White County Community Counseling Services
Informed Consent Form
I understand I have made a voluntary choice to be involved in counseling provided by a mental health professional as defined by Indiana law. I understand counseling is a cooperative effort between me and my counselor and I agree to keep him/her aware of my needs, resolving any difficulties which may arise. I am free to terminate counseling at any time.
I understand I am consenting only to those mental health services that my counselor is qualified to provide within the scope of the professional (or his/her supervisor’s) license, certification, and training he/she has obtained.
I understand my treatment will be kept in confidence. Release of information will only occur by my informed, signed, and witnessed consent. The only exceptions to this are those required/allowed by law, including but not limited to perpetration of sexual abuse, danger to self or others, and treatment of minors. (Discuss with your therapist questions you might have.)
I authorize the White County Community Counseling Services (WCC Counseling) to release necessary medical information to appropriate third parties for reimbursement purposes and/or to person authorized to conduct service utilization reviews.
I authorize my counselor to contact my Primary Care Physician to coordinate services.
I understand and agree: I am personally and fully responsible to pay for all services rendered; if I have insurance with a carrier which has a contract with White County Community Counseling Services. WCC Counseling will file claims on my behalf, and I agree to pay the balance of any and all services not deemed “reasonable and necessary” by my carrier, as well as any co-payments or other payments according to the terms of the applicable carrier’s contract. I agree to pay in full and non-covered services which are not covered by my insurance carrier.
I understand that I am responsible to give at least 24 hour notice when canceling appointments and that I am responsible to pay for my appointments in full if 24 hour notice is not given. Missed appointments without cancellation notice cannot be billed to insurance.
