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Debbie Urban, MEd, NCC, LPC, EFT-ADV

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New Client Information

New Client Information, Financial Responsibility, & Informed Consent

Please read all sections 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...

Aims and Goals of Treatment:

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.

If you know that you will need me to represent you in court, please be aware that I am not a custudy evaluator or anything related finding a wrong verses right person or hurting another person, mentally, physically, financially, or otherwise not related to healing or what I have been trained to do. If your purpose in seeing me is for a legal proceeding, please find another therapist as these sorts of things go against the goals of therapy, in my opinion.

Appointments:

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 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.

Confidentiality:

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 I believe 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 me to inform that person as well as the legal authorities.
  • If I am 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 I 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.

Record Keeping:

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 (573) 727-6007 instead, to schedule a face to face session or email DebbieUrbanLPC@aol.com.

Fees:

 

 

 

Initial phone call, online chat, email, or IM inquiries about my services are free.

My standard fees are as following:

Office sessions are $125/hour and by appointment only. If you have insurance and my services are covered, my fees are then under a provider contract with your insurance company and are paid accordingly under their rules, by them, however, you are ultimately responsible for my payment and for knowing what your co-pay, co-insurance payment, deductibles are. Payments are due to me at the time of your appointment.

Pre-scheduled phone calls, online chats, email consultations, or IMs over 15 minutes are billed at $125/hour and must be prepaid.

Brief phone calls, online chats, emails, or IMs under 15 minutes are free unless they are more than usual.

Extra reports or services for courts or lawyers, if not part of my standard incuded procedures, will be billed according to how long it takes me to write, travel for notaries, time spent for court appearances, making files into pdf form for email transmission, or anything over and above my standard services, at $125/hour. Insurance companies do not cover these services.

 

 

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.

Acknowledgement of Receipt of Notice of Privacy Practices:

By submitting this form, you acknowledge and understand that Debbie Urban, LPC, may share your confidential health information with others in order to treat you, in order to arrange for payment of your bill, and for issues that concern Debbie Urban’s operation and responsibilities.

Assignment of Counseling Benefits:

BY SUBMITTING THIS FORM, You hereby assign payment of insurance benefits, including but not limited to Medicaid health maintenance organizations or preferred provider organizations, to be paid directly to Debbie Urban, LPC, for treatment charges and on your behalf.

Future Authorizations for Sessions:

SUBMITTING THIS FORM will also allow Debbie Urban, LPC, to complete the necessary paper work to request additional sessions from your health insurance/third party provider if additional sessions are necessary.

RELEASE OF INFORMATION

BY SUBMITTING THIS FORM BELOW, you, as the client or guardian, authorize and direct any holder of medical and other information about you as it pertains to your health care, to release all needed information to determine benefits payable, process your claims, or to collect the fees for counseling. You also understand and agree that certain elements of your treatment information may be used for research and education. All reasonable efforts will be made to maintain personal confidentiality.

INFORMED CONSENT FOR TREATMENT

BY SUBMITTING THIS FORM BELOW, you are requesting treatment by Deborah (Debbie) Lee Urban, who is a Licensed Professional Counselor in Missouri and a National Board Certified Counselor. You consent to routine assessment evaluations and counseling as deemed necessary. You understand that Debbie Urban LPC makes no guarantee as to the results of treatment or evaluation. The therapy process is one in which you seek to understand yourself, your feelings, and your concerns more clearly, and to make changes in your life as a result of what you have learned. The role of the therapist in this process is to help you gain a different perspective on yourself, your feelings and your life. The therapist will seek, first, to get to know you so that she can better understand your concerns. You will aid the therapist by being open and honest in your sessions and providing as much information as you can concerning the issues that trouble you. Occasionally, the therapist may say things that you find difficult to hear. Your therapy goals will best be achieved if you can remain open to emotions, insights, and ideas, which may be different than what you have experienced before. Because the therapy process sometimes involves an examination of aspects of yourself, which have previously remained hidden, you may be surprised by the intensity of new emotions. Be assured that this is a normal part of healing and change that occurs through therapy.

BY SUBMITTING THIS FORM BELOW, YOU ARE CERTIFYING THAT YOU HAVE READ THE STATEMENTS ABOVE, HAVE COMPLETED THE INFORMATION CORRECTLY, AND ACCEPT, UNDERSTAND AND AGREE TO ABIDE BY THE CONTENTS AND TERMS OF THIS AGREEMENT, AND FURTHER, CONSENT TO PARTICIPATE IN EVALUATION AND/OR TREATMENT, THAT YOU MAY WITHDRAW FROM TREATMENT AT ANY TIME, AND THAT YOU AGREE TO BE FINANCIALLY RESPONSIBLE FOR ALL FEES THAT ARE NOT COVERED BY A THIRD PARTY.

Thanks for using this. Please provide the following information and submit. This information goes directly to my email box. I will contact you if you have indicated that I do so. If you would like to call me instead of submitting this, please call 573-727-6007.


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