805 Holcomb Boulevard Ocean Springs, MS 39564
Appointment: 228-324-5767 Counselor: 228-323244
DISCLOSURE AND CONSENT
Thank you for deciding to seek counseling at Islands Counseling. Our office is committed to the patient’s rights of information regarding office policy, non-discrimination, confidentiality, consent and competent service. In keeping with this policy, various office policies are listed below for your information. Please read through these and sign. Thank you for allowing us to serve you. The practice of both licensed and unlicensed persons in the field of psychotherapy is regulated by the Mississippi State Departments of Regulatory Agencies. Although the exact length of treatment is difficult to predict, your therapist will be glad to discuss her average treatment duration for conditions similar to yours. You may, at any time, seek a second opinion from another therapist and/or may terminate therapy.
Our policy is for each person receiving counseling or testing services to pay for such service at the time the professional services are rendered. Any other arrangements must be made in advance. A $35 administrative fee will be charged on all checks that are returned for non-sufficient funds. In case of an emergency, please call 911.
Many insurance plans reimburse for some portion of psychotherapy. Please direct questions about reimbursement amounts and timeliness to your insurance company. We will complete insurance forms for you each session. Please be sure to provide us with your insurance card and the birth date and social security number of the policy holder.
We understand that it may be necessary to cancel an appointment. To help us be most responsible in the use of our time, we require that any changes or cancellations be made at least 24 hours in advance. Any changed, cancelled, or missed appointment with less than 24-hour notice will be charged $80.00.
The confidentiality of the counseling provided by us is protected by law. Unless you grant us permission to do so in writing, therapists and office personnel will neither inform anyone that you are receiving therapy, nor will therapists disclose the content of any session. The only circumstances under which such professional confidentiality may be broken are if one or more of the following conditions apply:
If abuse or neglect is disclosed under the conditions given above, we are mandated by Mississippi law to report such information to an appropriate state agency.
If I elect to use my health insurance plan to assist in the payment of treatment then I understand that my insurance carrier and the National Information Center will have access to my diagnosis code and other pertinent data needed for claim processing.
FINANCIAL AGREEMENT AND AUTHORIZATION FOR TREATMENT
I have been informed of and read the preceding information and agree to it. I authorize treatment of the person named below and agree to pay all fees as stated.
Client Signature or Parent (Guardian) if Minor Date