Barnum Counseling New Client Contract and Financial Agreement

Client Contract and Financial Agreement

This form is called a Consent for Services (the “Consent”). Your counselor has asked you to read and sign this Consent before you start therapy. Please review the information. If you have any questions, contact your Provider.

As a client, you have the right to know your counselor’s qualifications, methods, and mutual expectations of our professional relationship. The information presented here is provided to help you decide if these services are suitable for your needs at this time.

Ali Barnum is the founder of Barnum Counseling and has been practicing for over 11 years in the mental health field. She obtained her Master of Arts Degree in Clinical Professional Psychology from Roosevelt University and is a Licensed Clinical Professional Counselor in Illinois. You may contact her directly with specific questions regarding her individual approach and training.

As a part of best clinical practice, Ali participates in individual and group supervision/consultation with other therapists where she discusses and collaborates on cases to provide the best support for her clients.

THE PROCESS

During the initial meeting together, your therapist will assess your current needs and concerns. Together, you will collaboratively decide if the therapeutic relationship is a good fit. If you decide to move forward, your therapist will periodically evaluate the results of your work together with you, to determine the need for additional sessions, termination, or an outside referral for further assistance.

APPOINTMENTS

Sessions are usually 45-60 minutes in length. Most individuals begin the therapeutic process by attending therapy weekly. Occasionally, based on recommendations, some people may attend therapy more often. Others may reduce frequency once progress is made and skills are gained.

BENEFITS AND RISKS

At Barnum Counseling, we tailor our approach to your individual needs. We use a variety of evidence-based techniques and therapeutic approaches, considered “Best Practices” in our industry. These techniques may include but are not limited to dialogue; interpretation and cognitive reframing; awareness exercises; psychoeducation; exploration of your history, emotions, thoughts, beliefs and relationship patterns; self-monitoring exercises; visualization exercises; journal-keeping and bibliotherapy.

As part of your work with us and in order to support your goals, we may also request that you consult with other healthcare providers such as primary care physicians, psychiatrists, group therapists, and/or nutrition counselors, or ask that you participate in movement therapy. We will discuss the pros and cons of these various alternatives upon recommendation.

Sometimes, counseling has the potential to evoke uncomfortable or painful thoughts and feelings. This may be because you have tried to avoid thinking about them or you have not thought about them in a long time. Bringing them to the surface in counseling can be temporarily overwhelming at times. Also, making changes to your thoughts, beliefs or behaviors can be scary and sometimes disruptive to the relationships that you already have established. You may also find your relationship with your therapist to be a source of strong feelings, some of them painful at times. It is important that you carefully consider the benefits to making changes. Many people who make the choice to participate in therapy find it to be helpful and healing.

CONFIDENTIALITY

Please understand that while most of our communication is confidential there are circumstances when disclosure can occur without your prior consent. The following are typical, but not exhaustive, examples of situations and circumstances under which information may be disclosed without prior consent:

• You are a danger to yourself or someone else.
• In situations of suspected child, spouse, or elder abuse, it is the duty of the mental health provider to notify medical, legal, or other authorities.
• You disclose sexual contact with another mental health professional.
• If you are involved in legal action/proceedings, your records may be subject to subpoena or lawful directive from a court.
• Your therapist is ordered by a court-appointed judge to disclose information.
• You direct your therapist in writing to release your records.
• Your therapist is otherwise required by law to disclose information.

TELEHEALTH COUNSELING

Telehealth counseling is similar to face-to-face counseling, except sessions are conducted either over the telephone, or over the internet using a platform that can be accessed through your computer or mobile device. Although face-to-face counseling is the preferred approach for conducting therapy, electronic forms of counseling can provide therapy services for clients when there are extenuating circumstances.

Benefits/Limitations of Telehealth Counseling

Electronic forms of counseling can be a helpful alternative approach to traditional, face-to-face counseling. At the same time, there are some limitations that could impede the therapy experience.

Some of the benefits include:

• Flexibility for individuals that work excessive hours and experience trouble meeting traditional business hours
• Accessibility for individuals with disabilities, limited transportation or limited childcare options
• May be ideal for those residing in rural areas
• Comfort for people experiencing social anxiety issues
• Other extenuating circumstances such as a global pandemic

Some limitations include:

• Not appropriate for those with a history of severe/chronic mental health issues and/or suicidal/homicidal ideations/attempts except in extenuating circumstances
• Some confidentiality limitations
• Not all insurance providers reimburse Telehealth Counseling (contact your provider)
• Potential for connections to be disrupted or disconnected
• Possibility of miscommunication due to limited body language cues and/or misinterpretation of tone of voice/inflection.

PLEASE NOTE THE FOLLOWING POLICIES REGARDING TELEHEALTH SESSIONS:

• AUDIO AND/OR VIDEO RECORDING OF SESSIONS IS STRICTLY PROHIBITED
• UNLESS YOU ARE PARTICIPATING IN COUPLES/FAMILY COUNSELING, YOU MUST ATTEND YOUR SESSION ALONE IN A QUIET, PRIVATE AREA, WITH MINIMAL DISTRACTIONS
• FOR YOUR SAFETY, DRIVING AN AUTOMOBILE DURING YOUR SESSION IS STRICTLY PROHIBITED

USE OF SECURE PLATFORMS

As a practice, Barnum Counseling utilizes Therapy Notes, our HIPAA-compliant partner, for the completion of intake documents, updating of documents, and completion of other forms electronically. The platform is also used for scheduling, documentation, practice management, billing and record-keeping purposes. Additionally, our practice uses Spruce Health to facilitate secure, HIPAA-compliant communication with our clients. As secure communication with our clients is best practice, your therapist will invite you to join Spruce through a Spruce link which can be accessed on a mobile phone, tablet, or desktop computer. Our practice also requires downloading of the Spruce App (free to use) to your phone to support secure communication. Further, our practice uses Swipe Simple, a secure platform for payment processing.

TERMINATION

If your therapist initiates termination of therapy with you, it will be because:

1) They feel that they are no longer being helpful to you

2) You have reached your therapy goals

3) A more appropriate type of care or level of care is required

4) Non-payment of services or refusal to pay an outstanding balance

5) You discontinued contact with your therapist for greater than 90 days

Ending therapy well is important. If you feel ready to terminate counseling, please inform your therapist so that you can have 1-2 wrap-up sessions to discuss recommendations to maintain your progress.

UNDERSTANDING THE COUNSELOR-CLIENT RELATIONSHIP

• Please note: your therapist does not provide 24-hour crisis counseling. Should you experience an emergency necessitating immediate mental health attention, you will immediately call 9-1-1, or 9-8-8, or the crisis hotline, National Suicide Hotline 630-482-9699, or go to an emergency room.

• Please understand that during the time we work together we may meet weekly, bi-weekly or monthly for approximately 1 hour. While our sessions may be very intimate psychologically, ours is a professional relationship rather than a social one.
• Please understand our contact will be limited to scheduled phone or secure video counseling sessions.
• Please understand email/text correspondence is not a guaranteed, confidential method of communication. If you are interested in communicating securely with your therapist, you will download the Spruce Health App to your phone/desktop.
• Please note that in utilizing email, SMS or Spruce for secure communication, your therapist cannot offer advice. Please use electronic communication for scheduling/cancellations only.
• Please understand that your therapist does not accept invitations from current or former clients via social networking sites (LinkedIn, Twitter, FB, Instagram, etc.) for ethical reasons.
• Please understand that at any time, you may initiate a discussion of possible positive or negative effects of entering into the counseling relationship and specific results are not guaranteed although benefits are expected from counseling.
• Please note that you are in control of the counseling relationship and may choose at any time to end our therapeutic relationship.
• Please understand that our paths may cross in social situations, but our therapeutic relationship comes first, along with protection of my confidentiality. This means your therapist will not initiate public greetings.
• Please understand that because your therapist is licensed solely in the state of Illinois, you are unable to receive services by them if you are outside of the state and they are unable to provide services to you while out of state.

RECORDS

• All of your sessions and communications with your therapist becomes part of your clinical record. Records are the property of Barnum Counseling. These records help ensure the quality and continuity of your care, as well as provide evidence that the services you receive meet the appropriate standards of care.
• Your records are maintained in an electronic health record provided by TherapyNotes. TherapyNotes has several safety features to protect your personal information, including advanced encryption techniques to make your personal information difficult to decode, firewalls to prevent unauthorized access, and a team of professionals monitoring the system for suspicious activity. TherapyNotes keeps records of all log-ins and actions within the system.
• The practice is required by law to keep adult client records for seven (7) years after a client has stopped receiving services. The record will be shredded per medical record disposal requirements after seven (7) years.
• Please note: in Illinois, by law, children ages 12-17 have the right to confidentiality. Anything discussed in session AND/OR their progress notes will not be released without the minor’s consent.
• If you are interested in a copy of your record, you must make this request in writing. If someone makes a request for your record on your behalf and you have authorized this, there may be a fee associated with sending another individual or organization your record. These fees are set by the Illinois Comptroller.

FEES AND PAYMENT FOR SERVICES

Payments and copayments for services are required at the time services are rendered. In the event that you are utilizing your insurance and we are in-network, you will receive an adjusted rate according to our contract with your insurance company. However, we will bill your insurance our standard rate(s) for the service that is rendered. Before starting therapy, you should confirm with your insurance company if:

• Your benefits cover the type of therapy you will receive; • Your benefits cover in-person and telehealth sessions;
• You may be responsible for any portion of the payment; and • Your Provider is in-network or out-of-network.
• Sharing Information with Insurance Companies
• If you choose to use insurance benefits to pay for services, you will be required to share personal information with your insurance company. Insurance companies keep personal information confidential unless they must share to act on your behalf, comply with federal or state law, or complete administrative work.
• Covered and Non-Covered Services
• When your Provider is in-network, they have a contract with your insurance company. Your insurance plan may cover all or part of the cost of therapy. You are responsible for any part of this cost not covered by insurance, such as deductibles, copays, or coinsurance. You may also be responsible for any services not covered by your insurance.
• When your Provider is out-of-network, they do not have a contract with your insurance company. You can still choose to see your Provider; however, all fees will be due at the time of your session to your Provider. Your Provider will tell you if they can help you file for reimbursement from your insurance company. If your insurance company decides that they will not reimburse you, you are still responsible for the full amount.

EXPLANATION OF OUT-OF-POCKET EXPENSES

Case Management Fees

Included, but not limited to: client phone and email correspondence, coordination of care with other professionals or providers, composition of formal letters, reports, production of medical records for a third party.

Case management fees must be paid at the time of service or prior to Barnum Counseling/your therapist releasing the associated case management document(s)

10-15 minutes $35 16-20 minutes $50 21-30 minutes $75 31-40 minutes $95 41-50 minutes $125 51-60 minutes $150

Cancellation and No-Show Policy

• I understand that should I, at any time during the course of my treatment, need to cancel or change an appointment time, I will need to do it 24 hours in advance of the appointment time or be charged $110 for the hour, since it has been reserved for me and without sufficient notice is unavailable for another client. EXCEPTIONS ARE EMERGENCIES OR FEVER/SICKNESS. Please also note: this is not a charge which can be submitted to insurance.
• After three consecutive cancellations, I understand that Barnum Counseling will no longer be able to hold my reoccurring appointment slot and at this point, will discuss my options with my therapist.

Legal Fees

• I understand conducting expert witness and testimonial services is not an area of interest of my therapist and should I subpoena my therapist as a factual case witness or involve my therapist in any court-related processes, my therapist charges a retainer fee of $2,000.00 with an additional $250.00 every hour she/he is involved in legal depositions, case preparation, travel, and witness time.
• I understand if I do issue my therapist a subpoena without his/her approval, my subpoena will be directly turned over to the practice attorney and a bill will be rendered to me for immediate retainer fee payment ($300/hour).

CLIENT/RESPONSIBLE PARTY ACKNOWLEDGEMENT AND ACCEPTANCE OF FINANCIAL AGREEMENT

• I have reviewed the fees for service section, including case management fees, and out-of-pocket expenses for therapy sessions and agree to pay the associated fees according to the terms outlined in this contract (e.g. co-pay, deductible, coinsurance, self-pay fee, case management or cancellation/no-show fee).
• I understand that acceptable forms of payment include debit card, credit card, or FSA/HSA card.*
• I authorize Barnum Counseling, which includes my provider and/or the administrative team, to electronically debit or charge my credit card for payment for services, out-of-pocket expenses, or any outstanding balance owed per this agreement. I agree that no prior notification may be provided for these charges and that I do not have to be present for this transaction/these transactions to occur.
• I understand that if a payment is returned or a credit card, debit card, or HSA/FSA card is declined for insufficient funds, I am responsible for any bank fees assessed and I will provide an alternate method of payment is required within one week. Please note: there will be a pause in services until payment issues have been resolved.
• I understand that if Barnum Counseling has charged my credit card for services rendered or an outstanding balance and later receives notification that I have disputed these charges, a $50 fee will be added to my account. If there are multiple disputes, a $50 fee will be added for each dispute.
• I understand that if my account has an outstanding balance that is 90 days past due, my information will be forwarded to a collection agency and I will be responsible for a 30% fee for the total amount submitted to collections. Continued non-payment will result in a report to the credit bureau and unpaid balances will remain on my credit report until payment is received in full.

*Use of FSA or HSA Cards (must read if using this type of card to pay for services):

• I understand I must notify Barnum Counseling if I am choosing to use a FSA/HSA card.
• In choosing to use my FSA/HSA card, I understand that the card can only be utilized from the time I have provided my card information to Barnum Counseling and they have confirmed the card is active- it cannot be used retroactively, for sessions previously rendered.
• In choosing to put a FSA/HSA card on file with Barnum Counseling, I understand that FSA/HSA cards can only be used for counseling and therapy services (excludes out-of-pocket expenses).
• I understand that FSA/HSA cards cannot be used for late cancellations or no-show charges and that I will be required to place an additional credit card on file with Barnum Counseling to cover these types of charges.
• In choosing to use a FSA/HSA card, I understand that it is my responsibility to reload the card with funds in order to pay for services. I also understand that if funds have not been reloaded and the card declines, my other credit card on file will be charged.

CLIENT CONSENT TO COUNSELING

I have read this document in its entirety, considered it carefully, and asked my therapist any questions that I needed to understand it. I understand the limits of confidentiality required by law and inherent to previously detailed mediums. I understand the risks and benefits of receiving these services and the risks and benefits of not receiving these services.

Additionally, I understand I am expected to be an active and cooperative participant in this process to the best of my ability. Furthermore, I understand there will be fees associated with receiving services at Barnum Counseling and that I will be responsible for any services not covered by insurance or other out of pocket expenses as outlined in this contract.

Client Signature (age 12+):_____________________________________ Date:_____________________ If client under 18, Guardian Signature: ______________________________ Date:__________________