Patient Agreement

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Disclosure of Information, Policies and Client Agreement
-and-
Insurance Billing Authorization

Provision of the following information and written acknowledgement of its receipt are required by Washington State Law. Please read carefully.

Mental health counselors practicing counseling for a fee must be licensed. Any counselor that you meet with at PEOPLEinc. is licensed.

Your Rights as a Client in Counseling:

As a client of a counselor licensed by the State of Washington, you have privileged communications under the law. With the exceptions listed below, you have the right to confidentiality. This right cannot be waived without your specific written consent.

If I believe you are likely to do harm to yourself or another person, I am required by law to take steps to protect you and/or the other person.
If I believe that you may be physically or sexually abusing or neglecting a minor child or vulnerable adult, I am required by law to report this to Children’s Protective Services or Adult Protective Services.
Occasionally there is reason for me to discuss the general details of my cases with other professionals and colleagues to better meet the needs of my clients, yet without revealing any identifying information about you or your family.

You always have the right to change or refuse treatment. It is important that we work together in order to meet your needs. You may terminate therapy at any time; however, I believe it is of great value to you to discuss the decisions, reasons and process for termination with me prior to terminating.

Our Training and Approach:

Our preparation and education includes a Master’s Degree and/or Ph.D. with a concentration in Counseling.

We use a variety of approaches to counseling. Each therapist has their unique style of working effectively with clients to achieve the highest level of success. Any methods used are consistent with generally accepted theory and practice.

Sessions and Fees:

Sessions are scheduled for 50 minutes. Fees charged per session are $175 and/or other negotiated amounts that are unique to specific insurance plans. Payment is due at the beginning of each session. Should you need to reschedule or cancel an appointment we request a notice of 24 hours, otherwise, it will be necessary to charge for the time that has been reserved for your session. The charge for a session that you do not show up for or cancel with less than a 24 (business) hour notice will be billed at $175. Under this policy, sessions on Monday require cancellation the Friday prior. Please be aware that if your sessions are covered under your insurance provider; they will not reimburse for missed appointments. Therefore, it will be your obligation to pay for any missed appointments that have not been cancelled or rescheduled within the 24-hour notice referred to above. Any outstanding balances are charged late fees of $25 per month.

Acknowledgement

Fees and Policies*

I have read and accept the fees, and policies for late cancellation and no shows

HIPAA*

I have been provided and have reviewed the HIPAA privacy rules

View HIPAA Notice of Privacy Practices

Client Signatures

Signature is required for client 13 or older and for parent or guardian of client 12 or younger

If you or your dependent child is in treatment with one of our clinicians that is licensed as an Associate level clinician, that clinician will be under the direct supervision of an authorized supervisor. Your signature on this form indicates your understanding and approval of that.

If you are signing this agreement for a minor child, please be advised that it is your responsibility as their parent/guardian to have them show up for their scheduled appointments. It is not the responsibility of their clinician to reach out to you or attempt to track down the client for attending any sessions. The clinician's only responsibility is to show up at the agreed upon time and date to hold that session with the client. Just as it would be for any other client; adult or child. No show or late cancellation charges apply the same in these circumstances, as stated in another part of this agreement.

Name*

First Last

Today's Date*

Signature*

I consent to treatment from PEOPLEinc.

Name*

First Last

Today's Date*

Signature*

I consent to a follow up call regarding satisfaction of therapy and treatment*

Yes

Please fill in the following information as completely as possible

Patient Information

Name*

First Last

Address*

Street Address City ZIP / Postal Code

Date of Birth*

Phone*

Employer/School*

OK to receive voicemail from PEOPLEinc?*

Yes

Email*

OK to receive email from PEOPLEinc?*

Yes

*I understand that email and standard SMS messaging are not confidential methods of communication and may be insecure. I further understand that, because of this, there is a risk that email and standard SMS messaging regarding my care might be intercepted and read by a third party.

Gender*

Preferred Pronoun*

Relationship Status*

Married

Separated

Divorced/Permanently Separated

Partnered

Single

Emergency Contact Name*

Relation*

Phone*

Guarantor (Person Responsible for the Bill and/or the Primary Individual Insured)*

Self

Partner/Spouse

parent

Other

Please Provide Relationship (if other)*

Name*

Date of Birth*

Billing Email Address*

Insurance Information

Name of Insurance Company/Plan you want us to bill*

If you would like us to bill on your behalf, please provide us with your insurance card to copy. We will bill your insurance as a courtesy but it is ultimately your responsibility to be sure that payment is made for your services. If we bill your insurance and they do not pay, it is your responsibility to pay for your services and any discrepancies with your insurance reimbursement will be yours to clear up with them directly.

Please also be sure to obtain any prior authorizations that may be required for your insurance to pay for this and future visits.

I authorize the release of all medical records to my insurance company. I further authorize insurance payments to be made directly to PEOPLEinc. I understand payment is due at time of service, even though we may choose to delay receipt until your insurance has been billed.

Name*

Signature of Responsible Party*

Today's Date*

Clinician

Please select your clinician from the list*

Untitled

First Choice

Second Choice

Third Choice

Patient Agreement

Disclosure of Information, Policies and Client Agreement
-and-
Insurance Billing Authorization

Acknowledgement

Client Signatures

Please fill in the following information as completely as possible

Insurance Information

Clinician

Seattle / Fremont

Fall City

Kent

Links

Patient Agreement​

Disclosure of Information, Policies and Client Agreement -and- Insurance Billing Authorization

Acknowledgement

Client Signatures

Please fill in the following information as completely as possible

Insurance Information

Clinician

Seattle​ / Fremont

Fall City

Kent

Links

Patient Agreement

Disclosure of Information, Policies and Client Agreement
-and-
Insurance Billing Authorization

Seattle / Fremont