Informed Consent

Thank you for choosing Clifton Burns Jr, LCPC and/or Thy X My Therapeutic Services, LLC. Clinical appointments will take approximately 45 – 50 minutes. We realize that starting counseling is a major decision and you may have many questions. This document is intended to inform you of our policies, State and Federal Laws and your rights. If you have other questions or concerns, please ask and Clifton will try his best to give you all the information you need. Clifton Burns Jr, LCPC earned a Bachelor of Science Degree in Sociology from Mississippi Valley State University (1995), and a Masters Degree in Human Services – Mental Health Counseling from Capella University (2010). He is clinically licensed by the State of Illinois as a Licensed Clinical Professional Counselor. He has over 10 years of clinical experience in treating adolescents, adults and families using integrative individual and family therapy interventions. Clifton practices cognitive behavioral therapy for most conditions.

Although other treatment approaches are used depending on the person or condition.

Treatment practices, philosophy and plan imitations and risks will be discussed with you today.

CONFIDENTIALITY AND EMERGENCY SITUATIONS:

Your verbal communication and clinical records are strictly confidential except for: a) information (diagnosis and dates of service) shared with your insurance company to process your claims, b) information you and/or you child or children report about physical, sexual abuse or elder abuse; then, by State Law, I am obligated to report this to the Department of Children and Family Services, c) where you sign a release of information to have specific information shared and d) if you are determined to be a clear and present danger to yourself or others, developmentally or intellectually disabled then I am mandated to report you to the Department of Human Services e) information necessary for case supervision or consultation and f) or when required by law. If an emergency situation for which the client or their guardian feels immediate attention is necessary, the client or guardian understands that they are to contact the emergency services in the community (911) for those services. Clifton Burns, Jr. will follow those emergency services with standard counseling and support to the client or the client's family. E-mail, text messages and social networking sites are not confidential and I may not be able to respond.

FINANCIAL/INSURANCE ISSUES:

As a courtesy we will bill your insurance company, HMO, responsible party or third party payer for you if you wish. We ask that at each session you pay your co-pay or 50% of the fee. In the event you have not met your deductible, the full fee of $75 is due at each session until the deductible is satisfied. If your insurance company denies payment or does not cover counseling, we request that you pay the balance due at that time. If your balance exceeds $300.00 we will need to ask that you pay for services when rendered.

After 60 days any unpaid balance will be charged 1.5% interest a month (18% APR). In the event that an account is overdue and turned over to our collection agency, the client or responsible party will be held responsible for any collection fee charged to our office to collect the debt owed. We ask that every client authorize payment of medical benefits directly to Clifton Burns Jr or Thy X My Therapeutic Services, LLC.

By signing this form I agree that I have received a copy of my fee schedule ($75 45-50 min)

Lastly, if you need to cancel or reschedule an appointment, please give 24 business hours advance notice, otherwise you will be billed at the hourly rate. We sincerely appreciate your cooperation and at any time you have any questions regarding insurance, fees, balances or payments please feel free to ask. You may have a copy of this form if requested.

COORDINATION OF TREAMENT:

It is important that all health care providers work together. As such, we would like your permission to communicate with your primary care physician and/or psychiatrist. If you prefer to decline consent no inform will be shared.

Consent(Required)
Physician Address
Full name (As shown on the insurance card)
Client's Address(Required)
MM slash DD slash YYYY

NOTICE OF PRIVACY PRACTICES AND CLIENT RIGHTS:

By signing this form I agree that I/we have read and received a copy of the, Notice of Privacy Practices and Client Rights document.

May we contact you at home?(Required)
May we contact you at work?(Required)
May we contact you by cell phone?(Required)

CONSENT FOR TREATMENT OF CHILDREN OR ADOLESCENTS:

I/We consent that maybe treated as a client by Clifton Burns Jr, or Thy X My Therapeutic Services, LLC. It is understood that children over the age of 12 have confidentiality protected by law. At times it may be necessary to schedule appointments during school hours. We ask for your cooperation to provide the most timely treatment for you and your children. This consent to treat expires at the end of treatment or if revoked in writing.

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