INFORMED CONSENT
Thank you for choosing Katherine B. Therrell, LPC, PLLC. Your first appointment will take approximately 45 – 50 minutes. We realize that starting counseling is a major decision and you may have many questions. This document is intended to inform you of our policies, State and Federal Laws and your rights. If you have other questions or concerns, please ask and we will try our best to give you all the information you need. Katherine B. Therrell has earned a Bachelor of Science Degree from High Point College and a Masters Degree from the University of North Carolina at Greensboro. In addition, she has completed more than 40 graduate semester hours in counseling through Murray State University, the University of Louisville, and Western Kentucky University. She is licensed by the State of North Carolina as a Licensed Professional Counselor. She has over nine years of clinical experience in treating adolescents, adults and families using individual and family therapy. Katherine B. Therrell practices standard cognitive behavioral therapy for most conditions. Although other treatment approaches are used depending on the person or condition. Treatment practices, philosophy, plan imitations, and risks will be discussed with you today.
CONFIDENTIALITY AND EMERGENCY SITUATIONS: Your verbal communication and clinical records are strictly confidential except for: a) information for which you sign a release (if you desire to do so) to share with other treatment providers including your medical doctor, b) information (diagnosis and dates of service) shared with your insurance company to process your claims, c) information you report about physical or sexual abuse, d) information you provide that informs me that you are in danger of harming yourself or others, e) information necessary for case supervision or consultation and f) information required by the court. North Carolina law requires that I report indications of physical abuse, sexual abuse, or imminent danger to law enforcement authorities.
If an emergency situation for which the client or their guardian feels immediate attention is necessary, the client or guardian understands that they are to contact the emergency services in the community (911) for assistance. Katherine B. Therrell will follow those emergency services with standard counseling and support to the client or the client's family.
Signature(s)_________________________________________Date:________
FINANCIAL/INSURANCE ISSUES:As a courtesy we will bill your insurance company, HMO, responsible party or third party payer for you if you wish. We ask that at each session you pay your co-pay in full.. In the event you have not met your deductible, the full fee is due at each session until the deductible is satisfied. If your insurance company denies payment or does not cover counseling, we request that you pay the balance due when services are received. If your balance exceeds $500.00 we ask that you pay in full for services when rendered. After 60 we will charge 1.5% a month (18% APR) on any unpaid balance. In the event that an account is overdue and turned over to our collection agency, the client or responsible party will be held responsible for any collection fee charged to our office to collect the debt owed. We ask that every client authorize payment of medical benefits directly to Katherine B. Therrell, LPC, PLLC..
I have received a copy of my fee schedule.
Signature(s) _______________________________________Date__________________
Lastly, if you need to cancel or reschedule an appointment, please give 24 business hours advance notice, otherwise you will be billed at the hourly rate. We sincerely appreciate your cooperation. At any time you have any questions regarding insurance, fees, balances or payments please feel free to ask. You may have a copy of this form if requested.
Signature(s)__________________________________________________Date_____________________
COORDINATION OF TREAMENT: It is importantthat all health care providers work together. As such, we would like your permission to communicate with your primary care physician and/or psychiatrist. Your consent is valid for one year. Please understand that you have the right to revoke this authorization, in writing, at any time by sending notice. However, a revocation is not valid to the extent that we have acted in reliance on such authorization. If you prefer to decline consent no inform will be shared.
____You may inform my physician ____I decline to inform my phsician
PHYSICIAN NAME:_________________________________________________
CLINIC:__________________________________________________________
ADDRESS:________________________________________________________
PHONE:__________________________________________________________
Signature(s)_________________________________________________Date_________________
CONSENT FOR TREATMENT OF CHILDREN OR ADOLESCENTS: I/We consent for _____________________________________ to be treated as a client by Katherine B. Therrell, LPC. At times it may be necessary to schedule appointments during school hours. We ask for your cooperation to provide timely treatment for you and your children.
Signature(s)________________________________________Date__________
Thank you for choosing Katherine B. Therrell, LPC, PLLC. Your first appointment will take approximately 45 – 50 minutes. We realize that starting counseling is a major decision and you may have many questions. This document is intended to inform you of our policies, State and Federal Laws and your rights. If you have other questions or concerns, please ask and we will try our best to give you all the information you need. Katherine B. Therrell has earned a Bachelor of Science Degree from High Point College and a Masters Degree from the University of North Carolina at Greensboro. In addition, she has completed more than 40 graduate semester hours in counseling through Murray State University, the University of Louisville, and Western Kentucky University. She is licensed by the State of North Carolina as a Licensed Professional Counselor. She has over nine years of clinical experience in treating adolescents, adults and families using individual and family therapy. Katherine B. Therrell practices standard cognitive behavioral therapy for most conditions. Although other treatment approaches are used depending on the person or condition. Treatment practices, philosophy, plan imitations, and risks will be discussed with you today.
CONFIDENTIALITY AND EMERGENCY SITUATIONS: Your verbal communication and clinical records are strictly confidential except for: a) information for which you sign a release (if you desire to do so) to share with other treatment providers including your medical doctor, b) information (diagnosis and dates of service) shared with your insurance company to process your claims, c) information you report about physical or sexual abuse, d) information you provide that informs me that you are in danger of harming yourself or others, e) information necessary for case supervision or consultation and f) information required by the court. North Carolina law requires that I report indications of physical abuse, sexual abuse, or imminent danger to law enforcement authorities.
If an emergency situation for which the client or their guardian feels immediate attention is necessary, the client or guardian understands that they are to contact the emergency services in the community (911) for assistance. Katherine B. Therrell will follow those emergency services with standard counseling and support to the client or the client's family.
Signature(s)_________________________________________Date:________
FINANCIAL/INSURANCE ISSUES:As a courtesy we will bill your insurance company, HMO, responsible party or third party payer for you if you wish. We ask that at each session you pay your co-pay in full.. In the event you have not met your deductible, the full fee is due at each session until the deductible is satisfied. If your insurance company denies payment or does not cover counseling, we request that you pay the balance due when services are received. If your balance exceeds $500.00 we ask that you pay in full for services when rendered. After 60 we will charge 1.5% a month (18% APR) on any unpaid balance. In the event that an account is overdue and turned over to our collection agency, the client or responsible party will be held responsible for any collection fee charged to our office to collect the debt owed. We ask that every client authorize payment of medical benefits directly to Katherine B. Therrell, LPC, PLLC..
I have received a copy of my fee schedule.
Signature(s) _______________________________________Date__________________
Lastly, if you need to cancel or reschedule an appointment, please give 24 business hours advance notice, otherwise you will be billed at the hourly rate. We sincerely appreciate your cooperation. At any time you have any questions regarding insurance, fees, balances or payments please feel free to ask. You may have a copy of this form if requested.
Signature(s)__________________________________________________Date_____________________
COORDINATION OF TREAMENT: It is importantthat all health care providers work together. As such, we would like your permission to communicate with your primary care physician and/or psychiatrist. Your consent is valid for one year. Please understand that you have the right to revoke this authorization, in writing, at any time by sending notice. However, a revocation is not valid to the extent that we have acted in reliance on such authorization. If you prefer to decline consent no inform will be shared.
____You may inform my physician ____I decline to inform my phsician
PHYSICIAN NAME:_________________________________________________
CLINIC:__________________________________________________________
ADDRESS:________________________________________________________
PHONE:__________________________________________________________
Signature(s)_________________________________________________Date_________________
CONSENT FOR TREATMENT OF CHILDREN OR ADOLESCENTS: I/We consent for _____________________________________ to be treated as a client by Katherine B. Therrell, LPC. At times it may be necessary to schedule appointments during school hours. We ask for your cooperation to provide timely treatment for you and your children.
Signature(s)________________________________________Date__________
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