ICD


Springfield, MO | Kansas City, MO | Columbia, MO | Denver, CO

Phone: 855.593.4357 • www.MyCounselor.Online

Biblically Christian, Clinically Proven, Professional Counseling”

Informed Consent Documents

Terms of Service

Table of Contents

  • Counseling Service Agreement
  • Consent to Christian Counseling
  • Notice of Privacy Practices
  • Insurance Claim Processing
  • Financial Responsibility Agreement

 

Counseling Services Agreement

Ensuring Fully Informed Consent for Counseling and Introducing How We Do Therapy

            Welcome to MyCounselor. We appreciate the opportunity to serve you.

This document answers questions which clients often ask about counseling. We believe our work will be most helpful to you when you have a clear idea of what we are trying to do. This document also contains important information about our professional services and business policies. Please read it carefully and jot down any questions you might have so we can discuss them at our next meeting. When you sign this document, it will represent an agreement between us.

A primary commitment of MyCounselor is to provide you with Biblically Christian and Clinically Proven counseling services.  In keeping with this commitment, we have listed below various counseling standards.  Our standards are established by state and professional guidelines, as well as Biblical teaching regarding the care of others. 

MyCounselorhereafter MCO, is committed to your right of information regarding:

  • Standards of Competent Service
    • Services the counselor will provide
    • Goals of the therapeutic relationship
    • Risks and benefits of therapeutic procedures
  • Policies and Procedures
    • Behavior expected of the client
    • Physical evaluation
    • Financial considerations
    • Payment arrangements
    • Insurance reimbursement
    • Electronic & Phone Sessions
    • Emergency Sessions
    • Non-discrimination
    • Sexual conduct
    • Contact information
  • Qualifications, Credentials, and Associations
  • Confidentiality
    • Electronic Communication
    • Taping or recording of sessions
    • Minors 

Standards of Competent Service

Services the counselor will provide. Counseling is not easily described in general statements. It varies depending on the personalities of the counselor and client, and the particular problems you bring forward. There are many different methods we may use to deal with the problems that you hope to address. Counseling is not like a medical doctor visit. Instead, it calls for a very active effort on your part. In order for the therapy to be most successful, you will have to work on things we talk about both during our sessions and at home. Our first few sessions will involve an evaluation of your needs. By the end of the evaluation, your counselor 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. You should evaluate this information along with your own opinions of whether you feel comfortable working with your counselor. 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 MCO procedures, you should discuss them whenever they arise. If your doubts persist, your counselor will be happy to help you set up a meeting with another mental health professional for a second opinion. All counselors of MCO have been trained to know a variety of methods and techniques. Your counselor will determine from his or her assessment of your situation and through consultation, if deemed beneficial, which is the most effective for you.

Goals of the therapeutic relationship. Your counselor will work with you to determine the goals you would like to set for counseling and to help you achieve those goals. While length of treatment is difficult to determine, your counselor will be happy to discuss this and the style of treatment with you. 

Risks and benefits of therapeutic procedures. Counseling can have both 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, counseling has also been shown to have considerable 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. You may, at any time, seek a second opinion and/or terminate treatment.

Policies and Procedures

Client behavior expected. Your counselor will normally conduct an evaluation during the first few sessions. During this time, both you and your counselor can decide if he or she is the best person to provide the services you need in order to meet your treatment goals. Once therapy is begins, your counselor will usually schedule one 45-minute session per week at a time you agree on, although some sessions may be longer or more frequent. Once an appointment hour is scheduled, you will be expected to pay for it unless you give notice of cancellation by 5 pm the business day before your scheduled appointment. Sessions will begin at the time scheduled.  If the counselor causes a late start, the session will still last for 45 minutes.  If you arrive late for your appointment, the session will have to end at the regularly scheduled time, and the charge will be for the full amount of the appointment fee.  Missed appointments or frequent rescheduling may result in termination of counseling.  In this case, the counselor will make a referral to another mental health professional. Children under 12 years of age are not to be left unattended in the waiting room while parents or guardians are at their appointment.

Physical Evaluation. It is strongly recommended that you be current on your physical examinations from your personal physician.  This is important to make sure none of the problems discussed are the result of physical health difficulties.  Your counselor is not a physician and will not use physical interventions such as medications. When medications are appropriate your counselor will work closely with your physician.

Financial considerations. The hourly fee will depend on the specific counselor you see. Please reference the MCO Fee Schedule at MCOHelps.com. The same charges that apply to counseling also apply to other professional services you may need, though we will prorate the hourly fee if we work for periods of less than an 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 may request of MCO. At times it may be necessary to briefly speak to your counselor by telephone, for which there is no charge.  However, when phone counseling occurs, the fees will be the same as for “in office” visits. If you become involved in legal proceedings that require MCO participation, you will be expected to pay for professional clinical time even if your counselor is called to testify by another party.

Payment arrangements. You will be expected to pay for each session at the time it is held. Payment schedules for other professional services will be agreed to when they are requested. There will be a $35 check charge for each check returned due to insufficient funds. If your account has not been paid for more than 60 days and arrangements for payment have not been agreed upon, MCO has 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 we release regarding a patient’s treatment is his/her name, the nature of services provided, and the amount due. If you have a question about these costs please feel free to speak to your counselor.

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 may provide some coverage for mental health treatment. MCO will provide you with whatever assistance we can in helping you receive the benefits to which you are entitled; however, you (not your insurance company) are responsible for full payment of MCO fees. A receipt will be provided for you to submit to your insurance if you so desire. To simplify the claim submission process, MCO has contracted with independent medical billers to process claims on behalf of our clients. If you wish to take advantage of this service there is a $5 fee. MCO will not contact or submit any information to insurance for you and has no control over the amount of reimbursement you may or may not receive. 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. You should also be aware that most insurance companies require you to authorize us to provide them with a clinical diagnosis. Sometimes MCO must provide additional clinical information such as treatment plans or summaries, or copies of the entire record (in rare cases). This information 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, MCO has no control over what they do with it once it is in their hands. In some cases, they may share the information with a national medical information databank. MCO will provide you with a copy of any report we submit, if you request it.

Electronic & Phone Sessions.  An electronic or phone session is defined as a counseling session conducted via internet video/audio conferencing or telephone. Advancements in technology have enabled the use of video counseling and coaching sessions that are very near an in person experience. However, technology does not always cooperate. If an electronic session is scheduled and there is a technical difficulty where a video session is not possible, a phone session will be provided as an equivalent service.   

Emergency Sessions.  An emergency session is defined as a counseling session requested during a time of crisis that is outside of a therapist’s office hours.  Clients are able to request such sessions in time of need, and, if the therapist is able to accommodate the request, sessions can be conducted during off hours.  Such sessions are charged at a 150% the therapist’s hourly rate and can be booked for a minimum time of 90 minutes.  A client also has the option, of seeing another counselor at the center, if they have availability, at the normal hourly rate during office hours to address their emergency.  This counselor will confer with your regular therapist about the content of such sessions.

Non-discrimination. MCO is committed to help all who come to us, regardless of age, sex, race, ethnicity or religious affiliation.  We understand there are areas of counseling which are out of our expertise.  In such cases, we seek to assist clients in locating the appropriate resources. MCO is a Christian organization and the services we offer are centered on Christian values.  Even though we do not seek to impose personal values on the client, we do consider the spiritual along with the physical, social, and psychological aspects of the person. 

Sexual Conduct. Please be informed that any sexual contact between client and therapist of any kind is strictly unethical and is not a part of any recognized therapy. Sexual intimacy, including intercourse, fondling or seductive language, is not allowed and should be reported to the State Grievance Board by letter or by phone.

Contact information. Your counselor may not be immediately available by telephone. While he or she may be in their office, they probably will not answer the phone when with a client. For non-emergency services please call our office at 855-593-4357. When we are unavailable, our telephone is answered by an answering service voice mail that we monitor frequently. We will make every effort to return your call on the same day you make it. If you are difficult to reach, please inform us of some times when you will be available. If you are unable to reach us and feel that you can’t wait for us to return your call, contact your family physician or the nearest emergency room and ask for the psychologist or psychiatrist on call. You may also contact the Emergency Hotline 24 hours a day by calling: 1-800-494-7355. If you are experiencing a life-threatening emergency, please call 911 or go to the nearest hospital emergency room. If your counselor will be unavailable for an extended time, he or she will provide you with the name of a colleague to contact, if necessary.

Qualifications, Credentials, and Associations

Qualifications, credentials, and associations will vary upon who your counselor is. Please reference the bios of each professional on the MyCounselor.Online webisite for the qualifications, credentials, and associations of your specific counselor.

If you have any questions about your counselor’s experience, training or education feel free to ask them as they arise.

Confidentiality

The law protects the confidentiality of client information retained at MCO.  Unless you grant us written permission we will neither inform anyone that you are receiving counseling, nor will we disclose the content of counseling sessions.  However, there are some limits to confidentiality.  These situations rarely occur in outpatient practice, but if a similar situation occurs, your counselor will make every effort to fully discuss it with you before taking any action. The state mandates that confidentiality be broken if one or more of the following applies:

  • In most legal proceedings, you have the right to prevent MCO 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 your counselor’s testimony and/or case files if he/she determines that the issues demand it.
  • There are some situations in which MCO is legally obligated to take action to protect others from harm, even if we have to reveal some information about a client’s treatment. For example, if we believe that a child or elderly person or disabled person is being neglected or abused, we are required file a report with the appropriate state agency.
  • If we believe that a client is threatening serious bodily harm to self and/or another, we are required to take protective actions. These actions may include notifying the potential victim, contacting the police, or seeking hospitalization for the client. If the client threatens to harm himself/herself, we may be obligated to seek hospitalization for him/her or to contact family members or others who can help provide protection.
  • Your counselor may occasionally find it helpful to consult other professionals about a case. During a consultation, every effort is made to avoid revealing the identity of our clients. The consultant is also legally bound to keep the information confidential. If you don’t object, we will not tell you about these consultations unless your counselor feels that it is important to your work together.
  • If your therapist is not yet licensed, he or she may share the content of your session with his or her supervisor who is legally bound to the above referenced limits of confidentiality.

Electronic communication. While MCO is committed to maintaining the privacy and confidentiality of all communications between you and your therapist, it is important to know that the confidentiality of communication through electronic means such as: telephone, cell phone, e-mail, chat, or other electronic means cannot be guaranteed. 

 

Taping or recording of sessions. MCO is committed to providing the highest quality mental health and counseling services possible. To ensure the quality of the services you receive and to facilitate the training of our counselors MCO may tape or record counseling sessions. This may include audio, video, and/ or live supervision. The signing of this counseling services agreement constitutes a release of liability and written permission to record your sessions for quality assurance and training purposes.  A few things you should know regarding the recording of sessions are:

  • You are not required to be recorded or have any obligation from being recorded.
  • You can withdraw permission to record at any time.
  • Recording is for the purpose of insuring excellent client care and the training of therapists of MyCounselor.
  • All information presented in a recorded session will remain confidential.
  • Any concerns you may have regarding the recording process can be addressed at any time with your counselor or you may contact MCO at 855.593.4357 regarding this matter.

If you do not wish to have your counseling services recorded MCO may refer you to other counseling resources in the community where your counseling needs can be met without the recording of your sessions.

 

Minors. When you meet with a counselor you will discuss with the challenges you are facing in your life. Your counselor will ask questions, listen to you and suggest a plan for improving these problems. It is important that you feel comfortable talking to your counselor about the issues that are bothering you. Sometimes these issues will include things you don’t want your parents or guardians to know about. For most people, knowing that what they say will be kept private helps them feel more comfortable and have more trust in their counselor or therapist. Privacy, also called confidentiality, is an important and necessary part of good counseling. As a general rule, your counselor will keep the information you share with them in your sessions confidential, unless they have your written consent to disclose certain information.  There are, however, important exceptions to this rule that are important for you to understand before you share personal information with your counselor in a therapy session.  In some situations, your counselor is required by law or by the guidelines of their profession to disclose information whether or not they have your permission. Some of these situations are listed below.

 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 MCO’s policy to request an agreement from parents that they agree to give up access to your records. If they agree, your counselor will provide them only with general information about your work together, unless he or she feels there is a high risk that you will seriously harm yourself or someone else. In this case, your counselor will notify them of his or her concern.  Furthermore, if you are involved in a court case and a request is made for information about your counseling or therapy your counselor will not disclose information without your written agreement unless the court requires them to. Your counselor will do all they can within the law to protect your confidentiality, and if they are required to disclose information to the court, they will inform you that this is happening. Except for situations such as those mentioned above, your counselor will not tell your parent or guardian specific things you share with them in your private therapy sessions. This includes activities and behavior that your parent/guardian would not approve of or would be upset by but that do not put you at risk of serious and immediate harm. However, if your risk taking behavior becomes more serious, then your counselor will need to use their professional judgment to decide whether you are in serious and immediate danger of being harmed. If your counselor feels that you are in such danger, they will communicate this information to your parent or guardian. Your counselor may also provide them with a summary of your treatment when it is complete. Before giving them any information, your counselor will discuss the matter with you, if possible, and do his or her best to handle any objections you may have with what your counselor is prepared to discuss.

While this written summary of exceptions to confidentiality should prove helpful in informing you about potential problems, it is important that we discuss any questions or concerns that you may have at our next meeting. Your counselor 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 we are not attorneys.

 

Consent To Christian Counseling

Value Neutral Counseling

At MyCounselor.Online we do not believe value-neutral counseling is possible. We believe the counseling relationship is an intensely human interaction. One where the personality, character, beliefs, and values of the professional and client influence the therapeutic process.

The questions asked or not, interpretations made, the framing of thoughts, feelings, and actions are all influenced by the perspective of the professional. To pretend a value-neutral stance is to deny the reality of these influences in a way that we believe is deceptive and unethical.

Informed Consent 

Informed consent is an important ethical concept. The principle says that clients should be made aware of the risks and benefits of counseling, the limits of confidentiality, and other relevant matters involved in counseling so they may grant permission for the treatment with full knowledge.

At MyCounselor.Online we believe disclosure of our values and beliefs as well as how they influence the way we do therapy is a matter of informed consent.

A detailed explanation of the statement of faith and ethics we adhere to at MyCounselor.Online can be found in these documents available on our website:

  • Focus On The Family Statement of Faith
  • American Association of Christian Counselors Code of Ethics 2014

 

 

The briefest summary of our beliefs and values as they effect our counseling practices is:

We believe the Bible itself, as the inspired and infallible Word of God that speaks with final authority concerning truth, morality, and the proper conduct of mankind, is the sole and final source of all that we believe.

Consent to Christian Counseling

In signing this document and accepting services from MyCounselor you are granting permission for MyCounselor to treat you in accordance with the principles of Christian Counseling as defined in the Focus on the Family Statement of Faith and the American Association of Christian Counselors Code of Ethics 2014.

Notice of Privacy Practices

 

This notice describes how psychological and clinical health care information about you may be used and disclosed and how you can get access to this information.  Please review it carefully.

Uses and Disclosures for Treatment, Payment and Health Care Operations

MyCounselor (MCO) may use or disclose your protected health information (PHI) for treatment, payment, and health care operations for the purposes within your written authorization.  To help clarify these terms, here are some definitions:

  • The term “PHI” refers to information in your health record that could identify you.
  • “Treatment, Payment and Health Care Operations”
    • Treatment is when we provide, coordinate, or manage your mental health care and related services.  An example would be when your counselor consults with another health care provider, such as your family physician or another counselor.
    • Payment is when MCO is reimbursed for services provided to you.  Examples of payment related disclosures are when information is disclosed to your health insurer for the purposes of reimbursement to you or to determine eligibility or coverage.
    • Health Care Operations are activities that relate to the operation of MCO’s office practices.  Examples are quality assessment and improvement activities, business related matters such as audits and administrative services, and case management, scheduling and care coordination.
  • “Use” applies to actions within MCO such as sharing, employing, applying, utilizing, examining, and analyzing information that identifies you.
  • “Disclosure” applies to activities outside of MCO such as releasing, transferring, or providing access to information about you to other parties.
  • “Authorization” is your written permission to disclose confidential mental health information.  All authorizations to disclose must be on a specific legally required form.

Other uses and Disclosures Requiring Authorization

MCO may disclose PHI for purposes outside of regular treatment, payment, or health care operation only when you sign a specific authorization for that purpose.  An “authorization” is written permission above and beyond the general consent that permits the normal PHI disclosures.  An example would be if an attorney or one of your family members wanted to know about your treatment.  In those instances, your MCO counselor would obtain written authorization from you before releasing this information.

PHI normally includes information such as the date and time of a session, the type of session (individual, couples, testing, etc.), fee, diagnosis codes, basic treatment plan, and your counselor’s name, credentials and signature.  “Psychotherapy Notes” are more detailed and sensitive notes made about your conversations during a counseling session which your counselor has kept separate from the rest of your medical record.  These notes are given a greater degree of protection than PHI.  MCO will need to obtain signed authorization from you before releasing these notes.

You may revoke all such authorizations of PHI or psychotherapy notes at any time, provided each revocation is in writing.  You may not revoke an authorization to the extent that (1) MCO has relied on that authorization and already followed through on the action you authorized; or (2) if the authorization was obtained as a condition of obtaining insurance coverage, and the law provides the insurer the right to contest the claim under the policy.

Uses and Disclosures with Neither Consent nor Authorization

MCO may use or disclose PHI without your consent or authorization in the following circumstances:

  • Child Abuse:  If MCO has reasonable cause to believe a child under the age of 18 has been abused or neglected, MCO must report this belief to the appropriate authorities.
  • Adult Abuse:  If MCO has reasonable cause to believe that a disabled adult or elderly person has had a physical injury or injuries inflicted upon such disabled adult or elderly person, other than by accidental means, or has been neglected or exploited, MCO must report that concern to the appropriate authorities. 
  • Health Oversight Activities:  MCO may disclose PHI regarding you to a health oversight agency for oversight activities authorized by law, including licensure and disciplinary activities.  Examples would be to the Missouri State Committee of Licensed Professional Counselors and to the Missouri State Committee of Psychologists.
  • Judicial and Administrative Proceedings:  If you are involved in a court proceeding and a request is made about professional services MCO provided you or the records thereof, such information is privileged under state law, and MCO will not release information without your written consent or a court order.  The privilege does not apply when you are being evaluated for a third party or where the evaluation is court ordered.  You will be informed in advance if this is the case.
  • Serious Threat to Health or Safety:  If your provider at MCO determines, or pursuant of the standards of their profession would determine, that you present a serious danger of violence to yourself or someone else, MCO may disclose information in order to provide protection against such danger for you or the intended victim.
  • Worker’s Compensation:  MCO may disclose PHI regarding you as authorized by and to the extent necessary to comply with laws relating to worker’s compensation or other similar programs, established by law, that provide benefits for work-related injuries or illness without regard to fault.

Patient’s rights and Therapist’s Duties

  • Right to request restrictions:  You have the right to request restrictions on certain uses and disclosures of PHI.  However, MCO is not required to agree to a restriction you request.
  • Right to receive confidential communications by alternative means and at alternative locations:  You have the right to request and receive confidential communications of PHI by alternative means and at alternative locations.  For example, you may not want a family member to know that you are seeing a clinician at MCO.  On your written request, MCO will send your bills to another address.
  • Right to inspect and copy:  You have the right to look at and/or obtain a copy of PHI and psychotherapy notes in the mental health and billing records used to make decision about you for as long as PHI is maintained in the record.  MCO may deny your access to PHI under certain circumstances, but in some cases you may have this decision reviewed.  On your request, MCO will discuss with you the details of the request and denial process.  If you desire copies, we will charge a fee for costs associated with our request including the cost of copies, mailing or other supplies in accordance with Federal and/or State regulations.
  • Right to amend:  You have the right to request an amendment of PHI for as long as the PHI is maintained in the record.  MCO may deny your request.  On your request, MCO will discuss with you the details of the amendment process.
  • Right to accounting:  You generally have the right to receive an accounting of the disclosures of PHI.  On your request, MCO will discuss with you the details of the accounting process.
  • Right to a paper copy:  You have a right to obtain a paper copy of this notice upon request, even if you have agreed to receive this notice electronically.
  • Duty:  In the case of marital counseling, it is the position of MCO that therapists not engage in the withholding of information vital to the relationship from spouses.  Specifically, infidelity, criminal acts, and behaviors of a spouse which place the other spouse at risk of physical or emotional damage will not be kept private.  Instead, your therapist will work with you on a plan of disclosing this information to your spouse as a part of a couple’s session set at the soonest possible date. 

MyCounselor Duties

  • MCO is required by law to maintain the privacy of PHI and to provide you with a notice of MCO’s legal duties and privacy practices with respect to PHI.
  • MCO reserves the right to change the privacy policies and practices described in this notice.  Unless MCO notifies you of such changes, however, MCO is required to abide by the terms currently in effect.
  • If MCO revises its policies and procedures, MCO will provide you with an updated notice at your next scheduled visit to your facilities or by mail.  MCO will also post this notice in a public area in its office.
  • MCO cannot guarantee the absolute confidentiality of electronic & phone sessions, as these are not in office sessions and utilize technology beyond the counseling center.

Complaints

If you are concerned that MCO has violated your privacy rights, or you disagree with a decision made about your access to records, you may contact our Director of Operations, Shaun Lotter, LPC, at 855-593-4357.

You may also send a written complaint to the Secretary of the U.S. Department of Health and Human Services.  Information about filing such a complaint can be found online at:  www.hhs.gov/ocr/privacyhowtofile.htm or the person listed above can provide you with the appropriate address upon request.  Please note that you will not receive retaliation for filing a complaint with either MCO-S or the U.S. Department of Health and Human Services.

Effective Date, Restrictions, and Changes to Privacy Policy

This policy went into effect on June 20, 2008.  MCO reserves the right to change the terms of this notice and to make the new notice provisions effective for all PHI that MCO maintains.  MCO will provide you with a revised notice at the time of your next visit to our facilities or by mail.

 

INSURANCE CLAIM PROCESSING

If you have a health insurance policy, it may provide some coverage for mental health treatment. MyCounselor will provide you with whatever assistance we can in helping you receive the benefits to which you are entitled; however, you (not your insurance company) are responsible for full payment of your fees. A receipt will be provided for you to submit to your insurance if you so desire or for a fee of $5 MCO will process your claim using an independent medical claims processor. 

 

However, MCO has no control over the amount of reimbursement you may or may not receive. 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. You should also be aware that most insurance companies require you to authorize us to provide them with a clinical diagnosis.

 

Sometimes MCO must provide additional clinical information such as treatment plans or summaries, or copies of the entire record (in rare cases). This information 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, MCO has no control over what they do with it once it is in their hands. In some cases, they may share the information with a national medical information databank. MCO will provide you with a copy of any report we submit, if you request it.

FINANCIAL RESPONSIBILITY AGREEMENT

Financial Policies

  • I agree to be responsible for the charges I incur as a result of counseling and/or assessment.
  • I understand that charges are based on the amount of professional time used / reserved for me by my request regardless of whether I appear for my session or not.
  • I understand that all payments are due at the time services are rendered.
  • I understand if I am approved for a weekly payment arrangement I will be invoiced for the full amount of my session and payments will be drawn until my balance is satisfied.
  • I understand MyCounselor does not accept cash and all checks are processed electronically via check draft.
  • I understand 5 pm the business day before my appointment is the LATEST I can cancel. Please let us know as soon as you can if you will be unable to use time you have reserved. Late cancellations result in people who need help being delayed in getting help unnecessarily.  Frequent late (day before) cancellations will result in a 7 day cancellation / reschedule notice requirement. 
  • I understand if I reserve 4 hours or more of professional time in a week this is considered “intensive” and is subject to a 7 day cancellation / reschedule notice requirement.

Fees

Level 5 – $155| Level 4 – $125 | Level 3– $95 | Level 2 – $75| Level 1 – $50

In addition to the standard session fee, all 1st session appointments will be charged a one-time $30 assessment and setup fee as a non-refundable deposit on my first appointment.

Credit or Debit Card AuthorizationI hereby authorize Paraclete Ministry Group LLC, dba MyCounselor, to charge the credit card provided to MyCounselor. I guarantee and warrant that I am the legal cardholder for this credit card and that I am legally authorized to enter into this agreement. 

eCheck AuthorizationI authorize Paraclete Ministry Group LLC, dba MyCounselor, to initiate either an electronic debit or to create and process a demand draft against my bank account. I acknowledge that the origination of ACH transactions to my account must comply with the provisioning of United States law.

*If you elect to utilize eCheck MCO will require a voided personal check to facilitate this payment method. 

Cancellation / Reschedule / Refund Policy: I understand that if I fail to give notice of cancellation or request for reschedule by 5 pm the business day before my scheduled appointment I am responsible for the full fee of my session and my credit or debit card or checking account will be charged for the time I have requested to be reserved for me.  

Consent and Agreement to Terms of Service

When you have read this document please electronically sign it below.  Your signature indicates you have read and understand the conditions as read and agree to receive services under these conditions.

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MyCounselor.Online http://mycounselor.online
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June 29, 2017 10:07 am CSTICD Uploaded by MyCounselor Receptionist - forms@mycounselor.online IP 75.166.180.29