Definition of Counseling
Counseling, also known as psychotherapy, is defined by the American Counseling Association as “a professional relationship that empowers diverse individuals, families, and groups to accomplish mental health, wellness, education, and career goals.”
Consent to Counseling Services
I consent to counseling services provided by Wellness Grove. I understand that these services include assessment, diagnosis, and/or treatment, that are deemed necessary by my clinician’s professional judgment.
I understand that:
- For counseling to be most effective, it is important for me to take an active role in the process to include keeping scheduled appointments, being honest with my clinician, discussing the counseling process with my clinician, and maintaining ownership of mutually agreed upon goals.
- Counseling is a confidential process that involves sharing sensitive, personal, and private information that can be accompanied by an array of experiences, thoughts, and feelings.
- All confidentiality protections required by law or regulation will apply to my care.
- Counseling decisions will be discussed and negotiated between me and my clinician to include, but not limited to frequency of sessions, number of sessions, goals, type of counseling, and any alternative counseling methods.
- I am encouraged to regularly discuss progress and review goals with my clinician, and to address any concerns or questions regarding progress and goals should they arise.
- I can refuse to accept clinical recommendations from my clinician.
- I have the right to refuse, or discontinue, counseling services at any time without the decision impacting my right to future care or treatment, and without risking any service benefits to which I would otherwise be entitled.
- I will have access to all medical information resulting from counseling services as provided by law, and that my express permission is required before my medical information may be shared with a third-party, unless otherwise allowed by law.
- No staff member or clinician will discriminate clients on the basis of race, religion, age, sex, sexual orientation, gender identity, ethnicity, color, national origin, developmental disability, genetic information, human immunodeficiency virus status, physical or mental impairment, financial or social status, or in any manner prohibited by local, state, or federal law.
- I have the right to be treated with the upmost respect and courtesy by all Wellness Grove staff members and clinicians who participate in my care.
- I have the right to be treated with consideration and respect for personal dignity, automony, and privacy.
- I have the right to reasonable protection from physical, sexual, or emotional abuse, neglect, and inhumane treatment.
- I have the right to participate in any appropriate and available service that is consistent with an individual service plan (ISP), regardless of the refusal of any other service, unless that service is a necessity for clear treatment reasons and requires the person's participation.
- I have the right to give informed consent to or to refuse any service, treatment or therapy, including medication absent an emergency.
- I have the right to participate in the development, review and revision of one's own individualized treatment plan and receive a copy of it.
- I understand that Wellness Grove does not prescribe nor provide any form of medication management.
- I understand that Wellness Grove does not provide any unusual or hazardous treatment procedures.
- I have the right to be free from restraint or seclusion unless there is an immediate risk of physical harm to self or others.
- I have the right to be advised and the right to refuse observation by others.
- I have the right to have access to one's own client record unless access to certain information is restricted for clear treatment reasons. If access is restricted, the treatment plan shall include the reason for the restriction, a goal to remove the restriction, and the treatment being offered to remove the restriction.
- I have the right to be informed of the reason for denial of a service should this occur.
- I have the right to be verbally informed of all client rights, and to receive a written copy upon request.
- I have the right to exercise one's own rights without reprisal, except that no right extends so far as to supersede health and safety considerations.
- I have the right to file a grievance and to have oral and written instructions concerning the procedure for filing a grievance, and to have assistance in filing a grievance if requested (see Wellness Grove Review & Grievance Reporting below).
- I have the right to one's own condition and to consult with an independent treatment specialist or legal counsel at one's own expense.
- I have the right to be evaluated in a physical environment affording as much privacy as feasible.
Benefits of Counseling
I understand that counseling has numerous benefits. I understand and acknowledge that for many clients, the outcomes of counseling are positive and can include, but are not limited to: a greater understanding of self, learning effective personal and interpersonal copies strategies, a reduction of mental health symptoms, greater quality of life, and increased happiness and satisfaction.
Risks of Counseling
I understand that there are potential risks with any form of counseling. I understand that potential risks associated with participation in counseling can include, but are not limited to: experiencing increased stress or uncomfortable emotions (such as sadness, guilt, anxiety, frustration), relational difficulties, and no change or an increase in problematic symptoms despite personal and clinician efforts.
I understand that should any of these risks occur, I will discuss my experienced concerns, discomfort, behavior changes, or questions with my clinician who may be able to help me better understand my experience and/or use different methods or techniques that may be more satisfying. I understand that when appropriate my clinician may desire to coordinate care with another provider or entity, but only with my written consent. I understand that if my clinical needs exceed the scope of services offered by Wellness Grove, I will be offered appropriate referrals.
Confidentiality
I acknowledge and understand that discussions between a clinician and client are confidential. I understand that no information concerning my care will be released without written consent unless mandated by law. I understand that possible exceptions to confidentiality include, but are not limited to the following situations: danger of harming myself or others, child abuse, elder abuse, criminal prosecutions, suits in which the mental health of a party is in issue, and the filing of a complaint with a licensing board or other state or federal regulatory authority.
I also understand that my clinician may disclose my confidential information to any other person or entity of my choice upon receipt of a valid and executed release of information from me.
I also understand that if I am using insurance for services, Wellness Grove is required to communicate information about my treatment to my carrier such as, but not limited to, my clinical diagnosis for the purposes of reimbursement.
Confidentiality policy for minors (for clients under 18 years of age): I acknowledge and understand that parent(s)/guardian(s)/legal representative(s) have a legal right to examine a minor’s counseling records. However, in order for many minor clients to feel comfortable in counseling, it is beneficial for them to talk with their clinician about the counseling process and to know that what they tell the clinician will be kept private/confidential except in cases of imminent danger to themselves or others, or in instances when the clinician considers the information to be so serious that the parents’/guardians’/legal representatives’ be kept informed to promote the client’s welfare.
By signing this agreement, you are agreeing to this informal waiver of your right to full disclosure of the minor’s records. If you choose not to informally waive this right, please talk with the clinician about your concerns prior to signing this form.
Clinician Incapacity or Death
I understand and acknowledge that in the event that my clinician becomes incapacitated or dies, it will become necessary for another clinician to take possession of my records and provide continued care. I understand that I have the right to seek counseling services elsewhere, and if I should choose to do so my records will be communicated once I complete and sign a release of information form.
Counseling Records
I understand that my counseling sessions shall not be audio/video recorded, through audio/visual technology, in any way unless agreed to in writing by mutual consent. I understand that my clinician will maintain a record of the sessions using a HIPPA-compliant electronic health records system. I understand that correspondence via email will also be through a HIPPA-compliant email service.
I understand that upon written request I may review my counseling records. I acknowledge and understand that in order to ensure the information in my records is clearly understood, I will be asked to schedule an appointment with my clinician or another member of the counseling staff to review the information.
Client-Clinician Boundaries and Relationships
I understand that personal and/or business relationships can undermine the effectiveness of the therapeutic relationship and cause my clinician’s professional judgements to be compromised. I understand that my clinician is responsible for monitoring and discussing issues related to professional boundaries with me and is required to ensure that professional boundaries are upheld as ethically necessary.
Social Media and Online Engagement
I understand that as a client I am free to share (or not share) about my counseling experiences at Wellness Grove at any time, in any way, and with anyone of my choosing. I understand that my clinician, and all clinicians at Wellness Grove, are bound to confidentiality and cannot publicly acknowledge or respond to any inference or possible interpretation of their connection with current or former clients.
I understand the following:
- To maintain confidentiality and keep the clear, professional boundaries in the counseling relationship, my clinician will not respond to or accept friend or contact requests from current or former clients on any social networking sites to include, but not limited to: Facebook, Instagram, LinkedIn, and Twitter.
- To maintain confidentiality and keep clear, professional boundaries in the counseling relationship, my clinician will not use social media platforms for any direct communication with current or former clients.
- If I wish to share my online experiences with my clinician I will do so during the session where information/experiences can be reviewed together during the counseling session.
- Wellness Grove maintains a social media presence for educational and marketing purposes and there is no expectation for me to access, follow, or like it.
- Should I choose to engage with social media platforms for Wellness Grove, I have a right to do so using my own discretion, and my choice has no bearing on access or utilization of the counseling services available to me.
- My clinician does not engage in the practice of looking up clients should they have a social media presence.
Access to Services
I understand that counseling services are generally available during normal business hours. Those hours are: (in Eastern)
Monday through Friday: 7am to 9pm
Saturday: 9am to 5pm
Sunday: CLOSED
Wellness Grove offices are closed on the following designated holidays:
- New Year's Day
- Martin Luther King Jr. Day
- Memorial Day
- Independence Day
- Labor Day
- Veterans Day
- Thanksgiving Day
- Christmas Day
Wellness Grove offices close at 5pm on the following days:
- Christmas Eve
- Thanksgiving Eve
- New Year’s Eve
I understand that in the event of experiencing a crisis I can come to the office location at any time during office hours and be worked into a schedule for a brief evaluation. I acknowledge and understand that in the event of experiencing an imminent crisis, I will call 911 or visit my local emergency room.
Counseling Appointments
I understand that my clinician is responsible for conveying respect by keeping counseling appointments or contacting me if a change in date/time is necessary, giving their complete attention during session, and avoiding interruptions during sessions. I understand that on rare occasions sessions may be interrupted if my clinician is called to respond to a crisis situation. I acknowledge and understand that I am responsible for attending appointments on time and will call in advance in the event that I will be more than a few minutes late or have to miss an appointment.
I acknowledge and understand that I am responsible for scheduling appointments and will contact Wellness Grove for all scheduling requests and/or concerns. I further understand that I will receive automated text and phone reminders prior to each scheduled appointment and can choose to opt-out at any time.
Counseling Fees
| Service Item: |
Cost: |
| Psychiatric Diagnostic Evaluations |
$150.00 |
| 53-60 minutes of Psychotherapy |
$125.00 |
| 38-52 minutes of Psychotherapy |
$90.00 |
| 16-37 minutes of Psychotherapy |
$75.00 |
| 53-60 minutes of Psychotherapy for Crisis |
$200.00 |
| Group Psychotherapy Non-Family |
$40.00 |
I acknowledge and understand that while most insurance companies offer coverage for counseling services, some do not. I understand that it is my obligation to contact my insurance provider before engaging in counseling services to determine if there are applicable co-pays or fees which I am responsible for. I understand that if my insurance, HMO, third-party payor, or other managed care provider does not cover counseling services, I will be solely responsible for the entire fee of the session.
I acknowledge and understand that I am responsible for notifying Wellness Grove of any changes to my insurance coverage. I understand that I am responsible for the entire fee of a session in the event of an insurance change that was not communicated and not reimbursed with the new coverage.
I acknowledge and understand that any fees that I incur on my account must be paid in full before my next scheduled appointment.
No-show/late cancellation fees: I acknowledge and understand that prompt arrival for appointments is important for my care. I understand that I will notify Wellness Grove should I be more than a few minutes late or have to miss an appointment. I understand the fee schedule for no-show/late cancellations is as follows:
| Service Item: |
Cost: |
| No-Show (arriving more than 10 minutes after session start time) |
$125.00 |
| Late Cancellation (24 hours or less from session start time) |
$60.00 |
Court-related fees: I acknowledge and understand that the following fee schedule applies when there is any court-related work that my clinician is requested/mandated to perform. I understand that court-related services may include, but are not limited to phone calls, court appearances, depositions, written documentation, and travel. I understand that these charges are not covered/reimbursed by insurance plans.
| Service Item: |
Cost: |
| Court-Related Work |
$250.00/hour |
| Court-Related Work (48 hour or less notice) |
$500.00/hour |
Non-court-related fees: I acknowledge and understand that the following fee schedule applies when there is any non-court-related work that my clinician is requested to perform. I understand that non-court-related services may include, but are not limited to: preparing and writing treatment summaries, letters, and accommodations/disability paperwork. I understand that these charges are not covered/reimbursed by insurance plans.
| Service Item: |
Cost: |
| Non-Court-Related Work |
$30.00/15 minutes |
Payment fees: I acknowledge and understand that the following fee schedule applies when there are any issues with making or processing payments.
| Service Item: |
Cost: |
| Non-Sufficient Funds |
$25.00 |
| Returned Checks (due to insufficient funds) |
$50.00 |
Consultation fees: I acknowledge and understand that the following fee schedule applies to instances when my clinician is requested to provide expert knowledge outside of performing direct clinical counseling duties which include, but are not limited to: assessment, diagnosis, and treatment. I understand that these charges are not covered/reimbursed by insurance plans.
| Service Item: |
Cost: |
| 10-29 minutes of Consultation |
$75.00 |
| 30-44 minutes of Consultation |
$90.00 |
| 45-60 minutes of Consultation |
$125.00 |
* For minor children: I acknowledge and understand that I am the parent/guardian/legal representative responsible for financial billing.
For Parents/Guardians/Legal Representatives
If the client is under 18 years old, I understand that Wellness Grove will need to have a copy of court documents or custody papers that prove I am a legal guardian.
I understand that if there is a shared parenting agreement in my custody agreement, Wellness Grove will need a copy of this paperwork demonstrating my right to make decisions concerning my child’s mental health treatment.
I understand that if I am in a co-parenting arrangement, it is most beneficial for both parents to be involved in my child’s treatment in some capacity. I understand that decisions will always be based upon what is in the best interest for my child.
I understand that parents/guardians/legal representatives are encouraged to participate in ongoing communication with the clinician who is providing services to a child or youth. Ongoing communication can include, but is not limited to: participating in clinical sessions, scheduling individual sessions with a clinician without a child or youth present, phone or email consultation, completing standardized assessment for clinical data, and record review. I understand that I have a right to discuss the ways in which communication can occur with my child’s clinician in order to promote my child’s mental health and wellness. I understand that if I have concerns regarding my child’s care, I can discuss them with my child’s clinician or clinical leadership upon request.
Wellness Grove Review & Grievance Reporting
I understand that Wellness Grove will periodically send out electronic review requests to the primary email address on file in order to gain feedback for the continual improvement of quality client care. I understand that these requests are optional and should I opt-in to provide a review, my responses will be reviewed by Wellness Grove management and kept confidential.
I acknowledge and understand that I have the right to file a grievance at any time with Wellness Grove should I ever have any issues in my interactions with any Wellness Grove staff member or clinician. I further understand that my grievance will be reviewed by management and taken seriously, that my grievance will be investigated fully, with a resolution/remedy, within twenty business days, unless extenuating circumstances require an extension for resolution (determined on a case-by-case basis), and that reporting a grievance will not result in retribution or impact my continuation of care at Wellness Grove. To file a grievance, please visit the following link:
Client Grievance Reporting
https://wellnessgrove.jotform.com/210881220390144
All Client Grievance Reporting submissions are automatically sent to the Client Rights Advocate for Wellness Grove (listed below).
If you are unable to access the online form or would like the grievance made verbally, please contact the Client Rights Advocate, as follows:
CLIENT RIGHTS ADVOCATE CONTACT INFORMATION:
Xavier Swiger (Vice President of Operations)
4522 Fulton Dr NW
Canton, OH 44718
Phone: (330) 915-2907 (Option 1, ask for Xavier Swiger)
Availability: Monday through Friday, 9am to 5pm
All client grievance submissions are kept confidential and secure. All client grievance submissions are dated and signed by the individual filling out the grievance and all submissions are automatically placed into a written format by the forms system. All reports are kept for a minimum of ten years as it relates to our standard records retention policy.
I acknowledge and understand that I have a right to file a grievance with an outside organization. Those organization include, but are not limited to, the following:
Alcohol, Drug Addiction and Mental Health Services (ADAMHS) Board
121 Cleveland Ave SW
Canton, OH 44702
Phone: (330) 455-6644
Counselor, Social Worker, and Marriage and Family Therapist Board
77 S High St 24th Floor, Room 2468
Columbus, OH 43215
Phone: (614) 466-0912
Ohio Department of Mental Health
30 E Broad St
Columbus, OH 43215
Phone: (614) 466-2596
Disability Rights Ohio
200 S Civic Center Dr #300
Columbus, OH 43215
Phone: (800) 282-9181
U.S. Department of Health and Human Services, Civil Rights Regional Office (Chicago)
230 South Dearborn Street, Suite 3187
Chicago, IL 60604-1505
Phone: (312) 886-1709
Wellness Grove is nationally accreditated by The Joint Commission. To file a grievance with The Joint Commission, please use the following:
The Joint Commission
1 Renaissance Blvd.
Oakbrook Terrace, IL 60181
Website: https://www.jointcommission.org/contact-us/
Termination of Treatment
I acknowledge and understand that termination is a valuable part of the treatment process. I understand that ending treatment should not be done casually, although either my clinician or I may decide to end treatment if either of us believes it is in my best interest. I understand that should I wish to stop treatment at any time, I am encouraged to meet for at least one additional session to review my treatment goals and progress with my clinician, and to receive any clinical recommendations that my clinician believes are important to my well-being.
I acknowledge and understand that termination may occur as a result of excessive no call/no shows, late cancellations, cancellations in general, and/or unpaid balances. I understand that I will be contacted the moment that the decision is made at Wellness Grove to terminate services and will be informed of this decision and the reasons why. I also understand that, should I choose, Wellness Grove will provide a referral, unless the service is unavailable or not necessary.