Consent for Treatment

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I understand that I must be committed to attend sessions on a consistent basis in order to  receive the greatest benefit from therapy. Although I may stop therapy at any time, I agree to  inform my therapist of my decision prior to my last visit. If my therapist believes that I can  receive more effective treatment elsewhere, I will be given referrals. I understand that I may not  attend a session if I am under the influence of alcohol or drugs, or if I am in possession of a  dangerous weapon. My signature below indicates my desire and consent to receive mental  health services from Awaken360 Therapeutic Center.

 

I understand that I (the client) am fully responsible for the payment of all fees for services  provided regardless of any insurance coverage I may have. I understand that it is Awaken360’s  policy that the fee for any session is payable at the beginning of the session. Awaken360  accepts cash, checks or credit cards as forms of payment. All sessions are 45 - 60-minutes in  length. Follow up session fees for individuals ($100-$150), couples or families ($165-$200). I  understand that if I have a coinsurance, I will be billed that percentage at time of service, which  will be applied the contracted in-network fee established by your insurance which will be  invoiced at a later time. I will be invoiced if an emergency phone consultation is initiated by the  client, the first 10-minutes are at no charge. However, $25.00 will be billed to your account for  each subsequent 15-minute period. 

I understand that if I have insurance, Awaken360 will either file the claim on my behalf or will  provide me with the necessary information so that I can file the claim. I understand that I am  ultimately responsible for any therapy fee(s) not covered by my insurance carrier. Co-pays and  non-covered services are payable at time of service unless other arrangements have been  made. In the event that insurance is billed on my (the client) behalf, I authorize payment of  mental health benefits to Awaken360, Inc. or the name of the therapist as indicated above  (please check name of attending therapist). 

My signature below indicates that I have read, understand, and agree to the statements made  above regarding Treatment, Payment & Insurance Reimbursement, and Cancellations and  Missed Appointment Policy. 

Client Information

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By Clicking "Submit" below you agree to the above terms for treatment and consent Awaken360 to bill insurance for services rendered if applicable.