Welcome to Heartland Christian Counseling!

Please read the following document carefully, as it contains important information regarding the treatment you and/or your family will receive at Heartland Christian Counseling. After careful review, please sign your acknowledgement of our policies and procedures.

Confidentiality: The information you share with your health care professional is held in the strictest confidence and may not be released to anyone without your written consent, as prescribed by law. There are a few exceptions to this, which are also regulated by state law. For example, in cases of suspected child or elderly abuse, or if a person poses a serious and imminent danger to her/himself or to someone else, your health care professional is required by law to report this information to the proper authorities. Information subpoenaed by a valid court order is usually not protected by this limit on confidentiality. These situations rarely occur and are the only exceptions to otherwise 100% confidentiality of what you talk about during therapy. In addition, some insurance companies require very brief and limited treatment information including diagnosis, and in some cases, information about presenting symptoms and treatment planning. Upon signing consent to release information, you are encouraged to discuss the amount, type, and purpose of information to be released if you have any concerns in this area. Our policy is to allow you to maintain the highest possible level of confidentiality.

Fees/Billing: Each client (parent/ legal guardian for minors) is responsible for managing the finances of the therapy relationship. Your health insurance may cover all or part of the fees, and we will work with you to facilitate the exchange of information with your insurance company for payment, as well as directly submitting claims electronically to your insurance carrier. It is your responsibility to check with your insurance carrier to make sure that Heartland Christian Counseling is a participant in your insurance plan. If your insurance company requires a pre-authorization, please bring the authorization number with you at the time of your first visit. You should contact your health insurance company or consult with our office for additional information. If you choose not to access your medical insurance for payment, or do not have coverage, please note that each client is responsible for payment for services rendered the day of the appointment. Cash, check, and most major credit cards are acceptable payment methods. We encourage you to leave payment information in our secure computer system so we can take care of your payment conveniently. Clients who only have sessions by Teletherapy are required to have credit card information in our computer system.

Phone calls and other contacts: The scheduling and canceling of appointments are handled through the same phone number (though follow-up appointments will generally be set up at the end of the previous session). If you need to reschedule your appointment, please leave a message on the office voicemail, and your call will be returned by the end of the next business day. You may also leave a message on the voicemail to cancel appointments 24 business hours PRIOR to your scheduled time. Please include your name, the appointment time, and a contact phone number. Less than 24 business hours cancelation notice PRIOR to your appointment may result in a $75 charge.

Supervision of Children: 

If a minor is being seen at Heartland, the Parent/Legal Guardian shall agree to the following:

• All initial intake appointments must have a parent/legal guardian present in the clinic for the duration of the appointment.
• All minors age 15 and younger must have a parent/legal guardian present in the clinic for the duration of every appointment scheduled.
• Minors age 16 and older may be dropped off for appointments, but Heartland must have a valid phone number in the event that Heartland needs to communicate with the parent/legal guardian. If Heartland is unable to communicate with the parent/legal guardian, we reserve the right to require the parent/legal guardian attend the minor's appointment in person.
• It is the parent/legal guardian's responsibility to supervise additional children in our waiting room. Heartland is not responsible for any issues that may arise due to under supervised children, and we reserve the right to cancel/reschedule the appointment if concerns arise.

In the event of an emergency, we recommend you contact 911 or head to your nearest emergency department, whichever is most appropriate for the situation.

By signing this consent form, I agree to pay Heartland Christian Counseling for any co-insurance, co-payments, deductibles or other amount not paid for by insurance. Failure to do so may result in collection action or denial of future treatment.

I have read Heartland Christian Counseling's Terms of Care and agree to follow all policies and procedures as described above.

Late Arrival - You agree to arrive to your scheduled appointments on time. You understand that if you do show up more than 15 minutes after the agreed upon time that we may not be able to keep the appointment. Should this occur, we will gladly make another appointment for you at the earliest possible time.

Cancelation Notice - We do realize that there may be times when you do need to cancel your appointment with us. If this happens, please provide us with at least 24 Business Hours PRIOR Notice before your scheduled appointment so that we may reschedule you. This also gives us the ability to help those patients that are waiting for an appointment.

Fees - If you do not cancel or reschedule your appointment with at least 24 Business Hours PRIOR Notice, you may be charged a "no-show" service fee of $75. Unfortunately, this "no-show fee" is not reimbursable by your insurance company, and you will be billed for it directly.

Dismissal - Unfortunately, if you fail to show up for two consecutive scheduled appointments without providing us with at least 24 Business Hours PRIOR Notice, our practice may have no option but to terminate our relationship with you. Should this occur, you will receive written notification from our practice with specific details.