BINGHAM COUNSELING SERVICES
Barbara and John Bingham
Licensed Marriage and Family Therapists
Licensed Marriage and Family Therapists
John's Policies
DIRECTIONS
Please print 2 copies of this information, read it, then sign one copy and keep one copy for your files. Please bring the signed copy with you to the first meeting. For couples, both need to sign their own copy and bring it to the first meeting.
I will do everything within my professional capacity to be helpful to you. I want you to find your expenditure of time, energy and money worthwhile. It is my practice to discuss fees prior to the start of therapy. I will be happy to answer any questions you may have about these policies before we begin.
CONFIDENTIALITY
The information discussed in the sessions is held in strict confidence. Information about you will be given to another professional only with your written consent.
When you or your legal representative signed your health plan application (Individual Election Form), you gave routine consent to the health plan. Routine consent covers the use of your personal health information that is needed for your insurance company operations, such as treatment, coordination of care, use of measurement and survey data to improve care and service, utilization review, billing or fraud detection.
MANDATED REPORTING
If I suspect abuse of a child, an elderly individual, or a handicapped person, I am mandated by law to report my suspicions to the proper authorities. I also have the duty to warn the authorities if you express the intent to harm another person or yourself.
APPOINTMENTS
The length of the counseling session is 50 minutes. Sessions are reserved for you in advance. Cancellations or rescheduling of appointments made 24 hours in advance will not be charged to you. If you fail to cancel or reschedule in advance you are responsible for the full hourly fee.
FEES AND PAYMENT
My standard hourly fee for both individuals and couples is $100.
The fee for group therapy, usually 90 minutes, is $45.
Visa, MasterCard, ATM cards, personal checks and cash are accepted.
There is a $15 fee for all checks returned by the bank.
You are responsible for paying all the fees associated with your therapy even when there is insurance for the services rendered.
EMERGENCIES
I do NOT provide 24-hour emergency telephone coverage. However, confidential messages may be left on the office answering machine at any time. The office telephone number is 916-366-0164.
If you are in immediate danger, call 911 or go directly to an hospital emergency room.
TREATMENT
The goals of treatment are established by you and me together. The length of treatment is determined by the progress you make.
Clear communication between us is vital. Please speak up if something is a problem or is bothering you. Questions about treatment and progress are encouraged.
ACKNOWLEDGEMENT
I have read the above policies. I understand my role and responsibiliies and accept them. I give my consent to have Mr. Bingham bill my insurance company (when appropriate) and to provide them with the information they require.
Print Name:
Signature:
Date:
Please print 2 copies of this information, read it, then sign one copy and keep one copy for your files. Please bring the signed copy with you to the first meeting. For couples, both need to sign their own copy and bring it to the first meeting.
I will do everything within my professional capacity to be helpful to you. I want you to find your expenditure of time, energy and money worthwhile. It is my practice to discuss fees prior to the start of therapy. I will be happy to answer any questions you may have about these policies before we begin.
CONFIDENTIALITY
The information discussed in the sessions is held in strict confidence. Information about you will be given to another professional only with your written consent.
When you or your legal representative signed your health plan application (Individual Election Form), you gave routine consent to the health plan. Routine consent covers the use of your personal health information that is needed for your insurance company operations, such as treatment, coordination of care, use of measurement and survey data to improve care and service, utilization review, billing or fraud detection.
MANDATED REPORTING
If I suspect abuse of a child, an elderly individual, or a handicapped person, I am mandated by law to report my suspicions to the proper authorities. I also have the duty to warn the authorities if you express the intent to harm another person or yourself.
APPOINTMENTS
The length of the counseling session is 50 minutes. Sessions are reserved for you in advance. Cancellations or rescheduling of appointments made 24 hours in advance will not be charged to you. If you fail to cancel or reschedule in advance you are responsible for the full hourly fee.
FEES AND PAYMENT
My standard hourly fee for both individuals and couples is $100.
The fee for group therapy, usually 90 minutes, is $45.
Visa, MasterCard, ATM cards, personal checks and cash are accepted.
There is a $15 fee for all checks returned by the bank.
You are responsible for paying all the fees associated with your therapy even when there is insurance for the services rendered.
EMERGENCIES
I do NOT provide 24-hour emergency telephone coverage. However, confidential messages may be left on the office answering machine at any time. The office telephone number is 916-366-0164.
If you are in immediate danger, call 911 or go directly to an hospital emergency room.
TREATMENT
The goals of treatment are established by you and me together. The length of treatment is determined by the progress you make.
Clear communication between us is vital. Please speak up if something is a problem or is bothering you. Questions about treatment and progress are encouraged.
ACKNOWLEDGEMENT
I have read the above policies. I understand my role and responsibiliies and accept them. I give my consent to have Mr. Bingham bill my insurance company (when appropriate) and to provide them with the information they require.
Print Name:
Signature:
Date:
Copyright John Bingham, 2007. All rights reserved.
