---

The clinicians and staff of Lifestyle Therapy & Coaching appreciate the confidence you have shown in choosing us to provide for your health care needs. We are committed to providing you the best possible care. It is important to us that you fully understand your rights and responsibilities as our client. Please carefully read this document and attest with your signature below. All additional adult family members in treatment need to complete a copy of this form as well.

BUSINESS HOURS

Our normal office hours are currently Monday – Thursday from 8:10 AM to 6:00 PM and on Fridays 8:10-2:00 PM. Therapy & Coaching appointments are normally 50 minutes in duration. Appointments can be made by calling our office at (256) 850-4426 or online at www.lifestyletherapycoach.com.

EMERGENCY SERVICES

We are not available for emergencies or after-hours calls. If you have a history of frequent emergencies, or if you anticipate circumstances that will require emergency intervention, your needs will be better served by local providers who are designed to address these critical situations. If you do have an emergency while in treatment with us, you will need to use the available emergency options. Some of the emergency rooms in this area are: Crestwood Hospital – Huntsville Hospital – Decatur General West. You can also call Crisis Services at 256-716-1000 for 24 hour crises consulting.

TELEPHONE CALLS

If you have administrative questions or concerns, please leave a message at our answering service at (256) 850-4426. We generally return your call within one business day. Telephone and Skype consultations are billed at the regular rate.

As a provider of professional services, our role is to provide professional assessment and treatment to help you reach your goals. To establish and maintain a good working relationship, there are certain rights and principles, of which you should be aware. The goal is for you to have all necessary information prior to the start of treatment.

YOUR RIGHTS

1. You have the right to receive treatment from another provider.
2. You have the right to refuse treatment or to end treatment at any time without any moral or legal (except fee agreement) obligation.
3. You have the right to ask questions about everything that has taken place at any time with regard to administrative or clinical functions at our office.
4. You have the right to voice your opinion, recommendations and grievances in relation to policies and services without fear of interference, coercion, discrimination or reprisal.
5. You have the right to receive a copy of your records. However, a request for records more than likely indicates termination of therapy. Record requests cost $1 per page.
6. You have the right to continuity of care. If discharge, termination, or transfer becomes necessary you will be given adequate assistance and information to make the transition.
7. You understand that communication between you, as a client, and the professional is protected by law (HIPAA) and that we can only release information about our sessions to others with your written permission using a HIPAA compliant release of information form.
8. In most judicial proceedings, YOU have the right to prevent your counselor from testifying, however, in child custody and adoption proceedings and proceedings in which your emotional condition is an important element, a judge may require your counselor’s testimony. If you are involved in litigation, or are anticipating litigation, and you choose to include your mental or emotional state as part of the litigation, your counselor may have to reveal part or all of your treatment or evaluation records, impressions, and recommendations. You should seek legal advice regarding your specific legal matters.
9. If you are called as a witness in criminal proceedings, opposing counsel may have some limited access to your treatment records. Testimony may also be ordered in (a) legal proceedings relating to psychiatric hospitalization; (b) in malpractice and disciplinary proceedings brought against a mental health professional; (c) court-ordered mental health evaluation; and, (d) certain legal cases where the client has died. Our counselors are prohibited to testify in divorce proceedings where both parties have been seen by the counselor. You should seek legal advice regarding your specific legal matters.
10. There are some circumstances when a counselor is required to breach confidentiality without a client’s permission. This occurs if the counselor suspects the neglect or abuse of a minor, in which case he/she must file a report with the appropriate state agency. If, in your counselor’s professional judgment, it is believed that a client is threatening serious harm to another, he/she is required to take protective action that may include notifying the police, warning the intended victim, or seeking the client’s hospitalization. If a client threatens to harm him or herself, the counselor may be required to seek hospitalization for the client.
11. On occasion it may be helpful or necessary for your counselor to consult about a case with another professional. Our counselors in training consult with supervisors in our office to ensure they are following protocol and providing effective treatment. In these consultations, client confidentiality is maintained.
12. From time to time a counseling session may be recorded for the sake of therapeutic intervention or training. Recordings are kept confidential and your written permission will be required prior to recording.
13. In the case of third party reimbursement we are often required to provide the insurer with a clinical diagnostic impression and sometimes a treatment plan or summary.

The clear intent of these requirements is that your counselor has both a legal and ethical responsibility to take action to protect endangered individuals from harm when their judgment indicates that such danger exists. Fortunately, these situations rarely arise.

FINANCIAL POLICY

The services you allow us to provide imply a financial responsibility on your part. This responsibility obligates you to ensure payment in full for services. As a courtesy we can bill your insurance carrier on your behalf. However, you are ultimately responsible for payment for any and all services rendered by Lifestyle Therapy & Coaching. Your signature below forms a binding agreement between Lifestyle Therapy & Coaching and the client or responsible party, and authorizes Lifestyle Therapy & Coaching to: release to insurer any medical information necessary to process your insurance claims, and authorize payment of benefits directly to clinicians on your behalf.

INSURANCE

While the filing of an insurance claim is a courtesy that we extend to our clients, it is your responsibility to:

1. Bring your insurance card to each visit,
2. Notify our office of any changes to your insurance information.
3. Know your co-pay and deductible and be prepared to pay at the time of each visit,
4. Know your insurance benefits and coverage,
5. Determine if your clinician(s) are network providers prior to first visit,
6. Pay for any remaining amount not covered by your insurance policy.

PAYMENTS

1. All payments, co-pays, co-insurance, and deductibles are due PRIOR to services being rendered.
2. Procedures, services and products which are excluded from insurance coverage, based on your plan’s determination of medical necessity, will be your responsibility.
3. Over payments will be refunded after all charges have been processed and paid by your insurance company. A refund check or credit to your card will be applied or mailed within 30 days of your request.
4. If you miss more than two appointments without calling or rescheduling, you may be terminated from treatment. There is a $75 fee for sessions not cancelled within 24 hours. There is a $35 charge for NSF.
5. Clients are responsible for programs, packages and coupons whether or not they use the allotted sessions. Refunds may take up to 60 days to be processed. No refunds on assessments taken. No refunds on programs or packages after treatments begins.
6. A late fee of 15% of unpaid balances will be assessed each month. We initiate collections after 60 days of non-payment. Should collection proceedings or other legal action become necessary to collect an overdue account, the client/responsible party, understands that Lifestyle Therapy & Coaching has the right to disclose to an outside collection agency all relevant personal account information necessary to collect payment for services rendered. The client/responsible party understands that they are responsible for all costs of collections including, but not limited to, all court costs and attorney’s fees. A collection fee will be added to the outstanding balance.

ATTESTATION

I have read the above authorization and understand it.

I acknowledge that I am responsible to discuss the following with my healthcare provider:

1. The condition that the treatment is to address;
2. The nature of the treatment;
3. The risks and benefits of that treatment; and
4. Any alternatives to that treatment

I recognize that I have the opportunity to ask questions and receive answers regarding the treatment at any time.

I consent to the treatments offered or recommended to me by my healthcare provider. I intend this consent to apply to all my present and future care from all professionals at Lifestyle Therapy & Coaching. I accept responsibility for all agreed upon fees for services, programs and products I utilize at Lifestyle Therapy & Coaching. If there happens to be any medical emergency while in treatment at Lifestyle, if there is any physical or mental incapacity on my part I give permission for clinicians and staff to act on my behalf.