Dottie Claggett, MA, LPC-S by 7ZXB40

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									                                         Dottie Claggett, MA, LPC-S
                                       Behavioral Strategies for Health
                               500 Turtle Cove Suite 220 Rockwall, Texas 75087
                                           Telephone: 214-797-7221
                                          dottieclaggett@charter.net
                                           www.dottieclaggett.com

                                          AGREEMENT FOR SERVICES

I request that Dottie Claggett, MA, LPC-S, provide counseling, behavior modification, a behavioral health assessment for
bariatric surgical clearance or EEG services to me and if applicable, to my minor child or children listed below: Name of
Patient: ____________________________________________________________________________________

If this is an individual appointment through Dottie’s private practice, I agree to pay for missed appointments unless I provide
Dottie Claggett with notice of cancellation 24 hours in advance. I understand that the missed appointment will be noted on
the bill, and since third party payers do not pay for missed appointments, you will be charged for the full hour that was
allotted to you. If this is an appointment through contracted services by Dottie Claggett and an agency, rules of that
institution will be implemented.

If Dottie Claggett, MA, LPC-S is requested by me or subpoenaed by me or someone else to testify in any court related
proceeding in which I am a party, I agree to pay Dottie Claggett’s fee of $200 per hour for preparation and testifying time
(including depositions) and $.25 per page for record photocopying. If Dottie Claggett’s testimony is required by another
party, she will attempt to obtain payment from that party, however, the ultimate responsibility for payment is mine and I
agree to pay all costs and time incurred prior to or at the time of testimony.

Violations of the Licensed Professional Counselors Act may be reported to the Texas State Board of Examiners of
Professional Counselors, 1100 West 49th Street, Austin, Texas 77856-3183, phone 1-800-942-5540.

I have had an opportunity to read this Agreement and I agree with all of the provisions contained in this agreement. I
understand that if I have any reservations, I should not sign this Agreement.

                        ______________________________________________________________

Thank you for choosing me for your Behavioral Health assessment, counseling or Neurofeedback needs. This document is
designed to inform you about my background and to ensure that you understand the professional relationship of counseling.
Dottie Claggett is a Texas State Licensed Professional Counselor and has the following experience and list of specialties:

Extensive training in the Bariatrics field:
     Close to 1800 surgical clearance psychological evaluations
     Pre and Post Surgical Counseling and Behavior Modification
     Preparation class for pre-surgical patients
     Group counseling and Psycho-education groups for Weight Loss Surgery
     Completed Masters Behavioral course with the American Society of Bariatric Surgeons

Trained in Professional EEG and Neurofeedback Applications
Certified Anger Resolution Therapist
Advanced Training and Certified in Emotional Freedom Technique
**Trained in BAUD/Bio Acoustical Utilization (brain entrainment)
Aspergers, HFA and Autism Spectrum Disorders
ADHD
Social Skills Training
Specializing in Law Enforcement Dynamics
Strategic Safety and Wellness for Adolescents and Teens. (SSWAT)
Distance Counseling Certification and provides On-Line Counseling.

  **The BAUD is an FDA-approved bio-feedback device used to improve symptoms of anxiety, depression, stress,
 overactive appetite and smoking by using binaural beats and neutralizing the visual negative images and emotions.

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Some clients need only a few counseling sessions to achieve these goals, while others may require months or even years of
counseling. As a client, you are in complete control and may end our counseling relationship at any point. I will be
supportive of that decision. If counseling is successful, you should feel that you are able to face life’s challenges in the
future without my support or intervention.

Neurofeedback or EEG sessions can be done in itself or in conjunction with other therapeutic modalities.

**EEG training is a learning process, and therefore results are seen gradually over time. For most conditions, initial
progress can be seen within about ten sessions. Initial training goals may be met by twenty sessions, at which time
retests are usually performed. In the case of hyperactivity and attention deficit disorder, training is expected to take
about 20 to 40 sessions, or even more in cases such as Autism Spectrum Disorders.

I assure you that my services will be rendered in a professional manner consistent with accepted ethical standards. Sessions
are fifty minutes in duration or 30 minutes for a Neurofeedback session. Please note that it is impossible to guarantee any
specific results regarding your counseling or Neurofeedback goals. Together we will work to achieve the best possible
results for you. Other options for counseling include talking with other professionals, your clergy person, or choosing to let
the situation remain the same. If you have any complaints please discuss them with me.

The fee for each counseling session will be due and must be paid at the beginning of each session unless we are filing
insurance claims and then co-payment will be collected. Cash, Master Card, Visa or Discover are preferred methods for
payment. I will provide you with a receipt for all fees paid. In the event that you will not be able to keep an appointment,
you must notify me 24 hours in advance. If I do not receive such advance notice, you will be responsible for paying for the
session that you missed. In the event I am asked to appear at court and/or to provide testimony regarding your case, a fee of
$200.00 per hour will be required. The fee for this service begins from the time I leave my office until I return to the office.

If you are paying for out of network benefits and wish to seek reimbursement for my services from your health insurance
company, I will be happy to complete any forms related to your reimbursement provided by you or the insurance company.
Because you will be paying each session for my services, any later reimbursement from the insurance company should be
sent directly to you.

Some health insurance companies will reimburse clients for my counseling services and some will not. Those that do
reimburse usually require a standard amount to be paid by you before reimbursement is allowed, and then usually only a
percentage of my fee is reimbursable. You should contact your insurance company to determine whether your insurance will
reimburse you and what schedule of reimbursement will be used. You will be responsible for any amount not paid by your
insurance company.

Health insurance companies often require that I submit a diagnosis code in order to receive payment or reimbursement. In
the event a diagnosis is required, I will inform you of the diagnosis I plan to render before I submit it to your insurance
company. Any diagnosis made may become a part of your permanent insurance records.

Please be advised that I am an independent mental health provider. The other colleagues that occupy
my office space (now and in the future) are not a part of the counseling practice identified as Dorothy Claggett or Dottie
Claggett, MA, LPC-S unless otherwise specified.

If you have any questions, please ask your therapist.

_____________________________________                           ______________________________
       Client Signature                                                Date

_____________________________________
Parent/Conservator’s Signature if Client is a Minor

_____________________________________                           ______________________________
Dottie Claggett, MA, LPC-S                                             Date




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                       CONFIDENTIALITY/RELEASE OF INFORMATION

Dottie Claggett recognizes the importance of confidentiality of client communications in the therapeutic
and counseling process and agrees to treat information obtained confidentially in accordance with law
and professional standards. I understand that confidentiality is not only an ethical concept but also a
legal concept and that certain exceptions to confidentiality exist.

I understand that Dottie Claggett may communicate confidential information when permitted or required
by law. Some of the exceptions include reporting child or elder abuse, in response to legal process, in
conjunction with legal proceedings including licensing complaints, in connection with billing efforts or
in conjunction with treatment efforts for persons operating under her direction. I also authorize Dottie
Claggett to disclose confidential information when required by the code of ethics for professional
associations to which she belongs; or in other circumstances where release appears proper as viewed by
Dottie Claggett using her best professional judgment.

I also authorize the release of confidential information for the purpose of processing third party payor
forms or when obtaining payment for third party payors such as my medical/mental health insurance
company or other managed care organizations who provide payment for my care.

I authorize Dottie Claggett to release such information about me which in her opinion is reasonably
necessary to protect others from risk of death or serious harm, including information regarding any
sexually transmitted disease. Said information may be released to whoever is reasonably necessary to
accomplish protection.

I further understand that it may be beneficial in the course of my therapy to release information to family
members or others. I, therefore, specifically authorize the release of confidential information to the
following:
        1. _____________________________________________________________________
        2. _____________________________________________________________________
        3. _____________________________________________________________________
        4. _____________________________________________________________________

If Dottie Claggett transfers or sells her counseling practice I consent to the release of my records and all
information contained in the records to the person to whom the practice is transferred or sold. I
understand that Dottie Claggett may, at some times be unavailable due to illness, disability or vacation.
At such time, I authorize Dottie Claggett to release information to her substitute or personal
representative.

The term “information” as used in this release means all information contained in written records and
also information known to Dottie Claggett, which may be communicated verbally. By signing this
release, I also give Dottie Claggett permission to release information regarding my minor children.

_____________________________________                         ______________________________
      Client Signature                                              Date

_____________________________________                    _____________________________________
Parent/Conservator’s Signature if Client is a Minor       Dottie Claggett, MA, LPC-S




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                                                     CLIENT RIGHTS

1. You have the right to be treated fairly and with respect.

2. You have the right to ask questions at any point in the therapeutic process.

3. You have the right to know the policy concerning canceled appointments (as during vacations, illness, etc.).

4. You have the right to request another therapist and receive competent referrals.

5. All people, including your therapist, have biases and values. You have the right to a therapist who will acknowledge
    personal values and will not attempt to impose them on you. The job of the therapist is to help you find your own way.

6. You have the right to ask about your therapist’s training, theoretical orientation, techniques, and supervised experience.

7. You have the right to ask about your therapist’s policy regarding confidentiality. You have the right to grant or deny
    permission to your therapist to discuss your progress with others.

8. You have the right to know your therapist’s policy regarding medication. A medical doctor (M.D. or D.O.) is the only
    person who can prescribe medication. You have the right to take or not to take medication, to discuss pros and cons of it,
    and to be involved in the decision. If you disagree with your therapist about whether you should take medication, you
    have the right to seek another opinion.

9. You have the right to discuss what is happening in your sessions with other people and to consider and accept or reject
    this feedback about your progress.

10. You have the right to have a consultation with another therapist if you wish. It is usually a good idea to discuss your
    wish for a consultation with your present therapist, whether or not your therapist agrees. If after such a discussion you
    still wish to have the consultation, it is important for you to trust your own feelings and use your own judgment.

11. You have the right to stop counseling when you want, whether or not your therapist agrees with your decision. It is
    usually worthwhile to discuss with your therapist your reasons for wanting to stop your sessions. However, the decision
    is always yours.

* I understand and have received a copy of my rights as a client seeking therapeutic counseling services.

         ____________________________________                  ________________________
                             Client Signature                                                Date




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     PATIENT CONSENT FOR USE AND/OR DISCLOSURE OF HIPAA DEFINED PROTECTED HEALTH
       INFORMATION TO CARRY OUT TREATMENT, PAYMENT AND HEALTHCARE OPERATIONS

I, _____________________________________, hereby state that by signing this Consent, I acknowledge and
agree as follows:

The Provider's Privacy Notice has been provided to me prior to my signing this Consent. The Privacy Notice includes a
        complete description of the uses and/or disclosures of my protected health information ("PHI) necessary for-the
        Provider to provide treatment to me, and also necessary for the Provider to obtain payment for that treatment and to
        carry out his health care operations. The Provider explained to me that the Privacy Notice will be available to me in
        the future at my request. The Provider has further explained my right to obtain a copy of the Privacy Notice prior to
        signing this Consent, and has encouraged me to read the Privacy Notice carefully prior to my signing this Consent.

         The Provider reserves the right to change his privacy practices that are described in his Privacy Notice, in
         accordance with applicable law.           .

I understand that, and consent to, the following appointment reminders that may be used by the Provider:
         _____ Yes _____ No - a postcard mailed to me at the address provided by me
         ____Yes ______ No - telephoning my home and leaving a message on my answering machine or with the individual
         answering the phone at the following number: ______________________________________________
         ______Yes _____No - telephoning my office and leaving a message on my phone mail or with the individual
         answering the phone at the following number: _____________________________________________________
         ____Yes_____No- emailing me a reminder at the following email address: _______________________________

The Provider may use and/or disclose my PHI (which includes information about my health or condition and the treatment
        provided to me) in order for the Provider to treat me and obtain payment for that treatment, and as necessary for the
        Provider to conduct its specific health care operations.

I understand that I have a right to request that the Provider restrict how my PHI is used and/or disclosed to carry out
         treatment, payment and/or health care operations. However, the Provider is not required to agree to any restrictions
         that I have requested. If the Provider agrees to a requested restriction, then the restriction is binding on the Provider.

I understand that this Consent is valid for seven years and that I have the right to revoke this Consent, in writing, at any time
         for all future transactions, with the understanding that any such revocation shall not apply to the extent that the
         Provider has already taken action in reliance on this consent.

I understand that if I revoke this consent at any time, the Provider has the right to refuse to treat me.

I understand that if I do not sign this Consent evidencing my consent to the uses and disclosures described to
         me above and contained in the Privacy Notice, then the Provider will not treat me.

                   I have read and understand the foregoing notice, and all of my questions have been answered to my
         full satisfaction in a way that I can understand.


         ________________________________________                 ________________________________________
         Name of Individual (Printed)                             Signature of Individual


         Signature of Legal Representative                     Relationship to Patient
         (e.g., Attorney-In-Fact, Guardian, Parent if a minor)

         ________________________________________                __________________________________________

         Date Signed _____/______/___________                     Witness:_________________________________




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