policies by lanyuehua


									                                                                                             ID _________
                                                Amber Kuntz, LPCS and Associates
                                                 Licensed Professional Counselors

                                                        Inf ormed Consent f or Therapy
Thank you for choosing Mrs. Amber Kuntz, LPCS and Associates. Today’s intake appointment will take
approximately 35-45 minutes. We realize that starting counseling is a major decision and you may have many
questions. The counseling relationship is a partnership in which you, the client, are the best judge of your
capabilities, interests, needs, and desires while the counselor offers tools, support, guidance, training, exploration
of alternatives and potential, help with clarifying issues, and experience to help you through this process. Amber
Kuntz, LPCS and Associates provide outpatient mental health services and assessments for most conditions.
Techniques used may include but are not limited to cognitive -behavioral therapy, family therapy, individual
therapy, couples therapy, play and activity therapy, adolescent therapy, guided imagery, client-centered counseling,
motivational interviewing, solution-focused therapy, and animal-assisted therapy. Your therapist will provide you
with their particular approach to therapy. We understand that each client is an individual and we tailor the
counseling experience to suite the client’s needs. Also, the main responsibility for change rests with the client. You
have the right to decline any technique or procedure. It is the client’s responsibility to discuss any concerns with
the staff and to be aware that we are here to support and are not liable for emotional health. If there are signs of
serious mental illness client should see a local psychiatrist or be assessed by a local hospital. This document is
intended to inform you of our policies, State and Federal laws and your rights.
    1.    Improved understanding of self and oth ers          1. Lack of progress
    2.    Progress toward defin ed goals and objectives       2. Up setting insight
    1.    Greater sense of control over moods and beh avior   3. Feelings of distress
    2.    Improved self-esteem                                4. Chang e in relation ships
    3.    Improved self-assertion
    4.    Improved relatio n ships with oth ers
    5.    Improved cap acity for indep enden ce

Counseling Relationship:
During your counseling sessions, your counselor will direct you mutual efforts towards the agreed upon goals set
forth on the individual or family basis. Sessions are usually h eld on a weekly basis and are approximately 45 -50
minutes long. Although your sessions may be personal and intimate in nature, the relationship between you and
your counselor is a professional one, not a social relationship. Contact with your counselor wil l be limited to your
counseling sessions, the arrangement of counseling sessions, billing, and counseling updates, with the exception
of emergencies. If you see your counselor in public, they will protect your confidentiality by acknowledging you
only if you approach them first. Counseling sessions are available by appointment only.
In the case of marriage and family counseling, your counselor will keep confidential (within the limits of
confidentiality as indicated herein) anything you disclose to them wit hout your family member’s knowledge.
However, we encourage open communication between family members and your counselor reserves the right to
terminate the counseling relationship if they judge the disclosed information to the detrimental to the therapeuti c

24-Hour Cancellation Policy: You will be required to pay for a “no show” for an appointment that is not cancelled
within 24 hours prior to the session.

15-Minute Policy: If you are 15 minutes late it is considered a “no show.” The 24 -hour cancellation policy will
apply. You will be charged for that session and we will reschedule your appointment.

Rescheduling: You may reschedule an appointment 24 hours in advance. Anything cancelled the day of will be
charged the full counseling fee.

Telephone and Email Policy: Mrs. Kuntz and staff returns phone calls on a regular basis during office hours. You
may leave a detailed message. Phone calls over 10 minutes will be billed at $2.00 per minute. For appointments e -
mail ambercounselor@gmail.com or call 940.600.4560. In the event of an emergency contact the Emergency Hotline
at 972-233-2233 or 911.

                                                                                                                            ID _________
                                             Amber Kuntz, LPCS and Associates
                                              Licensed Professional Counselors
By signing here, you authorize and consent for Amber Kuntz, LPCS and Associates to contact you via emai l and/or
telephone. I understand that if I choose to be contact by email, confidentiality cannot be ensured. Furthermore if I
chose to be contacted via telephone I understand that Amber Kuntz, LPCS and Associates or its designee will take
the necessary efforts to preserve your confidentiality.
   You may contact client by telephone               I decline contact via telephone
   You may contact client via email                          I decline contact via email

___________________________________                  ________________________________________                             __________________
Client Printed Name                                  Client/ Parent or Guardian Signature                                 Date

                                          COORDINATION OF TREATMENT:
It is important that all health care providers work together. As such, we would like your permission to
communicate with your primary care physician and/or psychiatrist. Your consent is valid for one year. Please
understand that you have the right to revoke this authorization, in writing, at any time by sending notice.
However, a revocation is not valid to the extent that we have acted in reliance on such authorization. If you prefer
to decline consent no information will be shared.
   You may inform my physician (s)                             I decline to inform my physician

1. Physician Name: _________________________________________2. Physician Name: ___________________________________

Clinic: __________________________________________________Phone:____________________________________

Address: _____________________________________________________________________________________________________________

Under no circumstances will a counselor treat a client in the event that the client is under the influence of drugs,
alcohol, or any illegal substances of any kind. If the counselor suspects that the client is under the influence, the
client will be asked to leave. At this time the client will be required to pay the designated amount for the session,
as it will be qualified as a missed session. The counselor has a legal duty to inform the proper authorities if it is
suspected that the client is in danger of harming one’s self or another by driving from the office . A cab or your
emergency contact can be called for you. This policy is made for the protection of the clients, counselors, other
persons, and the relationship between the client and counselor. Our goal is to help the client to the best of our
means and when a client is not in the state of mind to be an active and lucid participant in the therapeutic process,
we are not upholding our duties as mental health professionals.

Client Bill of Rights
Amber Kuntz, LPCS and Associates earnestly wish to provide you with the best possible services while you are a client and to
treat you with the utmost respect. We have listed the considerations you may expect while a client at Amber Kuntz, LPCS and
Associates. Please see full Bill of Rights and Grievance policy on our website for you to print out and have at anytime.
    o   You have the right to be treated with consideration, respect, and dignity by the staff and designees Amber Kuntz, LPCS and Associates.
    o   You have a right to the highest quality of services available, regardless of your race, nationality, age, sex, disability, sexual orientation or religion.
    o   You have the right to be told about services and recommendations in terms you can understand.
    o   You have the right to have all releases and other forms requiring your signature explained to you before signing.
    o   You have the right not to be exploited or abused in any way while you are a client of Amber Kuntz, LPCS and Associates.
    o   You have the right to refuse to participate in surveys, evaluations, assessments, and research projects.
    o   You have the right to have your interests and self-determination recognized as our primary responsibility.
    o   You have a right to have your civil and legal rights protected.
    o   You have the right to have your privacy and confidentiality respects, except when the information disclosed is subject to mandatory reporting as
        required by laws and regulations.
    o   You have the right to stop counseling when you want, whether or not your therapist agrees with your decision.
    o   You have the right to be provided with personalized services, including referrals that are in your best interest.
    o   You have the right to refuse any services offered.
    o   You have the right to choose you therapist and reserve the right to seek another therapist if you so choose.
    o   You have the right to file a client grievance procedure if you feel your rights have not been respected.
                                                                                                                         ID _________
                                             Amber Kuntz, LPCS and Associates
                                              Licensed Professional Counselors

                                                      CLIENT GRIEVANCE POLICY
Amber Kuntz, LPCS and Associates are committed to providing the highest quality of services to all clients. If a person receiving
services at Amber Kuntz, LPCS and Associates is not satisfied with the services being provided or experiences a situation that
cannot be resolved satisfactorily between themselves and a counselor, dietician, volunteer, staff member, or intern, he or she
will be provided the opportunity to initiate a grievance with Amber Kuntz, LPCS and Associates or its designees and the Texas
Department of Human Services (DHS) to further assist him or her in resolving the matter.
Each step of the outlined procedure should be carried out within a timely manner. In addition to an oral conference throughout this process, the client shall
submit in writing a statement of the grievance issue to Amber Kuntz, LPCS and Associates designee.
The following procedure should be implemented by the client:
1.        Discuss the matter with the staff, counselor, dietician, volunteer, intern or representative of the private practice to seek a satisfactory resolution,
          which may include referral.
2.        In the event that a satisfactory resolution cannot be achieved, the client reserves the right to file a grievance with the Texas Department of State

The information below is provided in the event the client finds it necessary to file a grievance with the Texas Department of Health and
Human Services and/or the counselor’s licensing board.

Texas Department of Health and Human Services                               Texas State Board of Examiners of Professional Counselors
701 W. 51 st Street                                                         P.O. Box 141369
Austin, Texas 78751                                                         Austin, Texas 78714-1369
512-438-3011                                                                1-800-942-5540

                                     CONFIDENTIALITY AND EMERGENCY SITUATIONS:
Your verbal communication and clinical records are strictly confidential except for a) information shared with
psychiatrist, and or LPC Counselor b) information (diagnosis and dates of service) shared with your insurance
company to process your claims, c) information you and/or your child or children report about physical or sexual
abuse; then, by Texas State Law, I am obligated to report this information to the Department of Children and
Family Services, or proper authorities d) where you sign a release of information to have specific information
shared and, e) if you provide information that informs me that you are in danger of harming yourself or others,
f)information necessary for case supervision or consultation, g) information you and/or your child or children
report about a threat to National Security or a plot of terrorism h) or when required by law. If an emergency
situation for which the client or their guardian feels immediat e attention is necessary, the client or guardian
understands that they are to contact the emergency services in the community (911) for those services. Amber
Kuntz, LPCS and Associates will follow those emergency services with standard counseling and suppo rt to the
client or the client’s family. Amber Kuntz, LPCS and Associates keep treatment plans on clients for all practical
purposes and some billing purposes. Treatment plans are kept in client’s chart. I understand that Amber Kuntz,
LPCS and Associates use phone and e-mail to correspond with clients, and by signing below I waive my right for
her to use these means to discuss the client being my child or myself. If Amber Kuntz, LPCS or Associates becomes
incapacitated or dies, I give my consent for Counselor of Amber Kuntz, LPCS to be custodian of my file and to
access it for me. I also give my consent to contact me via telephone or email in the event my therapist becomes
incapacitated or dies.
I understand that Amber Kuntz, LPCS and Associates may have a duty to warn. Below is a list of people (but not
limited to) that may be contacted in order to help prevent harm.
Name                                                  Relationship                    Phone                            Email:
_________________________________                     _______________________          _____________________           __________________________

_________________________________                     ________________________          _____________________          ___________________________

____________________________________________                     ___________________________________________                      ____________
Client/ Parent/ Guardian Printed Name                            Client/Parent/Guardian Signature                                 Date

                                                                                                                          ID _________
                                              Amber Kuntz, LPCS and Associates
                                               Licensed Professional Counselors
___________________________________________                      __________________________________________                        ____________
Amber Kuntz, LPCS or Associate                                   Amber Kuntz, LPCS or Associate                                    Date
Printed Name                                                     Signature
                          Health Insurance Portability and Accountability Act Privacy Rule (45C.F.R, parts 160 and 164)
The federal government mandated that as of April 14, 2003 all health care patients are to receive from their clinicians a notice (hereafter
referred to as "Notice") regarding the protection of their private health care information in compliance with the Health Insurance Portability
and Accountability Act ("HIPAA") Privacy Rule (45 C.F.R. parts 160 and 164).This form documents that Mrs. Amber Kuntz, LPC, NCC, NBCCH,
MS has given you the "Notice" that is required. HIPAA covers what is called "protected health information" (PHI) that is used for treatment,
payment, and health care operations. PHI is information in your health record that could identify you. The Notice contains basic information
1. How your PHI may be used and disclosed for treatment, payment and health care operations (these terms are defined in the Notice)
2. Which uses and disclosures require authorization from you and which don't
3. How you may revoke an authorization you have made
4. Certain rights you have to restrict use and disclosure of PHI, to receive confidential communications by alternative means and at alternative locations, to
inspect and copy your records, to amend your records, to have an accounting of disclosures
5. A list of my duties to protect the privacy of your PHI, my right to change the privacy policies and practices described in the Notice, and how I will inform you
of changes
6. What you can do if you have any complaints about violations of your privacy rights, about decisions about access to your records I may make
7. Any restrictions and limitations you or I wish to put on the use and disclosure of your PHI.
This page documents that you have received a copy of the Notice that can be seen fully on line or where given to you in person.

______________________________________                           _____________________________________                              ___________
Client Printed Name                                              Client Signature                                                   Date

                                  POLICY OF FINANCIAL AND INSURANCE :
We ask that at each session you pay 100% of your fees. If fees are not rendered at the time of service there will be
a $25.00 fee attachment. In the event you have insurance, you may submit for reimbursement yourself. There is a
$30 overdraft fee for returned checks which will be added to the cost of the session. If insurance is filed and the
insurance company fails to pay, the client is responsible for all fees. In the event that an account is overdue and
turned over to our collection agency, the client or responsible party will be held responsible for any collection fee
charged to our office to collect the debt owed plus a $50.00 fee.

Intake session: $60.00 -$100.00            Sliding scale: Family annual income of less than $25, 000 for $68.00
Half-sessions (30 minutes): $55-$60                         $25,000 to $30,000 for $72.00
Full sessions (45-50 minutes): $80-$90                      $35,000 to $40,000 for $76.00
Family and Couples (45-50 minutes): $90-$100

    - In order to qualify for the sliding scale, proof of inc ome is required.
    - Missed session fee: the cost of the agreed upon session fee
    - Reschedule with less than 24 hours until appointment: the FULL cost of the agreed upon session fee
    - Copy of chart is .35 cents per page, $35.00 per hour clerical fee, $150.00 per h our redacting fee.
In the event that your session exceeds the allotted time, you will be billed at the rate of $1 per minute, in addition
to the agreed upon session cost. Counselors will travel to accommodate the client’s needs, however there is a
minimum $10 travel fee plus $0.25 charge per mile traveled fee that will be added to the cost of the counseling
session. There is no refund policy. Hypnosis is not guaranteed and there are no refunds. All policies apply in all
cases. All fees are dependent on the requirements of the service provided. In the event that 3 Add/ADHD
assessments are performed, a $30 discount will be applied.
Assessments:                                                            Court Charges:
Depression: $ 50                                                        Supervised Visitation: $135.00
ADD/ADHD: $160 per test, results, repo rt                               Treatment Reports: minimum $225.00
Achievement: $325                                                       Mediation or Consultation: $135.00
IQ: $225                                                                Deposition: $175.00 per hour
Psychological/ MMPI: $425
                                                                                                ID _________
                                       Amber Kuntz, LPCS and Associates
                                        Licensed Professional Counselors
Full Psychological Evaluation without ADD/ADHD: $1,175
                                 With ADD/ADHD: $1,375

I have received a copy of my fee schedule ____________________________               ____________
                                               Client Signature                      Date
                                       Consenting Signature Page

____________ Client Initials      CONSENT FOR SERVICES
                                  I have read and understand the copy of the Information Po licy for Amber Kuntz,
                                  LPCs and Associates. I understand my rights and responsibilities and choose to
                                  enter into services with Amber Kuntz, LPCS and Associates and/or its designee.

                                  CLIENT GRIEVANCE POLICY
____________ Client Initials       I have received and read a copy of Amber Kuntz, LPCS and Associates’ Client Grievance
                                  Policy. The grievance policy was explained to me, and I understand that I may file a grievance
                                  if I feel I have been treated unfairly or in a less than supportive manner during my time of
                                  services at Amber Kuntz, LPCS and Associates.

____________ Client Initials      STATEMENT OF CONFIDENTIALITY
                                  I have received and read a copy of Amber Kuntz, LPCS and Associates’ Statement of
                                  Confidentiality Policy. The policy was explained to me, and I understan d my right to
                                  confidentiality, the limits to confidentiality and the duty to report. I understand that
                                  if I have questions, I can approach Amber Kuntz, LPCS and Associates staff and
                                  receive information at any time.

____________ Client Initials      CLIENT BILL OF RIGHTS
                                  I acknowledge that I have reviewed, had a copy made available to, and understand
                                  my rights as a client seeking counseling services and/or other services provided by
                                  Amber Kuntz, LPCS and Associates.

____________ Client Initials      STATEMENT OF FINANCES AND INSURANCE:
                                  I acknowledge that a copy of the Statement of Finances and Insurance has been
                                  explained, reviewed, made available to me. I acknowledge that I am responsible for
                                  payments of services at the time of service and understand the purpose of and
                                  limitations to the Statement of Finances and Insurance. Furthermore, I acknowledge
                                  that if payment is not rendered, Amber Kuntz, LPCS and Associates reserves the
                                  right to breech confidentiality by contacting a designated collection agency to
                                  ascertain payment.

____________ Client Initials      STATEMENT OF RECEIPT OF PRIVACY POLICY:
                                  I acknowledge that Amber Kuntz, LPCS, NCC, NBCCH, MS and/or Associates have
                                  given me a copy of the Privacy Notice either by web, email, US Mail, or in person,
                                  (version dated 4/14/03) as required by the federal government's HIPAA legislation.
                                  I have been provided with the opportunity to discuss concerns I may have regarding
                                  the privacy of my health information.

By signing below I acknowledge, agree to, and understand all policies here within.

____________________________________               ________ _________________________________          ___________________
Printed Name of Client or                          Signature of Client or                              Date
Managing Conservator                               Managing Conservator

                                                                                              ID _________
                                       Amber Kuntz, LPCS and Associates
                                        Licensed Professional Counselors
____________________________________             ________ _________________________________        ___________________
Printed Name Amber Kuntz,                        Signature of Amber Kuntz,                         Date
LPCS or Associate                                   LPCS or Associate


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