I, ________________________________ (Client) agree to engage Charles Hughes, LCPC (Counselor) to provide counseling or psychotherapy services as follows:
Individual Psychotherapy or counseling
Partner Counseling or Family Counseling
I understand and agree to the following terms: Date: _________________________
This document contains important sections of my INFORMED CONSENT, SOCIAL MEDIA POLICY, AND HIPAA NOTICE. The full documents may be viewed on my website or my online office.
Cost of Services
Payment for Services is due at the time of service and will be at the rate stated on the FEE SCHEDULE on the reverse side of this agreement. If you are using insurance, your insurance company sets the fee amount for your services. You are responsible for paying any amount denied by the insurance company including co-pays, deductibles, and services not covered by your policy. You will be billed for these amounts if not paid at the time of service. You are encouraged to call your insurance company to inquire about the benefits under your policy.
The Counselor shall treat all information provided during the counseling sessions as confidential. No information obtained during the counseling sessions will be given to an outside person or organization without written release from the Client. If the Client is a minor, the release must be co-signed by the minor’s legal guardian.
Exceptions to Confidentiality
The Client understands that the Counselor may disclose statements indicating the intent of a Client to harm him/herself or a threat to another person or the commission of criminal acts. If the Client is a minor, the counselor may make this disclosure to the Client’s legal guardian as well as other potentially affected parties.
The Client understands that the Counselor is a mandated reporter under the Illinois Abused and Neglected Child Reporting Act and the Elder Abuse and Neglect Act. The Counselor is required by law to report any reasonable suspicion of child or elder abuse or neglect
Under the Illinois Concealed Firearm Carry Act, if I believe you would be a “clear and present danger” to the public when carrying a firearm, I may be required to report this to The Illinois Department of Human Services.
If I am under 18, I understand that my parents have the right to know the date, time and place of my appointments, services provided, my diagnosis if any, and follow-up care if any.
Waiver of Confidentiality Between Couples
If you are in Partner (Couples) Counseling, the Counselor may want to see each of you one on one. You understand that, at the Counselors discretion, anything you say in a one-on-one session may be brought up in joint session by the Counselor.
Insurance and Diagnosis
The Client understands that if insurance is being used in payment of services, it will be necessary to show a mental health diagnosis in the requests for payment to the insurance company.
Notice of a Reschedule or Cancellation
Notice of a rescheduled appointment or a cancellation must be given not less than twenty four hours in advance of the appointment. The client understands that insurance will not pay for missed or cancelled appointments. If client misses or cancels an appointment with less than 24 hours notice, client will be billed for the service. See fee schedule.
Termination of Counseling
Counseling is a voluntary process. Any person in counseling may terminate the counseling at any time. If the client is a minor and terminates counseling or fails to come to a scheduled counseling session, the Counselor will disclose this to the Client’s legal guardian.