Primary Insurance-Please be advised if you have more than one insurance, you are required to upload both insurances.

Secondary Insurance

The policies and procedures of Mind Body & Sol Counseling and Consultation comply with applicable Delaware State regulations. We provide this form to give you important information regarding your legal rights and responsibilities as a client. Please ask for any clarification if you have questions. We will be happy to discuss these with you. We commit to providing quality service. In our practice, we take steps to support the values of equal opportunity, human dignity, and racial/cultural/ethnic/gender/status diversity. If you feel that we have inadvertently discriminated against you, please bring this to our attention immediately.

• You have the right to choose the provider and modality that best suits your needs.
• You have the right to discontinue treatment at any time, for any reason, with or without notice.
•  You have the right to ask questions about the procedures used in therapy. If you wish, your clinician will explain their usual methods of practice to you.
• You have the right to learn about alternative methods of treatment, and we will gladly discuss these at your request during your treatment.
• Occasionally, it may be appropriate to refer you to another therapist or related health care professional. Such referrals are suggestions only and the referral does not guarantee any success regarding an appropriate match or treatment outcome.

According to State law, anything you tell your clinician/therapist is privileged information and will be held in confidence by them. Your therapist/psychologist/clinician will not release any information to others about you unless you give them explicit permission to do so in writing. If at your request, MBS staff release information about you, they will discuss any implications to you of making your records public. Please be aware that there are certain situations in which therapists are required by law to reveal information without your permission. Limitations explained below:

• If your clinician comes to believe that you are threatening serious harm to another person, they are required to protect that person.

• If you seriously threaten, or act in a way that is likely to harm yourself, they will have to seek a hospital for you, or to call on your family members or others who can help protect you.

• In an emergency where your life or health is in danger, your clinician cannot get your consent, they may give another professional some information to protect your life.

• When your clinician believes or suspects that you, or someone else, are abusing a child, an elderly person, or a disabled person, they must file a report with a state agency. This includes perpetrators who have abused people in the past and still have access to the type of victims (e.g., children).

• Your clinician may occasionally consult with other health and mental health professionals about your case. If so, they will try to avoid revealing your identity. These professionals are also legally bound to keep the information confidential.

• If you are involved in a court proceeding and there is a request for information concerning the services provided to you, your clinician will seek your written authorization prior to disclosing any information.

• Please advise, if you should decide to instigate any legal proceedings against your therapist/clinician/psychologist or any other staff at MBS, for any reason, you will forfeit your guarantee of confidentiality.

• Should you elect to use insurance benefits to pay for a psychotherapy, your insurance company has the rights to information about your diagnosis, symptoms, history and substance abuse issues (if any). Your clinician and MBS can provide no assurance that the confidentiality of your information will maintain.

• Call 911.
• Call 988.
• Adult Mobile Crisis Line: Northern Delaware Hotline: 800-652-2929 and Southern Delaware Hotline: 800-345-6785
• Delaware and Guidance Child Mobile Crisis: 800-969-4357
• Crisis by County in Pennsylvania: https://elurimdpc.com/pdf/Suicide_Prevetion_Hotlines.pdf​
• Contact Lifeline, Suicide Prevention: 800-262-9800
• National Suicide Prevention Lifeline: 1-800-273-TALK (8255)
• Text Crisis Intervention: 741741

* Insurance companies will be billed upon completion of therapeutic service. Although we will bill your insurance carrier, and accept assignment of benefits on your behalf, you will be responsible for any fees that are not a covered service as determined by your insurance carrier. This includes claims denied because of not meeting the medical necessity criteria of your insurance company.

* Our fees range in cost depending on the service(s) that you receive and the qualifications of your provider. Your insurance company typically has a fixed fee for various services. If we are contracted with your insurance, we will accept their rate, which is typically lower.

                    Intake session: $200

                    Individual therapy: $130-175

                    Family therapy: $200

                    Couple’s therapy: $200, not including assessment fees.

                    Group rates: $60-100/person depending on the group.

*  It is our policy to request out-of-pocket payments 24 hours prior to session. Appointments not paid within 24 hours will be canceled. These appointments may include individual, family, or couple’s therapy. You will be expected to pay for your co-pay or the full cost of the session within 24 hours of the session. All payments are taken electronically.

* Should additional services be provided outside of your typical therapy appointment, or an assessment be extended, and/or fees need to be changed, fair notice will be given to you.

* If circumstances have led to a time of difficulty for you, we urge you to talk to your clinician so we can make appropriate financial and session arrangements. In times of unusual financial hardship, we may negotiate a fee adjustment or payment installation plan.

* We take ACH payments. We reserve the right to utilize a collection agency for outstanding balances not paid in full by the time therapy is terminated (whether by client or therapist). Accounts that go unpaid beyond 14 days from last date of service will accrue 35% interest every three months from last session.

* Outside of court cost, we charge our usual hourly fee of $200/hr for other professional services you may need. Other services include report or letter writing, telephone conversations, consulting with other professionals with your permission, preparation of records or treatment summaries, and the time spent performing any other services you may request from your provider.

* Telephone consultations with you, or on your behalf, that extend longer than 15 minutes will be charged. There is no charge for phone calls about appointments or regular business matters pertaining to sessions. If you elect to communicate with us via e-mail or text, we assume that you accept that confidentiality cannot be completely guaranteed.

* Signing this informed consent serves as your consent for us to use our office staff to manage billing issues. They have the same confidentiality agreements as therapists. They have no access to any clinical or personal information other than what is needed to bill for services.

* Court and Medical related cost (attending court, completing forms, writing letters, ext.) will be charged at a rate of $200/hour. Clinicians will be compensated from the time they leave home/office until they return from the court related request. You will be expected to pay for all of our professional time, including preparation and transportation costs, even if we are called to testify by another party. We do not bill these fees to insurance and estimated cost will need to be paid 48 hours before the clinician attends or provides documents.

* If your account has not been paid for over 14 days and arrangements for payment have not been agreed upon, we have the option of using legal means to secure the payment. In most collection situations, the only information we would release regarding a patient is his/her name and contact information, the nature of services provided, the dates those services were rendered, and the amount due. If such legal action is necessary, its costs will be included in the claim.

*It is your responsibility to inform MBS if you have two insurances (primary and secondary). This will avoid repossession of distribution of funds from MBS. Any repossession of distribution of funds related to this matter that are not paid by insurance will need to be paid in full by the client.

*Client is responsible to provide all updates of insurance including new cards, termination of services, and attaining new carriers.

*Clients that have more than one insurance and do not disclose, will be fully responsible to reimburse MBS for any reversal of payments.

• Appointment times are reserved for you, usually on an ongoing basis. If you arrive late, your clinician will probably only be able to see you for the rest of your session, as they will probably have another appointment scheduled. If you arrive 10 minutes late, then you may need to reschedule as the work is compromised by the limited time.
• Once an appointment is scheduled, we will expect you to pay for it in full unless you provide 24 hours of advanced notice of cancellation. Please understand that you will be charged for all missed appointments in full, even if you usually only pay a copay, or your insurance carrier usually pays for your entire treatment. Please note that your insurance company cannot be billed for any missed or cancelled sessions. Therefore, you will be responsible for the hourly rate of your therapy.
• Sometimes it may be helpful to extend a session. Please note that you will be charged for sessions that extend over ten minutes past the hour and insurance may not pay for the additional time. A session will not be extended unless you agree.
•  Two missed appointments (late cancellations or missing appointments without notice) will result in losing your scheduled appointment time on the clinician’s schedule. All outstanding balances will need to be paid prior to beginning therapy again.

* Delaware Law authorize the parent (s) or legal guardian to give informed consent for most medical decisions, including mental health treatment, on behalf of the minor. However, there are exceptions for which minors may themselves consent. If the minor is age 14 and is mature enough to participate in therapy (per the therapist’s evaluation), and the therapist’s clinical judgment deems it appropriate for the situation, the minor may be seen without parental consent. However, if there is a way to include the parent (s) and family, this approach is the more ideal course of treatment. 

* If the parents are married, not separated, either parent acting alone may consent to mental health treatment for the minor. However, it may be prudent to seek consent of both parents in an effort to include both parents in the therapeutic process and to have support of both parents in the therapy with the minor. 

* For parents who are divorced, it is critical that we receive a copy of the custody order showing which parent has legal, medical decision-making authority prior to the treatment of the minor. Report of physical custody arrangements does not fulfill this requirement. If there is joint legal custody, either parent acting alone may consent to mental health treatment unless the joint legal custody order has language to the contrary. A stepparent does not have the authority to make mental health decisions for the child unless he or she has legally adopted the minor. A legal guardian has the same right as a parent having legal custody of a minor to consent to mental health treatment.

* When a parent/guardian requests treatment of a minor child, it is important that the minor has confidentiality for therapy to have the most successful outcome. Therefore, as a parent/guardian, you are giving consent for the minor’s therapy to be confidential (between their therapist and the minor). The following areas are exceptions:

§  The minor is a threat to his/herself or others. 

§  Explaining any mental health diagnosis (i.e., major depression). 

§  Periodic summaries of how therapy is progressing. Either you or the therapist may initiate the timing of these summaries as the parent/guardian.

The following is a summary of our most important policies. Details are provided in the Informed Consent for Therapy. We ask that you review that document in its entirety before your first appointment. If you have any questions regarding these policies, please direct questions first to your assigned clinician.

Payments for services and insurance:

If you elect to use your medical insurance to cover therapy services at MBS, you will be expected to pay your copay (or the full cost of the session with private pay clients) prior to the session. You agree to have a credit/debit card on file at all times and prior to beginning treatment. All payments will be charged prior to session.

Your health insurance is a contract between you and your insurance carrier. It is your responsibility to know the terms of your policy regarding coverage, copays, co-insurance, deductibles, and non-covered services. If you have questions about your insurance, you will need to contact your carrier directly. Current insurance cards must sent to administration prior to beginning treatment, or if you change your insurance during your treatment. You are responsible for all costs not covered by your insurance carrier, regardless of the reason for denial. You will need a credit/debit card on file at all times.

Please note that your insurance covers only services they determine are medically necessary. Your insurance is not responsible for additional services that we might provide, or for clerical services such as phone calls, writing letters on your behalf, etc. If your insurance company determines that your treatment is not covered, and/or does not meet their criteria as medically necessary, then you will be responsible for payment of uncovered sessions at the regular rate per hour (listed above).

If services are not covered by insurance companies that we are not contracted with, your signed agreement for treatment or assessment shows commitment to pay above rates for each therapy session at MBS at the time of service, unless alternative arrangements have been made.

It is your responsibility to inform MBS if you have two insurances (primary and secondary). This will avoid repossession of distribution of funds from MBS. Any repossession of distribution of funds related to this matter that are not paid by insurance will need to be paid in full by the client.

Client is responsible to provide all updates of insurance including new cards, termination of services, and attaining new carriers.

The form of payment we accept include credit/debit cards processed through Therapy Notes. We reserve the right to use a collection agency for outstanding balances not paid in full by the time therapy is terminated. The only information we would release for this purpose would be the client’s name and contact information, the nature of services provided, the dates those services were rendered, and the amount due. If such legal action is necessary, its costs will be included in the claim and a 35% surcharge on the outstanding balance will be applied beginning last scheduled session and increasing every 3 months.

If your account has an outstanding balance, you will be expected to pay before seeing the provider through Therapy Notes.

Signing this informed consent serves as your consent for us to use office staff to manage billing issues. They have the same confidentiality agreements as therapist. They have no access to any clinical or personal information other than what is needed to bill for services.

Court and Medical related cost (attending court, completing forms, writing letters, medical records requests, ext.) will be charged at a rate of $200/hour. Clinicians will be compensated from the time they leave home/office until they return from the court related request. You will be expected to pay for all of our professional time, including preparation and transportation costs, even if we are called to testify by another party. We do not bill these fees to insurance and estimated cost will need to be paid 24 hours before the clinician attends or provides documents.

Appointment times are reserved for you. Once an appointment is scheduled, you will be expected to pay for it in full unless you provide 24 hours’ notice (except in unforeseen circumstances). This means that if you “no-show” or make a late cancellation for an appointment, you will need to pay the session in full at the reate of $130-200, depending of type of service.

Appointment times are reserved for you, usually on an ongoing basis. If you arrive late, your clinician will probably only be able to see you for the remainder of your session, as they will probably have another appointment scheduled. If you arrive 10 minutes late, then you may need to reschedule as the work is compromised by the limited time.

You will be charged for all missed appointments in full if you fail to contact us, even if you usually only pay a copay, or your insurance typically covers sessions. Your insurance company cannot be billed for any missed or cancelled sessions. You will need to have a debit/credit card on file at all times.

Telephone consultations with you, or on your behalf, that extend longer than fifteen minutes will be charged on a prorated basis. There is no charge for phone calls about appointments or regular business matters pertaining to our sessions. If you elect to communicate with us via e-mail or text, we will assume that you are accepting that confidentiality cannot be completely guaranteed.

There is a formal or informal custody agreement in place, and we understand we must provide a copy of the agreement and sign a consent for treatment in joint custody cases.

The parent/guardian signing has sole custody and will provide that paperwork.