18353 W. McNichols, Detroit, MI 48219-4199
313-208-3407 (office) 313-209-4533 (fax)

Motor City Center for Hope  - Counseling and MIHP Service Provider

Pain is real, but so is hope!

MCCH Consent for Treatment


OUTPATIENT SERVICES CONTRACT Welcome to my practice. I am governed by various laws and regulations and by the code of ethics of my profession. The ethics code requires that I make you aware of specific office policies and how these procedures may impact you. This document contains important information about my professional services and business policies. Please read it carefully and jot down any questions you might have so that we can discuss them at our next meeting. When you sign this document, it will represent an agreement between us.


COUNSELING SERVICES Psychotherapy is not easily described in general statements. It varies depending on the personalities of the therapist and client, and the particular problems you bring forward. There are many different methods I may use to deal with the problems that you hope to address. Psychotherapy is not like a medical doctor visit. Instead, it calls for a very active effort on your part. In order for therapy to be most successful, you will have to work on things we talk about both during our sessions and at home.

Psychotherapy can have benefits and risks. Since therapy often involves discussing unpleasant aspects of your life, you may experience uncomfortable feelings like sadness, guilt, anger, frustration, loneliness and helplessness. On the other hand, psychotherapy has also been shown to have benefits for people who go through it. Therapy often leads to better relationships, solutions to specific problems, and significant reductions in feelings of distress. But there are no guarantees of what you will experience. Sometimes counseling services are provided primarily to prevent further deterioration of your mental or emotional status which is considered maintenance treatment.

Our first few sessions will involve an evaluation of your needs. By the end of the evaluation, I will be able to offer you some first impressions of what our work will include and a treatment plan to follow, if you decide to continue with therapy. Under certain circumstances I may recommend a psychiatric consult; conjoint marital/couple, conjoint parent/child sessions and/or group psychotherapy. You should evaluate this information along with your own opinions of whether you feel comfortable working with me. Therapy involves a large commitment of time, money and energy, so you should be very careful about the therapist you select. If you have questions about my procedures, we should discuss them whenever they arise. If your doubts persist, I will be happy to refer you to another mental health professional for a second opinion.


I normally conduct an evaluation that will last from 1-2 sessions. During this time, we can both decide whether I am the best person to provide the services you need in order to meet your treatment goals. If you decide to continue treatment, I will usually schedule one 30 to 50-minute session per week at a time we agree upon, although some sessions may be longer or more frequent. Once an appointment time is scheduled, you will be expected to pay for it unless you provide 24 hours advance notice of cancellation or unless we both agree that you were unable to attend due to circumstances beyond your control. If it is possible, I will try to find another time to reschedule the appointment.


PROFESSIONAL FEES My hourly fee is $______.00. In addition to weekly appointments, I charge this amount for other professional services you may need, though I will break down the hourly cost if I work for periods of less than one hour. Other services include report writing, telephone conversations lasting longer than 5 minutes, attendance at meetings with other professionals you have authorized, preparation of records or treatment summaries, and the time spent performing any other service you request of me.


BILLING AND PAYMENTS You will be expected to pay for each session at the time it is held, unless we agree otherwise or unless you have insurance coverage which requires another arrangement. If you wish to pay by check, please make it payable to: Motor City Center for Hope, LLC. To avoid wasting your valuable session time, please have your check made out and ready before your session. Payment schedules for other professional services will be agreed to when they are requested. In circumstances of unusual financial hardship, I may be willing to negotiate a fee adjustment or payment installment plan.

You will be allowed to accrue uncollected fees up to and no more than $200.00 owed for counseling services (due to financial hardships and unusual circumstances), except when otherwise agreed or when third party reimbursement is involved. In the event that a debt of $200.00 or greater of uncollected fees is accrued, counseling services will be terminated so that your bill does not become unmanageable and create additional stress. You will be expected to repay the debt as soon as you can. If your account has not been paid for more than 60 days and arrangements for payment have not been agreed upon, I have the option of using legal means to secure the payment. This may involve hiring a collection agency or going through small claims court. If such legal action is necessary, its costs will be included in the claim. In most collection situations, the only information I release regarding a client’s treatment is his/her name, the nature of services provided, and the amount due.


INSURANCE REIMBURSEMENT In order for us to set realistic treatment goals and priorities, it is important to evaluate what resources you have available to pay for your treatment. If you have a health insurance policy, it will usually provide some coverage for mental health treatment. I will fill out forms and provide you with whatever assistance I can in helping you receive the benefits to which you are entitled; however, you (not your insurance company) are responsible for full payment of my fees. It is very important that you find out exactly what mental health services your insurance policy covers. You should carefully read the section in your insurance coverage booklet that describes mental health services. If you have questions about the coverage, call your plan administrator. Of course I will provide you with whatever information I can based on my experience and will be happy to help you in understanding the information you receive from your insurance company.

Due to the rising costs of health care, insurance benefits have become increasingly more complex. It is sometimes difficult to determine exactly how much mental health coverage is available. “Managed Health Care” PPO plans often require authorization before they provide reimbursement for mental health services. These plans are often limited to short-term treatment approaches designed to work out specific problems that interfere with a person’s usual level of functioning. It may be necessary to seek

approval for more therapy after a certain number of sessions. While a lot can be accomplished in short-term therapy, some clients feel that they need more services after insurance benefits end. Seeking treatment after your insurance benefits end is your option to pursue and charges for services will be based on my current private pay rate.

You should be aware that most insurance companies require you to authorize me to provide them with a clinical diagnosis. Sometimes I have to provide them with additional clinical information such as treatment plans or summaries, or copies of the entire record (in rare cases). This record will become part of the insurance company files and will probably be stored in a computer. Though all insurance companies claim to keep such information confidential, I have no control over what they do once it is in their hands. In some cases, they may share information with a national medical information databank.

Once I have all the information about your insurance coverage, we will discuss what we can expect to accomplish with the benefits that are available and what will happen if they run out before you feel ready to end our sessions. It is important to remember that you always have the right to pay for my services yourself to avoid the problems described above.


CONTACTING ME Telephone calls are offered as a professional courtesy and this service does not constitute an emergency service. I am not responsible for your behaviors or decisions occurring outside the consultation room at any given time, whether before or after a telephone call or consultation. If you are unable to reach me and feel that you can’t wait for me to return your call, contact 911, your family physician or the nearest emergency room. If I will be unavailable for an extended time, I will provide you with the name of a colleague to contact, if necessary.


PROFESSIONAL RECORDS The laws and standards of my profession require that I keep treatment records. You are entitled to receive a copy of your records, or I can prepare a summary for you instead. Because these are professional records, they can be misinterpreted and/or upsetting to untrained readers. If you wish to see your records, I recommend that you review them in my presence so that we can discuss the contents. Clients will be charged an appropriate fee for any professional time spent in responding to information requests.

MINORS If you are under eighteen years of age, please be aware that the law may provide your parents the right to examine your treatment records. It is my policy to request an agreement from parents that they give up access to your records. If they agree, I will provide them only with general information about our work together, unless I feel there is a high risk that you will seriously harm yourself or someone else. In this case, I will notify them of my concern. Before giving them any information, I will discuss the matter with you, if possible, and do my best to handle objections you may have with what I am prepared to discuss.


CONFIDENTIALITY In general, the privacy of all communications between a client and a Marriage and Family Therapist is protected by law, and I can only release information about our work to others with your written permission. But there are a few exceptions. In most legal proceedings, you have the right to

prevent me from providing any information about your treatment. In some proceedings involving child custody and those in which your emotional condition is an important issue, a judge may order my testimony if he/she determines that the issues demand it.

There are some situations in which I am legally obligated to take action to protect others from harm, even if I have to reveal some information about a client’s treatment. For example, if I believe that a child, elderly person or disabled person is being abused, I must file a report with the appropriate state agency.

If I believe that a client is threatening serious bodily harm to another, I am required to take protective actions. These actions may include notifying the potential victim, contacting the police and seeking hospitalization for the client. If the client threatens to harm himself/herself, I may be obligated to seek hospitalization for him/her or contact family members or others who can help provide protection. I will take any threats seriously whether I am informed by you or someone you know. Therefore, please use discretion when providing my contact information to a third party.

You should be aware that when counseling services are sought by third parties such as employers, lawyers, or the courts, disclosure of some information is required by law. You should also be aware that disclosure of requested information to third parties, when mandated by law, could potentially have an adverse effect on your life.

These situations have rarely occurred in my practice. I will make every effort to discuss it with you before taking any action, unless I believe that notifying you may put you or your health in jeopardy.

I may occasionally find it helpful to consult other professionals about a case. During a consultation, I make every effort to avoid revealing the identity of my client. The consultation is also legally bound to keep the information confidential. If you don’t object, I will not tell you about these consultations unless I feel that it is important to our work together.

While this written summary of exceptions to confidentiality should prove helpful in informing you about potential situations, it is important that we discuss any questions or concerns that you may have at our next meeting. I will be happy to discuss these issues with you if you need specific advice, but formal legal advice may be needed because the laws governing confidentiality are quite complex, and I am not an attorney.


TERMINATION Your participation in psychotherapy is voluntary and you have the right to withdraw from treatment without adversity at any time. I would recommend that when termination is considered, you discuss this with me, so that we can create a plan for termination to minimize any possible negative effects. If you don’t show-up for 3 consecutive scheduled appointments, your treatment will be considered canceled and terminated and you will be financially responsible for the fees of the missed sessions. A letter will be sent to you acknowledging the termination along with a closing bill for any unpaid balance.


Authorization to Bill Insurance I, _____________________________________________________, hereby give my consent for Motor City Center for Hope to bill my/my child’s insurance carrier for the services rendered to myself or my child/family by the above-mentioned provider. In addition, I agree to pay any deductible or uncovered charge in accordance with my health care plan.

Client/Parent/Guardian Signature: ________________________________________________________

Authorization to release medical information to insurance carrier - I understand that my express consent is required to release any health care information relating to testing, diagnosis, and/or treatment for HIV, sexually transmitted disease, psychiatric disorders, or drug/alcohol use.

I, ________________________________________________, hereby give my consent for Motor City Center for Hope to release medical and other relevant information to our insurance carrier as required my my/our insurance carrier to process medical billings.

Client/Parent/Guardian Signature: ________________________________________________________

Your signature below indicates that have received MCCH’s Consent for Treatment and were offered a copy of MCCH’s Privacy Practices. You were also informed where you could find both forms electronically if ever needed them in the future (www.motorcityhope.org). You have read the information in this document, were provided accurate information, and agree to abide by the terms during our professional relationship.