WELCOME

Thank you for choosing Mindful Wellness. We realize that starting counseling is a major decision and you may have many questions. This document is intended to inform you of our policies, State and Federal Laws and your rights. If you have other questions or concerns, please ask and we will try our best to give you all the information you need. Treatment practices, philosophy and plan limitations and risks will be discussed with you today.

CONFIDENTIALITY AND EMERGENCY SITUATIONS

Your verbal communication and clinical records are strictly confidential except for: a) information shared with consultants, b) information (diagnosis and dates of service) shared with your insurance company to process your claims, c) information you and/or you child or children report about physical or sexual abuse; then, by Illinois State Law, Mindful Wellness is obligated to report this to the Department of Children and Family Services, d) where you sign a release of information to have specific information shared and e) if you provide information that informs us that you are in danger of harming yourself or others f) information necessary for case supervision or consultation and h) or when required by law.

If an emergency situation for which the client or their guardian feels immediate attention is necessary, please call Mindful Wellness immediately. If no call is received within 15 minutes or you cannot wait, the client or guardian understands that they are to contact the emergency services in the community (911) or local emergency room for those services. Mindful Wellness will follow those emergency services with standard counseling and support to the client or the client's family. E-mail, text messages and social networking sites are not confidential and we may not be able to respond.

FINANCIAL/INSURANCE ISSUES

As a courtesy Mindful Wellness will bill your insurance company, HMO, responsible party, or third party payer. Signing below indicates written consent for said billing on your behalf.

If you are using your insurance, we ask that you pay your co-pay at the time of session. If you are not using insurance, we ask that you pay the full fee that we have agreed upon at the time of session. In the event you have not met your deductible, Mindful Wellness will charge you the rate contracted with your insurance company at each session until the deductible is satisfied. If your insurance company denies payment or does not cover counseling, we request that you pay the balance due at that time. If you have an outstanding balance, Mindful Wellness withholds the right to provide further services until the balance is paid.

Signing below also acknowledges that you received a copy of the Mindful Wellness fee schedule.

Lastly, if you need to cancel or reschedule an appointment, please give 24 business hours advance notice, otherwise you will be billed a $100 no show fee. We sincerely appreciate your cooperation and at any time you have any questions regarding insurance, fees, balances or payments please feel free to ask. You may have a copy of this form if requested.


CREDIT CARD ON FILE

Mindful Wellness requests that you keep a credit card on file. This card will not be charged without pending charges being communicated to you first.

I authorize Mindful Wellness to bill my credit card.