Request edit access
Renewal Informed Consent
This is a copy of the informed consent document you have previously signed; it must be updated each year. Please review the text and sign (enter) your name and the date below to acknowledge and accept the agreement.
CONFIDENTIALITY AND EMERGENCY SITUATIONS
Your verbal communication and clinical records are strictly confidential except for: a) information shared with consultants, b) information (diagnosis and dates of service) shared with your insurance company to process your claims, c) information you and/or you child or children report about physical or sexual abuse; then, by Illinois State Law, Mindful Wellness is obligated to report this to the Department of Children and Family Services, d) where you sign a release of information to have specific information shared and e) if you provide information that informs us that you are in danger of harming yourself or others f) information necessary for case supervision or consultation and h) or when required by law.
If an emergency situation for which the client or their guardian feels immediate attention is necessary, please call Mindful Wellness immediately. If no call is received within 15 minutes or you cannot wait, the client or guardian understands that they are to contact the emergency services in the community (911) or local emergency room for those services. Mindful Wellness will follow those emergency services with standard counseling and support to the client or the client's family. E-mail, text messages and social networking sites are not confidential and we may not be able to respond.
As a courtesy Mindful Wellness will bill your insurance company, responsible party, or third party payer. Signing below indicates written consent for said billing on your behalf.
If you are using your insurance, we ask that you pay your co-pay at the time of session. If you are not using insurance, we ask that you pay the full fee that we have agreed upon at the time of session. In the event you have not met your deductible, Mindful Wellness will charge you the rate contracted with your insurance company at each session until the deductible is satisfied. If your insurance company denies payment or does not cover counseling, we request that you pay the balance due at that time. If you have an outstanding balance, Mindful Wellness withholds the right to provide further services until the balance is paid.
After 60 days any unpaid balance will be charged 1.5% interest a month (18% APR). In the event that an account is overdue and turned over to a collection agency, the client or responsible party will be held responsible for any collection fee charged to my office to collect the debt owed. We ask that every client authorize payment of medical benefits directly to Mindful Wellness.
Lastly, if you need to cancel or reschedule an appointment, please give 24 business hours advance notice, otherwise you will be billed a $65 no show fee. We sincerely appreciate your cooperation and at any time you have any questions regarding insurance, fees, balances or payments please feel free to ask. You may have a copy of this form if requested.
Never submit passwords through Google Forms.
This content is neither created nor endorsed by Google.
Terms of Service