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CRT COUNSELING-Change, Renewal, Transition, PA


FEES: Counseling sessions typically last about 45-50 minutes. Fees are paid at the time of the session unless other arrangements have been made. A monthly statement will be provided if requested, showing dates of service, charges, fees, etc. Accounts delinquent over three months will be sent to collections.


APPOINTMENTS:     Appointments are usually scheduled on first-come, first serve basis, however, standing appointments can be arranged. It is requested that changes and cancellations be made at least 24 hours in advance so that time may be made for someone else. PLEASE BE ADVISED YOU ARE FINANCIALLY RESPONSIBLE FOR ALL SCHEDULED APPOINTMENTS UNLESS A 24 HOUR CANCELLATION NOTICE IS GIVEN (PLEASE NOTE THAT INSURANCE COMPANIES DO NOT PAY FOR MISSED APPOINTMENTS).YOU ARE RESPONSIBLE FOR ALL INSURANCE CLAIMS THAT HAVE BEEN DENIED BY YOUR INSURANCE COMPANY OR HAVE REMAINED UNPAID FOR A 45 DAY PERIOD OF TIME. THE OFFICE WILL BILL YOU FOR ALL CLAIMS BEYOND THE 45 DAY PERIOD. If it is possible to reschedule your cancelled appointment within the same week, there will be no charge for late cancellations.

CONFIDENTIALITY: I am required by ethics to safeguard your privacy. All conversations and written material regarding client remains confidential. Current written permission from you will be necessary for any records to be released. Only under very serious and specific circumstances or legal situations will exceptions to this rule be taken. Exceptions to confidentiality may include but are not limitted to: child abuse; abuse of the elderly or disabled; abuse of patients in mental health facilities; sexual exploitation; child custody cases; or court order. Should you choose to utilize insurance benefits or a plan whose benefits are managed, please be advised that we may be required to release clinical information to personnel involved in managing your care for you to receive maximum benefits. If this is the case, your confidentiality may be affected. If you have any concerns about this, please talk to your therapist.

Providers at CRT Counseling are Masters Level clinicians.  This includes Licensed Professional Counselor, Licensed Marriage Family Therapists, and Licensed Chemical Dependency Counselors.

I certify that I have read and understand the General Policies:

____________________________________                                                 __________________________
Signature                                                                                                                          Date

Consent to treat minor:

____________________________________                                                 _____________________________  
Parent/Guardian signature                                                                                   Date

INSURANCE ASSIGNMENT: I authorize the release of any medical or other information necessary to process insurance claims. I authorize payment of medical benefits lo CRT Counseling.

____________________________________                                                 __________________________
Signature                                                                                                                  Date