Informed Consent for Treatment

This agreement contains important information about the professional services and business policies.  It is important that you read this Agreement carefully and that you discuss any questions you may have.  When you sign this document, it also represents an agreement between us.

PSYCHOTHERAPY SERVICES

Psychotherapy is not an exact science and success in therapy is dependent upon many factors that reside within the client (i.e., motivation for change), some that reside within the therapist (i.e., particular skills and techniques), and some that result from the interaction and match between therapist and client.

INFORMED CONSENT

I, agree and consent to participate in behavioral health care services offered at and provided by Crystal Counseling and Coaching, LLC, via Teletherapy Video or Telephone.  I understand that I am consenting and agreeing only to those services that the provider is qualified to provide within the scope of the provider’s license, certification, and training.  If the patient is under the age of eighteen or unable to consent to treatment, I attest that I have legal custody of this individual and am authorized to initiate consent to treatment, and I am legally authorized to initiate and consent to treatment on behalf of this individual.

I, agree that there will be no voice or video recording of sessions without consent from all parties, including the clinician.

BILLING AND PAYMENTS

You will be expected to pay $225.00 for each 50-minute session, (48) hours prior to the beginning of the session.  We accept payment in the form of the credit card.

There will be a $75.00 charge for each returned charge.

CANCELLATION & DISCHARGE POLICY

All appointments must be canceled at least twenty-four (24), Business Hours prior to your scheduled appointment. Failure to do so will result in a missed appointment fee of $225 for each missed session.  If I arrive 20 or more minutes late to my therapist’s appointment, I will be charged the missed appointment fee.

Discharge Practices: Unless other arrangements have been made in advance, our policy to assist you is based on the frequency and continuity of the therapeutic relationship. Therefore, if there has been no service or contact within thirty (30) Business Days the relationship is considered terminated.

RELEASE, ASSIGNMENT, AND FINANCIAL RESPONSIBILITY  

1. A) I accept financial responsibility for all clinical and administrative services provided by Crystal Counseling and Coaching, LLC. My financial responsibility explicitly includes, but is not limited to, initial evaluations, individual therapy, marriage counseling, couples counseling, group therapy, assessments, professional fees, attorney fees, or collection fees if my account goes to a third party.
2. B) Ancillary services, including but are not limited to, writing a letter or phone calls are billed at $225.00/hour.
3. C) Your treatment or that of your child is based on our mutual understanding that I will not go to court. Treatment success is based on trust and our mutual ability to maintain nondisclosure of court except as required by law. Any request or plea for me to appear in court for any reason will be billed at the following rate: A $7,000.00 non-refundable fee is due 60 days in advance of file review and preparation of court. In addition to any court preparation fees, services such as (i.e., court appearance, conveying information to the court, letters to an attorney, and other related tasks), are billed at a rate of $500.00/hour in addition to travel costs.
4. D) I acknowledge that Crystal Counseling and Coaching, LLC may in accordance with applicable State Codes, release limited information related to my medical, mental health, or other information necessary to business associates including billing and insurance providers and or to the extent required for the purposes of collection.
5. E) In many cases, there is a need for us to exchange information with other parties, such as treating physicians. If, and when this occurs, it will be necessary for you to sign a HIPAA release for this to take place.
6. F) Any dispute arising from this Agreement shall be determined in accordance with the laws of Virginia. Parties agree to Jurisdiction and Venue in Loudoun County, Virginia.

CONFIDENTIALITY

Confidentiality rules for Licensed Professional Counselors convey that communication between a client and Licensed Professional Counselor is privileged (confidential) and, in general, may not be disclosed to anyone without your prior written consent.  There are, however, some exceptions to your privilege of confidentiality.  Even without your consent, I may be required to disclose certain information if: (a) you are under 18 years of age and your parents request access to your records; (b) there is a serious threat of physical violence to yourself or a third party or a serious threat of substantial damage to real property; (c) there is reason to suspect that a minor child (under age 18) or an incapacitated adult is being or has been subjected to abuse or neglect; (d) if the Department of Behavioral Health Professions or Division of Consumer Affairs is conducting investigations, we will be required to cooperate and allow access to your records.

MINORS & PARENTS

Clients under 18 years of age that are not emancipated, and their parents should be aware that the law allows parents to examine their child’s treatment records unless it is decided that such access is likely to injure the child, or we agree otherwise.  Because privacy in psychotherapy is often crucial to successful progress, particularly with adolescents, it is often my policy to request an agreement from parents that they consent to give up their child’s records.  If the parent agrees, we will provide them with general information about the progress.  Under ethical requirements, I may be required to disclose information compelled by a court of competent jurisdiction. Although we encourage all minors to allow parental participation in therapy, any sensitive communication to the parents will require the child’s knowledge, unless we feel that the child is in danger to him or herself or to someone else.  In this case, we will notify the parents of our concern.

CONTACTING US

Every effort is made to ensure that each phone call made to our office is answered.  The hours that phone calls are returned are between 8:30 a.m. – 5:00 p.m. Monday – Friday.  Voicemails are returned within a 24-hour turnaround.  In case of an emergency, please contact 911, or go to your nearest emergency room.