Informed Consent | NewLeaf Counseling of the River Valley

Therapeutic Contract, Fee Schedule, and Informed Consent
for NewLeaf Counseling of the River Valley, Inc.

Client’s Legal Name:

Relationship to Client:

Select Assigned Therapist

Legal Guardian Name (if client is a minor):

Client’s Phone Number:

Place of Service

1. By checking the boxes below, I, the above-named client, or legal guardian of the above-named client, hereby express I have read and understand FEES AND LENGTH OF THERAPY, and agree to enter therapy with the above ASSIGNED THERAPIST for as needed 50-minute sessions during the next year consent.

I understand

1a. I (or my current health insurance provider) agree to pay the standard fee of $217.00 for each completed Individual/Family Session (prorated for longer sessions), or $222.00 for a Diagnostic Evaluation. I will make payment in cash, debit or credit card at the time of the therapy appointment, unless we have made other arrangements and said arrangement has been documented in my chart. I agree that I am financially responsible if my insurance company denies any payment on any claim made on my behalf for my, or my dependent’s, treatment. I understand that I can leave therapy at any time and that I have no financial (except what has accrued), legal, or moral obligation to complete therapy services in this contract. I am contracting only to pay for completed therapy sessions, sessions I miss without providing 24-hour notice, no-shows, and telephone time as delineated further down in this contract.

I agree

1b. Court Related Fees: Mental Health Therapists do not normally make court appearances. If court ordered (subpoenaed), the therapist is legally bound to comply with the court order. However, the charge of $3,500.00 per day for any court related activities will be charged to the client/attorney requesting the court order, regardless of whether or not the therapist actually testifies or not. This includes any court order (subpoena) from opposing counsel/attorney, seeing as this particular situation is contingent on the client signing a release of information legally authorizing the opposing counsel direct access to their case including, but not limited to: release of diagnostic evaluation, progress notes, demographic information, as well as the possibility of the therapist having to testify concerning information pertaining to the client’s mental health record and/or clinical observations. By signing such a release of information, the client is assuming financial responsibility in the case of an opposing counsel/attorney requiring the therapist to testify as to their mental health record. This includes an additional cost for travel to and from court. The therapist will block their schedules for a minimum of four (4) hours, unless otherwise notified ahead of time to block out more time, whether the therapist actually testifies or not. The entire fee must be paid prior to the therapist leaving the office for the court date. In addition, a fee of $500.00 an hour will be charged for having to testify at a deposition, as well as an additional charge for travel expenses to and from the deposition., whether the therapist actually testifies or not. Since there is no way to determine the length of time a deposition will take, a minimum of two (2) hours will be blocked off on the therapist’s schedule and will be charged before the therapist leaves for the deposition. Any additional time will be charged immediately after the deposition, unless prior arrangements have been made between the client and the therapist and have been formally documented in the client’s chart. The therapist will not be on-call for court testimony or depositions without receiving retainer for the time scheduled to be on-call at the rates mentioned above. We do not apply scholarship assistance to time spent making court appearances. We reserve the right to file a complaint with the Arkansas Bar Association for non-payment if necessary.

I agree

1c. If the therapist prepares correspondence or documentation for you during a therapy session, the normal fee will be applied for the session. However, a $220.00 per hour prorated fee will be charged for all correspondence prepared outside of clinical sessions. If the therapist must prepare a letter for immigration purposes a set fee of $600.00 will be charged for said letter or documentation. You will be charged $20.00 for copying and forwarding records if correspondence is not necessary, but this does not include Explanation of Benefits (EOB’s) or copays, seeing as this is information that your insurance supplies.

I agree

1d. Telephone Time: After 5 minutes of telephone time, you will be charged a prorated fee at your regular fee of $217.00 per hour for the time incurred. Therapists do not normally speak to attorney’s over the phone, but if a situation requires for this type of communication to occur a prorated fee of $185.00 per hour will be charged to you, and you will be held responsible for this fee.

I agree

2. By checking the boxes below, I, the above-named client, or legal guardian of the above-named client, hereby express I have read and understand CONSENT FOR TREATMENT terms, and agree to enter therapy, under these terms, with the above ASSIGNED THERAPIST during the next year consent.

I understand

2a. I authorize Bryant O. Prieto, MS, LPC-TA, NCC to carry out psychological examinations, diagnostic procedures, and/or treatments that are advisable now or during the course of my treatment as a client. I understand that the purpose of any procedure will be explained and be subject to my agreement.

I authorize

2b. I acknowledge that no guarantees have been made to regarding the results of this treatment.

I acknowledge

2c. I understand that within the scope of this treatment there is no intent to cause detrimental effects to the individual.

I understand

2d. I understand that I may withdraw consent for treatment at any time.

I understand

2e. The consent is effective for one year from the day of my approval.

I agree

2e. I have read and fully understand the terms of this Consent for Treatment

I understand

3. By checking the boxes below, I, the above-named client, or legal guardian of the above-named client, hereby express I have read and understand CONSENT FOR TELEMENTAL HEALTH/ONLINE COUNSELING terms, and agree to enter therapy, under these terms, with the above ASSIGNED THERAPIST during the next year consent.

I understand

3a. I have received and/or reviewed a copy of the Informed Consent for Telemental Health/Online Counseling, and I authorize Bryant O. Prieto, MS, LPC-TA, NCC to carry out therapeutic/counseling treatments that are advisable now or during the course of my treatment as a client by means of Telemental Health Counseling services.

I authorize

3b. I have read and understand the points concerning Telemental Health Counseling, and by signing below I agree to everything and express understanding.

I understand

3c. I understand that I may withdraw consent for treatment via Telemental Health Counseling at any time.

I understand

3d. The consent is effective for one year from the day of my approval.

I understand

3e. I have read and fully understand the terms of this Consent for Telemental Health/Online Counseling.

I understand

4. By checking the boxes below, I, the above-named client, or legal guardian of the above-named client, hereby express I have read, understand, and acknowledge that I have read and understand the following forms to my fullest capability, and acknowledge that I have:

I understand

4a. Received and/or reviewed a copy of the Notice of Privacy Practices, have the right to make changes in writing to this acknowledgement, or the right to refuse to sign this acknowledgement.

I have

4b. Received and/or reviewed a copy of the No Show/Cancellation Policy, and accept its terms.

I have

4c. Received a copy of the Client Handbook which has been communicated to me in a meaningful way. Furthermore, I have read and understand the information contained within the Client Handbook in its entirety and further certify that I agree to the terms and provisions stated therein.

I have

No, I am not a Medicaid Client

4d. Reviewed the Office Communications Policy and understand that any information that I send/receive to/from Stonehaven via text messaging, email, or other means such as Facebook Messenger is not secure per the requirements of the Health Information Portability and Accountability Act of 1996 and that any data sent thereby could be compromised.

I have

By signing below, as well as validating my signature by uploading a copy of my State ID, I express I have fully read and accept the terms of the THERAPEUTIC CONTRACT, FEE SCHEDULE, AND INFORMED CONSENT FOR TREATMENT. Furthermore, by signing below, I fully agree to enter therapy with the above ASSIGNED THERAPIST for as needed 50-minute sessions during the next year consent. I understand that there is a ZERO-TOLERANCE policy in place for violence or mistreatment of the staff or therapists of NewLeaf Counseling of the River Valley, Inc. and that violating such policy, or any of the policies of NewLeaf, is sufficient cause for termination of services.

I agree

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Client, or Legal Guardian Signature (if client is minor), as on State Issued ID

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Therapeutic Contract, Fee Schedule, and Informed Consent for NewLeaf Counseling of the River Valley, Inc.

Therapeutic Contract, Fee Schedule, and Informed Consent
for NewLeaf Counseling of the River Valley, Inc.