Practice Policies

Date(Required)

Client(s) Name(s)(Required)

Relationship to Client

Name(Required)

First Last

Your Phone Number(Required)

Your Email(Required)

Do you need a superbill to submit to insurance? (Please note that Lighthouse cannot provide a superbill for any sessions utilizing the sliding fee scale)(Required)

Yes

Financial Policies

The fee for therapy is based on a sliding fee scale based on information provided below and is the fee for a 50-60 minute session. The fee will be discussed with you prior to your first appointment. You have the right to ask for a Good Faith Estimate at any point in time before or during your services. You can request your Estimate by calling our office at (970) 413-8998.

Payment of your fee is expected at the beginning of each session. A pro-rated fee will be charged for phone consultations greater than 5 minutes in duration, talking with professionals at your request, any written correspondences, travel time, or other requested time spent outside of the session.

**It is required to have a credit card on file. If you would like to pay with cash or check, you must do so at the time of service. If payment for services has not been made or arranged at the end of the day, Lighthouse will use the credit card on file to charge for the services.**

The full session fee is charged for appointments at which you do not show or cancel with less than 24-hour notice of the reserved appointment time. Two-hour sessions must be cancelled one week in advance.

A $20 fee will be charged for all (payments) returned for insufficient funds.

If a court appearance/deposition is required, please ask for the separate consent form.

**REUNIFICATION BILLING IS DONE SEPARATELY AND IN A DIFFERENT MANNER, WITH A DIFFERENT COST**

We currently accept private payment in the forms of cash, check or credit card.

Medicaid
We do not accept Medicaid. If you have Medicaid, we cannot accept any payment from you, even cash. However, a Community Sponsor can make our mental health services a reality for you. The office will supply you and your community sponsor the paperwork needed to begin services.

Insurance Considerations
We do not bill insurance for our services.

If you would like to have managed care assist with your session fee, we offer the following options:

1. We can directly bill the credit card associated with your health savings account.
2. We can send you a superbill that you can submit for reimbursement from your health savings account.
3. We can send you an superbill for you to submit to your insurance company for out-of-network reimbursement.

To determine your session fee, please indicate your annual gross (pre-tax) income for your household. If you do not wish to disclose your income, you can write N/A and your session fee will automatically be the counselor's standard rate. (The Sliding Fee Scale is not available for Reunification cases )(Required)

Are you splitting the cost of services with anyone?(Required)

Yes

Please provide the name and contact information for any other party responsible for billing.

Are you on Medicaid?(Required)

Yes

If on Medicaid, please provide the name and contact information for your Community Sponsor.(Required)

HIPAA / Privacy Practices(Required)

Mandatory Disclosure Statement The Colorado Department of Regulatory Agencies has the general responsibility of regulating the practice of licensed and unlicensed counselors and marriage and family therapists. The agency with this responsibility is the State Grievance Board, 1560 Broadway, Suite 1350, Denver, CO, 80202, 303-894-7766. The regulatory requirements for mental health professionals provide that a Licensed Clinical Social Worker, a Licensed Marriage and Family Therapist, and a Licensed Professional Counselor must hold a master's degree in their profession and have two years of post-master's supervision. A Licensed Psychologist must hold a doctorate degree in psychology and have one year of post-doctoral supervision. A Licensed Social Worker must hold a master's degree in social work. A Psychologist Candidate, a Marriage and Family Therapist Candidate, and a Licensed Professional Counselor Candidate must hold the necessary licensing degree and be in the process of completing the required supervision for licensure. A Certified Addiction Counselor I (CACI) must be a high school graduate, and complete required training hours and 1,000 hours of supervised experience. A CAC II must complete additional required training hours and 2,000 hours of supervised experience. A CAC III must have a bachelor's degree in behavioral health, and complete additional required training hours and 2,000 hours of supervised experience. A Licensed Addiction Counselor must have a clinical master's degree and meet the CAC III requirements. A Registered Psychotherapist is registered/listed with the State Board of Registered Psychotherapists, but is not licensed or certified by the state, and no degree, testing, training or experience is required to obtain registration from the state. You are entitled to receive information from your therapist about the methods of therapy, the techniques used, fee structure and the duration of your therapy (if known). You may ask questions about your therapy at any time. You may discontinue therapy services at any time and for any reason. You are entitled to receive a second opinion from another therapist. If necessary, referrals to other counselors or marital and family therapists will be made available. In a professional therapeutic relationship sexual contact of any kind between a therapist and a client is never appropriate. If sexual intimacy between a client and therapist occurs, it should be reported to the State Grievance Board. **

CONFIDENTIALITY(Required)

Both professional ethics and the Colorado State Mental Health Code-CRS 112.43.214 (1) (d) require that your privacy be carefully protected. Generally speaking, information provided by and to a client in therapy is legally confidential and will not be released to anyone without your written permission. Confidentiality can be broken by your therapist in certain circumstances as required by Colorado law (listed in section 12-43-218 of the Colorado Revised Statutes and the Notice of Privacy Rights you were provided) These circumstances are summarized below: (1) if you sign a release of information form that allows me to disclose information to individuals or institutions specified by you; (2) if you are using insurance benefits, I may disclose relevant information regarding diagnosis and treatment if requested by your insurance company; (3) if you are in danger of causing immediate harm to yourself or another person, I am required by law to report this to appropriate authorities; (4) if I am ordered by a court of law to disclose information about you (e.g., if I am served with a legitimate subpoena), I am required in some cases to respond to that order; (5) if you reveal information concerning neglect, physical or sexual abuse of a child or an elder, I am required by law to report this knowledge to the appropriate authorities; (6) if you are in therapy by order of a court of law; (7) if you are involved in a criminal or delinquency proceeding; (8) if I need to provide another therapist with pertinent information when that therapist is on-call for my practice in my absence, or if, I consult with another colleague about your treatment. Supervision and case consultation of cases will occur with staff members of Lighthouse Christian Counseling. Any objections to this supervision or known affiliations with these parties should be shared with your therapist immediately. Couples attending therapy together are informed that information shared with the therapist by one individual may be disclosed to the other party at the therapist's discretion. Other than these exceptions noted above, information shared in therapy is privileged communication and cannot be disclosed in any court of competent jurisdiction in the state of Colorado without your consent. Information shared in couple's therapy when both parties are present cannot be disclosed to other parties without the written consent of both parties attending the couples' sessions. Our online forms and communications through TherapyNotes are secure. Any information you choose to send, or request your counselor send through any other method is not secure.

Lighthouse Practice Policies

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5236 Strauss Cabin Rd, Fort Collins, CO 80528
info@lighthousecounselingnoco.com