Thank you for choosing LifeSolutions Counseling Associates, P.C. Today’s appointment will take approximately 45 – 50 minutes. We realize that starting counseling is a major decision, and you may have many questions. This document is intended to inform you of our policies, State and Federal Laws and your rights. If you have other questions or concerns, please ask. We will try our best to give you all the information you need. All our associates have obtained their clinical degrees from accredited universities, have extensive experience working with individuals and families and are licensed by the State of Indiana to provide mental health
counseling. LifeSolutions therapists have developed strong reputations in the metropolitan area and keep abreast of evidence based practices in our field. We are strongly grounded in cognitive-behavior therapy due to its proven effectiveness but do modify our approach depending on the person and/or condition. We also adhere to a strength-based approach that dictates all treatment options, planning and implementation be done in a collaborative effort with you. Thus, treatment practices, philosophy and plan imitations and
risks will be discussed with you today.
CONFIDENTIALITY AND EMERGENCY SITUATIONS: Your verbal communication and clinical records are strictly confidential except for: a) information shared with consultants, b) information (diagnosis and dates of service) shared with your insurance company to process your claims, c) information that is reported about neglect, or physical or sexual abuse of minors, elderly, or disabled individuals; (by Indiana State Law, I am mandated to report this) d) where you sign a release of information to have specific information shared, e) if you provide information that informs LifeSolutions that you are in danger of harming yourself or others f) information necessary for case supervision or consultation and g) or when required by law. If an emergency situation for which the client and/or their guardian feels immediate attention is necessary, the client and/or guardian understands that they are to contact the emergency services at the nearest emergency room or call 911. LifeSolutions therapists will follow those emergency
services with standard counseling and support to the client and/or the client's family. Please keep in mind that communications via email and text messages are not secure. Although it is unlikely, there is a possibility that information you include in an email or text message can be intercepted and read by other parties besides the person to whom it is addressed. Please do not include personal identifying information such as your birth date, or personal medical information in any emails or text messages you send to us.
COORDINATION OF TREATMENT: It is important that all health care providers work together. As such, we would like your permission to communicate with your primary care physician and/or psychiatrist. Your consent is valid for one year. If you prefer to decline consent no information will be shared.
COORDINATION OF MEDICATION: It is important that we gather your medication history to formulate an effective plan of care. As such, we would like your permission download your medication history from electronically connected sources. This data can come from pharmacies, PBMs and health insurers all of which collect this medication history. Medication history is helpful to provide
treat of your symptoms and/or illness and to avoid potentially dangerous drug interactions. It is very important that you and your provider discuss all your medications in order to insure that your recorded medication history and current medications are accurate. Some pharmacies do not make drug history information available, and your drug history might not include drugs purchased without using your health insurance. Over‐the‐counter (OTC) medications, vitamins and the like that you take on your own may not be included. This may or may not include AIDS/HIV medications and mental health medications.
By signing this consent form you are giving your healthcare provider permission to collect and giving your pharmacy and your health insurer permission to disclose information about your prescriptions that have been filled at any pharmacy or covered by any health insurance plan. Your consent is valid for one year. If you prefer to decline consent we will not access this information.
FINANCIAL/INSURANCE ISSUES: By signing below, you agree to be financially responsible for all fees incurred while accessing services at LifeSolutions Counseling Associates, P.C. As a courtesy we will bill your insurance company, HMO, responsible party or third party payer if you wish. We do request that at each session you pay your fee in full by check or credit card. If your insurance company denies payment, we will help with any appeal process but you are ultimately responsible for fees associated with services at LifeSolutions. However, if your insurance does not cover charges incurred at LifeSolutions, you shall be responsible for all reasonable cost of the collection of this account, which may include but not limit to, client collection fees, late fees, rebilling charges, interest, reasonable attorney fees and court cost on any outstanding balance. If you need to cancel or reschedule an appointment, please give at least 24 hours advance notice so that your therapist can schedule the time for other clients waiting for open appointments. We do charge a $75 no-show rate if you do not notify us within 24 hours that you cannot make your appointment. We sincerely appreciate your cooperation and at any time you have any questions regarding insurance, fees, balances or payments please feel free to ask. You may have a copy of this form if requested. I agree to the financial arrangements listed in this sections and have
a right to receive a copy of my fee schedule.
If your account should be sent to collections, you agree in order for us to service our account or to collect any amounts you may owe, we may contact you by telephone at the numbers associated with your account, including wireless telephone numbers, which could result in charges to you. We may also contact you by sending a text message or e-mails, using any e-mail address you provide to
use. Methods of contact may include using pre-recorded / artificial voice messages and/or use of an automatic dialing service, as applicable.
I/We have read this disclosure and agree that the Creditor may contact me/us as described above. I/We shall be responsible for all reasonable costs of the collection of this account, which may include but not limited to, client collection fees of 30%, reasonable attorney fees and court costs on any outstanding balance.
NOTICE CLIENT RIGHTS: I/We have read and received a copy of the Client Rights document
CONSENT FOR TREATMENT OF SELF:
consent to be treated as a client at LifeSolutions Counseling Associates, P.C. At times it may be necessary to schedule appointments during school/work hours. We ask for your cooperation to provide the timeliest treatment for you.
CONSENT FOR TREATMENT OF MINORS OR ADULT UNDER LEGAL GUARDIANSHIP:
I/We consent that
may be treated as a client at LifeSolutions Counseling
Associates, P.C.. At times it may be necessary to schedule appointments during school hours. We ask for your cooperation to provide the timeliest treatment for you and/or your children.
LifeSolutions provides professional services that will help improve your mind, spirit, and wellness in life.
Call (317) 569-5433 Today.
We’re Here To Help.
Old Meridian Professional Center1185 W. Carmel DriveSuite D-4Carmel, IN 46032(317) 569-5433
Riverview Medical Arts14540 Prairie LakesBoulevard North Suite 202Noblesville, IN 46060(317) 569-5433
Beginning April 19, 2021, all client information, forms, and balances can be viewed from a New Client Portal. You will receive access to this New Client Portal via two emails, one providing you with your user name and one providing you with a temporary password and a link to the New Client Portal. Please contact support staff with any questions at 317-569-5433.