Consent to Treatment
I acknowledge that I have received, have read (or have had read to me), and understand the “Policies and Procedures” description about the therapy I am considering. I have had all my questions answered fully.
I do hereby seek and consent to take part in the treatment by the provider named in my appointment confirmation email. I understand that developing a treatment plan with this provider and regularly reviewing our work toward meeting the treatment goals are in my best interest. I agree to play an active role in this process.
I understand that no promises have been made to me as the results of treatment or any procedures provided by this provider.
I am aware that I may stop my treatment with this provider at any time. The only thing I will still be responsible for is paying for the services I have already received. I understand that I may lose other services or any have to deal with other issues if I stop treatment. (For example, if my treatment has been court-ordered, I will have to answer to the court.)
I know that I must call to cancel an appointment at least 24 business hours before the scheduled time of an appointment for therapy or 48 business hours for an appointment for psychiatry services. If I do not cancel or do not show up, I will be charged as indicated in the Therapy or Psychiatry Policies and Procedures for that appointment. I understand that I will be responsible for full payment for such sessions, and that my insurance company cannot be billed for them.
I am aware that an agent of my insurance or other third-party payer may be given information about the type(s), cost(s), date(s), and providers of any services or treatments I receive. It may also be necessary to provide treatment information such as notes or diagnosis to third party payers. I agree to allow the release of any information necessary for third party payment to be remitted if I choose to use my insurance. I also understand that if payment for the services I receive here is not made, the provider may stop my treatment.
I am aware that I am fully responsible for payment for treatment I receive, regardless of the determination of insurance company eligibility. I further understand that my provider can employ the services of a collection agency to retrieve any monies I owe after a reasonable attempt has been made to request payment.
I am aware that I can discuss the issues above with the my provider. In the state of Pennsylvania, a child who is fourteen (14) years of age or older and still below the age of eighteen (18), may seek, receive and consent to mental health care without the express consent of the parent/s or legal guardian.