Professional Counselors of Lansing
913 W. Holmes Road., Ste #A125
Lansing, MI 48910
Office Number (517) 394-0929
Fax Number (866) 268 -7774
INFORMED CONSENT
SESSIONS: Sessions will be 45-50 minutes for individuals. Families or psycho-educational groups will be 60 to 90 minutes on a weekly basis. As we progress, the time between sessions may decrease to every other week. The number of weeks of therapy is decided mutually. Some insurance companies limit the number of authorized sessions for therapy. A separate fee schedule will be provided.
POSSIBLE RISKS OF THERAPY: The benefits of therapy can be increased understanding, self-confidence, control and accomplishments of goals. However, there may be some risks involved. Painful memories or feelings can be recalled. You may decide to change aspects of your life, which could result in changes in relationships with friends, family or others. We can work together to resolve any difficulties that therapy may cause.
TERMINATION: You may choose to leave therapy at any time, however, it is best if this decision is discussed with me and planned in a mutual way. I may recommend certain alternatives to therapy such as workshops, reading materials, or support groups. I may also refer you to a different therapist.
COMPLAINTS: If you feel your rights as a client have been violated, or I have handled your case unethically, I would hope that the issue could be resolved between the counselor and client. If not, you have the right to file a complaint through the State of Michigan – Department of Licensing and Regulatory Affairs P.O. Box 30670, Lansing, MI 48909. (517) 335-0918.
MISSED APPOINTMENTS: Appointments must be cancelled at least 24 hours before the schedule time. True emergencies will be waived. Missed appointments without proper cancellation will be charged a $50 fee per occurrence. After two missed appointments, sessions will be postponed.
REACHING ME BY PHONE: When I am in the office, please keep in mind that I could be on the other line, or with a client. Please leave your message and I will return your call as soon as possible. Telephone calls lasting over 15 minutes will be charged at a rate of $1.00 per minute. For after-hours non-emergency concerns, please leave a voice mail at (517) 394-0929. In the case of a life-threatening emergency, call 911, or Community Mental Health Crisis number (517) 346-8460.
INSURANCE COVERAGE: Before our first appointment, it is your responsibility to communicate with your insurance company. You will want to confirm that I am covered by your insurance, amount of any deductible, the amount of your co-pay and the number of allotted sessions. I will communicate with your insurance company to obtain authorizations for treatment and to secure payments. If for any reason, your insurance company does not pay for therapy service. IT IS YOUR RESPONSIBILITY TO PAY ALL FEES DUE.
CONFIDENTIALITY: Our office complies with the Health Insurance Portability and Accountability Act of 1996 (HIPAA). You may request a copy of Consent to Use and Disclose, and Health Information and Notice of Privacy Practices at any time. No one other than clerical staff and your counselor will have access to your information without your consent to the extent allowable by Michigan law. Information shared is strictly confidential with the exception of threat of harm to self or others including suicide, homicide & sexual abuse, insurance billing or collection of past due payments.
EMERGENCIES: Please call 911 or Community Mental Health Crisis Services at (517) 346-8460.
CONTRACT: I have read and accept that conditions of this Professional Disclosure Statement & have received a copy of the fee schedule. This office may request permission to coordinate your care with your primary care physician. If needed, do you give permission for this office to communicate in writing, electronically or over the telephone with your primary care physician?
Yes No
Printed Name: ______Signature: ______
I/We consent that ______a minor, be treated by Professional Counselors of Lansing.
Parent or Guardian: ______Date: ______
Beverly Boatley-Rainey, MA, LLPC., FLE, NCC
MI Licensure #6401014380