New Client Information, Financial Responsibility, & Informed Consent
This form is multi-purpose. It is for me, Deborah Lee (Debbie) Urban, LPC, to (#1) provide information to you, (#2) for you to request information from me, (#3) for you to provide initial assessment information to me, (#4) to verify financial responsibility, and (#5) for you to consent to treatment (if applicable). If you are not comfortable with on-line communication, please read through this information, call 314-304-2942 or 573-727-6007, or email me at DebbieUrbanLPC@aol.com to make an appointment.
Please read all sections, fill out and submit this at the end of the "Client Information, Financial Responsibility, & Informed Consent" section.
You will not be billed for submitting this form, but, if submitted, I will take it as you are stating that you understand and agree with what is contained in the form. Please read it carefully. It is legally required that I provide you with this information. Some of it may seem redundant, however, I am working to downsize it as soon as I figure out what is necessary and what is not. Meanwhile bear with me...
The major goal of treatment is to help you identify and cope more effectively with problems in daily living and to deal with inner conflicts which may disrupt your ability to function effectively. This purpose is accomplished by:
- Increasing personal awareness and accessing your own abilities and strengths that you can use to cope and feel good about daily living.
- Identifying your personal goals.
- Increasing personal responsibility and acceptance to make changes necessary to attain your goals.
- Promoting wholeness through healing and growth.
You are responsible for providing the necessary information to facilitate effective treatment. You are also expected to play an active role in your treatment, including working with me to outline your treatment goals and needs and to assess your progress. There can also be negative consequences if you do not follow through with recommended treatment(s). I will always try to answer any questions that you may have.
During the course of treatment, I may ask you to do homework assignments or to practice certain behaviors. It is important to remember that your progress in therapy often depends much more on what YOU do between sessions than on what happens in the session.
Initial appointments are usually scheduled for up to 90 minutes. Following sessions are scheduled for approximately 45-60 minutes. My hours are varied and scheduled according to individual needs and my availability.
You may discontinue therapy at any time, but please discuss your decisions with me as my goal is for you to receive the best, whatever that may be. I do not bite and can handle it if we do not click.
In the event of an emergency, I can be reached at 314-304-2942 or 573-727-6007, however, if you are suicidal or homicidal, please call 911, or take yourself or have someone else take you to the hospital.
Issues discussed in therapy are important and are generally legally protected as both confidential and “privileged.” However, there are limits to the privilege of confidentiality. These situations include:
- Suspected abuse or neglect of a child, elderly person or a disabled person.
- When your psychiatrist or therapist believes you are in danger of harming yourself or another person or you are unable to care for yourself.
- If you report that you intend to physically injure someone the law requires your therapist to inform that person as well as the legal authorities.
- If your psychiatrist or therapist is ordered by a court to release information as part of a legal involvement in a company litigation, etc.
- When your insurance company is involved, e.g. in filing a claim, insurance audits, case review or appeals, etc.
- In natural disasters whereby protected records may become exposed or
- When otherwise required by law.
You may be asked to sign a "Release of Information" so that your therapist may speak with other mental health professionals, family members, or someone else, if it is in your best interests. You have the right to refuse this, however, legal issues (noted above=) can override your refusal.
IF YOU ARE
SERIOUSLY CONSIDERING SUICIDE, PLEASE LOG OFF YOUR COMPUTER AND
TELEPHONE THE POLICE (911) OR EMERGENCY MEDICAL SERVICES.
- Most courts in the U.S. have the power to subpoena counseling records if involved in a court case in which they may be somehow relevant. I do keep records of my services. Although this may be rare, if you have any questions, it is better to contact your lawyer prior to disclosing any information you may deem private.
- Please be aware that efforts to fulfill the above obligations are limited by the information that you provide me. I cannot and will not be held responsible for failure to act if you do not provide me with sufficient information.
- My online services are not meant to replace regular face to face counseling when your situation requires it. I will make an effort to advise you of such a need if it appears that your situation is too serious for online consulting.
- Information is limited in confidentiality due to the nature of internet communication limitations and that I am not liable for any internet related problems with confidentiality because I am not an internet wizard but merely a therapist trying to make information more readily available to the public. If you have major concerns with this method of communication, please call (314) 304-2942 or (573) 727-6007 instead, to schedule a face to face session or email DebbieUrbanLPC@aol.com.
Initial phone call, online chat, email, or IM inquiries about my services are free.
My standard fees are as following:
Office sessions are $125 and by appointment only. If you have insurance and my services are covered, my fees are according to the contract I have as a provider with your insurance company. You are responsible for knowing if you have a co-pay or co-insurance. Those payments are due at each session.
Scheduled phone calls, online chats, email consultations, or IMs over 15 minutes are billed the same as office sessions however your insurance may not cover these. You are responsible for these fees and must be prepaid.
Payments are due at the time of the session unless other arrangements have been made. I will file your insurance claim, but you are ultimately responsible for deductibles, co-insurance, co-payments, and if your insurance fails to pay me. It is your responsibility to familiarize yourself with your insurance benefits.
Cancellations and Missed Appointments:
It is your responsibility to notify me, Debbie Urban, at least 24 hours in advance of any cancellations. You may leave messages 24 hours per day. My voicemail has the time and date for CST.
Except in the event of a REAL emergency, you will be billed directly for $125.00, for less than a 24 hours notice. Insurance companies generally do not reimburse for failed appointments. My time is valuable and can possibly serve another if there is enough time to schedule someone in your place.
Two missed appointments without a 24 hour notice will result in a cancellation of my services as this usually indicates that you do not really want therapy.
Client Information, Financial Responsibility, & Informed Consent: