Minor Client Information Form - Centerpoint Counseling (Page 3 of 4) in pdf

Client/Child Name: _____________________________

Therapist:_________________________

Therapeutic Disclosure - CenterPoint Counseling

Welcome to CenterPoint Counseling. Entering into a therapeutic relationship is unique and is guided by

professional governing ethical standards that we feel are important to share with you at this time.

Confidentiality: The therapeutic relationship is a privileged relationship and the content of all discussions,

testing, notes and evaluations are protected. This information can only be released by your signed consent.

In addition, written permission by all participating parties must be granted in order for recording devices to

be utilized during counseling sessions.

Exceptions to Confidentiality: While the therapeutic relationship is confidential, the professional standards

and Indiana law require these exceptions:

a) When physical harm is threatened against another person,

b) When physical harm is threatened against one’s self,

c) When physical abuse or neglect is directed at a child or adult,

d) When records are subpoenaed by a local, state or federal court,

e) Any other provision covered under Indiana Code 25-23.6 et. Seq.

Fee Policy: The initial intake appointment is $125.00 for all new clients. Beyond that, a typical 45 minute

session is $125 for Doctoral level clinicians and $100 for Master’s level clinicians. However, charges are

ultimately subject to the procedure code selected. In cases of financial hardship, CenterPoint does offer a

fee subsidy through our Samaritan Fund. It is your responsibility to inquire about this with your therapist if

needed. Regardless of negotiated fee arrangements and/or insurance coverage, payment for counseling

services is your responsibility and due at the time of your counseling appointment. If filing with insurance,

you are ultimately responsible for any claims not paid by your insurance company for any reason.

Cancellation Policy: We understand that illness and other unforeseen events are inevitable. Therefore,

CenterPoint Counseling grants one missed appointment as a show of grace. After the first missed

appointment, cancellations received with less than 24 hours notice will be charged a $50 missed

appointment fee. Unfortunately, because missed appointments cannot be billed to insurance, you are

responsible for the full cost of this fee. Please discuss situations with your therapist that you think warrant

further consideration.

Safety Policy: The use and/or possession of drugs, alcohol, firearms and weapons of any kind are strictly

prohibited on any location where therapy sessions are being conducted through CenterPoint Counseling.

I have read, understand and agree to the policies of CenterPoint Counseling provided in this document as

they relate to confidentiality, exceptions to confidentiality, fees, cancellation and safety policies.

Parent/Guardian Signature __________________________________________Date___________________

(If Applicable)

Acknowledgement-Receipt of Notice of Privacy Practices-Effective 6/1/13

By signing below, I acknowledge that I have received the Notice of Privacy Practices from CenterPoint

Counseling. I am also aware that a Notice of Privacy Practices is obtainable by going to CenterPoint’s website

and clicking on the “Intake Forms” link ( ). Forms are also available on location.

Parent/Guardian Signature __________________________________________Date___________________

(If Applicable)

Minor Client Information Form - Centerpoint Counseling Page 3