PROFESSIONAL SERVICE AGREEMENT
Thank you for choosing Calm Life Counseling. My goal is to provide you with the best service possible so that you can receive hope and healing. I look forward to working with you to improve your life and your relationships.
• I cannot stress too heavily that there are no magic cures for what is bothering you. I am not a physician, so I cannot prescribe medications for you. I am neither a mystic nor a magician, so I cannot control your thoughts or behavior, nor will I accept responsibility for what you ultimately decide to do with your life. What I CAN do as a therapist is to listen and understand. I may offer suggestions regarding alternative solutions to your problem or new behaviors for you to try. I can help you to examine aspects of your problem that you may not have thought of before. At times, I may introduce specific therapeutic intervention techniques to help you make the changes that you desire. And I will confront you from time to time with the reality of your behavior. Sometimes I may say things you might not like hearing.
• You have the right to seek a second opinion from another therapist. In addition, I reserve the right to terminate the relationship for any reason, including but not limited to, anytime I feel an effective therapeutic relationship cannot be established or maintained.
In short, I can help facilitate the process of identification, realization and change. The success of this process is largely predicated on three factors; 1) adequate goal identification, 2) your own level of motivation to remain committed to the process of change, 3) and how hard you are willing to work at it.
Degrees and Credentials
Bachelor of Social Work, University of Kansas, 1983
Master of Social Work, University of Nevada, Las Vegas, 2003
Colorado LCSW (Licensed Clinical Social Worker) #672
Virginia LCSW (Licensed Clinical Social Worker) #0904016631
1. The practice of licensed or registered persons in the field of psychotherapy is regulated by the Mental Health Licensing Section of the Division of Registrations. The Colorado Board of Social Work Examiners can be reached at 1560 Broadway, Suite 1350, Denver, Colorado 80202, (303) 894-7800. The Virginia Board of Social Work can be reached at 9960 Maryland Dr., Suite 300, Henrico, VA 23233, (804) 367-4400. A Licensed Clinical Social Worker must hold a master’s degree in social work and and have completed 3000 hours of Clinical Supervision.
For mental health service to be most effective, it is essential to have these services coordinated with other health care providers. Information will only be shared in accordance with the Privacy Policies of Calm Life Counseling. For any person or institution that is not directly related to treatment, payment of services or health care operations of Calm Life Counseling, all protected health information will be kept confidential UNLESS you sign a specific authorization. However, all health care providers are legally required to report and release the following information without specific authorization: Suspected physical/sexual abuse and/or neglect of a child or elderly person, to prevent injury to self or others, in a medical emergency to save lives, or if ordered by the court.
This document is an agreement between Calm Life Counseling and the Patient and/or the Patient’s Guarantor (“You”). In consideration of the health care services provided to you or the Patient and on all other accounts for future health care by Calm Life Counseling, you agree as follows:
1. CONSENT FOR TREATMENT. You consent to mental health care as provided by Calm Life Counseling as directed by the mental health professional. You understand that due to factors beyond my control, such benefits and desired outcomes cannot be guaranteed. A variety of treatment methods will be used to provide relief of your symptoms and to improve coping and problem- solving skills.
2. FINANCIAL AGREEMENT. You agree to pay your Calm Life Counseling bill in full within 30 days of provided services. You will be charged Calm Life Counseling’s regular fees, or if you have health insurance or health benefits coverage, the rate Calm Life Counseling has negotiated with that benefit provider. A financial deposit in the form of a valid credit card will be required and kept on-file to pay for services and fees. You agree to pay 1 ½% interest per month (annual percentage rate of 18%) of the unpaid balance if your account becomes more than 30 days past due from the date of the invoice. Acceptable forms of payment are cash, check, credit card (Visa, MasterCard, American Express or Discover), HSA or FSA debit cards. Should collection become necessary by legal suit or other means, you will pay all costs of collection including attorney fees, court costs, including charges and collection agency fees, which would be 35% of the balance signed, with or without suit.
3. INSURANCE SUBMISSION AND ASSIGNMENT OF BENEFITS. As a convenience to you, we can bill your insurance company for each service. You authorize Calm Life Counseling to apply, on your behalf, to Medicare, Medicaid or any other insurance for payment of Calm Life Counseling health care services. You confirm that the information you have provided to allow Calm Life Counseling to apply for payment by any health care insurance or benefit is correct. Your authorized insurance, health plan, or statutory benefits, settlements and judgments to which you are entitled in connection with your Calm Life Counseling health care services are to be paid directly to Calm Life Counseling In consideration of the health care services provided, you give Calm Life Counseling an irrevocable assignment to all rights you have in your insurance, health plan, statutory benefits, settlements and judgments for which you are entitled, as necessary for payment for your Calm Life Counseling health care service. You agree that you are financially responsible for charges that are not covered by this assignment and that you are responsible for satisfying any conditions necessary for insurance or health benefits.
4. CO-PAYMENT COLLECTION. Per your contract with your insurance company(s), all co-payments must be satisfied during each visit. Payment will be expected at the beginning of the session. There can be no exceptions due to legally binding contracts and uniform compliance rules.
5. INSURANCE PLAN RESTRICTIONS. You understand it is your responsibility to contact your insurance company regarding your plan benefits and exclusions. Exclusions may include, but not limited to, whether the Mental Health Provider you are scheduled to see is a provider for your plan, whether certain services are covered benefits, and if your plan requires a referral before seeing a specialist. Some plans have reduced benefits for restrictions, while others simply
refuse to pay if you receive services outside of your contract. You are also responsible for all copayments, deductibles and charges not covered by your insurance as specified in your insurance plan contract.
6. SECONDARY INSURANCE. Having more than one insurer DOES NOT necessarily mean that your services are covered 100%. Secondary insurers have specific guidelines, stated in your contract with them, for what they will consider for payment in coordination with your primary insurance payment. I bill your primary and secondary insurance carrier as a courtesy. You are responsible for any balances after your insurance(s) has cleared. If the subsequent insurance carrier doesn’t pay after 45 days, we may turn the balance due to your responsibility. Subsequent insurance billing may be subject to a billing fee of $5.00 per claim.
7. DIVORCE DECREES. Calm Life Counseling is NOT a party to your divorce decree. Adult clients/patients are responsible for their bill at the time of service. The responsibility for services to minors rests with the accompanying adult. If the divorced couple is splitting costs, one person must take responsibility for coordinating the insurance benefits, payment for services and keeping track of documentation related to the services provided.
8. RETURNED CHECKS AND CREDIT CARD DENIALS. If a check has been returned for insufficient funds or a credit card transaction is declined, Calm Life Counseling will reverse the payment amount and add a $30.00 service fee to cover our costs.
9. MISSED OR CANCELLED APPOINTMENTS. When you make an appointment, we reserve that time for you. When a patient misses or cancels their appointment, it takes away precious time the mental health provider could be spending treating another patient. PLEASE BE ADVISED THAT CALM LIFE COUNSELING WILL CHARGE A $50 LATE CANCELLATION FEE IF 24 HRS ADVANCED NOTICE IS NOT GIVEN AND UP TO THE FULL SERVICE AMOUNT IF YOU MISS YOUR APPOINTMENT WITH NO ADVANCED NOTICE.
10. IN CASE OF EMERGENCY. In the event of an emotional, behavioral or medical crisis call 988 or go to the nearest emergency room. PLEASE BE ADVISED THAT CALM LIFE COUNSELING DOES NOT PROVIDE 24 HR CRISIS SERVICES.
11. SPECIAL REQUESTS. Calm Life Counseling reserves the right to charge additional fees for special requests such as, but not limited to: telephone consultations, letters, billing summaries, transportation costs and court appearances.
BALANCE OF THIS PAGE LEFT INTENTIONALLY BLANK
Professional Service Agreement
BY SIGNING, YOU INDICATE THAT YOU HAVE READ, UNDERSTAND AND AGREE TO THESE TERMS, YOU HAVE RECEIVED A COPY OF THIS DOCUMENT, AND THAT YOU ARE THE PATIENT, THE GUARANTOR, THE PATIENTS LEGAL REPRESENTATIVE, OR LEGALLY AUTHORIZED TO SIGN THIS AGREEMENT AND ACCEPT THESE TERMS.