Client Emergencies. Your therapist at CFC is available for counseling appointments at selected times throughout the week. Because your therapist turns off their phone while not working and does not keep a phone on their person at all times, your therapist at CFC is not considered available 24/7 for crisis situations. If you experience a crisis or emergency, you may obtain assistance by calling the Crisis Hotline at (000) 000-0000 or 0-000-000-0000, calling 911, or by going to your local hospital emergency room. Your signature below indicates you have read the Client Services Agreement in its entirety, understand it, and agree to abide by its terms during this professional relationship. You also agree you have had sufficient time to be sure you considered it carefully and had any questions you had answered by your therapist at CFC. Client Signature Date Witness (Staff) Signature Date If client is under 18: Parent or Legal Guardian Date
Client Emergencies. The therapist is not available on a crisis or emergency basis. In the advent of an emergency that threatens the health or well-being of yourself or someone else and requires immediate assistance, you are to call 911 or go to the nearest hospital emergency room. Professional Consultation: In order to ensure proper treatment, the therapist may seek outside consultation with other professionals in order to discuss a case. In order to protect confidentiality, no identifying information will be provided to the consultants, unless the client provides permission. Treatment Disclaimer: The goal of the therapy process is to help resolve personal difficulties. The therapist will attempt to help clients to feel comfortable during sessions and assist them towards meeting goals. However, clients should be aware that psychotherapy may periodically produce heightened feelings of emotional distress and discomfort. If this occurs, clients should notify their therapist in order that the symptoms are properly addressed. Discontinuation of Service: Usually therapy is ended when the client’s goals have been achieved. Regular attendance in therapy helps produce maximum benefits but clients are free to discontinue treatment at any time. If you decide to do so, please notify the therapist at least two weeks in advance so that effective planning for continued care can be implemented. Fee and Payment Guidelines Cost: Individual sessions are billed at a rate of $160 for the first session and after that at $150 per session. Responsibility: Clients are responsible for all treatment costs. Clients using insurance will also be responsible for all non-reimbursed services. These non- reimbursed costs may include deductibles, co-payments, claim rejections, missed sessions and non-covered procedures. Insurance Coverage: Prior to treatment, clients are strongly encouraged to contact their carriers to determine their coverage and benefit information. The therapist is not responsible for finding this information. Out-of-Network Reimbursement: If the therapist is not part of your insurance provider’s network, you may request out-of-network reimbursement from your insurer for fees you paid. The therapist will provide you with the necessary receipts and documentation to simplify this process. If your insurance provider denies payment, you do not have insurance coverage, or you choose not to use such coverage, you will be responsible for all fees for services provided. Payment Method: The therapis...
Client Emergencies. Applicant shall notify Supervisor of any client emergency. A “Client Emergency” shall be defined as circumstances under which a reasonable person would believe that: The client represents serious threat to him/herself or others; or Immediate therapeutic contact is reasonably necessary for the well-being of the client MODIFICATION OF THIS AGREEMENT: This agreement may be modified provided: The modification is evidenced in writing The modification is agreeable to both parties The new agreement satisfies all Board requirements This agreement is entered into as of the date and year first above written. SUPERVISOR APPLICANT ___________________________________________________ ________________________________________________ Name (please print) Name (please print) __________________________________________________ ________________________________________________ Signature Signature 0000 Xxxx Xxxxx, Suite 350 ________________________________________________ Plano, Texas 75075 ________________________________________________ Phone # 000-000-0000 _______________________________________________ Licensed Professional Counselor Licensed Professional Counselor - Intern
Client Emergencies. If a client is in imminent danger (threat of homicide or suicide) call 911, 988 and/or Multnomah County Crisis Line immediately at 988 or 000-000-0000. In the event of child/elder/dependent adult abuse and/or neglect, contact Oregon’s reporting line immediately and within 24 hours at (000) 000-0000. Also, inform your primary Clinical Supervisor and any other appropriate individual in your agency of employment. I may be contacted at (000) 000-0000. If you are unable to reach me in the event of an emergency, leave a confidential voicemail and contact the next agreed upon person to call in such cases.
