Capturing Hope Counseling Participation Agreement
To the client or authorized guardian, please read the following information carefully:
Client's Name *
Authorized Guardian's Name (if applicable)
APPOINTMENTS: Counseling outcomes are most successful when clients attend their regularly scheduled appointments and participate in agreed-upon assignments.  Progress toward counseling goals will be evaluated periodically to determine the need for future appointments.  You can discontinue the therapeutic relationship at any time you feel it is not in your best interest to continue.  Therapists at Capturing Hope Counseling have the ethical responsibility to end services if they determine the sessions are no longer benefiting the client, or if an issue is outside of their clinical expertise and they deem it necessary to refer elsewhere. The undersigned understands and acknowledges that the counselors at Capturing Hope Counseling use a Biblical perspective and a faith-based understanding of treatment. *
PAYMENTS: Full payment is expected at the time of service.  Cash, checks and credit cards are accepted.  A $20 fee will be charged for a returned check, and another form of payment will be expected to cover the session.  If the fee for a session has not been paid and accommodations have not been discussed with your therapist, Capturing Hope Counseling has the right to cancel services. Up-to-date service pricing is located at *
CANCELLATIONS:  A 24-hour notice is required to cancel an appointment without charge. The full fee is charged for appointments not cancelled within this time frame. There is no charge for missed appointments due to emergencies, illness or weather.  On occasion, your therapist may need to miss a session and will make every effort to reschedule your appointment as quickly as possible. *
INSURANCE: Capturing Hope Counseling is considered an “out-of-network” provider.   No claims will be submitted to insurance by Capturing Hope Counseling.  Submissions are the responsibility of the client.  If you request a receipt for reimbursement, communication may occur between Capturing Hope Counseling and your health insurance company, as needed.  We are able to provide a receipt with the diagnostic codes necessary to submit to an insurance company. *
TECHNOLOGY: Capturing Hope recognizes the convenience of communication technologies such as social media, email, texting and voicemail. Although we are careful in our use of technology, there is a risk with these forms of communication. We do not use an encrypted system (guaranteed secure for HIPPA requirements); therefore, we try to limit identifying information and details of treatment via these communication methods. However, a client may choose to use one of these methods and include more details with the understanding that the therapist may only respond in acknowledgment of receiving the information. By using these methods, the client agrees to accept these risks. *
CONFIDENTIALITY:  Information will not be released to a third party without the signed consent of the client.  The client has the right to confidentiality regarding evaluation and treatment, except in the following situations: 1) When client gives written permission to release information 2) Medical emergencies 3) Records subpoenaed for legal reasons 4) Any suspicion of child abuse or neglect 5) Any suspicion of elder abuse or neglect 6) Any suspicion that suicidal or homicidal behavior might occur 7) Insurance companies will be provided your diagnostic code for the purpose of reimbursement. No additional information is given concerning your treatment. 8) We reserve the right to consult with peers or other experts for guidance in developing areas for the benefit of continuing education and growth as a mental health therapist.  Client name and identifying factors will not be disclosed for this purpose without the consent of the client. *
By signing below, the client or authorized guardian agrees to these conditions of treatment and acknowledge that I have received a copy of Capturing Hope Counseling's Notice of Privacy Practices (HIPPA). *
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