575 S Royal St, #24, Jackson TN 38301
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LifeWorks Resources, LLC
We are pleased you have selected one of our staff as your counselor. This document is designed to inform you about LifeWorks Resources and to ensure that you understand our professional relationship. Please ask any questions that you may have before signing this form. Please let us know if you would like a copy of this document for your own reference.
Counseling is a unique professional relationship. Although our sessions may be very intimate emotionally and psychologically, it is important for you to realize that we have a professional relationship rather than a personal one. Our contact will be limited to the paid sessions you have with me. The Counselor’s role is to help empower the client to make positive changes to better his/her life. The client’s role is to work diligently toward personal goals in an effort to better one’s own life.
Christian Counseling is a unique service in that the values of the Counselor are revealed at the forefront. Each therapist will utilize a variety of approaches and will be flexible to tailor the approaches to meet individual needs. It is important for you to understand that there are risks involved with counseling. For example, it is impossible to predict how others may react to the changes you make in your life. Because counseling often involves talking about painful experiences and emotions it can bring about feelings of anxiety, sadness, and anger. However, we will support and guide you through these experiences.
All of our communication becomes part of your clinical record, which is accessible to you on request as a summary (see fees listed below) of the record. We will keep confidential anything you say, with the following exceptions:
1. You give written permission to tell someone else.
2. WE determine that you are a danger to yourself or others.
3. Instances of any type of abuse by you or someone else.
4. We are ordered by a court to disclose information.
5. In keeping with generally accepted standards of practice, we may consult with other mental-health professionals regarding the management of cases. The purpose of consultation is to ensure quality care. Every effort is made to protect the identity of clients.
If you want us to bill your insurance: We will file a claim with the insurance. It is your responsibility to check whether we are in-network with your specific plan. This is your financial responsibility:
1. The fee is $110 per visit. You will be responsible for any copays/deductible and any portion not covered by the insurance, including if they deny payment on the claim for any reason.
2. Payments owed (copay/deductibles) are rendered at the beginning of each session.
3. Failure to notify of cancellation 24 hours prior to the scheduled session will result in a 100% charge of the fee for a missed session ($110), which will be due at the beginning of the next appointment. This cannot be billed to insurance.
4. Furthermore, most insurance companies will require a clinical diagnosis, which would then become a part of your permanent health record.
If this is a self-pay (paying the entire fee out of pocket) agreement. This is your financial responsibility:
1. The fee is $110 per visit for counseling.
2. Payment is rendered at the beginning of each session.
3. Failure to notify of cancellation 24 hours prior to the scheduled session will result in a 100% charge of the fee ($110) for a missed session, which will be due at the beginning of the next appointment.
Other fees: all fees are due prior to services rendered:
1. Court ordered evaluations and/or evaluations for your attorney are $250 and include a report sent to the client or his/her designee (attorney, etc).
a. If the session (evaluation) is covered by insurance, this does NOT include the writing of a report for court or attorney. This cost is $50 per report.
2. Drug Screens: Urine drug screens can be conducted but may not be admissible in court. They can be a good starting point to help determine if analysis at a lab would be recommended.
a. Cost: $20 per drug screen
3. Standardized Testing or Assessments may be recommended. These fees will be discussed with you on a case-by-case basis but are typically $50 each.
4. Letters/Record Summaries regarding number sessions, progress, diagnosis, etc. provided to attorneys, schools, court, probation, etc are $40 per letter/summary.
5. Attendance in Court:
a. Clients are discouraged from having their counselor subpoenaed. Session are confidential (privileged communication). In most cases LifeWorks Resources, LLC will involve an attorney make attempts to NOT release confidential information.
i. Preparation time (including submission of records): $110/hr
ii. Phone calls, depositions, time in court, time away from the office: $110/hr
iii. Mileage: $0.50/mile
iv. All attorney fees and costs incurred by the therapist as a result of the legal action.
Counseling sessions are 40 minutes in length. Some clients need only a few counseling sessions to achieve their goals, while other clients may require more time. We cannot guarantee positive results (namely becoming happier, less tense or depressed, save the marriage, stop drug use, obtain a good job, and so forth). This is a voluntary agreement, and you should feel free to terminate at any time without penalty. We would be glad to further explore these areas with you.
In the case of an emergency LifeWorks Resources can be reached by calling (731) 215-0502 and leaving a message or, in more serious circumstances, please call your local crisis number. For West TN this number is 800-372-0693.
Complaints regarding ethical behavior may be sent to the same address and must be marked “confidential”. As a Licensed Professional Counselors we also abide by the ethical guidelines of the American Counseling Association. Complaints regarding ethical behavior may be sent to the American Counseling Association.
If this agreement is not acceptable, please address this with me and we will work hard to refer you to a more appropriate counselor, if necessary, or work with you in a creative way.
My signature waives to LifeWorks Resources my rights, title and interest to my medical reimbursement benefits under my insurance policy. I authorize the release of any medical info needed to determine these benefits. I further authorize consent for treatment for myself and/or the minors in my care. This authorization shall remain valid until I revoke said authorization by written notice and understand that I am financially responsible for all charges whether or not they are covered by insurance. I agree to pay the co-payment/deductible each time before the counseling session begins and 100% of the total charges in case of not giving 24 hours notice.
I have been made available a copy of LifeWorks Resources HIPPA Notice of Privacy Practices and have read the full Informed Consent document and Client Rights and Responsibilities. All of my question have been answered regarding these documents.
By signing this, you agree to the above stated terms and any questions you may have had were answered.
Consent for Use or Disclosure of Health Information
We are very concerned with protecting your privacy. While the law require us to give you this disclosure, please understand that we have,and always will, respect the privacy of your health information.
There are several circumstances in which we may have to use or disclose your health care information.
-We may have to disclose your health information to another health care provider or a hospital if it is necessary to refer you to them for the diagnosis, assessment, or treatment of your health condition.
-We may have to disclose your health information and billing records to another party if they are potentially responsible for the payment of your services.
-We may need to use your health information within our practice for quality control or other operational purposes such as recall notices, reminder calls, and treatment news.
Your right to limit uses or disclosures
You have the right to request that we do not disclose your health information to specific individuals,companies, or organizations. If you would like to place any restrictions other use or disclosure of your health information, please let us know in writing. We are not required to agree to your restrictions. However, if we agree with your restrictions, the restriction is binding on us.
Your right to revoke your authorization
You may revoke any of your authorizations at any time; however, your revocation must be in writing.We will not be able to honor your revocation request if we have already released your health information before we receive your request to revoke your authorization. If you were required to give authorization as a condition of obtaining insurance, the insurance company may have a right to your health information if they decide to contest any of your claims.
YOUR RIGHTS AND RESPONSIBILITIES AS A CLIENT OF LIFEWORKS RESOURCES
Welcome to LifeWorks Resources.
We hope that we can give you the kind of support and help that you are looking for.
When you receive services from LifeWorks Resources you have the right to:
- Receive high-quality service
- Be treated with respect, courtesy, and dignity.
- Have your information kept private and confidential except as described in LifeWorks Resources privacy statement
- Be listened to and have staff work with you to make a plan to address your concerns and needs
- Receive service in offices that are safe, clean and accessible
- Get information and support to help you make decisions to improve your situation
- Be served without discrimination
- Discuss your service with staff to identify if it is working for you and express any questions or complaints that you may have
- Request a change of staff member if there is another staff person available who can address your issues and your request is reasonable
-- you should know that discriminatory requests will not be considered
- Request and receive information about your medical records.
o As stated in the “RULES OF TENNESSEE BOARD FOR PROFESSIONAL COUNSELORS…” 0450-1-.18 MANDATORY RELEASE OF CLIENT RECORDS.
(1) Upon request from a client or the client’s authorized representative, an individual registered with this board shall provide a complete copy of the client’s records or summary of such records which were maintained by the provider.
(2) It shall be the provider’s option as to whether copies of the records or a summary will be given to the client.
(3) Requests for records shall be honored by the provider in a timely manner.
(4) The individual requesting the records shall be responsible for payment of a reasonable fee to the provider for copying and mailing of the records.
Authority: T.C.A. §§4-5-202, 63-2-101 and 63-2-102. Administrative History: Original rule filed April 29, 1992; effective June 13, 1992.
o LifeWorks Resources policy is to provide a summary of the record
THIS IS WHAT WE ASK FROM YOU:
- Treat the staff and others at LifeWorks Resources with courtesy and respect
- Let LifeWorks Resources know 24 hours before if you can not come to an appointment.
- You are responsible for providing accurate information to ensure that you receive appropriate and quality care.
The Privacy Officer for LifeWorks Resources is Mark Baldwin, Owner, who can be contacted at 731-215-0502.
Client First Name
Client's Last Name
Guardian's First Name
Guardian Name (if the client is a minor)
Guardian's Last Name
Guardian Name (if the client is a minor)
I have been made available a copy of LifeWorks Resources HIPPA Notice of Privacy Practices and have read the full Informed Consent document and Client Rights and Responsibilities. All of my question have been answered regarding these documents. By signing this, you agree to the above stated terms and any questions you may have had were answered.
I agree to pay 100% of the total charges ($110) in case of not giving 24 hours notice.
LifeWorks Resources LLC would like to offer you the ability to receive automated text and voice messages (SMS)reminders for your appointments. Messages are generated by our Electronic Health Records, however they are transmitted over a public network to a personal phone. I understand that this service is offered free of charge. However, standard text messaging rates from my mobile carrier may apply. Please select either yes or no to give your consent: