Unabridged Informed Consent – Adult Client

Last updated July 2023

Welcome

The decision to seek professional counsel is an important and courageous step. We are honored you have chosen our group to walk with you through this season of life. We will make every effort to bring our skills and resources to each session in order to help you find solutions for your specific concerns.

Because of our Christian perspective, we offer therapy that stems from our belief in acceptance, compassion, and respect for each person. It is our desire that you will not feel pressured or obligated to believe a certain way, but it is important you understand our Christian faith is foundational to our approach.

All of our therapists are credentialed and licensed to practice in North Carolina, however, we are not physicians, and cannot prescribe medication.

The therapeutic relationship is unique in that it is highly personal. Given this uniqueness, it is important for us to reach a clear understanding of how our relationship will work and what each of us can expect. This consent will provide a clear framework for working together. Feel free to discuss any of this with your therapist.

Intake and Appointments

In Office: Please check in with the receptionist at the beginning of your session. If you are coming after the reception office is closed, please take a seat in the waiting area, and your therapist will come to get you.

Telehealth: Prior to your scheduled time, you will receive a link to join the appointment. Please log in and join your telehealth appointment when it is scheduled to start. You may be placed in a virtual "waiting room" prior to your therapist joining the session. Please make sure your environment and equipment are suitable. (See the telehealth consent form).

All paperwork must be completed by 8 AM the morning of your appointment or your appointment will be rescheduled.

You can schedule using the portal, calling the office, or checking with the receptionists before or after your appointment.

Please note: If you haven't had a session in a couple of months and don't have an appointment scheduled, our system might make your portal account inactive. It has nothing to do with your relationship with your provider or CCG. It is a feature of our scheduling system. Please contact the front desk and your account will be reactivated.

The initial session will help you gain an in-depth understanding of what brought you to counseling and what to expect going forward. The first few sessions are also important for establishing a working relationship, rapport, and setting some preliminary goals.

Appointments are usually scheduled for about 60 minutes once a week. In some circumstances, you may need more or less than one appointment each week. Your therapist can discuss how often you will be seen. Schedules may fill up rapidly, so please consider scheduling several appointments to prevent long gaps between your sessions.

Account Responsibility

By consenting to treatment, you agree to make payment for all services rendered at the time of service. You can pay in-office or through the client portal. If you have credit/debit card information on file, the card will be charged for the session. You understand that when counseling ends, all outstanding balances are due and payable.

In addition, you understand you will be charged based on the amount of time you are with your therapist, and you also agree to the fees listed in this consent. You agree that any additional time (consultations, reports, letters, email, etc.) will be prorated and charged to you at the normal rate, and these will NOT be paid by your insurance company.

Carolinas Counseling Group (CCG) also reserves the right to forward your information to a collection service if there is a default on any payment obligations described in this agreement.

Payments can be made with cash, check, credit/debit cards, and flex/HSA cards.

Missed Appointments

By consenting to treatment, you are financially responsible for all scheduled appointments unless canceled at least 24 business hours in advance. If the appointment you wish to cancel is on a Monday, please cancel on the previous Friday. It is very hard to fill an appointment if the cancellation happens over the weekend. If you do not cancel within the 24-hour time frame, you agree to pay $75 for the first three missed appointments and full fee for subsequent missed appointments. Excessively missed appointments may result in the end of treatment or referral to another provider. Your consent attests that you understand that missed fees are NOT covered by your insurance.

Insurance Billing

If you plan to use insurance to pay for your therapy, this consent authorizes CCG to release any medical information to your insurance company that is necessary in order to process an insurance claim. (Typically this will include a diagnosis and the dates of the submitted appointments.) You are therefore authorizing your insurance company to assign benefits to CCG.

You understand you are responsible for payment for services regardless of reimbursement by your insurance company. You understand that CCG will charge fees in accordance with our agreement with the insurance company. In addition, you agree to pay for any non-covered or unauthorized services. You agree to notify CCG if there are any changes to your coverage while you are an active client.

We cannot guarantee payment of benefits by your insurance company. Claims are subject to all plan provisions and terms. Payments are determined by many factors, including eligibility, limitations, exclusions, and conditions of the plan. Final benefit determination of claim payments will be made at the time the claim is processed. We do not file for services not authorized by your carrier. Therefore, NON-COVERED or UNAUTHORIZED services are paid according to the fee schedule below, and you will be responsible for the full amount. If the insurance information provided is inaccurate resulting in a denial of your claim, you will be responsible for the amount of the claim. If you attend an appointment without verification of your coverage, you will be responsible to pay the private pay fee for services at the time of your visit.

Not every therapist is a provider on every insurance panel. Please check with the receptionists when you are scheduling to find out which insurance(s) your therapist accepts. It is your responsibility to understand the limitations, deductibles, and exclusions of your plan. For benefit coverage questions, please call the customer service number on the back of your insurance card.

Benefits and Risks of Counseling

The research demonstrating that counseling is effective is extensive and clearly proves it is effective in so many ways. Here is a good summary. Nevertheless, therapy involves the possibility of both risks and benefits. Generally, there are no quick results. Therapy will require commitment and often hard work. There is every reason to be hopeful, yet It is impossible to guarantee you will get the results you seek.

Clients are provided with tools, information, and steps to overcome their problems. The client’s relationships and coping skills may improve greatly. They may get more satisfaction out of social and family relationships. Their personal goals and values may become clearer. They may grow in many directions—as individuals, in their close relationships, in their work or education, and in the ability to enjoy their lives.

There are also risks such as experiencing uncomfortable levels of sadness, guilt, anxiety, anger, frustration, loneliness, helplessness, or other negative feelings. Some people recall unpleasant memories. Clients may have problems with people important to them. Family secrets may be told. Problems may temporarily worsen after the beginning of treatment. Most of these risks are to be expected when people are making any important changes in their lives. Finally, even with our best efforts, there is a risk that therapy may not work out well for you.

Use of Diagnosis

Insurance companies will require a diagnosis of a mental health condition before they will agree to reimburse you. Any diagnosis made will become part of your permanent insurance record. The diagnosis will indicate that you have an “illness”. Some conditions or situations will not qualify for reimbursement. You are not required to use your insurance if you do not want this information reported. In that case, you will be responsible for the entire session fee based on the fee schedule below. You may request information about your diagnosis at any time from your therapist.

Relationship between Client and Therapist

It is natural in a counseling situation for a valued relationship to develop between therapist and client(s). However, in order for the most professional and best quality therapy to occur, the discussion of counseling issues must be confined to a professional setting. You may run into your therapist in another setting (i.e. grocery store, outdoor events, church, etc.). Your therapist will NOT be able to talk to you about your therapy in those settings and may even be hesitant to greet you with familiarity. This restriction is to protect your privacy and keep the relationship professional. Relationships that develop in counseling will not be able to continue once counseling has ended. This is mandated by the ethical guidelines of our profession.

Your therapist will NOT be available for phone consultations between sessions unless you make specific arrangements. Phone or electronic (e.g., email, text) consultation will be charged at the listed rate. Your therapist will not connect to you via social media and please do not try to connect with or follow your therapist on personal social media. If you have any questions about this policy, please feel free to discuss it with your therapist.

Communication with your Therapist

You will not be able to call your therapist directly. All calls go through our receptionists. Voicemail is available but may not be checked routinely. Messages will be returned as soon as possible during normal business hours. Voicemail will not be monitored after hours and should not be considered as a means to contact your therapist in a crisis or emergency.

If you are an existing client and are used to communicating with your therapist via email or text, please understand we cannot guarantee the security of communication. If you do have access to personal phone numbers, please do not use that as a method to communicate about therapeutic issues.

Court and Legal Action

Because of the adverse impact on the therapeutic relationship, by consenting to treatment, you agree that, should there be any legal proceedings (such as, but not limited to divorce, custody, injuries, lawsuits, etc.), neither you nor your attorney (or anyone acting on your behalf) will call on your therapist to testify in court or any other proceeding. Additionally, you agree that you will direct your attorney NOT to subpoena or request psychotherapy records as part of an adversarial legal action.

Our services are designed to assist in alleviating problems through assessment and/or the process of psychotherapy. CCG providers do NOT perform court evaluations, nor do they appear in court on behalf of individuals, children or adults. If there is the possibility that your therapy may become involved in legal or court action, please inform your therapist as soon as possible. A referral can be made to a clinician that is trained appropriately.

CCG therapists are not trained for, nor do they maintain records with the intended purpose of court involvement. In addition, the legal process is such that we may be compelled to reveal information about you that could affect you negatively or undermine your relationship with your therapist. Because the client-therapist relationship is built on trust, with the foundation of that trust being confidentiality, it is often damaging to the therapeutic relationship for the therapist to be asked to present records to the court or testify - whether factual or in an expert nature - in court or deposition.

In the event that it is necessary by court order or subpoena for the therapist to testify before any court, arbitrator, or other hearing officer at a deposition - whether the testimony is factual or expert - or to present any records pertaining to the counseling relationship to a court official, the client agrees to pay the therapist for his or her services (including but not limited to: travel, necessary expenditures [copies, parking, meals, and the like], time spent speaking with attorneys, reviewing records and preparation of reports) at the rate of $250.00 per hour, rounded to the nearest half hour. The client further agrees to pay a retainer fee of $1,500.00 one week prior to the appearance, presentation of records, or testimony requested. Checks are not an acceptable form of payment for these services.

According to General Statute 50-5.1, 50-6, 50-7, 50-16.2A and 50-16.3A, if either or both parties have sought and obtained marital counseling by a licensed physician, psychologist, psychological associate, clinical social worker, or marriage and family therapist, the person(s) rendering such counseling shall not be competent to testify in the action concerning information acquired while rendering such counseling. In other words, if you saw a therapist for marriage counseling, that therapist is not considered a competent witness about anything that was part of the therapy.

Length and End of Counseling

It is difficult to judge the length of therapy. Your counselor may be able to give you some idea regarding the possible length, but it is just an estimate. The end of therapy can happen for different reasons: (1) A natural ending occurs after goals are reached. (2) You may feel your needs are not being met. In this case, it may be possible to reevaluate the goals or approach if you discuss this with your therapist. If not, referrals can be offered to you. (3) You and/or your therapist may determine she or he is not the best fit for you. Typically, this would be done in the first few sessions, but sometimes it can happen later in the process. (4) It may be determined that the particular treatment you are receiving is not suitable; for example, if you are coming to counseling once a week but you really need intensive outpatient or inpatient treatment. (5) You may have other reasons or circumstances that lead to your decision that are not related to counseling.

If you think you want to discontinue counseling, it is important to discuss these feelings with your therapist before you make a decision. However, you have the right to end counseling at any time and are not required to give an explanation to the counselor. After counseling has ended, you may return later for additional counseling sessions.

Records

Therapists are required to keep a record of each session. The kind and amount of information will vary with different therapists. You may ask questions about your counselor’s documentation. Your records are not shared with anyone unless noted in the privacy section. We are required to keep a copy of your records for 7 years for adults and 7 years after the 18th birthday of a minor. After that, the records will be destroyed.

However, when you elect to use insurance, we do not have control over and cannot assure confidentiality of anything provided to your insurance carrier, meaning employees of the insurer and employees of contracted organizations of the insurer may have access to your information.

A client record remains the property of CCG. However, clients may have access to information contained in the file, except in those cases where the release of such information may be deemed harmful to the client’s well-being.

Information can be released to others only upon your written consent. In the event of request for transfer of records, the records will be forwarded upon completion of a Release of Information Form.

Emergencies

The therapists at CCG are not on call. We do not have specific access to or privileges at any hospitals. We will do our best to respond to emergencies, but we do NOT provide 24-hour coverage. If you or a family member has an emergency, please call 988.

Couple and Family Therapy

Couple and family counseling differ somewhat from individual counseling. The couple or family unit is the “client,” and your therapist’s first priority is to the marriage/parental relationship. Your therapist will work hard to be impartial and not favor an individual. Often, there are good reasons to see members of a couple or family individually, or in smaller groups, such as just the parents or just the children. Even at those times, the focus is on the relationship.

Confidentiality policies also change in couple or family counseling. Asking your therapist to keep secret disclosures from others in the family puts the therapist in a difficult position. Generally speaking, anything shared in couple’s counseling is available to both parties. Sometimes, relationships do not work out. Only you and your partner can make the final decision to marry, separate, or divorce. If your relationship changes or you need individual therapy, your marriage therapist may need to refer you.

All the participants in couple or family therapy must sign the consent, privacy practices and fill out background questionnaire documents.

Unattended Children

We are unable to provide supervision for children in the waiting room and cannot accept responsibility for their safety, if left unattended. For the safety and welfare of the children and out of consideration for others, please make arrangements for childcare during therapy sessions or provide adult supervision for children in the waiting room.

Parents will be held responsible for any property damage caused by their child. If a child is too disruptive the session may be interrupted or if necessary, ended.

Private Pay Fees

The following fees represent the maximum charge for any single session or service. Typically the most sessions that someone might have in the course of a year is 52, or once a week. If you would like a specific estimate of your fees and length of treatment, please request that from your therapist. You have the right to request a good faith estimate of the cost of your treatment. Fees are subject to change.

Master/Doctor

Initial Appointment (90791) $170/$200

Therapy 53-60 min. (90837) $150/$180

Therapy 38-52 min. (90834) $125/$160

Therapy 16-37 min. (90832) $75/$105

Group Therapy 60-90 min. (90853) $60/$90

Assessments (96130/96136) $150/$180

Missed Appointment $75/Full Fee after 3rd miss (Not billable to Insurance)

Returned Check/Card Declined $40 (Not billable to Insurance)

Calls, Email, Letters, Reports regarding treatment $35/$45 (per 15 minutes) (Not billable to Insurance)

Court & Legal Activity if compelled $1500 retainer $250hr. (including prep & travel)

Complaints

It is our hope that if you have a serious complaint/concern with your therapist you will discuss that with him or her and try to resolve it. If you are still dissatisfied or have a complaint about Carolinas Counseling Group you can contact one the partners at 704-752-8414. If you feel your complaint is unresolved you have the right to contact the respective licensing board.

For Licensed Clinical Mental Health Counselors:

North Carolina Board of Licensed Clinical Mental Health Counselors,

P.O. Box 77819, Greensboro, NC 27417

Phone: 844-622-3572 or 336-217-6007, Fax: 336-217-9450, E-mail: complaints@ncblcmhc.org

For Marriage and Family Therapists:

North Carolina Board of Marriage and Family Therapists,

P.O. Box 37669, Raleigh, NC 27627.

Phone: (919) 469-8081, Fax: (919) 336-5156, Email: ncmftlb@nc.rr.com

For Psychologists:

North Carolina Psychology Board,

895 State Farm Road, Suite 101 Boone, NC 28607

Telephone: (828) 262-2258, ExecutiveDirector@NCPsychologyBoard.org.

Online complaint form: http://ncpsychologyboard.org/data/documents/Complaint_form_online-submission.pdf

For Social Workers:

North Carolina Social Work Certification and Licensure Board,

P.O. Box 1043, Asheboro, NC 27204, 336-625-1679 or go to https://www.ncswboard.org/page/complaintdisciplinary-process.html.

For Licensed Clinical Addiction Specialists

North Carolina Addiction Specialists Professional Practice Board

Online complaint form: https://www.ncsappb.org/ethical-complaint-form/