I understand that under the Health Insurance Portability and Accountability Act of 1996(HIPPA), I have certain rights to privacy regarding my protected health information. I understand that this information can and will be used to:

* Conduct, plan and direct my treatment and follow-up care among the multiple healthcare providers who may be involved in that
   treatment directly or indirectly.

* Obtain payment from designated third-party payers.

* Conduct normal health care operations such as quality assessments or evaluations and physician certifications.

I have been informed by you of your Notice of Privacy Practices containing a more complete description of the uses and disclosures of my health information (available in the office in print form). I have reviewed such Notice of Privacy Practices prior to signing this consent, and acknowledge that I have studied the Privacy Practices prior to signing this consent, and acknowledge that I have studied the Privacy Practices. I understand that this organization has the right to change its Notice of Privacy Practices from time to time, and that I may contact this organization at any time at the address above to obtain a current copy of the Notices of Privacy Practices.

I understand that I may request in writing that this organization restrict how my private information is used or disclosed to carry out treatment, payment or health care operations. I also understand the organization is not required to agree to my requested restrictions, but if the organization does agree, then it is abound to abide by such restrictions.

I understand that I may revoke this consent in writing at any time, except to the extent that the organization has taken action relying on this consent.

I, the undersigned do hereby voluntarily agree to counseling services either by group individual or family counseling to be provided by Integrative Counseling Solutions. I am aware that the practice of counseling is not an exact science. As a consequence, I acknowledge that no guarantee has been made to me concerning the result of any evaluation or treatment that may be rendered. Further, I understand that evaluation and treatment may involve discussion of personal events in my own history that, at times, may be discomforting.

Limitations on Confidentiality:

Information about the diagnosis, evaluation, or treatment of a client with Medicaid coverage and most private health insurance plans is usually confidential information that this office may disclose only to authorized people. Only the client may give written permission for release of any pertinent information before client information can be released, and confidentiality must be maintained in all other respects.

          The following are exceptions to confidentiality that every client needs to understand in advance.

          If a counselor learns of child or elder abuse that is currently taking place or has the possibility of recurring, he or she is legally required to report that abuse to the appropriate authorities.

          If a psychotherapy/counseling client discloses an intention to do something that is likely to harm him/her or others, the counselor is required to report that intention.

          If a court order, other legal proceedings, or statute requires disclosure.

BASIC RIGHTS FOR ALL CLIENTS

You have the right to impartial access to treatment regardless of race, religion, sex, age ethnicity, or handicap.

You have the right to considerate and respectful treatment and recognition of your personal dignity.

You have the right to a written statement of your rights.

You have the right to be informed of your rights in language you understand.

You have the right to participate in treatment decisions.

You may terminate services at any time unless legally prohibited from doing so.

You have the right to be informed of alternatives available when you leave treatment, and you will be given specific follow up recommendations outlined.

You have the right to report any incidents of abuse or neglect, whether you are a victim or an observer.

You have the right to withdraw your permission at any time in matters to which you have previously consented.

You have the right to request the opinion of another clinician at your own expense.

Grievance Procedure or Complaints

The therapist will provide services in a professional manner consistent with all applicable laws, rules, regulation guidelines and codes of ethics and conduct concerning the therapist and the client/therapist relationship. Any dissatisfaction with services or other complaint should be discussed with the therapist.

You may also file a complaint concerning a therapist to:

Texas State Board of Examiners of Professional Counselors

1100 West 49* Street

Austin, Texas 78756-3183

(512) 834-6658

I certify that:

I have received a copy of this document prior to treatment.

Staff has explained its content to me in a language I understand.

Policy Regarding Collection of: Co-Payments, Deductibles, Fees and Denied Insurance Claims

As a client of Integrative Counseling Solutions, you are responsible for the payment of therapy and counseling fees. If you choose to use your health insurance coverage in connection with counseling services, the administrative staff will attempt to assist you in filing and processing such insurance claims. However, it is your insurance policy and therefore your responsibility to make sure your insurance claims are paid.

Fees for counseling including co-payments, deductibles and insurance claims denied for any reason, unless otherwise provided for will be your responsibility. Fees will be charged against the credit card account as set forth in the Cancellation Agreement.

If your psychotherapist is ever asked to testify in court on your or your child's behalf, you are responsible for the professional testimony fee of $100.00 an hour.

If for any reason you do not pay or your account becomes delinquent, we will forward your delinquency to a collections agency and you will be responsible for any fees that may apply.

Confirmation calls/text from our office are a courtesy. It is NOT our responsibility to make sure you will be here. If you do not give enough notice, there will be a fee for a no-show or late cancellation. If you are more than 15 minutes late you will have to reschedule and pay for the appointment missed.

Cancellation Agreement

As either the patient in therapy, and/or the person responsible for the payment of fees in connection with counseling services, I agree that all counseling appointments made with Integrative Counseling Solutions will be kept. However if, for ANY reason, any scheduled appointment is not kept at the scheduled time, I agree to give Integrative Counseling Solutions no less than twenty-four hours advance notice. In the event Integrative Counseling Solutions does not receive at least twenty-four (24) hours advance notice of cancellation of any scheduled appointment, regardless of the reason for such cancellation, I agree to pay a cancellation fee of $75.00. I agree that the fee will be charged to the credit card account on file or billed to my account.

I am fully responsible and will pay any fees that may be added to my account due to a late cancellation or a no show.