent/Legal Guardian Signature (typing in your name below is considered your legal signature):

Electronic Signature *

Signature Date *

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Informed Consent for Treatment

Informed Consent for Treatment

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