Outpatient Service Agreement

FAYETTEVILLE FAMILY LIFE & ROBESON FAMILY COUNSELING SERVICES

Counseling is not easily described in general statements. It varies depending on the personality of the counselor and client and the particular problems which concern the client. There are a number of different approaches which can be utilized to address the problems you bring to counseling. One factor which makes this practice unique is our attention to spiritual as well as emotional and interpersonal issues. Our counselors are persons of faith. For those who consider spirituality significant, we integrate that aspect of your life into counseling so that your relationship with God can be used as a resource in the process of treatment. However, we will not attempt to change your religious beliefs or to promote any particular religious faith.

Any counseling requires a very active effort on your part. In order to be most successful you will have to work both during your sessions and outside them. Counseling has both benefits and risks. Risks sometimes include experiencing uncomfortable levels of feelings or recalling unpleasant aspects of your history. Counseling, though, has been shown to have benefits for people who undertake it. By the end of your first visit here, your counselor will be able to offer you some initial impressions of what your work will include and an initial treatment plan. You should evaluate this information along with your own assessment about whether you feel comfortable working with your counselor. If you have questions at any time, you should discuss them whenever they arise.

MEETINGS

Our normal practice is to conduct an evaluation which will take place in your first session. During this time, your counselor can decide whether s/he is the best person to provide the services which you need in order to help you meet your treatment objectives. If counseling is initiated, we will usually schedule a follow up appointment. Appointment times usually last 45-55 minutes, although sometimes sessions will be longer. The frequency of sessions will be decided between you and your counselor. Once an appointment time is scheduled, you will be expected to keep it unless you provide 24 hours advance notice of cancellation. Should you not give us adequate notice or fail to keep an appointment you will be charged your full appointment fee (unless your counselor agrees that you were unable to attend due to circumstances beyond your control). You will need to pay this fee before another appointment will be scheduled. Repeated late cancellations or missed appointments will result in the termination of therapy.

INSURANCE REIMBURSEMENT

In order for us to set realistic treatment goals and priorities, it is important to evaluate what resources are available to pay for your treatment. If you have health insurance that provides mental health coverage, it is important that you supply us with your insurance information so that we can verify coverage as it applies to your counseling sessions. If there is insurance coverage for your therapy we will file the necessary claim forms. However, if for any reason, your insurance company does not pay the claims, you are responsible for full payment of all fees. It is also your responsibility to pay for all annual deductibles as dictated by your policy. You should also be aware that all insurance agreements require you to authorize us to provide a clinical diagnosis, and sometimes additional clinical information such as a treatment plan or summary or in some cases a copy of the entire record. This information will become part of the insurance company files. You will be asked to sign an authorization to release this information.

PROFESSIONAL FEES, BILLING AND PAYMENTS

The Fayetteville Family Life Center/Robeson Family Counseling Center provides therapy for clients regardless of financial circumstances. The standard fee is charged whenever insurance is available or when family income warrants. Otherwise, fees are adjusted between client and counselor, based on client’s ability to pay. Our hourly fees are $95-$155 per therapy hour depending upon the credentials of the therapist. You will be expected to pay for each session at the time it is held unless we agree otherwise or you have insurance coverage which requires another arrangement. The particulars of your fee will be discussed during the initial session. In addition, it is our practice to charge for certain other activities such as school meetings and court appearances. In the event that you become involved in some litigation and we are required to give testimony, you agree to pay for the professional time required even if we are compelled to testify by another party. Because of the complexity and difficulty of legal involvement, we charge our regular hourly rate for preparation and attendance at any legal proceeding (fee adjustment does not apply). If you ever have questions about your fee or balance please ask anytime. Fees may be paid by check, cash, or credit card. We will file all appropriate insurance claims. You are expected to pay the insurance deductible within the first few sessions and the copay weekly unless other arrangements are made in advance. There is a $25 returned check charge. We will work with you to make the counseling affordable whatever your financial resources. Once a fee is set, however, we expect you to pay for the services. If you ignore your fees and do not honor your payment plan with us, we reserve the right to turn the account over to a Medical Collections Service.

PROFESSIONAL RECORDS

We are required to keep appropriate records of your treatment. These records are the property of CareNet Counseling/Fayetteville Family Life Center/Robeson Family Counseling Center. You may purchase copies of your records for your personal use or another party in accordance with our policy on record copying. Copies of your records will be sent to another party only with your written permission.

MINORS

If you are under 18 years of age, please be aware that the law may provide your parents with the right to examine your treatment records. It is our policy to request an agreement from parents that they consent to give up access to your records. If they agree, we will provide them only general information on how your treatment is proceeding unless we feel that there is a high risk that you will seriously harm yourself or another, in which case we will notify them of our concern. Before giving them information we will discuss the matter with you and will do the best we can to resolve any objections you may have about what we are prepared to discuss.

CONTACTING YOUR COUNSELOR

Office hours are 9am-7pm Monday thru Thursday. We are closed on Fridays. When someone is unavailable you may leave a message on the answering machine. In the case of emergency call 911, or you can ask your counselor about our on call emergency services at your first session. You will be provided with our on-call/after-hours phone number.

TERMINATION OF COUNSELING

Clients and/or counselors may terminate counseling in any one of the following ways:

• Client and counselor mutually determine that counseling goals have been adequately met.
• Client and/or counselor determine that counseling is not progressing satisfactorily and the process should be discontinued. In this case, the counselor can assist the client in finding a new counselor if this is the client’s desire.
• Client has not seen the counselor in 90 days and there has been no prior agreement to keep the case open.

When counseling is terminated there is no longer a counseling relationship between client and counselor, and the traditional obligations of client and counselor no longer exist.

ETHICS

We are committed to providing our clients with competent, professional counseling services conducted according to the highest ethical standards. All of our counselors ascribe to the codes of ethics governing the licenses in their professions. If at any time you feel that your counselor is acting in an unprofessional or unethical manner, you are urged to contact the Director of the Fayetteville Family Life Center/Robeson Family Counseling Center. If you do not receive a satisfactory response you may write to the President, CareNet Counseling Centers, 2000 W. First St., Suite 410, Winston-Salem NC 27104.