230 S. Court St.,Medina, OH 44256

avenuesofcounseling

andmediation, llc

230 S. Court St.,Medina, OH 44256

843 N. Cleve-Mass. Rd., Fairlawn, OH 44333

Ph: (330) 723-7977 Fax: (330) 725-5177

Relationship

I understand that the effectiveness of psychotherapy depends on the efforts of the client as well as the practitioner, and I promise to make my best effort to comply with those procedures. I understand that I am entering into a therapeutic relationship with a licensed professional. I understand that this professional may recommend that I complete other forms of treatment i.e. psychological testing, psychiatric evaluation, or clinical homework. I understand that I am fully responsible for the outcome of my treatment, and that results may vary based on adherence to such recommendations. I further understand that Avenues of Counseling & Mediation, LLC (AVC) is making no guarantees about the outcome of treatment, as the field of psychotherapy or psychiatry or hypnotherapy is based on individual response. In specific circumstances, a Clinician may offer a client a Teletherapy session, defined as the use of a HIPPA Compliant platform to video conference a session. The client is advised to discuss the option with their Clinician.

Cancellation Policy ** Initial ______

I understand that regular attendance will provide the maximum benefits but that I am free to discontinue treatment at any time. I will notify the Clinician at least 24 hours in advance if I will be unable to attend any session. If I fail to make such notification, I will be charged $100.00, which will not be reimbursed by my insurance company. I understand that I can call Avenues of Counseling & Mediation, LLC, 24 hours/7 days a week, and leave a message to cancel an appointment. In the event, I receive a text message reminder, I understand I CANNOT respond or cancel an appointment via text. After three no show appointments or less than 24 hour cancellations, Avenues’ may refer client out.

Confidentiality Policy

I further understand that conversations with the Clinician will almost always be confidential except in those circumstances in which failure to do so would violate other laws or result in clear and present danger to the client or to others. I understand that a mental health professional, by law, must report actual or suspected child abuse or neglect or elder abuse to the appropriate authorities. The Clinician has the legal responsibility to protect anyone that may be threatened with violence, harmful or dangerous actions (including those to myself) and may break confidentiality if such a situation arises. I understand that the mental health professional will make reasonable efforts to resolve these situations before breaking confidentiality. In addition, a Clinician will maintain professional boundaries with regards to social media (e.g. Facebook, text messaging etc.). Communication, correspondence and/or referencing through a social media source is discouraged due to confidentiality.

Appointments for Minors

At the first appointment for a minor, at least one biological parent must be present and bring a photo ID. AVC will need to match the signature on the ID with signatures on paperwork. AVC is ethically bound to verify a minor’s biological parents/guardian. A parent must remain present for the entire appointment for a child under 12 years of age. Parents must send a check/cash or have a credit card on file to be charged for copay/coinsurance for each session, or the appointment will be cancelled.

Payment Policy

It is necessary for all clients to pay their co-pay and coinsurance at the time of their visit, including balances. Otherwise your appointment will be cancelled. If you are unable to make your co-pay at the time of your scheduled visit, please reschedule more than 24 hours in advance to avoid a cancellation fee. Clients must pay balances in FULL within 10 days of receiving a statement or complete payment plan forms with a credit card to be charged on or about the 15th of the month with a minimum of $50.00. If your adolescent children are coming to visit us, please be sure they are prepared. I authorize Avenues of Counseling & Mediation, LLC to store & use my credit card to satisfy all unpaid balances or run at each session for copay, and to process any refunds that may be owed to me due to overpayment. I understand that Avenues of Counseling & Mediation, LLC will protect and keep my payment information secure and confidential.

Termination Policy

If we do not hear from you in 60 days, we will consider your file to be closed, with the understanding that you have the option to reopen your file at any time in the future if needed.

Patient Portal

Clients need to log into the Patient Portal to view balances or statements. I have granted permission to AVC to record my email, ______

(email address)

**Initial to receive Monthly Newsletters, re: additional services, groups, trainings & treatment options.

via email ______

01/2018

Financial Responsibilities **Initial ______

I understand that I am financially responsible for the cost of the psychological services or any portion of the fees not reimbursed by my health insurance. If mental health care is covered under the terms and conditions of my managed health care program in which the Clinician is contracted, my financial responsibility may be limited to the terms of the contract. Failure to pay these bills may result in collection procedures (including court proceedings) being taken against me by AVC or a collection agency contracted by same to collect these bills. I also understand that I will be responsible for any additional charges incurred by AVC to collect these bills. I agree that the adult bringing the child to the appointment will pay the copay or deductible expenses at the time of the visit.I also understand that I will be responsible for fees incurred due to the use of a collection agency, the filing of a subpoena or court related matter once there is court involvement including the Clinician’s professional time and/or representation by an attorney. I further understand that professional services may be discontinued to me by Avenues of Counseling & Mediation, LLC.

We are not forensic psychologists and therefore, do not conduct evaluations for the court system. If you become involved in legal proceedings that require our participation due to a court-ordered subpoena, you will be expected to pay for all of the providersprofessional time, including preparation and transportation costs, even if called to testify by another party. Because of the significant time and energy associated with legal involvement, AVC charges $350 per hour for preparation, travel and attendance at any legal proceedings.

The assessment fees and session fees are posted in the waiting area. Additional fees may be billed for extra services including treatment or case summaries and reports, court related proceedings, and phone calls lasting more than 10 minutes (including coordination of care with other professionals and phone calls to clients directly). Refills between appointments may be assessed a $20.00 fee at providers discretion. INSURANCE DOES NOT PAY FOR EXTRA TIME SPENT IN BETWEEN SESSIONS. AN HOURLY FEE WILL BE PRORATED BASED UPON THE SERVICES RENDERED. Psychiatrist fees range from $110.00-$350.00,the Psychiatrist decides codes based on the session. Clinical Nurse Specialist fees range from $75.00-$250.00. The Clinical Nurse Specialist decides codes based on the session. Psychotherapist fee (LISW, LPCC) is $145.00 for Assessment/$135.00 for a follow up. Psychologist fee (and LPC under a psychologist) for an Assessment is $170.00/$160.00 for a follow up. If you,a personal representative or an organization request a summary of care, we can do so with your written consent. A Records Search/Formsfee applies. It is the client’s responsibility to pay for extra services, prior to reports or copies being delivered. Though the privacy rule does afford patients the right to access and inspect their health records, psychotherapy notes are treated differently. The Clinician will determine release of the notes.

AcademicPsychological Services and Testing

I understand that insurance will often NOT cover academic services and academic/psychological testing. Services administered will be subject to payment at the time services are rendered. An estimation of the cost will be delivered to the client for a written signature of financial liability and paid prior to completion of all testing.The client must call their insurance to verify coverage and obtain pre-authorization for testing. The client is responsible for making sure an authorization is in place PRIOR to the services being rendered, or the client will be liable for the charges involved. Insurances may reimburse for portions of the testing, however AVC provides complete treatment according to the best Best Practices.

Grievance Procedure

You may contact the State of Ohio Counselor, Social Worker & Marriage and Family Therapist Board or the Ohio State Board of Psychology, OhioMedical Board, or Ohio Nursing Board.

Assignment & Release

I hereby assign my insurance benefits to be paid directly to Avenues of Counseling & Mediation, LLC. I am financially responsible for non-covered services and deductibles. I also authorize Avenues of Counseling & Mediation, LLC to release any information requested to my insurance company, managed care company, third party administrator or any other person or organization necessary in the submission, processing and approval of claims. My signature below indicates that I have agreed to all the above terms of this consent for treatment/professional services. In the event that my insurance company fails to observe Ohio prompt payment standards or otherwise fails to adhere to appropriate business standards, I grant permission to share information related to my insurance with the Ohio Department of Insurance.

I have been offered a copy of this consent and policy for my records.

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CLIENT/PARENT/GUARDIAN OR REPRESENTATIVESIGNATURE DATE

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ADDITIONAL ADULT PARTY SIGNATURE DATE

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PLEASE PRINT NAMES CLEARLY