Client rights and responsibilities
Every client of Joy Thacker counseling is entitled to:
• Participate in treatment decisions during his or her care.
• Be treated at all times with dignity and respect by counselors and staff.
• Request to review and discuss the information in your patient file, or to obtain a copy or summary of
it at a reasonable charge.
• Additionally clients have the right to ask for corrections to be made to his or her file or to write a note
of disagreement about information contained in his or her record.
Every client being treated has a responsibility to:
• Provide information the counselor needs to give appropriate care.
• Follow the counselor’s recommended plans and instructions for care.
• Participate in the treatment process through a focus on problems and the development of mutually
agreed upon treatment plans and goals.
• Payment of $75.00 is due at the time of your visit
• Personally submit your receipt to your health insurance company.
• Keep scheduled appointments and abide by the cancellation policy.
Privacy and Confidentiality
Your client records are protected from disclosure under both state and federal laws relating to mental health services. Conversations and test results are held in strict confidence unless otherwise provided for by state or federal regulations such as: You are a danger to yourself or to others, a child is endangered, medical emergencies and for third party billing. If I need to consult with someone regarding your treatment, you will be asked to sign a release form that will clearly identify the information to be exchanged, the parties involved in the exchange, and the reason for the communication.
Fees and payments
Your insurance policy is an agreement negotiated between you, or your employer, and the insurance company. While some insurance companies will cover services provided by Joy Thacker counseling, no guarantee is made of any coverage. As a reminder, regardless of your insurance coverage, services are provided to you and ultimately you are financially responsible for payment.
Appointment Scheduling, cancellation and no-show policies
If you are unable to keep your scheduled appointment, you are required to give 24-hour advance cancellation notice via phone call or text message at 814-494-8605. Without this notice, you will be charged a $25 cancellation fee.
Clinical emergency and after-hours procedures
I may not always be accessible by phone. You are free to leave me a message and I will return your call at my convenience. If you are experiencing a clinical emergency, please call 911 or go to your nearest hospital emergency room.
Termination of treatment
You may terminate treatment for any reason. Upon your request, I will be happy to provide you with a referral to another qualified provider. If you sign a release of information at that time, I will gladly forward a copy of your records to your new provider.
I agree that I have read and understand the policies stated above. I acknowledge that I may request a copy of this Client Information and Agreement form. I understand that a copy of this Agreement will be kept on file.
Client’s Signature__________________________________ Date: ____/____/____
Counselor’s Signature _______________________________ Date: ____/____/____