Counseling Now

  • Request an Appointment

    Tell us a little about yourself and our intake team will reach out within 24 business hours. If you need urgent help, see the crisis information below.

  • About you

  • Crisis support

  • If you or someone else is in immediate physical danger or has a medical emergency, call 911 now. In the U.S., call or text 988 for suicide, mental health or substance use crisis support. This appointment-request form does not provide an immediate clinical response. Do not wait for a reply before seeking urgent help.
  • Are you a new or existing client?*
  • Have you had a visit in the past 6 months?*
  • Best time to reach you (optional)
  • Who is this request for?*
  • Date of birth*
     - -
  • May we leave you a voicemail?*
  • May we text you?*
  • Has your name, insurance, address or phone changed? (optional)
  • Is there a legal guardian?*

  • Immediate physical danger or a medical emergency? Call 911. In the U.S., call or text 988 for crisis support. Do not wait for a reply to this form for urgent help.

  • Finding the right fit

  • Crisis support

  • If you or someone else is in immediate physical danger or has a medical emergency, call 911 now. In the U.S., call or text 988 for suicide, mental health or substance use crisis support. This appointment-request form does not provide an immediate clinical response. Do not wait for a reply before seeking urgent help.

  • How would you like to meet?*
  • What kind of care are you looking for?*
  • Are you interested in life coaching?*
  • Are you interested in an intensive program for depression or anxiety in Kentucky?*
  • Are you interested in an intensive program for substance use in Kentucky?*
  • Do you see another mental health provider? (optional)
  • Do you have a primary care provider? (optional)
  • May we work with your primary care provider? (optional)

  • Immediate physical danger or a medical emergency? Call 911. In the U.S., call or text 988 for crisis support. Do not wait for a reply to this form for urgent help.

  • Insurance and ID

  • Crisis support

  • If you or someone else is in immediate physical danger or has a medical emergency, call 911 now. In the U.S., call or text 988 for suicide, mental health or substance use crisis support. This appointment-request form does not provide an immediate clinical response. Do not wait for a reply before seeking urgent help.

  • Please upload a photo ID so we can review your request. If you’re using insurance, please also upload both sides of your insurance card. Paying yourself or not sure about coverage? You can skip the insurance-card uploads. If you’re not sure, our team will help review your coverage. Can’t upload? Ask our team for another way to provide what’s needed. Asking for help does not complete the required checks or confirm an appointment.

  • How will you pay for care?*

  • If you change this answer, we'll ask your Medicaid question again.

  • Will you also use health insurance for your visits? Some EAP plans cover a set number of visits, and insurance may cover the rest.*

  • If your insurance is Medicaid, choose Medicaid above instead.

    Not sure of your plan? Leave it blank and our team will confirm your coverage.

  • Is this insurance Kentucky Medicaid or a Medicaid managed care plan?*
  • Do you also have Kentucky Medicaid (including QMB or a Medicaid plan)?*
  • Upload a File
    Drag and drop files here
    Choose a file
    Cancelof
  • Upload a File
    Drag and drop files here
    Choose a file
    Cancelof
  • Upload a File
    Drag and drop files here
    Choose a file
    Cancelof

  • Immediate physical danger or a medical emergency? Call 911. In the U.S., call or text 988 for crisis support. Do not wait for a reply to this form for urgent help.

  • Crisis support

  • If you or someone else is in immediate physical danger or has a medical emergency, call 911 now. In the U.S., call or text 988 for suicide, mental health or substance use crisis support. This appointment-request form does not provide an immediate clinical response. Do not wait for a reply before seeking urgent help.

  • Card and appointment policy

    Our team will collect your card by phone before your appointment is confirmed. Please do not enter or upload card details here.

    Please give at least 48 hours' notice if you need to cancel. If you miss an appointment without letting us know, a $75 fee may apply. Counseling Now may also apply this fee if you cancel less than 48 hours before your appointment. These fees are part of the Financial Agreement. They are billed on your statement; this form does not charge your card. You will not be charged these fees if you have Kentucky Medicaid, including a Medicaid managed care plan or Medicaid as a second coverage, or for sessions paid by an Employee Assistance Program (EAP). We will not charge a fee if the appointment was missed or canceled late because of a medical or mental health emergency, a crisis, a hospital stay, a disability-related reason, or a problem on our side such as a scheduling or technology error. You may also ask us to waive a fee for illness or other circumstances beyond your control.

    Your card authorization covers copays, coinsurance, deductibles, and balances for services you received. It does not cover missed-appointment or late-cancellation fees, which are billed to you separately. We send a statement before we charge your card. Card payments to Counseling Now appear on your statement under the name our payment processor uses for Counseling Now. If you don't recognize a charge, please call us at 855-591-0092 before disputing it.

    Keeping a card on file does not by itself allow any other charge. Need help with this step? Ask our team.

  • Card and appointment policy

    Our team will collect your card by phone before your appointment is confirmed. Please do not enter or upload card details here.

    Please give at least 48 hours' notice if you need to cancel.

    Your card authorization covers copays, coinsurance, deductibles, and balances for services you received. We send a statement before we charge your card. Card payments to Counseling Now appear on your statement under the name our payment processor uses for Counseling Now. If you don't recognize a charge, please call us at 855-591-0092 before disputing it.

    Keeping a card on file does not by itself allow any other charge. Need help with this step? Ask our team.

  • Immediate physical danger or a medical emergency? Call 911. In the U.S., call or text 988 for crisis support. Do not wait for a reply to this form for urgent help.

  • Your forms and signature

  • Crisis support

  • If you or someone else is in immediate physical danger or has a medical emergency, call 911 now. In the U.S., call or text 988 for suicide, mental health or substance use crisis support. This appointment-request form does not provide an immediate clinical response. Do not wait for a reply before seeking urgent help.

  • Review and sign

  • Please read each document and choose the boxes that apply to you. You can ask questions before signing.

  • Consent for Treatment

    Kentucky Counseling Center, LLC DBA Counseling Now

    About your care

    This form explains how counseling and related services at Counseling Now work, the limits of confidentiality, and your rights. Please read it and ask us any questions before you sign. You can ask questions at any time during your care.

    Your clinician

    Your services are provided by a Counseling Now clinician. Counseling Now clinicians may be employees or contracted clinicians of Counseling Now. Each is licensed, or practicing under required supervision, as Kentucky law requires for their profession. You may ask about your clinician's license, training, and supervision.

    What to expect

    Counseling is voluntary. Your clinician will talk with you about your concerns, the approach they recommend, what you can expect, possible benefits, possible risks, and other options, including care elsewhere. Counseling can bring up uncomfortable feelings or memories; this is a normal part of the process, and you can tell your clinician if something is not working for you. Results are not guaranteed.

    Your treatment plan

    You and your clinician will work together on a treatment plan with goals that you help choose. You can ask to review or change your plan. You may refuse or stop any part of treatment, or stop services, at any time.

    Records

    Your clinician keeps records of your care, such as assessments, treatment plans, and progress notes. You have rights to access your records as described in our Notice of Privacy Practices.

    Confidentiality and its limits

    What you share is kept confidential and is used and shared only as described in our Notice of Privacy Practices or with your written permission. There are limits. We may share information without your permission when the law requires or allows it, including:

    - to report suspected abuse, neglect, or exploitation of a child or a vulnerable adult to the Kentucky Cabinet for Health and Family Services or other authorities as Kentucky law requires;

    - when there is a serious threat of harm to you or someone else, to help keep people safe as the law allows or requires;

    - when a court order or other law requires it;

    - with your insurance or other payer, as needed to get paid for your care;

    - with your clinician's clinical supervisor or treatment team, for your care.

    CONFIDENTIALITY AND EMERGENCY SITUATIONS:
    Confidential information discussed in session is not discussed with anyone without your written permission except for:
    1. Diagnosis and dates of service shared with your insurance company to process your claims
    2. Information you tell KCC about physical, sexual or elder abuse; then, by Kentucky State Law, I have to report this to the Kentucky Department of Children and Family Services
    3. Where you sign a release of information to have specific information shared
    4. If you tell KCC you are in danger of harming yourself or others
    5. Information shared with therapist’s clinical supervisor if applicable
    6. When required by law.

    If you need to contact us between counseling sessions we're available at kentuckycounselingcenter.com via live chat. Text messages and social networking sites are not confidential and we may not be able to respond. In the event of an emergency please call 911.

    Contacting us and emergencies

    Messages sent through our website, forms, chat, text, or social media are not for emergencies and won't get an immediate clinical response. Text messages and social media may not be private.

    If you or someone else is in immediate danger or has a medical emergency, call 911.

    In the U.S., you can call or text 988 any time for suicide, mental health or substance use crisis support.

    Fees and payment

    Fees, insurance billing, and payment terms are in the separate CN Financial Agreement. They are not part of this consent.

    By choosing "I consent" and signing, you confirm that you have read this consent, had the chance to ask questions, and agree to receive services from Counseling Now. You can withdraw this consent at any time by telling us.

  • Financial Agreement

    Kentucky Counseling Center, LLC DBA Counseling Now

    1. If you have Kentucky Medicaid

    If you have Kentucky Medicaid, including a Medicaid managed care plan or Medicaid as a second coverage:

    - You will not be charged any missed-appointment or late-cancellation fee.

    - We will not ask you to keep a payment card on file.

    - You will not be billed for Medicaid-covered services beyond any cost-sharing that Medicaid allows.

    If your Medicaid status changes, please tell us. These protections apply on any date you are Medicaid-eligible.

    2. Insurance billing (other insurance)

    If you use insurance, we bill your plan using the information you give us. Please tell us about any change to your coverage. If your plan says you owe a copay, coinsurance, or deductible, or does not cover a service, we will bill you for your share as your plan and the law allow. We will send you a statement showing what you owe and why.

    3. Employee Assistance Program (EAP) sessions

    No missed-appointment or late-cancellation fee is charged for sessions paid by an Employee Assistance Program (EAP).

    4. Cancellations and missed appointments (does not apply to Medicaid-eligible clients or EAP-paid sessions)

    Please give at least 48 hours' notice if you need to cancel or reschedule.

    If you miss an appointment without letting us know, a missed-appointment fee may apply. Counseling Now may also apply this fee if you cancel less than 48 hours before your appointment. If this fee applies to your visit type, the amount is shown in the card and appointment policy on this form.

    These fees are never billed to your insurance. If a fee applies, we will send you a bill on your statement. This form does not charge your card, and your card authorization does not cover these fees.

    We will not charge a fee if the appointment was missed or canceled late because of a medical or mental health emergency, a crisis, a hospital stay, a disability-related reason, or a problem on Counseling Now's side such as a scheduling or technology error. You may also ask us to waive a fee for illness or other circumstances beyond your control.

    4a. Missed appointments (applies to all clients)

    Missed appointments. If you miss two scheduled appointments within 12 months without letting us know before the appointment time, Counseling Now may pause scheduling new appointments for you for up to 12 months from the second missed appointment. Canceling with less than 48 hours' notice does not count toward this pause, although a late-cancellation fee may apply where your Financial Agreement allows it.

    Before any pause, we will contact you, listen to what happened, and give you names of other providers. We will not count a missed appointment caused by a medical or mental health emergency, an illness, a crisis, a hospital stay, a disability-related reason, or a problem on Counseling Now's side such as a scheduling or technology error. We will also make reasonable changes to this policy for disability-related needs when asked.

    A clinical manager may shorten or waive the pause at any time. If you are a Medicaid or Kentucky Medicaid managed care plan member, this policy applies only as your plan allows, and we will help you contact your plan to find another provider.

    A pause never limits your ability to get emergency help. Call 911 or call or text 988 at any time.

    5. Card on file (does not apply to Medicaid-eligible clients)

    For clients who do not have Medicaid, Counseling Now asks you to keep a credit or debit card on file. Our team will collect it by phone. Please do not enter or upload card details on this form.

    By agreeing, you authorize Counseling Now to charge your card for copays, coinsurance, deductibles, and other balances you owe for services you received. This authorization does not cover missed-appointment or late-cancellation fees; those are billed to you separately.

    We will send you a statement before we charge your card. We process card charges once a month, usually in the second week. If a charge is declined, we will contact you to arrange payment. Card payments to Counseling Now appear on your statement under the name our payment processor uses for Counseling Now. If you don't recognize a charge, please call us at 855-591-0092 before disputing it.

    You can cancel this card authorization at any time by telling us in writing or by phone. Canceling it does not cancel balances you already owe.

    Keeping a card on file does not by itself allow any other charge.

    6. Unpaid balances

    If a balance stays unpaid, we will contact you to set up payment or a payment plan. Unpaid Balances: Accounts with balances remaining unpaid after two (2) billing statement cycles may be referred to a partnered collections agency. We share only the information needed to collect the debt, such as your name, contact information, amount owed, and dates of service. We do not share your diagnosis or details of your care.

    We do not refer Medicaid-eligible clients to collections for Medicaid-covered services.

    If you have an unpaid balance, we may ask you to set up a payment plan before scheduling more routine visits. We will not end your care without notice, and we will help you find other care if needed.

    Collection Fees: If your account is referred to a collections agency, you will be responsible for any additional fees associated with the collection process, as permitted by applicable law.

    7. Questions

    Please ask our team any questions about these terms before you sign. These terms change only when we give you an updated version.

    By choosing "I agree" and signing, you confirm you have read these financial terms and agree to the ones that apply to you. If someone else is financially responsible for your care, that person must agree separately.

  • Notice of Privacy Practices

    Hipaa Notice Of Privacy Practices For Kentucky Counseling Center

    Last Updated: October 25, 2023

    1. Introduction

    Welcome to the Kentucky Counseling Center (KCC). Your privacy is our top priority. We are committed to safeguarding your personal data and maintaining client confidentiality in accordance with federal, state laws, and the ethics of the counseling profession.

    2. Who We Are

    Kentucky Counseling Center offers mental health counseling and related services.
    Data Controller Information:
    Kentucky Counseling Center
    Email: outreach@counselingnow.com
    Address: 3044 Bardstown Rd #148 Louisville KY 40205

    3. The Data We Collect About You

    We may collect and process:

    - Identity Data: Name, date of birth, gender.

    - Contact Data: Email, phone number, address.

    - Medical Data: Therapeutic history, medications, and related medical data.

    - Technical Data: IP address, browser type, and login data.

    - Usage Data: How you use our site and services.

    4. How We Use Your Personal Data

    We use your data to:

    - Provide, manage, or coordinate your care and therapeutic services.

    - Communicate with you, including sending appointment reminders via text or voicemail.

    - Maintain our website and enhance the user experience.

    - Comply with legal requirements and ensure patient safety.

    - Collect payment and verify insurance coverage.

    - Review our treatment procedures and conduct healthcare operations, such as certification, compliance, and licensing activities.

    5. Data Security

    Your data is protected from unauthorized access, alteration, or loss through secure methods and technologies. Only authorized personnel have access to your personal and medical data, and they are bound by strict confidentiality agreements.

    6. Data Retention

    We retain your data for as long as necessary to fulfill our services, legal obligations, resolve disputes, and other essential purposes. Medical data is retained following Kentucky’s specific medical record retention regulations.

    7. Your Legal Rights

    You have various rights concerning your data:

    - Access: Obtain a copy of your data.

    - Correction: Update or amend your data.

    - Erasure: Request deletion of your data.

    - Objection: Challenge our use of your data.

    - Transfer: Transfer your data to another entity.

    8. Third-Party Links

    Our website might have links to other sites. We are not accountable for their content or privacy practices. Review the privacy policies of any external sites you visit.

    9. Cookies

    We use cookies to improve the user experience. You can adjust browser settings to decline cookies, but this may affect website functionality.

    10. Disclosures

    - Treatment: Information about you may be used or disclosed for treatment purposes, including consultations and potential referrals.

    - Payment: Information may be used and disclosed to verify insurance coverage, process claims, and for billing and collection.

    - Healthcare Operations: Used to review our treatment and business activities, inform you about treatment alternatives, and for compliance purposes.

    - Others: In certain situations, we may share your information, such as with disaster relief agencies or when required by law, for public health and safety issues, or with health oversight agencies.

    - Your Consent: Certain disclosures require your written authorization. You can revoke this authorization at any time.

    11. Client Rights & Communications

    You have a right to:

    - Request alternative communication methods or locations.

    - Release your medical records with your written consent.

    - Inspect, copy, or amend your medical and billing records.

    - Request an accounting of certain disclosures.

    - Request restrictions on specific uses and disclosures.

    - Receive breach notifications.

    12. Questions, Complaints, and Contacts

    For inquiries about this policy, privacy practices, or to exercise any of your rights, please contact:

    Kentucky Counseling Center, LLC
    Attn: Privacy Officer
    3044 Bardstown Rd #148 Louisville, KY 40205
    Phone: 855-591-0092

    13. Revisions to This Notice

    This policy may be updated periodically. Any changes will be posted on our website at kentuckycounselingcenter.com and will be available upon request at our offices.

    Originally Published August 2014; Revised, Effective February 11, 2019.

  • Privacy notice receipt (Notice of Privacy Practices)

  • You can still get care if you can't or don't want to confirm receipt. Please let our team know.

  • Telehealth Consent

    Kentucky Counseling Center, LLC DBA Counseling Now

    What telehealth is

    Telehealth means getting care from your Counseling Now clinician by live video, or by phone when appropriate, instead of in person. Your clinician is a licensed professional, or practicing under required supervision, who provides services through Counseling Now.

    Clinician status

    Some Counseling Now clinicians are employees and some are independent contractors. You may ask which applies to your clinician. Every clinician who sees you through Counseling Now is licensed and carries their own professional liability insurance. Nothing in this consent limits any right you have under law.

    How it works

    - We use Zoom for video visits.

    - At each visit, your clinician will confirm your identity and the address or location where you are. Your clinician must be allowed to practice in the state where you are during the visit. Please tell us if you will be somewhere else.

    - At each visit we will confirm a phone number to reach you and a plan for emergencies, including local emergency help near you.

    - If the connection fails, your clinician will try to call you at the number you gave. If we cannot reconnect, we will reschedule.

    Benefits and risks

    Telehealth can save travel time and make care easier to fit into your day. It also has limits: technology can fail, your clinician cannot see everything they would see in person, and privacy depends partly on where you are. We use safeguards, but no technology is completely risk-free. Please join from a private place, and tell your clinician if anyone else is present. You may ask who is present with your clinician.

    Your choices

    - Telehealth is voluntary. You may refuse it or stop at any time and ask about in-person care where available, without losing your right to future care.

    - If you are offered a phone-only visit, you may ask for a video or in-person visit instead.

    - Your clinician may recommend in-person care if telehealth is not right for your needs.

    - Telehealth visits are not recorded. Any recording needs your separate written consent. Please do not record sessions without your clinician's agreement.

    Records and privacy

    Your telehealth care is documented in your Counseling Now record, just like an in-person visit, and is protected as described in our Notice of Privacy Practices.

    Emergencies

    Telehealth is not an emergency service. If you or someone else is in immediate danger or has a medical emergency, call 911. In the U.S., you can call or text 988 any time for suicide, mental health or substance use crisis support.

    Fees

    Telehealth visits follow the CN Financial Agreement. Insurance coverage for telehealth can vary; please ask us if you are unsure.

    By choosing "I consent" and signing, you confirm that you have read this consent, had the chance to ask questions, and agree to receive telehealth services from Counseling Now. Your clinician will also review telehealth with you, and you can ask questions at any time.

  • Card and appointment policy

    Our team will collect your card by phone before your appointment is confirmed. Please do not enter or upload card details here.

    Please give at least 48 hours' notice if you need to cancel. If you miss an appointment without letting us know, a $75 fee may apply. Counseling Now may also apply this fee if you cancel less than 48 hours before your appointment. These fees are part of the Financial Agreement. They are billed on your statement; this form does not charge your card. You will not be charged these fees if you have Kentucky Medicaid, including a Medicaid managed care plan or Medicaid as a second coverage, or for sessions paid by an Employee Assistance Program (EAP). We will not charge a fee if the appointment was missed or canceled late because of a medical or mental health emergency, a crisis, a hospital stay, a disability-related reason, or a problem on our side such as a scheduling or technology error. You may also ask us to waive a fee for illness or other circumstances beyond your control.

    Your card authorization covers copays, coinsurance, deductibles, and balances for services you received. It does not cover missed-appointment or late-cancellation fees, which are billed to you separately. We send a statement before we charge your card. Card payments to Counseling Now appear on your statement under the name our payment processor uses for Counseling Now. If you don't recognize a charge, please call us at 855-591-0092 before disputing it.

    Keeping a card on file does not by itself allow any other charge. Need help with this step? Ask our team.

  • Card and appointment policy

    Our team will collect your card by phone before your appointment is confirmed. Please do not enter or upload card details here.

    Please give at least 48 hours' notice if you need to cancel.

    Your card authorization covers copays, coinsurance, deductibles, and balances for services you received. We send a statement before we charge your card. Card payments to Counseling Now appear on your statement under the name our payment processor uses for Counseling Now. If you don't recognize a charge, please call us at 855-591-0092 before disputing it.

    Keeping a card on file does not by itself allow any other charge. Need help with this step? Ask our team.

  • Check your name, then confirm to sign the documents you selected.

  • Your signature applies only to the documents you selected. You can keep copies. If someone else needs to sign, our team can help.

  • Sharing information (optional)

  • Sharing information is your choice. This form has its own signature. You can say no and still get care.

  • Would you like to share information? (optional)

  • Read: Sharing information · version 1

    I consent for Kentucky Counseling Center, LLC DBA Counseling Now and those representing this group to share my private health care information with the following individuals and/or entities. KCC is permitted to send and receive information to and from the entities below if needed:

    I understand that I have the right to revoke this authorization, in writing, at any time by sending notice to KCC. I understand that a revocation is not valid to the extent that the company has acted in reliance on such authorization. This authorization does not expire until I submit a written request. A copy of this release shall have the same force and effect as the original.

    NOTICE TO RECEIVING INDIVIDUAL, PROVIDER, OR ENTITY: You may not re-disclose any of this information unless the person who consented to this disclosure specifically consents to such re-disclosure.

  • Sign this release only if you want to share information. It is separate from the other documents.

  • Immediate physical danger or a medical emergency? Call 911. In the U.S., call or text 988 for crisis support. Do not wait for a reply to this form for urgent help.
  • Should be Empty: