4 Consent forms
Informed Consent and Financial Agreement
About counseling and your rights
Counseling can help with stress, relationships, mood, life changes, and more. It can
also bring up uncomfortable feelings, and changes you make in therapy can affect your
relationships. Results are not guaranteed, and how much you get from counseling
often depends on your effort between sessions.
You have the right to ask questions about your treatment, to be treated with respect,
and to stop counseling at any time. If you have questions about how I work, please
ask.
Confidentiality and its limits
What you tell me is private. I will not share it without your written permission, with
these exceptions:
• Abuse or neglect. I must report suspected abuse or neglect of a child, an
elderly person, or a disabled adult.
• Safety. I may need to contact your emergency contact and/or local authorities if
you are at serious risk of harming yourself. I may also need to contact local
authorities if you are at serious risk of harming someone else.
• Legal orders. I may have to testify and/or share records if a court subpoena
orders me to.
• Insurance. If you use insurance, I share the information your plan needs to
process claims, including your diagnosis. Your plan may ask to review your
records.
If I ever need to share something beyond these exceptions, I will ask you to sign a
release first. A release should name who gets the information, what information will be
released, and when it expires. You can cancel a release in writing at any time.
Records, contact between sessions, and emergencies
I keep a record of your care, as the law and my license require. You may ask to see or
get a copy of your records, and I will respond within the time the law allows.
Please contact me via phone or email to schedule or reschedule. Email is not fully
secure, so please keep them to scheduling and avoid private details. I reply within 1-2
business days. I am not available outside of office hours for emergencies.
If you are in crisis or in danger, call or text 988 (Suicide and Crisis Lifeline), call
911, or go to the nearest emergency room.
Telehealth consent
I offer counseling by secure video or phone, in addition to in-person sessions. By
signing, you agree to the following:
• Telehealth is your choice. You may refuse it at any time and ask for in-person
sessions. If I cannot offer an alternative, there may be delays in care and you
may be referred to another provider.
• Benefits and risks. Telehealth can be more flexible about where and when we
meet. It also has risks, such as technology failures, privacy problems on your
end, and seeing fewer body-language cues.
• You must be in Ohio. Because I am licensed in Ohio, you must be physically in
Ohio during each telehealth session. If you are traveling, please tell me before
the session.
• Your location and backup number. At the start of each session, I will ask
where you are. Please give me a phone number to use if the connection drops. I
may need your location to send help in an emergency.
• Privacy. Please join from a private space where others cannot hear you. Do not
record sessions. I will not record them either, unless we both agree in writing.
• Platform. I use a HIPAA-compliant platform (Session by Psychology Today). It is
designed to protect your privacy, but no system is perfectly secure.
• Insurance. Your plan may cover telehealth differently from in-person care. You
are responsible for checking your benefits.
Fees
Self-pay clients pay $125 for the first session (intake) and $100 for each counseling
session after that. If you use insurance, your plan's agreed rate applies instead, and
you are responsible for any copay, deductible, or coinsurance your plan requires.
Payment
Payment is due at the time of each session. I accept credit or debit cards. A card on
file is required to book a session. If a payment is declined or returned, you will not be
able to schedule additional sessions until the balance is resolved. If a balance goes
unpaid, I will contact you to work out a payment plan. If it stays unpaid for 90 days
after that, I may send it to a collection agency. I would share only what is needed to
collect, such as your name, contact information, and the amount owed. I would not
share your diagnosis or anything we talking about in session.
Cancellations and missed sessions
If you need to cancel or reschedule, please give me at least 24 hours notice. Sessions
cancelled with less notice, or missed without notice, may be charged a fee of $65.
Insurance does not pay for missed sessions, so this fee is your responsibility. I may
waive the fee for emergencies or illness.
Using your insurance
By signing, you give me permission to bill your insurance plan for my services and to
share the information the plan needs to process claims.
• A diagnosis is required. To bill insurance, I must give your plan a mental health
diagnosis. It becomes part of your insurance record and could affect future
coverage in some situations.
• Your plan may ask for records. Insurance companies can request your
treatment notes or review your records to confirm the care was needed.
• Coverage is not guaranteed. I can help check your benefits, but you are
responsible for knowing what your plan covers. Please tell me right away if your
insurance changes.
• You pay your share. You are responsible for copays, deductibles, coinsurance,
and any charges your plan does not cover.
• If a claim is denied, I will let you know. You are responsible for the balance
unless my agreement with your plan says otherwise.
Depending on the type of insurance you have, you may choose to pay out of pocket
instead of using insurance. If so, no diagnosis or claim goes to your plan.
Assignment of benefits
I ask that your insurance plan pay my fees for covered services directly to me,
Lighthouse Hope & Healing LLC, instead of paying you. This does not change what you
owe. You still pay any copay, deductible, coinsurance, or non-covered amount. If your
plan sends a payment for my services to you by mistake, please forward it to me.
Good Faith Estimate (self-pay clients)
If you do not use insurance, you have the right to a written Good Faith Estimate of what
your care is expected to cost. I will give you one before your first session, or you can
ask for one any time. If your final bill is at least $400 more than the estimate, you may
have the right to dispute it. Visit www.cms.gov/nosurprises for details.
Ending counseling
You can terminate counseling services at any time. I will ask you to talk with me about
ending, when possible, so we can plan next steps. If I cannot continue to see you, or if
you need care I do not provide, I will give you referrals. If you miss sessions for 30 days
without contact, I may close your file.