Mindful Alternatives, Inc.Phone: (678) 884-4011

Rae Coley, LCSW Fax: (678)263-8511

370 East Lanier AvenueEmail:

Fayetteville, GA 30214Website:

CLIENT AND THERAPIST AGREEMENT

Listed below are my policies concerning fees, payment, and privacy as well as information on what you can expect during a session with me.

  1. My typical office hours are Monday: 4PM-6PM and Tuesdays-Thursdays: 10AM-6PM.
  1. All communication with me is strictly confidential. However, you may choose to provide written consent for me to talk with a family member, healthcare professional, etc. regarding your care.
  1. Professional guidelines and legal mandates require that I limit confidentiality if you indicate you are an immediate risk to yourself and/or others or you are abusing or neglecting a child, special needs, or elderly person. If you indicate an immediate plan to harm another, I have a duty to warn such person, and I may seek the resources of your loved ones, law enforcement, and/or family and child services agencies. Please know that my goal through our work together is to empower you and help you realize and utilize your natural strengths. Making decisions for you, especially without your consent, is the antithesis of how I prefer to provide treatment.
  1. When I work with children and adolescents, I maintain strict confidentiality. I determine what information is shared with parent(s) based on my assessment of the child’s best interests. When parent(s) would like specific concerns addressed in therapy, I ask parent(s): to share those concerns at the beginning of our session and to return at the end of the session so that the child may provide feedback regarding the identified concern. Of course, a family session can always be requested.
  1. Most therapy sessions are scheduled for 60 minutes; EAP sessions are 45-50 minute sessions.
  1. United Healthcare and its umbrella policies allow 45-50 minute sessions. They do not 60 minute sessions, unless prior authorization has been obtained, and then, only in very limited cases.
  1. I am dedicated to your care and growth. I need you to know that if at any point I realize your needs are beyond the scope of my expertise, it is my responsibility to make this known to you and help you find appropriate treatment. Likewise, please know it is your responsibility should you decide at any point during therapy with me that you would like to discontinue therapy.
  1. Please note that insurance companies have the authority to obtain my treatment plan for your care, session notes, diagnosis, and service dates. If at any time you prefer not to use your insurance due to confidentiality concerns and/or a preference to not have treatments and diagnoses on file with your insurance company or the Medical Information Bureau, I will ask for you to sign consent for me not to bill your insurance.
  1. Insurance companies only allow one 45 or 60 minute session per day. In the event that you would like to schedule a session for more time than your insurance allows, let me know the amount of time you prefer, so you may be scheduled for the extra time. In such cases, you will owe your co-payment, plus payment for the extra time based on our negotiated rate per hour. You will be asked to sign consent to for me to provide and privately bill you for the service not covered by your insurance.
  1. Sometimes insurance claims I file are denied, for reasons not shared with me at the time I check your insurance coverage. If the claim is denied, it is your responsibility to pay for your session at the rate negotiated between your insurance company and me. This rate is less than my full rate, and typically more than your co-payment.
  1. My telephone is typically answered between the hours of 10:00 A.M. and 6:00 P.M. Monday-Thursday. I make every effort to return phone calls within 24 hours Monday-Thursday. If you do not want me to leave a message on your phone, please say so in your voice mail. In the event of a life threatening emergency, never leave a message on my phone; rather call 911 immediately, Ridgeview's Access Center (open 24/7) @ (770) 434-4567 or 1(800) 329-9775or report to the nearest emergency room.
  1. Email and phone calls outside of sessions are intended primarily to address scheduling. Please know I do not provide therapy by phone or email and answer email, texts, and phone calls at my discretion. I often turn off my phone at the end of the work day. In the event of an emergency, please review coping strategies we have discussed, seek the support of a nurturing friend or family member, contact your physician or psychiatrist as needed, call any of the hotlines listed below, or in the case of a life threatening emergency call 911, or go to the nearest emergency room or access center for evaluation and treatment.
  1. Telephone calls over 15 minutes, letter writing, and report preparation will be billed at a rate of $100.00 per hour.
  1. Short or long term disability report preparation will be billed at a minimum of $150.00.
  1. My rate for one 60-minute session is $100.00 and my rate for a 45 to 50 minute session is $90.00.
  1. For missed appointments without 24 hour notice, there will be a $50.00 charge.
  1. For returned checks, there will be a $50.00 charge per check.
  1. Unpaid balances will be submitted to a collection agency.
  1. Signing this document indicates your consent that I may file claims to your insurance company and submit required information as mandated by your insurance company.
  1. Signing this document indicates your consent that I may send information to you by text, unencrypted email or postal mail.
  1. Please know that although I may be a provider with your insurance company at the time you begin treatment, I have the right to end my contract with your insurance company. In the event of such a decision, I will give you notice of at least one month so that we can make financial arrangements or find another therapist credentialed with your insurance provider.
  1. You have the right to view the information in the file I have for you. I do not release copies of session notes unless advised to do so by an attorney. There will be a charge for the release of session notes.
  1. You have a right to have a copy of this agreement. Please ask for a copy and one will be provided to you.
  1. I reserve the right to make changes to the above policies. I will make every effort to inform you as soon as possible when there are changes. However, there may be times when this is not possible, and I reserve the right to make changes without prior notice.

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Rae Coley, LCSWDate

National Alliance on Mental Illness (NAMI): (800) 950-6264

Georgia Crisis and Access Line:(800) 715-4225

National Suicide Prevention Lifeline:(800) 273-8255

Teen Helpline: (800) 400-0900

Adolescent Suicide Hotline: (800) 621-4000

Adolescent Crisis Intervention & Counseling Nineline: (800) 999-9999

Domestic Violence Hotline:(800) 799-7233

Child Abuse Hotline:(800) 422-4453

Drug & Alcohol Treatment Hotline:(800) 662-4357

Eating Disorders Center: (888) 236-1188

Panic Disorder Information Hotline:(800) 647-2642

Rape, Abuse, Incest, National Network (RAINN): (800) 656-4673

Updated October 2017