Creative Life Counseling Services
Laura Foster, MA, ATR-BC, LCPC ph. 773.576.7032
1925 N. Milwaukee Ave. fax. 773-304-3566
Chicago, IL
Consent for treatment - Ages 5 through 11
Creative Life Counseling Services, PC (CLCS) is a group organization with a commitment to providing quality individualized services. This consent addresses important information about CLCS’s service procedures and patient rights. A licensed professional counselor will explain this information in your initial session. It is important for you to understand the policy information and treatment information identified below prior to the start of your sessions.
Psychological Services for Children
If you are requesting service for a child as the guardian or parent of that child, it is critical that you understand the importance of maintaining a working professional relationship between yourself and the therapist of your child.
The guardian or parent has the right to ask questions about the therapy process, the therapist’s credentials, the nature of the activities completed during therapy, and the child’s progress. While parents have the legal right to obtain the child’s records, we ask, for the effectiveness of treatment, that you consider the therapist’s discretion. This serves to build a foundation and safe environment for your child to speak and act openly during times of treatment.
It is important, on occasion, that the parent or guardian of the child provide feedback on behavior and interactions outside of the therapy setting. It may also be important for parents/guardians to complete therapeutic home activities with the child to increase the success of the treatment. You will be required to meet periodically with your child’s therapist.
If you have any questions, please ask your therapist at any time during the therapy process.
Appointments
Appointments can be made by calling or texting 773-576-7032, or emailing , or by visiting the website at Sessions are scheduled for 45-55 minutes unless otherwise indicated. The time scheduled for your session is designated for you. Please give 24-hours notice when cancelling or rescheduling. You will be charged $75.00 for any session not cancelled or rescheduled within this 24-hour window. Note: Third-party payments will not cover or provide reimbursement for missed sessions. Please, be punctual. Each session has an allotted scheduled time and must end at the originally scheduled time, regardless of tardiness.
Professional Fees
CLCS charges $135.00 for each 45-minute session, $155.00 for each 55-minute session, and $175.00 for each family session. Exceptions to standard charges may be discussed and agreed upon by a parent or caregiver and the therapist. Any alternate services (such as phone calls, reports, consultation, and/or evaluations) will be discussed and fees disclosed prior to implementation. The client is responsible for all fees accumulated.
CLCS accepts BCBS PPO and Blue Choice insurance. It is important for you to be aware that it is not guaranteed that your health insurance will cover the cost of services. You, the client, are responsible for verifying your health insurance plan. If your health insurance policy covers the cost of mental health treatments and you choose to use your health insurance policy, the insurance group may require some information to be shared for their records. Some health insurance companies require authorization for treatment. If authorization is denied, the client is responsible for fees accrued. Under the circumstances that CLCS does not accept your health insurance policy, CLCS will supply you with a receipt for services. You can submit this receipt to your insurance company for reimbursement.
Payment must be made by check, cash, or credit. The fee or co-pay is due at the time services are provided. The patient is responsible for all fees. This includes any fees denied by health insurance providers. Fees must be paid within 30 days after the date that the claim is denied. Returned checks will result to an additional service fee of $35.00.
Confidentiality
CLCS is committed to following the Health Insurance Portability and Accountability Act (HIPAA), a federal law that provides privacy protections and patient rights about the use and disclosure of your Protected Health Information (PHI) for the purposes of treatment, payment, and health care operations. All information, discussions, and documents are confidential and privileged information for all patients. Under federal law, disclosure of information regarding services provided and information about a patient requires written consent of release to alternate or third parties.
The following are exceptions to the rules of confidentiality and will be understood by the patient involved.
- When there is imminent danger to another person.
- Under circumstances of suspected child, elder, or dependent adult abuse or neglect.
- When disclosure must be made to medical professionals in case of a medical emergency.
- When the mental health professional is compelled by law to disclose client records.
Information shared in the therapy setting will remain confidential. If information needs to be released to the school setting, permission and written consent will be requested. Information will not be transferred until permission is obtained. Your therapist may request consent to contact the school to obtain information about how your child is doing in the school environment. If the guardian or parent of the child and the therapist feels it is necessary to disclose information or discuss therapy with the school, the therapist will use appropriate clinical professional judgement.
This office does not provide emergency services. If you have an emergency, please call 911 or go to your closest emergency center.
Patient Rights
You have the right to considerate, safe, and respectful care, in the absence of discrimination regarding race, ethnicity, color, gender, sexual orientation, age, religion, national origin, or source of payment. You have the right to ask questions about any aspects of therapy, therapist training, and therapist experience. You have the right to communicate your therapeutic needs if you feel dissatisfied or feel like any of the aforementioned rights have been violated in any manner. You have the right to request a change in service providers. In this case, your current service provider will assist in providing the needed information to the new service provider with written consent from the patient.
Consent to Psychotherapy
I, the guardian or parent of ______, have read and understand the policies, procedure, and rights presented in this document. I understand my HIPAA notification. I understand and agree that I will be an active participant in my child’s therapy and will honor the terms of confidentiality. I understand in signing this document, I give the therapist permission to evaluate and treat ______. I understand that I have the right to terminate such care and services from the undersigned therapist at any time.
My signature affirms that I have read the above information and communicated with my mental health service provider. The information presented is understood and enables me to make an educated, voluntary consent to treatment for ______.
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Printed Name of Parent or Guardian
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Signature of Parent or Guardian Date
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Signature of Therapist Date