THE THERAPY PLACE
7200 W 13th Street North , Ste. 105 Wichita, KS 67212-2943 Phone (316) 516-7269
INFORMED CONSENT AND THERAPY CONTRACT
Welcome to The Therapy Place! It is our utmost desire to provide the best care for our clients
from a biblically sound perspective. Our clinicians profess faith in the Lord Jesus Christ and hold
to the following statement in both our personal and professional lives.
Statement of Faith
(American Association of Christian Counselors)
There exists only one God, creator and sustainer of all things, infinitely perfect and eternally co-
existing in three persons: Father, Son, and Holy Spirit.
The Scriptures, both Old and New testaments, are the inspired, inerrant and trustworthy Word
of God, the complete revelation of His will for the salvation of human beings, and the final
authority for all matters about which it speaks.
Human nature derives from two historical personas, male and female, created in God’s image.
They were created perfect, but they sinned, plunging themselves and all human beings into sin,
guilt, suffering, and death.
The substitutionary death of Jesus Christ and his bodily resurrection provide the only ground for
justification, forgiveness, and salvation for all who believe. Only those who trust in Him alone
are born of the Holy Spirit and are true members of the Church; only they will spend eternity
with Christ.
The Holy Spirit is the agent of regeneration and renewal for believers in Jesus Christ. He makes
the presence of Jesus Christ real in believers, and He comforts, guides, convicts, and enables
believers to live in ways that honor Christ.
Ministry to persons acknowledges the complexity of humans as physical, social, psychological,
and spiritual beings. The ultimate goal of Christian counseling is to help others move to personal
wholeness, interpersonal competence, mental stability, and spiritual maturity.
It is important for you, as a client, to be fully informed about the therapy services you will be receiving.
Your signature below indicates you have received, read, and understand the practice policies and are
able to make an informed decision about entering therapy. It is also important you understand HIPPA
regulations regarding client confidentiality.
Practical Issues
As our client(s), you have the right to be informed about the therapy program you will be engaged
in. These rights include:
1. The right to ask questions about therapy. Your therapist will explain his/her therapy approach
and methods used upon request.
2. The right to end therapy at any time without any moral, legal, or financial obligations other than
those already incurred.
3. The right to know the Code of Ethics followed by your therapist.
4. The right to specify and negotiate therapeutic goals and to renegotiate them when necessary.
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5. The right to be fully informed of the limits of confidentiality in the therapy setting.
6. The right to know if there has been no session activity or phone contact recorded for a period of 4
weeks, your client file will automatically closed. In most circumstances, a client file can be re-opened
upon completion of a new intake and payment of any delinquent fees.
Appointments
Appointments are usually scheduled for 45 - 50 minutes, commonly known as a “clinical hour”. Your
therapist will schedule your appointments and provide a reminder card and/or a reminder text
message. If you should need to cancel or reschedule an appointment, please contact your therapist
at least 24 hours in advance. Your therapist reserves the right to charge up to 100 percent of the
session fee for canceled or missed appointments if not notified 24 hours in advance.
Fees
As your therapist, I am committed to providing you with the best possible care. In order to achieve
these goals, I need your assistance and your understanding of my payment policy.
Fee Rates:
A discounted rate is available for non-insurance filing clients at $75 per clinical hour. Should there be
a change in fee amount, therapist will provide notification 30 days in advance. In
________(Initial Here) I agree to pay __________ prior to each therapy session.
Insurance Payments:
We are happy to file insurance for you. All co-payments are required at time of service. Client agrees
to pay for sessions NOT covered by insurance company. Typical insurance charge is approximately
$150 per clinical hour. Initial Diagnostic Assessment and other sessions consist of 45-50 minutes,
which constitutes a clinical hour. Additional fees may be incurred if additional time is available and
necessary.
The client is responsible for providing accurate and complete information regarding insurance on
the client information form. THERAPIST does not guarantee that your insurance will pay your claim.
You are responsible for the account balance and for deductibles, co-payments and/or coinsurance
required by your insurance. The client agrees to allow their therapist to release any and all
information necessary for filing insurance claims and collecting fees from your insurance company.
________(Initial Here) I give my assent for The Therapy Place, LLC to file claims with my insurance
company for all sessions administered. My co-pay is _________ and I agree to pay this amount prior
to each therapy session. I acknowledge my financial responsibility for fees NOT reimbursed by my
insurance company.
Missed Appointments:
The client agrees that if he/she is unable to keep an appointment, he/she will provide a minimum of
24 hours prior notice to the therapist by leaving a message or speaking with the therapist directly. If
an appointment is canceled or missed without 24 hour notice, the client understands that he/she
can be billed up to 100 percent of their session fee. In this event the bill will reflect a late
cancellation and not a clinical session. Exceptions may be made for emergencies. Your insurance
company will not pay for your missed appointments. If there are 3 or more missed appointments,
or multiple cancellations, your file may be terminated.
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Payment Method:
Payments for services are expected at the time of service. Payment may be made by check, cash,
Visa, MasterCard, Discover, or an FSA account card. Should the client’s account remain unpaid for 30
days, the therapist reserves the right to suspend or discontinue treatment until the charges are paid
in full or a suitable payment arrangement is agreed to in writing by both the client and the therapist.
Client agrees that THERAPIST shall be entitled to its reasonable costs for collection of all overdue
amounts, including, but not limited to, the amount of reasonable attorney’s fees, court costs, and
expenses of collection.
Returned Checks: A processing fee of $30.00 will be charged for all returned checks.
Confidentiality
Because of the personal nature of information revealed in therapy, every effort will be made to
respect the confidentiality of every client. The information from the therapy sessions will remain
confidential with the therapist within the guidelines established by Kansas State regulations and The
Health Insurance Portability and Accountability Act of 1996 (HIPAA), Public Law 104-191. By State
Law, the rights of confidentiality do not apply under the following conditions:
1. When a client may be a danger to himself/herself or to others;
2. When a child, elderly, or disabled person may be subject to abuse or neglect;
3. When a court order exists or the therapist or records are subpoenaed by the court.
Should any of the above situations occur, your therapist will inform you of his/her responsibilities
and actions.
Information about your case and treatment may be released to a third party only when all
participants involved in therapy sign an “Authorization & Request for Release of Confidential
Information and Privileged Communication” form. Where a minor is receiving services, the
appointment of a guardian ad litem may be necessary prior to the release of the minor’s
information. A release may also need to be signed to contact medical professionals on possible
physical/biological conditions which may be causing psychological problems. You do have the right
to waive this release if you so choose.
By signing this form you are agreeing to release any information related to and/or needed for
billing or claims to our Practice Management System as well as our billing administrator for the
purpose of verifying insurance coverage, claim status and payments.
Benefits and Risks
Any time you seek therapy to work with the difficulties in your relationships; there are benefits and
risks involved in the changes that may occur. The benefits of therapy can include the ability to
handle or cope with marital, family, and other interpersonal relationships in a healthier way. You
may also gain a greater understanding of personal and family goals and values. This new
understanding may lead the way to greater maturity and happiness as an individual, couple, or
family. In addition, there may be benefits that come as you work at resolving the specific concerns
you have brought into therapy.
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However, therapy can be challenging and uncomfortable at times. Remembering and resolving
unpleasant events may cause intense feelings of fear, anger, depression, frustration, and the like. As
you work to resolve issues between family members, marital partners, and other persons, you may
experience discomfort and an increase in conflict. There may be changes in your relationships you
had not originally intended.
Your therapist will discuss with you the benefits and risks involved in your particular situation. You
are encouraged to discuss with you therapist any concerns you have as your therapy progresses.
Physician Consultation
I understand, under Kansas Law and provisions of KSA 65-6404 (b) (3), my therapist is required to
consult with my primary care physician or psychiatrist to determine if there may be a medical condition
or medication that is contributing to symptoms of a mental disorder which may have been observed in
therapy. In order to complete such a consultation, my therapist will request I complete a Release of
Information form. The client/parent/legal guardian may choose to waive such consultation by initialing
________ I waive my right to a physician consultation by my therapist
OR
________ I would like for my therapist to contact my primary care physician.
Legalities
1. I understand that (The Therapy Place, LLC) is a limited liability company under Kansas law.
Accordingly, individual members of the Company and individual members of the Company are
not personally accountable for the liabilities of the Company or of one another, but each of the
Company's professionals (together with the Company as a separate legal entity) remains fully
subject to her or its own liabilities and professional responsibility. ______ (Initials)
2. I understand extra fees may apply if my therapist is required to be in court or court-related
documentation of my case is required. ______(Initials)
3. I acknowledge receipt of the NOTICE OF PRIVACY PRACTICES from The Therapy Place, LLC.
______(Initials)
Contacting Your Therapist
Phone
Your therapist is available to return phone calls during his/her designated business hours. Please
note that although your therapist may be in the office they may be with another client or in a
meeting. Messages received during business hours will be returned the same business day. Your
therapist will check his/her voicemail for the final time at the end of each business day. Should you
need to contact your therapist outside of the hours specified by their individual schedule, feel free
to leave a voicemail message with the understanding your call may not be returned until the next
business day. You may send a SMS text message to your therapist if you so choose but please be
aware that text messaging is not a secure form of communication and can be easily accessed by
others. Please note your therapist does not save client contact information in his/her phone so they
may not know who you are if you send a text message. Any SMS messages received by this therapist
will be deleted at the end of each business day. Your therapist will provide you with an after-hours
phone number to be used in crisis or emergency situations only. Please leave a voicemail message
and your crisis call will be returned as quickly as possible.
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Social Media
THERAPIST will NOT accept any friend or contact requests from current clients on any social
networking sites. (Facebook, LinkedIn, Pinterest, etc). We believe that adding clients as friends or
contacts on these sites can compromise your confidentiality and our respective privacy. It may also
blur the boundaries of your therapeutic relationship. It is NOT a regular part of our practice to
search for clients on Google or any other search engine sites. You may find our practice listed on
various business review sites. Some of these sites include forums in which users rate their providers
and post reviews. Many of these sites comb search engines for business listings and automatically
add listing regardless of whether the business has added itself or not. If you should find our listing
on any of these sites, please know that this listing is NOT a request for a testimonial, rating or
endorsement from you as a client. Of course, you have a right to express yourself on any site you
wish but due to confidentiality we cannot respond to any review whether positive or negative. I urge
you to take your own privacy as seriously as we take our commitment of confidentiality to you.
Email
It is important to be aware that email communication can be relatively easily accessed by
unauthorized people and can compromise the privacy and confidentiality of such communication.
Emails, in particular, are vulnerable to unauthorized access due to the fact that servers have
unlimited and direct access to all emails that go through them. A non-encrypted email, such as the
email THERAPIST uses, is even more vulnerable to unauthorized access. Your therapist will only
communicate with you via email if you initiate this kind of communication by sending an email to
the email address provided to you by your therapist. Your therapist will check his/her email
frequently during regular business hours and will respond to any emails received during business
hours the same day. Any emails sent after business hours will be replied to the next business day.
Email communication with your therapist should be limited to scheduling purposes only. Please do
not share detailed or personal information in emails. It is also important to know that any email
communication will be included in a client’s clinical file. Please do not use email for emergencies.
Consent
The following is my attestation to the acknowledgement, my therapist has thoroughly explained the
“Client Information” document to my satisfaction.
____________________________________ ___________________________________
Client Signature Date Client Signature Date
____________________________________ ____________________________________
Parent/Guardian Signature Date Parent/Guardian Signature Date
Bonnie Arredondo, TLMFT
____________________________________
Therapist Signature
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