We are happy that you chose us to assist you in improving your life. Every effort will be made to ensure that your experience here is beneficial. We want you to be an informed participant in the counseling process and to understand your rights and responsibilities as a client. If you have any questions or concerns, please discuss them with your therapist. 


Clients have the following rights:

to be treated with dignity and consideration.

  1. to be informed of a counselor's qualifications, training, and experience.

  2. to understand any issues related to treatment or the therapy process.

  3. to discontinue therapy at any time you deem appropriate. Should you decide to discontinue, a closing session will be scheduled to review progress, discuss areas of continuing concern, and make recommendations.


Clients are responsible:

  1. to keep appointments and arrive for counseling sessions on time, so that the hour (50 minutes) set aside can be fully utilized.

  2. to make any changes in appointments 48 hours in advance, so the hour can be reallocated. Cancellations made with less than 48-hour notice will be billed at half the normal rate on the first occurrence and at the normal session rate (not co-pay) for subsequent occurrences. (Emergencies are given consideration.)
  3. for actively participating in counseling sessions and completing prescribed activities ("homework") outside of the sessions, so as to make this process effective.

  4. for paying the balance due at the time of service.


As a client or parent/guardian of the client, you are financially responsible for payment, regardless of insurance.

The first session must be paid in full. (The only exception is for prior authorized Employee Assistance

Programs.) We will seek to determine insurance benefits and eligibility, and file claims accordingly. We cannot guarantee timely reimbursement, and any balance past 90 days must be paid.

*Parent bringing a child for services must pay amount due, regardless of divorce decree or parental arrangement.

Co-payments must be paid at each session.

Deductibles: our regular Fee is paid until the insurance company begins to reimburse for claims filed.

With certain insurance providers AND Secondary Insurance, you must pay at the time of service and will be given a completed claim form to send for reimbursement directly to you.


Psychological Assessment (testing) can be administered for adults, adolescents, and children. It is structured according to the client and purpose for which it is requested. It may or may not be reimbursable by your health insurance.

Custody Evaluations: require psychological and parenting assessments, individual and parent-child sessions. Fees are based on the number of hours required. Half is due at the first visit, with the balance due by the fourth session. Custody evaluations must be done by a member of the practice other than the parent’s or child’s counselor.

Court Appearances: Expert testimony is given by request with adequate notice. Court appearances are billed at the normal hourly rate, from portal to portal, regardless of subpoena. A 2-hour minimum must be paid 48 hours in advance of the court date.


Every effort is made to treat your confidential information in a professional manner in keeping with ethical and legal standards. Please be advised however, that there are certain circumstances under which confidential information may be, or is required by law to be, divulged without your express permission.

  1. A counselor would need to take steps to protect a client or others from threat of imminent danger.

  2. A counselor must report disclosures of physical or sexual abuse or neglect of a minor to the local children’s protective service agency.

  3. A therapist must report disclosures of elder abuse to Adult Protective Services.

  4. Counselors are required to provide information to a court of law as specified by a subpoena.

  5. Staff and office personnel have access to client information as needed for the provision of care and processing of claims.


We have policies in place to protect your privacy:

  • Electronic billing is transmitted through a health practice-management system that is HIPPA-compliant.

  • Fax transmissions are done only with authorized Release of Information, and with a Confidential cover sheet to other health care professionals, schools, or Employee Assistance Programs.

  • Professional Counselors and staff do not connect with clients or former clients on social media forums.

  • Email is an acceptable form of communication; however, understand that it is not encrypted.

  • Clients should not call or text counselors on their cellular devices.

My signature below serves as acknowledgement that I have read and understand my rights and responsibilities, the office policies, limits of confidentiality, and Electronic Transmission policies. I agree to participate in counseling services, agree to accept financial responsibility as outlined in the policy statement, and acknowledge receipt of the Notice of Privacy Practices.

Client’s Signature______________________________________ Date_____________

Client’s Signature______________________________________ Date_____________

(Spouse or minor 13-17 yrs.)

Counselor’s Signature__________________________________ Date_____________


I___________________ (Parent or Guardian) give permission to 5H Counseling & Consulting

(Print Name)

Services to provide behavioral health care to ____________________________.

(Print Child’s Name)

Parent/Guardian Signature________________________________ Date_____________

Parent/Guardian Signature________________________________ Date_____________