Informed Consent

  • INFORMED CONSENT


    Treatment Process

    Brave Soul Counseling Services (Brave Soul) is a private group practice. Brave Soul therapists are trained in a variety of therapeutic techniques. Your therapist will work with you during the first several sessions to develop a treatment plan and discuss treatment preferences. As the client, you have the right to ask your therapist questions about his or her background, qualifications and therapeutic orientation. Important factors in the success of therapy include good communication and a good rapport and relationship between the therapist and the client. However, not all individuals benefit from therapy or working with a particular therapist.

    You have a right to understand the therapist’s assessment, the recommended course of service and the estimated duration of counseling. The goals and outcomes of our work together are jointly determined and are tailored to fit the client’s needs and desired outcome. Although we are committed to working with you towards healthy outcomes, there is no guarantee of a particular outcome of therapy. As the client, you have the right to expect professional, courteous treatment.

    Children’s Therapy: Both parents are entitled to access and understand their child’s treatment unless their child’s therapist is provided with legal documentation limiting access or communication. In situations where both parents are not present, it is expected that both parents will talk with one another about their child’s treatment and develop a communication plan with their child’s therapist prior to the course of treatment.

    Billing and Insurance

    Brave Soul is an In-Network provider for most major insurance plans. You will need to consult with your medical benefits provider to determine if benefits apply. Benefits quoted from insurance companies are not a guarantee of payment. You agree to be financially responsible for all charges whether or not paid by your insurance company (including co-pays, deductibles and co-insurance), and by signing this form, you authorize Brave Soul to release all medical information to your insurance company deemed necessary for processing insurance claims. Brave Soul does NOT process Secondary Insurance Claims – this is the responsibility of the client to seek payment under any applicable Secondary insurance policies.

    Brave Soul offers a discounted fee of $105 for payments made at the time of service (private pay). Fees may increase periodically, however, 30 days notice will be provided to clients in such instances.

    Brave Soul reserves the right to suspend all services, including providing written documentation, until payment of any unpaid balance is received. If you end treatment at any time, you are responsible for any remaining balance on your account. If there is any balance that has not been paid within 60 days, Brave Soul reserves the right to submit the bill to a collection agency. You acknowledge that in this circumstance, you are waiving your right to confidentiality.

    Brave Soul requires a credit card be kept on file for purposes of paying any unpaid account balances (Credit Card Authorization Form to be filled out and signed by the client). We are happy to arrange an affordable payment plan, but require a minimum payment of $75 be paid each month towards unpaid account balances. Client agrees to a $75/month payment to be processed on the 1st of every month, unless an alternate payment plan has been arranged between Brave Soul and the client.


    **PAYMENT FOR PRIVATE PAY CLIENTS OR CO-PAYS ARE DUE AT THE BEGINNING OF EACH SESSION **
    Code Service Fee
    90791 Diagnostic Evaluation/Initial Intake $200
    90837 Psychotherapy (with patient) 53+ minutes $150
    90834 Psychotherapy (with patient) 45 minutes $125
    90846 Family Psychotherapy (without patient) 50 minutes $150
    90847 Family Psychotherapy (with patient) 50 minutes $150
    Not covered by insurance Late Cancellation/No Show Fee $50
    Not covered by insurance Out-of-session work (report writing, phone calls, letters) 15 minutes $25
    Not covered by insurance Consultation 20-25 minutes Free
    Not covered by insurance Court Appearances (60 minutes billed in 15-minute increments) Requires $1,000 retainer fee to be paid before services rendered $250+

    Cancellation Policy / Missed Appointments

    If you are more than 15 minutes late for your appointment and have not contacted Brave Soul, we reserve the right to cancel your appointment.

    If you need to cancel or reschedule your appointment, please contact Brave Soul within 24 hours of your scheduled appointment time. If you know sooner than 24 hours in advance that you cannot make a scheduled appointment, please contact Brave Soul to reschedule at your earliest possible convenience.

    While exceptions will be made for illnesses and emergencies, if an appointment is missed without giving 24-hour notice, a cancellation fee of $50 may be charged. Insurance providers will not cover the payments for missed appointments.

    Communication and Contact Information

    Clients may leave messages for their therapist by phone, text or email. Your therapist will respond to your communication within a 24 to 48-hour period or within 2 business days (excluding weekends).

    Emails and texts are not considered confidential and Brave Soul is not responsible for any information transmitted via email or text except under provider misconduct.

    Phone, text or email contact is not a replacement for therapy sessions, nor should they be used in emergency situations. If there is an emergency, please contact the Washington County Crisis Connection at 651-275-7400 or dial 911.


    Bill of Rights

    Consumers of marriage and family therapy services offered by marriage and family therapists licensed by the state of Minnesota have the right

    1. To expect that a therapist has met the minimal qualifications of education, training, and experience required by state law;
    2. To examine public records maintained by the Board of Marriage and Family Therapy that contain the credentials of a therapist;
    3. To report complaints to the Board of Marriage and Family Therapy;
    4. To be informed of the cost of professional services before receiving services;
    5. To privacy as defined and limited by rule and law;
    6. To be free from being the object of unlawful discrimination while receiving services;
    7. To have access to their records as provided in Minnesota Statutes, section 144.291 to 144.298, except as otherwise provided by law or prior written agreement; and
    8. To be free from exploitation for the benefit or advantage of a therapist.

    Confidentiality

    Information that a client shares with a therapist is considered privileged and confidential, except where otherwise specified by law. The following are limits to your confidentiality unless you authorize a release of information:

    • Suspected abuse or neglect of a child, elderly person or disabled person;
    • Any prenatal exposure to controlled substances;
    • When your therapist believes you are in danger of harming yourself or another person or you are unable to care for yourself;
    • If you report that you intend to physically injure someone, the law requires your therapist to inform that person as well as the legal authorities;
    • If your therapist is ordered by court to release information as part of a legal involvement in company litigation, etc.;
    • Involving your insurance company in filing a claim, insurance audits, case review or appeals, etc.;
    • In natural disasters whereby protected records may become exposed; and
    • When required by law.

    Privacy Notice (HIPAA)

    Brave Soul is committed to keeping your Protected Health Information secure and confidential. HIPAA requires Brave Soul to maintain your privacy, give you notice and follow the terms of the notice. You may obtain a copy of Brave Soul’s privacy policy at www.bravesoul.org under New Client Forms or request a paper copy.


    Informed Consent

    Your signature below indicates that you have read and understand the information in this document. You acknowledge that your signature represents your agreement and compliance to this document during the course of treatment.

    Your signature below also indicates that you have been provided with, read and understand the information contained in the Health Insurance Portability and Accountability Act (HIPAA)

    I have read, fully understand and accept the information presented in this form (in the case of a couple, both sign):

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