Online (Quick & Easy) Parent Consent FormLake Worth Counseling Practice Form

Please read the following policy and procedures for consent for treatment:



Insurance: Verification of insurance benefits by LWC does not guarantee payment of claims by the insurance company. Please contact the insurance company directly to review insurance benefits and financial responsibility for mental health benefits as plans may vary. The client is responsible for payment in full for any balances on the account as a result of an unpaid or denied claim. LWC does not file with secondary insurance plans or accept employee assistance plans (EAP).



Associates: An LPC/LMFT Associate holds a provisional Texas State License. This means he/she has met all the educational and competency requirements to be an LPC/LMFT Associate in the state of Texas including holding a master’s degree or higher and is in the process of completing 3,000 professional counseling hours. LPC/LMFT Associates are required to be trained and guided by a state-approved Supervisor. Insurance does not cover Associate counseling sessions.



Cancellation Policy: LWC has a strict cancellation policy in place. This allows LWC to serve clients who may be waiting to be seen. Please give us full 24-hour advance notice if needing to cancel or reschedule an appointment for any reason. If less than 24-hour notice, the client will be assessed a late cancel fee. Please call during office hours M-F 8:30 AM to 8:00 PM and Saturday 8:30 AM – 3:00 PM (excluding Sundays and Holidays). Please note if a cancellation is made after LWC business hours or on a Sunday or a Holiday immediately prior to a scheduled appointment it is considered a late cancel.



LATE CANCEL FEE: $75



No-Show Policy: If a client simply does not show up for an appointment, the client or the responsible party will be charged the full cost of a session at the time of the missed appointment.



All upcoming appointments may be cancelled by LWC written notice until client’s outstanding account balance is paid in full.



NO SHOW FEE: $75- $150/Interns & Associates, $150 Master’s & PhD level therapists



Telephone & Emergency Procedures: When calling or emailing, LWC administration staff can usually return a call or message within 24 hours during regular business hours. If the counselor is unavailable in the event of an emergency, it is imperative that the client is aware of resources in the area. If you have a life-threatening emergency, please call 911 or go to your nearest emergency room. If clients are in need of a follow-up consultation with a counselor, please call to schedule an appointment. Counselors are not typically available for free telephone consultations and clients are asked to schedule face-to-face appointments for counseling, parent consultations and case management issues. In the event the client requests a telephone consultation or phoning a third party (attorney, school, medical or other mental health specialist), a fee may apply.



Email: Email may compromise client confidentiality. If the client is in a crisis, please do not communicate this to LWC via email because LWC may not see email in a timely manner. Please call LWC for an appointment or if life threatening please go to the nearest emergency room or call 911. If a client still wishes to communicate by email, please email info@lwc.care and an administrative staff member will respond directly by email or phone or if requested, make sure the email is directed to the client’s counselor ATTN: ‘Counselor Name’.



Appointment Reminders LWC sends out an automated text and email reminder with client permission to the email address on file approximately 48 hours in advance, however, this is a courtesy service and the client is ultimately responsible for attending the scheduled appointment.



Client Notes: Progress notes are created by the counselor and considered confidential and shall not be released to the client or responsible party, including children’s progress notes. However, a summary report of treatment history is available upon written request. A fee will apply for written reports, documentation, and legal reports. If client requests to review treatment progress, diagnosis, goals, or any other information related to participation in counseling this may be discussed directly with the client’s counselor in session.



Electronic Medical Records: Client records include attendance, payment and insurance information, assessment, progress, diagnosis, and treatment goals. All client records are maintained according to state guidelines and are considered the possession of Lake Worth Counseling, PLLC. In the case of the counselor's incapacitation, death, retirement, or termination of practice, LWC shall prepare a plan for the transfer of clients and the dissemination of records to the LWC records custodian. Theranest is the software where client’s Electronic Medical Records will be stored and also used to organize client appointment, notes and billing. Client records will be maintained according to the Texas LPC Rules for 7 years after final counseling session. The LMFT Rules require records to be kept for 7 years for adults and 6 years past the age of 18 for a client, who is a minor.



Telehealth Services: LWC shall utilize Theranest for interactive video which is considered HIPPA compliant and secure. If client is requesting Telehealth services, a separate Telehealth Consent Form will be provided to the client.



Nature of Counseling: All of the counselors at LWC may have different styles, techniques and personalities but all have one mission; to provide clients with professional, qualified counseling services in a comfortable setting, facilitate personal growth and improve client’s overall well-being. You as the client, are freely choosing to enter into treatment and may choose to end treatment at any time. A client’s relationship with a counselor is a professional and therapeutic one only. LWC employees shall not participate in social or financial relationships or engage in social media networks with clients. If, for whatever reason, a client feels the counselor is just not a good ‘fit’ after an initial consultation, the client may request to transfer to another one of our professionals.



Grievances: LWC encourages clients to discuss any problems they may have directly with the counselor or practice manager. LWC will work with the client respectfully to resolve any issue brought to our attention in order to reach a satisfactory agreement. Clients may submit concerns to susan@lwc.care. To report a rules violation by a licensee, contact the appropriate Board: Texas State Board of Examiners of Licensed Professional Counselors; Texas State Board of Examiners of Marriage and Family Therapists; Texas State Board of Social Work Examiners at the following common address: P.O. Box 141369, Austin, TX 78714-1369 (1-800-942-5540).



Confidentiality: Discussions between a therapist and a client are confidential. No information will be released without the client’s written consent unless mandated by law. Possible exceptions to confidentiality include but are not limited to the following situations: court subpoena, suspected child abuse, abuse of the elderly or disabled, sexual exploitation, criminal prosecutions, child custody case, situations where the counselor has the duty to disclose, or where, in the therapist’s judgment it is necessary to warn or disclose. If the client has any questions regarding confidentiality, please bring them to the attention of the counselor to discuss. By signing this consent form the client is giving consent to the undersigned counselor to share confidential information with all persons mandated by law and the insurance carrier and billing companies responsible for providing mental health care services and payment for those services, and also releasing and holding harmless the counselor from any departure from right of confidentiality that may result. The client understands that there will be no recording of the session and that all information disclosed within sessions and the written records pertaining to those sessions are confidential and may not be revealed to anyone without written permission, except where disclosure is required by law. A counselor may converse with other counselors in the LWC group practice for confidential consult in order to provide the best possible treatment for a client. Acknowledgement of Review of Notice of Privacy Practices & Protected Health Information (PMI): Clients are provided online and upon check-in a written copy of the Notice of Privacy Practices.



Court Related Issues/Legal Matters & Fees: Although it is our goal to protect the confidentiality of confidential records, there may be times when disclosure of a client’s records or testimony will be compelled by law. If subpoenaed by a judge LWC may be obligated to provide the requested information, whether or not the information is favorable to the undersigned. Should the client involve the counselor in a legal matter, there may be fees associated with this matter due to the counselor time involved. LWC must be notified at least 14 days in advance of subpoena. All legal fees must be paid in advance or immediately upon request, including subpoena cost or the counselor shall deny any participation in court or other legal proceedings. LWC shall ultimately reserve the right to transfer any client case that becomes litigious.



Assignment of Insurance Benefits: The client authorizes all insurance payments to be made to the designated provider. This order does not relieve the client of obligation to pay such bills if not paid by the insurance company for any reason. It is the client’s responsibility to ultimately verify their behavioral health benefits directly with their insurance provider and any cost that may occur. LWC may provide benefit verification as a courtesy only and must have on file the correct insurance information in order to file claims with the insurance company. Denied claims will then become the client’s responsibility.



Behavioral Health Diagnosis: If client elects to use insurance, please be mindful that a behavioral health diagnosis must be provided by the counselor. This diagnosis may become a permanent part of the client’s medical records. It shall be determined by the mental health provider to provide the appropriate diagnosis and procedure code that will be assigned to client and billed to client’s insurance company. Please discuss any client concerns with the counselor. If client chooses not use behavior health benefits for any reason, please let LWC receptionist know at time of check-in.



Procedure Codes: LWC shall designate a procedure code based on type of office visit. Procedure codes may be billed on annual basis based on calendar year or according to client’s individual plan. LWC shall bill an initial Acute Intake session (90839) for the client’s first visit. Acute procedure code (90839) may also be required for follow-up visits that require in-depth treatment and/or safety plans. Assessment Sessions (90791) are billed up to two (2) follow-up visits (as typically allowed by insurance). Assessment Sessions include counselor conducting an initial evaluation, diagnosis, and treatment plan. Additional visits are considered standard follow-up visits (90837). Psychological testing with Dr. Shepard shall be billed under separate procedure codes. Reimbursement rates will vary depending on the procedure code and client’s insurance (if applicable).



Counseling Fees & Services: Fees may range from $225.00 to $60.00 per session and vary by provider and service provided. Please call for additional information about session fees. Some insurance plans accepted.



Outstanding Balances: Client agrees to keep ledger account in good standing with LWC at all times in order to ensure an excellent patient /counselor relationship. The client agrees to pay the charges incurred at the posted rates, including applicable late cancel fees or past due balances immediately upon request unless other arrangements have been made in advance. A credit card shall remain on file in order to reserve upcoming appointments and provide guarantee of payment for all outstanding balances. All outstanding balances 15 days past due will be charged to my CC on file and an invoice will be emailed to me. All CC information is stored in electronic and secure file format.



Credit Card Processing: Signapay is the company that processes the client’s credit card information. The credit card holder will receive an email receipt indicating the credit card was used for services, the date it was used and the amount that was charged. Additionally, please be aware that the transaction will appear on the cardholder’s credit card bill.



Invoices & Past Due Accounts: Clients are requested to keep a current email address on file and check their electronic mailbox (including junk mail) for correspondence by LWC. LWC shall make every attempt to contact the client by email and phone, however LWC is not responsible for unread email invoices and any past due balances on the account and shall be charged accordingly. All charges to the client’s account will appear on the client’s credit card or bank statement. Client agrees to pay the invoice charges, including applicable late cancel fees or past due balances (15 days or more delinquent) or immediately upon request unless other arrangements have been made in advance.



Telehealth Services: The client may voluntarily agree to receive online therapy services including video, audio or telephone format for an assessment, continued care, treatment, or other services. Additional Telehealth Consent Form is required from the client if they wish to utilize such resources. The virtual sessions can only be conducted while the client is within the state of Texas. The virtual sessions must be conducted on a Wi-Fi connection for the best connections and to minimize disruption. LWC strongly suggest that the client only communicate through a device that you know is safe and technologically secure (e.g. has a firewall, anti-virus software installed, is password protected, not accessing the internet through a public wireless network, etc.) Do not use “auto- remember” names and passwords. Make sure you have checked your company’s policy before using a work computer for personal communication.



Parent Signed Consent: I have read and understood the above provided information. My signature indicates I give full and informed consent for my CHILD to receive counseling services at Lake Worth Counseling and to the terms set forth in this agreement. Should I require services, including a Parent Only Consultation, I may contact the main phone number (817) 238-0106 and request an appointment with my child's counselor. Additional information and adult Consent for Treatment may be required.