Consent to treatment

Consent to


I, , the undersigned client, parent and/or legal guardian of hereby give my consent for and acknowledgement of the following items which are initialed:

I consent to receive treatment.

I authorize RoxAnne Koenig, MS, LIMHP, LLC, to release any information necessary for the completion of insurance forms for the determination of benefits payable to any insurance company, or any other institution/organization. A photocopy of this authorization shall be a valid as the original.

I have been informed of my therapist’s credentials, licensure, experience, specializations, and limitations.

I understand the possible psychological risks involved in psychotherapy and understand psychotherapy is not an exact science and that the results cannot be guaranteed. Psychotherapy is often beneficial, but as with any treatment, there are inherent risks. During therapy, I may have discussions about personal issues which may bring to the surface uncomfortable emotions such as anger, guilt, and sadness. Some of the possible benefits are improved interpersonal relationships, reduced feelings of emotional distress, resolution of problems resulting from past trauma, and increased problem solving skills.

The risks, benefits, side-effects, and alternatives of treatment, as well as the consequences of noncompliance with treatment, have been discussed with me and I have had the opportunity to ask questions.

I understand that I need to provide accurate information about myself to my therapist so that I will receive effective treatment. I also agree to play an active role in the therapeutic process.

I understand that alcohol, illegally obtained drugs, pornographic materials, paraphernalia, and weapons are prohibited on the premises.

I understand that my therapist may work with typists, internship students, colleagues at Mental Health Specialists of Bellevue, legal entities, and case managers regarding my treatment and/or clinical files.

I authorize RoxAnne Koenig, MS, LIMHP, LLC, to relate my presence in this facility to specified callers and visitors, as documented on my releases in my clinical file.

I authorize RoxAnne Koenig, MS, LIMHP, LLC to contact myself and/or my parent/guardian on my resident phone and/or my parent’s/guardian’s cell phone and/or my personal cell phone. I also authorize RoxAnne Koenig, MS, LIMHP, LLC to leave messages at any of the above phones


I have read and accept the above checked items and have received an explanation of this consent form:

Client Signature                                                                                  Date

RoxAnne Koenig, MS, LIMHP

Financial Policy

This statement is to inform you of RoxAnne Koenig, MS, LIMHP financial policy. I am committed to providing you with the highest quality mental health care. My financial policy is intended to facilitate excellent service to you, while minimizing administrative costs.

All charges incurred are your responsibility regardless of your insurance coverage. I must emphasize that as your provider, my relationship is with you, my client, not with your insurance company. As a courtesy to you, I will help you process all your insurance claims. In order for me to help, you must provide current and accurate insurance information.

I understand and agree:

• RoxAnne Koenig, MS, LIMHP performs services necessary for the well being of her clients regardless of insurance benefits.

• Regular therapy services are billed at: Initial session ($260) Individual ($200) Family ($200)

• My co-pay, deductible, or self-pay fee is due at the time of service. It is ultimately my responsibility to know what my copay and deductible are prior to services. If I need help with finding out what these copays and deductibles are, RoxAnne will help to try to find this information out from the insurance but she cannot guarantee these amounts.

• If there is a remaining balance upon payment by the insurance company, I will pay it in full at that time.

• I am responsible for the payment of all treatment fees on my account. If my insurance company fails to pay, I will be responsible for the full amount.

• A late fee of $10 will be added to overdue accounts each month.

• A $35 fee will be added for any return or insufficient fund checks written to RoxAnne Koenig, LLC

• Accounts over 90 days will be sent to a collection agency and will have additional fees.

• RoxAnne Koenig, MS, LIMHP requires a 24-hour notice for cancellations. When scheduling your appointment with the counselor, keep in mind that this is your agreement that the counselor will hold this time exclusively for you. Because this time is reserved by you, RoxAnne Koenig, MS, LIMHP will bill you $50 for any appointments that is not kept and $45 for appointments canceled or rescheduled less than 24 hours advance notice. I understand that insurance companies DO NOT get billed and will NOT pay for these fees. These will be paid by the client. Payment for late cancellation, fail to arrive charges, and return checks are due at the time of your next session.

If you have questions regarding my financial policy, please ask. I am committed to providing you with the most positive experience.

Signature                                                                                                     Date:

Service Agreement

Welcome to my practice.

This document contains important information about my professional services and business policies. It also contains summary information about the Health Insurance Portability and Accountability Act (HIPAA), a federal law that provides privacy protections and patient rights about the use and disclosure of your Protected Health Information (PHI) for the purposes of treatment, payment, and health care operations. Although these documents are long and sometimes complex, it is very important that you understand them. When you initial and sign the Client Information Form regarding this document, it will also represent an agreement between us. We can discuss any questions you have when you sign them or at any time in the future.

Therapy is a relationship between people that works in part because of clearly defined rights and responsibilities held by each person. As a client in psychotherapy, you have certain rights and responsibilities that are important for you to understand. There are also legal limitations to those rights that you should be aware of. I, as your therapist, have corresponding responsibilities to you. These rights and responsibilities are described in the following sections.

Psychotherapy has both benefits and risks. Risks may include experiencing uncomfortable feelings, such as sadness, guilt, anxiety, anger, frustration, loneliness and helplessness, because the process of psychotherapy often requires discussing the unpleasant aspects of your life, and taking behavioral steps that may be outside of your normal behavior. However, psychotherapy has been shown to have benefits for individuals who undertake it. Therapy often leads to a significant reduction in feelings of distress, increased satisfaction in interpersonal relationships, greater personal awareness and insight, increased skills for managing stress and resolutions to specific problems. But, there are no guarantees about what will happen. Psychotherapy requires a very active effort on your part. In order to be most successful, you will have to work on things we discuss outside of sessions.

The initial session will involve an assessment of your needs, which will help me to offer you some initial impressions of what our work might include, discuss your treatment goals, and create an initial treatment plan. Please evaluate this information and make your own assessment about whether you feel comfortable working with me. If you have questions about my procedures, it is beneficial to discuss them whenever they arise. If your doubts persist, I will be happy to help you set up a meeting with another mental health professional for a second opinion.

APPOINTMENTS : Appointments will ordinarily be 45-50 minutes in duration, once per week at a time we agree on, although some sessions may be more or less frequent as needed. The time scheduled for your appointment is assigned to you and you alone. If you need to cancel or reschedule a session, please provide me with 24-hours-notice. If you miss a session without canceling, or cancel with less than 24 hour notice, my policy is to collect $50.00 [unless we both agree that you were unable to attend due to circumstances beyond your control]. It is important to note that insurance companies do not provide reimbursement for cancelled sessions; thus, you will be responsible for the portion of the fee as described above. If it is possible, I will try to find another time to reschedule the appointment. In addition, you are responsible for coming to your session on time; if you are late, your appointment will still need to end on time.

In addition to weekly appointments, it is my practice to charge on a prorated basis (I will break down the hourly cost) for other professional services that you may require such as report writing, telephone conversations that last longer than 15 minutes, attendance at meetings or consultations which you have requested, or the time required to perform any other service which you may request of me. If you anticipate becoming involved in a court case, I recommend that we discuss this fully before you waive your right to confidentiality. If your case requires my participation, you will be expected to pay for the professional time required even if another party compels me to testify.

INSURANCE: In order for us to set realistic treatment goals and priorities, it is important to evaluate what resources you have available to pay for your treatment. If you have a health insurance policy, it will usually provide some coverage for mental health treatment. With your permission, I will assist you to the extent possible in filing claims and ascertaining information about your coverage, but you are responsible for knowing your coverage and for letting me know if/when your coverage changes.

Due to the rising costs of health care, insurance benefits have increasingly become more complex. It is sometimes difficult to determine exactly how much mental health coverage is available. Managed Health Care plans may refuse to provide reimbursement for services. Most insurance companies require you to authorize me to provide them with a clinical diagnosis. (Diagnoses are technical terms that describe the nature of your problems and whether they are short-term or long-term problems. All diagnoses come from a book entitled the DSM-V. There is a copy in my office and I will be glad to let you see it to learn more about your diagnosis, if applicable.). Sometimes I have to provide additional clinical information such as treatment plans or summaries, or copies of the entire record (in rare cases). This information will become part of the insurance company files.

Insurance companies have their own policies regarding patient information. In some cases, they may share the information with a national medical information databank. I will provide you with a copy of any report I submit, if you request it. By signing this Agreement, you agree that I can provide requested information to your carrier if you plan to pay with insurance.

Many policies leave a percentage of the fee (which is called co-insurance) or a flat dollar amount (referred to as a co-payment) to be covered by the client. Either amount is to be paid at the time of the visit. Some insurance companies also have an annual deductible, which is an out-of-pocket amount, paid by the patient before the insurance companies begin paying any amount for services until the annual deductible has been met. It is important to remember that you always have the right to pay for my services yourself, unless prohibited by my provider contract.

If I am not a participating provider for your insurance plan, I will supply you with a receipt of payment for services, which you can submit to your insurance company for reimbursement. Please note that not all insurance companies reimburse for out-of-network providers. If you prefer to use a participating provider, I will refer you to a colleague.

PROFESSIONAL RECORDS: I am required to keep appropriate records of the psychological services that I provide. Your records are maintained in a secure location. I keep brief records noting that you were here, your reasons for seeking therapy, the goals and progress we set for treatment, your diagnosis, topics we discussed, your medical, social, and treatment history, records I receive from other providers, copies of records I send to others, and your billing records. Except in specific circumstances, you have the right to a copy of your file. Because these are professional records, they may be misinterpreted and / or upsetting to untrained readers. For this reason, I recommend that you initially review them with me, or have them forwarded to another mental health professional to discuss the contents. If I refuse your request for access to your records, you have a right to have my decision reviewed by another mental health professional, which I will discuss with you upon your request. You also have the right to request that a copy of your file be made available to any other health care provider at your written request.

CONTACTING ME: I am often not immediately available by telephone. I do not answer my phone when I am with clients or otherwise unavailable. At these times, you may leave a message on my confidential voice mail and your call will be returned as soon as possible, but it may take a day or two for non-urgent matters. If, for any number of unseen reasons, you do not hear from me or I am unable to reach you, and you feel you cannot wait for a return call or if you feel unable to keep yourself safe, 1) contact 9-1-1 or your nearest emergency room. I will make every attempt to inform you in advance of planned absences, and provide you with the name and phone number of the mental health professional covering my practice.

OTHER RIGHTS: If you are unhappy with what is happening in therapy, I hope you will talk with me so that I can respond to your concerns. Such comments will be taken seriously and handled with care and respect. You may also request that I refer you to another therapist and are free to end therapy at any time. You have the right to considerate, safe and respectful care, without discrimination as to race, ethnicity, color, gender, sexual orientation, age, religion, national origin, or source of payment. You have the right to ask questions about any aspects of therapy and about my specific training and experience. You have the right to expect that I will not have social or sexual relationships with clients or with former clients.

CONSENT TO PSYCHOTHERAPY: Your signature below indicates that you have read this Agreement and the statement of Privacy Practices and agree to their terms.

Electronic Communication Policy: In order to maintain clarity regarding our use of electronic modes of communication during your treatment, I have prepared the following policy. This is because the use of various types of electronic communications is common in our society, and many individuals believe this is the preferred method of communication with others, whether their relationships are social or professional. MANY OF THESE FORMS OF COMMUNICATION ARE NOT HIPPA COMPLIANT AND THEREFORE PUT YOUR PRIVACY AT RISK AND CAN BE INCONSISTENT WITH THE LAW AND WITH STANDARDS OF MY PROFESSION. Consequently, this policy has been prepared to assure the security and confidentiality of your treatment and to assure that it is consistent with ethics and the law. If you have any questions about this policy, please feel free to discuss this with me.

Email Communications: I DO NOT use email communication as it is not HIPPA compliant, If you contact me via Email, I will respond, but I will not initiate contact in this form. It should be noted that my Email is not encrypted nor HIPPA compliant and you will be choosing this risk. I use Cellular Phone only with your permission and only for administrative purposes unless we have made another agreement. That means that email exchanges and cell phone messages with my office should be limited to things like setting and changing appointments, billing matters and other related issues. Please do not email me about clinical matters because email is not a secure way to contact me. If you need to discuss a clinical matter with me, please feel free to call me on my office phone so we can discuss it or wait so we can discuss it during your therapy session. The telephone or face-to-face context simply is much more secure as a mode of communication. Please be aware that both of these items have possible storage in “the cloud” and this is not HIPPA compliant or regulated from myself.

Cellular Phone and Text Messaging: Because text messaging is a very unsecure and impersonal mode of communication, I do not text message to nor do I suggest my response to text messages from anyone in treatment with me. So, please DO NOT text message me unless we have made other arrangements. I do not store client’s phone numbers in my phone and I will not know who you are, and I do not have control over who may receive your text message on your end. It should be noted as well that Cellular phones do not have the security of landlines and while are in wide and regular use these days are not 100% guaranteed to be confidential.

Social Media: I participate on various social networks, both personally and in a professional capacity. If you have an online presence, there is a possibility that you may encounter me by accident. If that occurs, please discuss it with me during our time together. I believe that any communications with clients online have a high potential to compromise the professional relationship. In addition, please do not try to contact me in this way. I will not respond and will terminate any online contact no matter how accidental. I do not communicate with, or contact, any of my clients through social media platforms like Twitter and Facebook. In addition, if I discover that I have accidentally established an online relationship with you, I will cancel that relationship. This is only because these types of casual social contacts can create significant security risks for you. Ethically, I am bound by my Standard of Ethics not to have outside relationships with my clients as to protect your privacy and your interests. If you comment or interact with my professional profiles, you should identify the risk that others may perceive or wonder about your relationship with myself as a professional and must judge the risk of your own security in doing so. If you use any of the current “check in” aps, you should be mindful of it “checking in” when you attend sessions at my office to protect your privacy.

Websites: I have a website that you are free to access. I use it for professional reasons to provide information to others about me and my practice. You are welcome to access and review the information that I have on my website and, if you have questions about it, we should discuss this during your therapy sessions. Communication via the website is not secure.

Web Searches: I will not use web searches to gather information about you without your permission. I believe that this violates your privacy rights; however, I understand that you might choose to gather information about me in this way. In this day and age there is an incredible amount of information available about individuals on the internet, much of which may actually be known to that person and some of which may be inaccurate or unknown. Unfortunately, mental health professionals cannot respond to such comments and related errors because of confidentiality restrictions. If you encounter any information about me through web searches, or in any other fashion for that matter, please discuss this with me during our time together so that we can deal with it and its potential impact on your treatment.

Other use of Electronic Information: I use “ Square” for all my credit card processing. If you choose to pay by credit card, your credit card information as well as personal information is not stored. All financial transactions are covered under privacy under PCI regulations. However, at the end of signing, if you press send Email receipt or Text receipt, they ARE NOT under these regulations and may be at risk. I will always supply you with a written receipt of payment for this option.

I also inform you that I use an Electronic Record for each client and these records are covered under HIPPA and privacy measures. If you have any questions or concerns please discuss with me.


• You have the right to refuse services. However, participation in treatment is an expectation and it should be known that such refusal may be cause for RoxAnne Koenig, MS, LIMHP, LLC to discharge a client from outpatient services.

• You have the right to have treatment provided on a standard schedule. Treatment schedules are given at the time of intake. In emergency situations, the client is advised to dial 9-1-1 or proceed to the nearest emergency room.

• You have the right to be treated with dignity and respect.

• You have the right to a prompt response to reasonable requests for service.

• You have the right to a safe environment, free from sexual, physical and emotional abuse.

• You have the right to help in the development of your treatment plan and discharge plan.

• You have the right to be informed of the type of treatment you receive and to be told of alternative ways you can receive care and treatment.

• You have the right to be informed of your progress and to discuss any questions or problems.

• You have the right to a timely referral upon discharge or when further services are determined to be necessary.

• You will be informed of your therapist’s credentials, licensure, experience, professional associations, specialization and limitations.

• You have the right to be treated fairly without discrimination as to race, color, religion, natural origin, economic status, disability, marital status, sexual orientation, gender, military status or age.

• You have the right to be treated equitably and without prejudice or favoritism.

• You have the right to be informed of confidentiality laws. The laws of the State of Nebraska require that most issues discussed during the course of therapy with a psychotherapist are confidential. These laws permit you to waive the privilege of confidentiality by signing a release of information form. However, the release of confidential materials is required in situations of suspected child abuse, of potential harm to oneself or others, and in instances where the court may subpoena records or testimony. If you desire that information be communicated about you to someone, please ask for a release of information form. Both you and your parent/legal guardian will sign releases upon admission giving consent for staff to communicate to individuals specifically involved in your treatment.

• You have the right to know the cost of your care.

• The purpose of your clinical record is to document and evaluate your progress and treatment. Clinical records are the property of RoxAnne Koenig, MS, LIMHP, LLC. You have the right to examine your records and refute any information by inserting a counter-statement of clarification. All information is confidential and will not be released without a proper authorization as detailed by Federal Confidentiality Regulations. You have the right to request the transfer of a copy of your files to another therapist or agency.

• You have the right to receive services when they are needed. In emergency situations, the client is advised to dial 9-1-1 or proceed to the nearest emergency room.

• You and your legal guardian have the right to an Advance Directive. An Advance Directive is a written statement in which you state your choice for health care or name someone to make such choices for you, if you become unable to make your own decisions about medical care. The two most common forms are a Living Will and Power of Attorney.

• You have the right to terminate services against medical advice, to the extent permitted by law, with the understanding that you will be responsible for any harm to you or others a result.

• Upon your request, you have a right to receive a copy of any release that you sign authorizing the disclosure of confidential information.

• You have the right to offer feedback and suggestions regarding any client rights and responsibilities.


• Clients have the responsibility to participate actively and honestly in treatment. In many cases, particularly when the client is a child or adolescent, effective treatment requires active involvement and participation of parents or other family members.

• Clients have the responsibility to keep scheduled appointments or to give notice of cancellation if client will be unable to keep an appointment.

• Clients have the responsibility to treat their therapist with dignity and respect.

• Clients are responsible for asking questions about any policy, procedure, or treatment which they do not understand or with which they do not agree.

• Clients are responsible for carefully reading and understanding any papers they may be asked to sign in relation to treatment.

• Clients have the responsibility to honor their financial contract by paying for the services received at the agreed-upon times and/or terms. The client is also responsible for providing RoxAnne Koenig, MS, LIMHP, LLC with all information necessary for billing health insurance or other third party insurance.

I have read and accept the Client Rights and Responsibilities:

Client Signature                                                                        Date

RoxAnne Koenig, MS, LIMHP                                                  Date

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