empowering your path to wellness.
ORGANIZATION: Our policies and procedures comply with applicable state regulations. By engaging with APPALACHIAN COUNSELING CENTER (ACC) you understand that the services provided are licensed in the WEST VIRGINIA unless otherwise noted in the beginning of your session. You agree to the terms and conditions of WEST VIRGINIA and the services provided within this state. You agree and understand that the service you are receiving is licensed therapy within this state. If you reside outside of the above-specified state (s), you understand that it is not licensed services, but rather a confidential consultation. Some sessions may consist of nutrition, psychotherapy, counseling, psycho-education, art therapy, EMDR, or other wellness activities including but not limited to mindfulness or movements. I understand I am receiving services at my own risk and hereby release ACC from any legal ramifications should I injure myself in any way including but not limited to physical, emotional, mental, or psychological distress or injury.
TEACHING CENTER: We are teaching center and may have graduate level interns observe from time to time. All interns have BAA agreements that protect your confidentiality and are covered with malpractice/liability insurance.
CONFIDENTIALITY: Under the law, what you reveal to your therapist and/or life coach is legally privileged communication. You understand that ACC is a collaborative behavioral health center and consultation with the clinical team may be necessary to ensure ethical standards and best practices are in compliance. During clinical consultations, your personal information will be kept confidential.
You understand that you must sign a written release of information (ROI) before any information about your treatment is disclosed. The following are exceptions to the general rule of confidentiality:
State laws mandate that all psychotherapists report all incidents of actual or suspected child abuse or neglect, elder abuse, and dependent adult abuse. The law also requires that incidents of threatened harm to self or others be reported. In addition, State law requires us to report incidents of loss of consciousness to local health officials. ACC complies with all prevailing laws.
Your therapist may make a diagnosis that documents the medical necessity of your treatment. Your therapist may also make periodic treatment plans; which document that treatment is being providing according to medical necessity. This information may be requested by other health professionals or insurance companies.
This information is confidential unless you render WRITTEN Release of Information
I/We understand that ACC, does not make custody recommendations, nor disability recommendations, nor legal or court recommendations nor determine an individual’s fitness to be a parent. I/We understand that ACC, can only provide verification that I/We are attending counseling and participating in the process. I/We understand the records are confidential unless a signed release of information or a court order allows the release of the records. I/We understand that there are additional state laws and ethical issues that govern the release of information to you or to certain parties. I/We understand that any relevant laws or issues will be explained along with the process for challenging these laws or issues.
If a court appoints an evaluator, mediator, or guardian ad litem, we will provide information as needed, if appropriate releases are signed or a court order is provided. We are ethically bound not to give our opinion about either parent’s custody or visitation suitability.
If, for any reason, we are required to participate in a legal dispute, the party responsible for my participation accepts financial responsibility and agrees to the following:
In the event that Provider (s) are subpoenaed or requested to attend court: Clients are subject to a legal/crises fee of $485 per hour with a 4-hour minimum. The 4-hour fee must be paid in advance ($1940), and if Provider’s appearance is required for more than 4 hours client is subject to the rate of $175 every 30 minutes.
Fees are paid in cash no later than 72 hours prior to court date.
If a client needs to cancel this block, a minimum of 72 hours’ notice must be provided, or half of the fee shall be forfeited by client. If at least 72 hours of notice has been given to the Provider, there shall be no fee to client. Less than 24 hours’ notice to Provider will result in the full fee being charged.
If a written clinical opinion and/or assessment is requested, the usual and customary fee for the assessment shall be $285. If an additional written opinion is requested, an additional fee shall be charged at a minimum of $285, depending on complexity of opinion. Court reports are subject to the documentation fee referenced above. A 48-hour notice is required for court reports.
Fees are inclusive of legal consultation, attendance at hearings, and/or any case-related costs to include time spent preparing treatment summary reports, telephoning, and travel time.
Providers will not make a disability determination.
The standard meeting time for psychotherapy is 55 minutes. It is up to you, however, to determine the length of time of your sessions. Requests to change the session needs to be discussed with the therapist in order for time to be scheduled in advance.
A minimum of 24 hours’ notice is required for rescheduling or canceling an appointment. PLEASE call the office (681-404-6869) or send an email to email@example.com to the Help Desk so that we have time to fill your slot and can put another client in your space that may need it. The more time, the better for the therapist and other clients who are in need. You can ALWAYS self-cancel through the portal at https://wvcounseling.clientsecure.me/ as long as it is 24 hours in advance.
Frequent cancellations (3 or more in 6 months or 2 consecutive) and/or missed appointments (no show) will result in the termination of treatment. If you have arranged with your therapist to have recurring appointments, the next recurring appointment will stay in the calendar. Therefore, please call the office if you choose to cancel that appointment to avoid a second No Show/Late Cancel charge of $100. A voice mail is sufficient as they are date and time stamped. The recurring appointment will be removed after the second consecutive No Show/Late Cancel.
Although Appalachian Counseling Center may send you text or email reminders about upcoming appointments, this is done as a courtesy and only if you consent to receive such communications by providing us with your email address and cell number. It remains your sole responsibility to keep track of and timely attend all scheduled therapy appointments, whether or not you receive the text or email reminder. It is your responsibility to inform the office if your phone number or email has changed. After 2 consecutive cancellations or no shows, you will not be able to schedule another appointment and will be referred to another provider.
How 24-hour Notice Works: A fee of $100 will be charged when you miss or cancel an appointment without giving 24 hours advanced notice. This means that if an appointment is scheduled for 3:00 pm on a Tuesday, notice must be given by 3:00 pm on Monday at the absolute latest. Note that if your appointment is on a Monday, the cancellation needs to be provided no later than the prior Friday, by your appointment time, to be considered proper 24-hour notice. You can cancel your appointment directly through the portal, by calling the office, or emailing the help desk at firstname.lastname@example.org
Wait Time/Grace Period: Your wait time is kept to a minimum. Due to the length of time provided for each appointment, it is critical that you arrive on time for your appointments. If you are more than 15 minutes late to your appointment, we will have no choice but to reschedule your appointment and you will be responsible for the $100 fee of a no show. To avoid paying no show fees, we require at least twenty-four (24) hours’ notice for all cancellations (as described above). Both therapist and client have a grace period of 15 minutes.
Medicaid Clients: Clients with Medicaid insurance who have three or more late cancellations within a six-month period or two consecutive no shows/late cancelled sessions will result in immediate discharge and referral elsewhere. Clients who are unsure if they can commit to therapy weekly should seek services elsewhere.
FEES and FEE POLICIES
Insufficient Funds and Bank Fees: A $50.00 service charge will be charged for any checks returned for any reason for special handling. A $50 service fee will be charged for Insufficient credit/debit cards handlings. $50 Late fee charge will be applied for all balanced 14 days past due and then 10% charge applied to the balance every 30 days thereafter. By providing us with your credit card information or booking an appointment, you consent to this policy. The credit card information you previously provided will be used to process these payments and will be immediately transacted.
No-Show Fees: See above. Anytime you fail to attend a scheduled appointment without giving appropriate prior notice of cancellation, you will be charged $100 for the no show session. The credit card information or other payment information you previously provided will be used to process this payment. Multiple no-shows will result in the termination of therapy. By providing us with your credit card information or booking an appointment, you consent to this policy. The credit card information you previously provided will be used to process this payment and will be immediately transacted.
Late Cancellation Fees: See above. Any session that is missed by canceling less than 24 hours in advance will be charged a $100 fee. You will be charged even if the cancellation is work related and even if you rescheduled the appointment. The credit card information you previously provided will be used to process this payment. By providing us with your credit card information or booking an appointment, you consent to this policy. Repeated late cancellations (more than two) may result in the termination of therapy. Multiple no-shows will result in the termination of therapy.
CO-PAY, DEDUCTIBLES, CO-SHARES, and STRAIGHT PAY: ALL co-pays, deductibles, and/or straight fee pays will be payable directly to APPALACHIAN LIFE and will be processed by the ACC support and tech team at the time of services. By providing us with your credit card information or booking an appointment, you consent to this policy. Fees will be processed using the credit card information you provide to ACC at time of service. ACC will not be held liable for any discrepancies in payment, nor demand for refunds. All non-sufficient funds and rejected payments will be charged a $50 service fee. All balances 14 days past due will be charged $50 late fee and then 10% of remaining balance every 30 days past due. Balances that are 90 days past due will be transferred to collection agency and/or small claims court. You agree that you will be responsible for legal and related fees accrued due to your non-payment. All fee policy questions and concerns can be sent to email@example.com. We submit all insurance claims but ultimately, you are responsible for your policy and all payments for services rendered. We encourage you to call your insurance directly and verify all benefits.
RECORDS if you need your clinical summary transferred to another provider, we will send them to another authorized provider electronically free of charge. Clinical summary requests for personal use are $50, including USPO fee. Records to be mailed to other entities will incur fees plus USPO fees (certified mail).
*We do not accept Medicare. You are responsible for fees as services are rendered.
*Should your insurance not pay for services for any reason, you agree that you are and responsible for all services rendered.
TELEPHONE ACCESSIBILITY If you need to contact your therapist between sessions, please send a secured message through the Portal or an email. You can leave a brief message leave a message on the ACC voicemail (681.404.6869). Therapists are often not immediately available; however, we will attempt to return your call within 24 hours. Please note that Face- to-face sessions are highly preferable to video sessions. However, if you are out of town, sick or need additional support, live video sessions are available. If a true emergency situation arises, please call 911 or any local emergency room.
ELECTRONIC COMMUNICATION We cannot ensure the confidentiality of any form of communication through electronic media, including text messages. If you prefer to communicate via email or text messaging for issues regarding scheduling or cancellations, we will do so. While we may try to return messages in a timely manner, we cannot guarantee immediate response and request that you do not use these methods of communication to discuss therapeutic content and/or request assistance for emergencies.
Services by electronic means, including but not limited to telephone communication, the Internet, facsimile machines, and e-mail is considered telemedicine. Telemedicine is broadly defined as the use of information technology to deliver medical services and information from one location to another. If you and your therapist chose to use information technology for some or all of your treatment, you need to understand that:
You retain the option to withhold or withdraw consent at any time without affecting the right to future care or treatment or risking the loss or withdrawal of any program benefits to which you would otherwise be entitled.
All existing confidentiality protections are equally applicable.
Your access to all medical information transmitted during a telemedicine consultation is guaranteed, and copies of this information are available for a reasonable fee.
Dissemination of any of your identifiable images or information from the telemedicine interaction to researchers or other entities shall not occur without your consent.
There are potential risks, consequences, and benefits of telemedicine. Potential benefits include, but are not limited to improved communication capabilities, providing convenient access to up-to-date information, consultations, support, reduced costs, improved quality, change in the conditions of practice, improved access to therapy, better continuity of care, and reduction of lost work time and travel costs. Effective therapy is often facilitated when the therapist gathers within a session or a series of sessions, a multitude of observations, information, and experiences about the client.
Therapists may make clinical assessments, diagnosis, and interventions based not only on direct verbal or auditory communications, written reports, and third person consultations, but also from direct visual and olfactory observations, information, and experiences. When using information technology in therapy services, potential risks include, but are not limited to the therapist's inability to make visual and olfactory observations of clinically or therapeutically potentially relevant issues such as: your physical condition including deformities, apparent height and weight, body type, attractiveness relative to social and cultural norms or standards, gait and motor coordination, posture, work speed, any noteworthy mannerism or gestures, physical or medical conditions including bruises or injuries, basic grooming and hygiene including appropriateness of dress, eye contact (including any changes in the previously listed issues), sex, chronological and apparent age, ethnicity, facial and body language, and congruence of language and facial or bodily expression. Potential consequences thus include the therapist not being aware of what he or she would consider important information, that you may not recognize as significant to present verbally the therapist.
MINORS If you are a minor, your parents may be legally entitled to some information about your therapy. Your therapist will discuss with you and your parents what information is appropriate for them to receive and which issues are more appropriately kept confidential.
CONDITIONS OF ONGOING COUNSELING We reserve the right to postpone and/or terminate counseling with you in any of the following circumstances:
If you come to session under the influence of alcohol or drugs
If you do not comply with the medication recommendations of your psychiatrist or physician
If we believe you are not benefiting from counseling
If, in couple counseling, we learn that you are battering your partner/spouse
If we are impaired in providing competent counseling to you
If you exhibit treatment interfering behaviors
If you solicit therapy sessions to be conducted privately with your therapist outside of Appalachian Counseling Center
If you exhibit threatening or violent behaviors
If you initiate or engage in any legal actions against us
If you defame us, to include social media defamation
TERMINATION Ending relationships can be difficult. Therefore, it is important to have a termination process in order to achieve some closure. The appropriate length of the termination depends on the length and intensity of the treatment. Your therapist may terminate treatment after appropriate discussion with you and a termination process if he/she determines that the psychotherapy is not being effectively used or if you are in default on payment. We will not terminate the therapeutic relationship without first discussing and exploring the reasons and purpose of terminating. If therapy is terminated for any reason or you request another therapist, your therapist will provide you with a list of qualified psychotherapists to treat you. You may also choose someone on your own or from another referral source.
updated February 1, 2023