Unabridged Informed Consent – Minor Client

Last updated August 2023

Welcome

The decision to seek professional counsel for your child(ren) is an important and sometimes difficult step. We are honored you have chosen our group to walk with you and your child(ren) through this season. We will make every effort to bring our skills and resources to each session to enable your child(ren) to find solutions for their specific concerns.

Because of our Christian perspective, we offer therapy rooted in our belief in acceptance, compassion, and respect for each person. You and your child(ren) will not feel pressured or obligated to believe a certain way, but it is important you understand this perspective 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, it is important for us to reach a clear understanding of how this 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 child’s therapist.

Intake and Appointments

In-Office: Please check in with the receptionist at the beginning of each 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.

Remote: An adult will need to be in the room or easily accessible when we meet with a minor via telehealth. Before your scheduled appointment, you will receive a link to join the session. Please log in and join your telehealth appointment when it is scheduled to start. Click to join the meeting. You may be placed in a virtual "waiting room" prior to the therapist joining the session. Please make sure your environment and equipment are suitable. (See the telehealth consent form).

Before the first appointment, you will receive an intake packet through our portal system. Please have the intake documents completed prior to your child’s appointment. Your therapist will be notified once you complete the documents. If the documents are not completed by 8 AM the morning of your appointment, that appointment will be rescheduled.

Please note: If your child hasn't had session in a couple months and doesn't have an appointment scheduled, our system might make your portal account inactive. It has nothing to do with the 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 orient you and your child as to what you can expect during counseling. This session will involve beginning to gain an in-depth understanding of what brought your child to counseling. The first few sessions are also important for establishing rapport and setting some preliminary goals.

Appointments are usually scheduled for about 60 minutes once a week. In some circumstances, your child(ren) may need more or less than one appointment each week. Your therapist can discuss how often you will meet.

Schedules may fill up rapidly, so please consider scheduling several appointments to prevent gaps between sessions.

Joint Custody

Consent from all custodial adults is required to begin treatment. If that is not yet clear or there are extenuating circumstances, those circumstances must be discussed in the initial parent session before therapy with your child begins. Generally, in situations with high conflict, this conversation is even more important as the quality and integrity of the counseling process could be impaired.

In cases of joint custody, if there is a written agreement, please provide a copy of applicable sections to your child's therapist.

Account Responsibility

By consenting to treatment, you authorize Carolinas Counseling Group (CCG) to charge your credit/debit/health account card for professional services at the time of my scheduled appointment. 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. Your card information is secured by Amazon web services, there are no written copies, and the card number is not visible to the staff after it is entered. You understand that when counseling ends, all outstanding balances are due and payable.

This consent verifies that your credit card information is accurate to the best of your knowledge. If this information is incorrect or fraudulent or if your payment is declined, you understand that you are responsible for the entire amount owed and any interest or additional costs incurred.

In addition, you understand you will be charged based upon 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, or flex/HSA cards.

Account Responsibility for Joint Custody and Separate Households

In cases of separation or divorce, the party responsible for payment is not always clear. Even though we understand the possible difficulties, our administrative department cannot be responsible for resolving this complication. Please clarify at your first appointment whose insurance will be used (if applicable) as well as, who will pay for the sessions, missed appointments, and any other fees. If this is not clear or our staff have difficulty in this regard, further sessions may be suspended until this is resolved.

Missed Appointments

By consenting to treatment, you are financially responsible for all scheduled appointments unless canceled at least 24 business hours in advance. 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. Excessive missed appointments may result in termination of therapy. Your consent attests that you understand missed fees are NOT covered by your insurance.

Insurance Billing

If you plan to use insurance to pay for therapy, your consent authorizes CCG to release any medical information necessary to process an insurance claim, to your insurance company. You authorize your insurance company to assign benefits to Carolinas Counseling Group.

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 CCG’s 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 with your (or your child’s) coverage while you (or he/she/they) 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 client coordinators when you are scheduling to find out which insurance(s) your therapist accepts. It is your responsibility to understand 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

Therapy involves the possibility of both risks and benefits. Generally, there are no quick results. Therapy will require commitment and often hard work. It is impossible to guarantee you and/or your child will get the results you seek.

However, the benefits of therapy have been demonstrated in hundreds of well-designed research studies. Children who are depressed may find their mood lifting. Others may no longer feel excessively afraid, angry, or anxious. In therapy, clients have a chance to talk things out fully until their feelings are relieved or the problems are solved.

Clients are provided with tools, information and steps to overcome their problems. Client’s relationships and coping skills may improve greatly. They may get more satisfaction out of social, academic and family relationships. They may grow in many directions and family and social relationships improve.

But there are also risks such as experiencing uncomfortable levels of sadness, guilt, anxiety, anger, frustration, loneliness, helplessness, or other negative feelings. This can be very confusing and overwhelming for children. Your child 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 clients 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 or your child.

Play Therapy

Play therapy is a model of therapeutic intervention for children. It is different from regular play in that it includes a set of techniques conducted by a licensed therapist who has special training in play therapy. Think of play therapy as talk therapy for adults. It works because developmentally children have a limited ability to use words to describe what they are experiencing. Play Therapy assists children to express their needs, wants, and wishes in a way that is developmentally appropriate for them. The use of therapy toys allows children to externalize their emotions, making them easier to face and resolve. Play therapy may involve the use of therapeutic touch and/or contact. The ethical guidelines regarding touch are quite strict but please discuss this with your child’s therapist if you have any questions.

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 child's permanent insurance record. The diagnosis will indicate that your child has an “illness”. Some conditions or situations will not qualify for reimbursement. You are not required to submit a claim with 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 child’s diagnosis at any time from your therapist.

Couple, Family, or Parenting Sessions

Couple, family, or parenting 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. 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. Information from parenting appointments may be disclosed to the child. Your therapist will exercise discretion in both the content and how it may be discussed.

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 or your child may run into your therapist in another setting (i.e. grocery store, outdoor events, church, etc.). Your therapist will NOT be able to talk about your child’s therapy in those settings and may even be hesitant to greet you or your child 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. Please make this clear to your child. If you have any questions about this policy, please feel free to discuss it with your therapist.

Communication between therapist, parent(s), and child

The client portal (if available) is the best way to communicate with your child(ren)'s therapist. It is secure, and the therapist will be notified when you leave a message. 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 child(ren)’s therapist in crisis or emergency.

We will make every effort to appropriately include and communicate with the parent’s and families of our minor clients. We believe that the ideal treatment for children is in the context of their families. For children with unmarried, separated or divorced parents, it our desire to communicate with all custodial parents unless it is clear that contact might be problematic for the child’s safety or mental health. Parents are entitled to understand the nature of their child’s problem as well as the method and course of treatment. Generally both parents have access to their child’s medical records unless full custody has been awarded to one parent. In such cases, the most up-to- date custody agreement will be required.

That being said, privacy is essential for successful treatment. It is our hope and request that you allow your child(ren)’s therapist professional discretion about what is disclosed to you regarding your child(ren). This confidentiality is especially true for adolescents. Disclosure, especially if the relationship of the custodial parents is adversarial, can irrevocably damage a therapeutic alliance. If the therapist determines that there are significant safety or mental health issues that should be discussed, every effort will be made to schedule a session with parent(s) and/or your child(ren). If there is no imminent crisis, then the therapist will likely encourage your child to disclose any information to you - if that communication is developmentally appropriate. By signing to this consent, you agree to the therapist’s professional discretion regarding the disclosure of details.

If your child is an existing client and you are used to communicating with their therapist via email or text, please use the client portal system for future communications. We cannot guarantee the security of communication that is outside of the client portal.

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 (or your child[ren]’s) therapy may be involved in a 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 (or his/her guardian/parent) 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 (or his/her guardian/parent) 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.

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 child's needs are not being met. In that case, it may be possible to reevaluate the goals or approach if you discuss this with their 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 your child. Typically, this discernment would be done in the first few sessions, but sometimes it can happen later in the process. (4) It may be determined the particular treatment your child is receiving is not suitable; for example, if your child is coming to counseling once a week but really needs 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 your child to stop counseling, it is important to discuss this with your child(ren)'s counselor 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. You may also change therapists within the group.

Records

Therapists are required to keep a record of each session. The kind and amount of information will vary with different therapists. You can ask questions about your child(ren)’s counselor’s documentation. Your child(ren)’s 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 may be destroyed.

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 (over 18 or parents of clients, if client is under 18) 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 (the parent/guardian’s) written informed 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 911. There are services available that provide rapid response and follow up access to psychiatric help.

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 or 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/concern about Carolinas Counseling Group you can contact one the partners: Patti McMillan, David Russ, or Linda McGrew 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.