Consent Form Please read each section and submit the form with your name, email, and date. Thank you! Service and FeesIt is the responsibility of all clients of MBS Performance Counseling to be aware of the fees due for services through private pay or health insurance. Payments are due at the beginning of each session. There will be a $30.00 service charge on returned checks (NSF). Counseling Rates for Private Pay (per 45-minute session): Individual Counseling $105.00 Mental Athletic Performance Counseling $125.00 College Counseling – Individual Session $150.00 College Counseling – ½ Year Package $1100.00 College Counseling – Full Year Package $2100.00 Speaking Events and Presentations Price Varies Returned Check Fee $30.00 Missed Appointment Fee $50.00 Health Insurance CoveragePlease bring a copy of your medical insurance card to each appointment. If prior authorization or approval is required for mental health services, it is the clients’ responsibility to contact the insurance agency. It is also your responsibility to understand your coverage, including co-pays, co-insurance, and deductibles, including which services are covered or not covered. It is also the responsibility of the client to let us know of any changes in insurance coverage or changes in employment. We will help complete the forms to request reimbursement from insurance. Financial ResponsibilitiesThe client is responsible for payments of fees (co-pays, co-insurance, deductibles, non-covered services) for MBS Performance Counseling. If we provide services that are not covered by medical insurance or EAP, the client is responsible for the payment of these services. Payment of fees are due prior to the start of an appointment. The person who signs below is agreeing to be the “financial guarantor,” which means this person agrees to pay any of these fees. If we determine there is a balance on the account (ex. Session fees, Missed Appointment, Returned Check, etc.), we will send a statement. We ask that full payment is submitted within 30 days. If the fees are not paid in 30 days, we will send the account to a collection agency where the client will be responsible for all collection fees, court costs, and legal fees. Unattended Child PolicyMBS Performance Counseling does not provide childcare and is not responsible for children or adolescents left unsupervised before, during or after counseling sessions. Minors must be picked up following their appointments on time. If the client’s child must be in the waiting room during a session, it is the client’s responsibility to provide appropriate supervision for that child. Children under the age of 10 may not be left without supervision in the waiting room. Cancellations and Missed AppointmentsMBS Performance Counseling services many clients, so we require 24-hour notice for cancellations and reschedules so that appointment times can be available for another client in need. If appointments are not canceled or rescheduled 24 hours before the time, a fee of $50.00 will be assessed to the client. Clients are responsible for all cancellation/no-show fees. Insurance companies will not reimburse for missed appointments. Fees MUST be paid before the next session is scheduled. Court Appearances and Legal PaperworkCourt appearances are billed at $200 per hour with a minimum charge of five (5) hours, totaling one thousand ($1000) dollars. If the therapist needs to testify or present records pertaining to the counseling relationship before any court, arbitrator, or other hearing officer the client agrees to pay the therapist for his or her services, including travel, preparation, materials and necessary expenditures at the rate of $200 per hour. The client agrees to pay the $1000 one week prior to the appearance, presentation of records, or testimony requested. End of TreatmentIn addition to the right to confidentiality, the client has the right to end counseling at any time, for whatever reason and without any obligation, with the exception of payment of fees for services already provided. The client has the right to question any aspect of treatment with the counselor as well as the right to expect that the counselor maintains professional and ethical boundaries by not entering into other personal, financial, or professional relationships with the client. MBS Performance Counseling reserves the right to discontinue counseling at any time including, if we do not believe the client will make progress on mental/emotional health conditions because of no-shows or late cancellations. We may consider the client inactive if there has been no contact or no scheduled appointments for sixty (60) days. You will receive a letter stating that your file has become inactive. You may contact us to set up an appointment to become active again. Electronic Signature and Date Name* Email* Date*SubmitReset