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Note: You may use the links below to navigate this page. FINANCIAL AGREEMENTPAYMENT: Payment is required at the time services are rendered. Acceptable methods of payment include cash, check, and credit card. INSURANCE: Insurance co-payments are due at the time of service. In addition, if your insurance deductible has not yet been met, you will be billed the full charge for services. As a service to you, we may bill your insurance. However, we cannot guarantee insurance coverage. Please be advised that in some instances, insurance companies refuse to pay for services for whatever reason. You are responsible for all fees not covered by your insurance. Certain information, including type of treatment, costs, dates, and providers, may be shared with your insurance company for reimbursement purposes. OUTSTANDING BALANCE: You are responsible for paying any outstanding balances that insurance companies have not covered. Once we receive an Explanation of Benefits from your insurance company, we may need to adjust your balance based on the contracted rate. If you discontinue treatment, you are still responsible for outstanding balances on your account. Please be advised that if your clinician does not receive payment for services, she may discontinue your treatment. THIRD PARTY PAYMENT: If your parent or legal guardian is paying for treatment, they must make financial arrangements with our Office Manager and sign a third party financial agreement prior to your next appointment. LATE FEES: A late fee of $25 will be charged to accounts that are not paid by the due date indicated on your first bill. If payment is not received by the third due date, your delinquent account will be referred to collections and you will be responsible for all associated collections and legal fees. CANCELLATIONS / NO SHOWS: You will be charged a rate of $75 for a missed appointment or cancellation with less than 1 business day notice, i.e. Monday appointments need to be cancelled by the preceding Friday. RETURNED CHECK: In the event that a check is returned, you will be charged a $25 fee, in addition to any bank fees. In the event that a second check is returned, you will be charged the same fees and have to arrange another method of payment. PHONE CALLS: Typically there is no charge for phone calls. However, phone calls that are extended or constitute therapy may be billed at our standard hourly rate, depending on the circumstances. PSYCHOLOGICAL TESTING: It is often the case that for psychological testing insurance companies will not reimburse or will reimburse at such a minimal rate that we are not compensated for our time and/or materials. In this event, you are responsible for all testing charges. ADDITIONAL SERVICES: In some circumstances, depending on the time involved and nature of task, you may be charged for additional services, such as extended sessions, scoring psych testing, preparing a psych report, writing letters of advocacy or documentation on your behalf, and extended consultation with other providers regarding your treatment. Please address any questions regarding financial policies with the Office Manager. q You have the right to be respected as an individual, regardless of your gender, race, religion, sexual orientation, or disability status. q You have the right to be treated in accordance with professional and ethical standards of conduct. q You have the right to confidentiality. We will not disclose any information outside of the Chrysalis Center without your written consent. Clinical records will be maintained in a secure, locked environment. Please be advised that state law requires that confidentiality be broken in certain emergency situations, such as to protect you or someone else from imminent danger, to report child or elder abuse, or if mandated by a court order. q You have the right to discontinue therapy at any time. However, it is expected that you will confer with your therapist rather than end treatment abruptly. If you decide to discontinue treatment, you have the right to request a treatment summary and referrals to other professionals. q I understand that sessions run for 45-50 minutes and will not be extended to accommodate tardy clients. In addition, if your session runs beyond the allotted time (such as in an emergency situation), your fee will be increased accordingly. q I consent to take part in treatment with this clinician. I understand that it is in my best interest to actively participate in treatment and follow treatment recommendations. q I understand that there is no guarantee that any particular outcome will result from treatment.
q
I understand that the Chrysalis Center staff may consult
with each other in order to provide me with the most effective, ethical
treatment possible. In addition, Kelly Broadwater, M.A., L.P.A., Julie
Stone, M.S.W., L.C.S.W., and Ashley Swinson, M.S.W., P.L.C.S.W., will be
supervised by Kayj Nash Okine, Ph.D., L.P., the clinical director. I have read and understood this document and will address any concerns or questions with my therapist and/or the office manager. I have addressed the client’s/parent’s/guardian’s concerns and/or questions. The client appears fully competent to give informed consent. CONTRACT FOR BARIATRIC SURGERY EVALUATION & FOLLOW-UP q I am aware that a pre-operative psychological evaluation is required. This evaluation will consist of an extended clinical interview and psychological assessments. Due to the extensive nature of the evaluation, 2 office visits will be required to complete the process. q The cost for the evaluation includes a clinical interview, psychological testing, scoring the testing, and preparing the psychological report. The cost of the evaluation will be determined at your initial appointment, based on your insurance coverage. Payment in full is expected at the time of the initial appointment. If full payment is not received by the completion of psychological testing, the psychological report will not be submitted to the surgeon until payment is remitted. q It is extremely important that I am completely honest with my psychologist so that she can make an informed decision and provide me with the optimal level of care as I go through this process. I understand that my psychologist wants to ensure my success with surgery. q I understand that I will need to sign a release of information to allow the psychologist who meets with me for the evaluation, and the doctor who will be performing the surgery, to communicate with each other. They will be sharing treatment recommendations. q I understand that neither raw test data nor the psychological report will be released directly to me. I am aware that if I desire feedback or an interpretation of my testing, I will need to schedule an additional session with the psychologist who performed the evaluation. q I am aware that the result of this evaluation is a recommendation regarding my appropriateness for surgery and the level of support I may need in order to optimize my success with the surgery. Typical recommendations include: patient seems appropriate for surgery; patient would benefit from additional support prior to and/or following surgery; patient does not seem appropriate for surgery at this time. q I am aware that the Chrysalis Center staff psychologists, Kayj Nash Okine, Ph.D., L.P., and Kelly Broadwater, M.A., L.P.A., may consult with each other in order to make the most effective recommendations regarding my appropriateness for surgery and level of care indicated. q I know that should I be approved for, and undergo bariatric surgery, that it is required that I attend a minimum of three post-operative counseling sessions, 3, 12, and 18 months following my surgery. The cost per session depends on my insurance coverage. q I am aware that optional group counseling is available to me, following my surgery, as a means of getting additional support. The cost for group is $30 per session, or my copay. Regular attendance is encouraged. My signature indicates that I understand and agree to all of the above.
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