Returning Client 12 and Over

Please answer each question as honestly and with as much detail as possible.

Please choose the option for each substance that best fits.

Please check YES or NO for each item below:

Please answer YES or NO to the following questions:

By entering your name and date below, you are either authorizing or refusing to authorize Haven of Hope Counseling Services to:

This section of questions is for individuals 12 through 21 years of age

 Issues discussed in counseling/therapy are important and are generally legally protected as both confidential and “privileged.” However, there are
limits to the privilege of confidentiality. These situations include: 1) possible abuse or neglect of a child, elderly person or a disabled person,
including meth being made or used in a home, 2) when your counselor/therapist believes you are in danger of harming yourself or another person, 3)
if you report that you intend to physically injure someone the law requires your counselor/therapist to inform that person as well as the legal
authorities, 4) if your counselor/therapist is ordered by a court to release information as part of a legal proceeding, 5) when your insurance company
is involved they receive information regarding diagnosis and dates of sessions. If your record is chosen for a quality assurance review of our agency,
the auditor will have access to your complete file. 6) in natural disasters, whereby protected records may become exposed or 7) when otherwise
required by law. 8) You may be asked to sign a Release of Information so that your counselor/therapist may speak with other health professions,
family members, or others connected with you.

 NOTICE OF PRIVACY PRACTICES
OF HAVEN OF HOPE COUNSELING
EFFECTIVE APRIL 15, 2009
THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW
YOU CAN GET ACCESS TO THIS INFORMATION.
PLEASE REVIEW THIS INFORMATION CAREFULLY
Note: If you have questions about this notice, please contact Haven of Hope Counseling’s Privacy Officer at 615-597-HOPE or
in writing at 301 West Main Street, Smithville, TN 37166.

WHO WILL FOLLOW THIS NOTICE:
This notice describes the privacy practices of Haven of Hope Counseling. All of our staff may have access to information in your chart for treatment, payment and health care operations, which are described below, and may use and disclose information as described in this Notice. This Notice also applies to any volunteer or trainee we allow to help you while seeking services from
us.

OUR PLEDGE REGARDING THE PRIVACY OF YOUR MEDICAL INFORMATION:
Your medical information includes information about your physical and mental health. We understand that information about your physical and mental health is personal. We are committed to protecting medical information about you. We create a record of the care and services you receive from us. We need this record to provide you with quality care and services and to comply with certain legal requirements. This notice applies to any and all of the records of your care generated by us.
This notice will tell you about the ways in which we may use and disclose medical information about you. We also describe your rights and certain obligations we have regarding the use and disclosure of medical information.
We reserve the right to revise or amend our notice of privacy practices without additional notice to you. Any revision or amendment to this notice will be effective for all of your records our practice has created or maintained in the past,
and for any of your records we may create or maintain in the future. We will post a copy of our current notice in our offices in a prominent place and will post the notice on our website (if available).

OUR OBLIGATIONS TO YOU
We are required by law to:
• make sure that medical information that identifies you is kept private except as otherwise provided by state or federal law;
• give you this notice of our legal duties and privacy practices with respect to medical information about you; and
• follow the terms of the notice that is currently in effect.

HOW WE MAY USE AND DISCLOSE MEDICAL INFORMATION ABOUT YOU:
The following categories describe different ways that we may use and disclose medical information. For each category of uses or disclosures we will explain what we mean and try to give some examples. Not every use or disclosure in a category will be
listed. This notice covers treatment, payment, and what are called health care operations, as discussed below. It also covers other uses and disclosures for which a consent or authorization are not necessary. Where Tennessee law is more protective of
your medical information, we will follow state law, as explained below.
For Treatment. We may use medical information about you to provide you with medical treatment or services without consent or authorization unless otherwise required by applicable state law. We may disclose medical information about you to doctors, pharmacists, laboratories, or other health care providers or case managers or case coordinators or other service providers who are involved in taking care of you whether or not they are affiliated with us. For example, we may disclose medical information concerning you to the local hospital, or physicians or counselors who care for you as well as to any other entity that has provided or will provide care to you.
We will disclose any mental health information, including psychotherapy notes, AIDS or HIV-related information, or drug treatment information, that we may have about you only with written authorization as required by Tennessee law, HIPAA and
other federal regulations.
During the course of your treatment, we may refer you to other health care providers with which you may not have direct
contact. These providers are called "indirect treatment providers." "Indirect treatment providers" are required to comply with the privacy requirements of state and federal law and keep your medical information confidential. These providers will be bound
by the HIPAA privacy rule.
For Payment. We may use and disclose medical information about you without consent or authorization so that the treatment and services you receive from us may be billed to and payment may be collected from you, an insurance company or a third
party. For example, we may need to give your health plan information about treatment received so your health plan will pay us or reimburse you for the treatment. We may also tell your health plan or insurance company about a treatment you are going to receive to obtain prior approval or to determine whether it will cover the treatment. We may also provide your information to case coordinators or case managers for payment purposes as well.
For Health Care Operations. We may use and disclose medical information about you without consent or authorization for "health care operations". These uses and disclosures are necessary to operate Haven of Hope Counseling and make sure that
all individuals receive quality care. For example, we may use medical information or mental health treatment information to review our treatment and services and to evaluate the performance of our staff in caring for you. We may also disclose your
protected health information to doctors or staff or consultants for review and learning purposes. We may also use your protected health information in preparing for litigation.
Appointment Reminders. We may use and disclose medical information to contact you by mail or phone to remind you that you have an appointment for treatment, unless you tell us otherwise in writing.
Treatment Alternatives. We may use and disclose medical information to tell you about or recommend possible treatment options or alternatives that may be of interest to you. However, we will not use or disclose medical information to market other
products and services, either ours or those of third parties, without your authorization.
Health-Related Benefits and Services. We may use and disclose medical information to tell you about health-related benefits or services that may be of interest to you.
Individuals Involved in Your Care or Payment for Your Care. We may release medical information, including mental health information, about you to a family member who is involved in your medical care without consent or authorization. We may also
give medical information, including prescription information or information concerning your appointments to other individuals who are involved in your care. We may also give such information to someone who helps pay for your care. In addition, we may disclose medical information about you to an entity assisting in a disaster relief effort so that your family can be notified about your condition, status and location. If Tennessee law requires specific authorization for such disclosures, we will obtain an authorization from you prior to such disclosures.
As Required By Law. We will disclose medical information about you when required to do so by federal, state or local law without your consent or authorization.
To Avert a Serious Threat to Health or Safety. We may disclose medical information about you when necessary to prevent a serious threat to your health and safety or the health and safety of the public or another person. Any disclosure, however, would
only be to someone able to help prevent the threat.
To Business Associates. Haven of Hope Counseling from time to time will hire consultants called "business associates," who render services to us. We may disclose your medical information to such business associates without your consent or
authorization. Business associates are required to maintain and comply with the privacy requirements of state and federal law and keep your medical information confidential. Examples of "business associates" are accounting firms that we hire to perform audits of billing and payment information, and computer software vendors who assist us in maintaining and processing medical information.
Military and Veterans. If you are a member of the armed forces, we may release medical information about you as required by military command authorities. We may also release medical information about foreign military personnel to the appropriate
foreign military authority.
Worker’s Compensation. We may release medical information about you for workers’ compensation or similar programs without consent or authorization. These programs provide benefits for work-related injuries or illnesses. For example, if you are injured
on the job, we may release information regarding that specific injury.
Public Health Risks. We may disclose medical information about you for public health activities without your consent or authorization. These activities generally include the following:
• to prevent or control disease, injury or disability;
• to report reactions to medications or problems with products;
• to notify people of recalls of products they may be using;
• to notify a person who may have been exposed to a disease or may be at risk for contracting or spreading a disease or condition;
• to notify the appropriate government authority if we believe an individual has been the victim of abuse, neglect or domestic violence. We will only make this disclosure if you agree or when required or authorized by law.

Health Oversight Activities. We may disclose medical information to a health oversight agency, such as the Department of Health and Human Services, for activities authorized by law. These oversight activities include, for example, audits,
investigations, inspections, and licensure. These activities are necessary for the government to monitor the health care system, government programs, and compliance with civil rights laws.
Lawsuits and Administrative Proceedings. If you are involved in a lawsuit or dispute as a party, we may disclose medical information about you in response to a court or administrative order. We may also disclose medical information about you in
response to a subpoena, discovery request, or other lawful process by someone else involved in the dispute. Similarly, we may disclose medical information about you in proceedings where you are not a party, but only if efforts have been made to tell you
or your attorney about the request or to obtain an order protecting the information requested. In addition, we may disclose medical information, including mental health treatment information, to the opposing party in any lawsuit or administrative
proceeding where you have put your physical or mental condition at issue if you have signed a valid release.

Law Enforcement. We may release medical information if asked to do so by a law enforcement official:
• in response to a court order, subpoena, warrant, summons or similar process;
• to identify or locate a suspect, fugitive, material witness, or missing person;
• about the victim of a crime if, under certain limited circumstances, we are unable to obtain the person’s agreement;
• about a death we believe may be the result of criminal conduct;
• about criminal conduct at Haven of Hope Counseling; and
• in emergency circumstances to report a crime; the location of the crime or victims; or the identity, description or location of the person who committed the crime.

Coroners, Medical Examiners and Funeral Directors. We may release medical information including mental health information
to a coroner or medical examiner. This may be necessary, for example, to identify a deceased person or determine the cause of death.
National Security and Intelligence Activities. We may release medical information about you to authorized federal officials for intelligence, counterintelligence, and other national security activities authorized by law.

Protective Services for the President and Others. We may disclose medical information about you to authorized federal officials so they may provide protection to the President, other authorized persons or foreign heads of state or conduct special
investigations.

Inmates. If you are an inmate of a correctional institution or under the custody of a law enforcement official, we may release medical information about you to the correctional institution or law enforcement official. This release would be necessary (1) for the institution to provide you with health care; (2) to protect your health and safety or the health and safety of others; or (3) for the safety and security of the correctional institution.

YOUR RIGHTS REGARDING MEDICAL INFORMATION ABOUT YOU.
You or your personal representative have the following rights regarding medical information we maintain about you (when we say "you" this also means your personal representative, which may be your parent or legal guardian or other individual who is
authorized to care for you):
Right to Inspect and Copy. You have the right to inspect and copy medical information that may be used to make decisions about your care.
If you wish to be provided a copy of medical information that may be used to make decisions about you, you must submit your request in writing to the Privacy Officer at Haven of Hope Counseling. If you request a copy of the information, we may charge a
reasonable fee for the costs of copying, mailing and or other supplies associated with your request.
We may deny your request to inspect and/or obtain a copy in certain very limited circumstances. If you are denied access to medical information, you may request that the denial be reviewed. Another licensed health care professional chosen by us will
review your request and the denial. The person conducting the review will not be the person who denied your request. We will comply with the outcome of the review.
Right to Request an Amendment. If you feel that medical information we have about you is incorrect or incomplete, you may ask us to amend the information. You have the right to request an amendment for as long as the information is kept by or for us.
To request an amendment, your request must be made in writing and submitted to the Privacy Officer at Haven of Hope Counseling. In addition, you must provide a reason that supports your request.
We may deny your request for an amendment if it is not in writing or does not include a reason to support the request. In addition, we may deny your request if you ask us to amend information that:
• Was not created by us, unless the person or entity that created the information is no longer available to make that amendment;
• Is not part of the medical information kept by us
• Is not part of the information which you would be permitted to inspect and copy; or
• Is accurate and complete.

Right to an Accounting of Disclosures. You have the right to request an “accounting of disclosures.” This is a list of some of the disclosures we made of medical information about you.
To request this list or accounting of disclosures, you must submit your request in writing to the Privacy Officer Haven of Hope Counseling. Your request must state a time period which may not be longer than six years starting with April 15, 2009. Your
request will be provided to you on paper. The first list you request within a 12-month period will be free. For additional lists, we may charge you for the costs of providing the list. We will notify you of the cost involved and you may choose to withdraw or
modify your request at that time before any costs are incurred.
Right to Request Restrictions. You have the right to request a restriction or limitation on the medical information we use or disclose about you for treatment, payment or health care operations. You also have the right to request a limit on the medical
information we disclose about you to someone who is involved in your care or the payment for your care, like a family member or friend. However, you will need to make alternative arrangements for payment if you restrict access of individuals responsible for the payment of your care.
We are not required to agree to your request. If we do agree, we will comply with your request unless the information is needed to provide you emergency treatment.
To request restrictions, you must make your request in writing to the Privacy Officer at Haven of Hope Counseling. In your request, you must tell us (1) what information you want to limit; (2) whether you want to limit our use, disclosure or both; and (3)
to whom you want the limits to apply, for example, disclosures to your spouse.

Right to Request Confidential Communications. You have the right to request that we communicate with you about medical matters in a certain way or at a certain location. For example, you can ask that we only contact you at work or by mail.
To request confidential communications, you must make your request in writing to the Privacy Officer at Haven of Hope Counseling. We will not ask the reason for your request. We will accommodate all reasonable requests. Your request must
specify how or where you wish to be contacted.
Right to a Paper Copy of This Notice. You have the right to a paper copy of this notice. You may ask us to give you a copy of this notice at any time. Even if you have agreed to receive this notice electronically, you are still entitled to a paper copy of this
notice.

COMPLAINTS. If you believe your privacy rights have been violated, you may file a complaint with us or with the Secretary of the Department of Health and Human Services. To file a complaint with us, submit your complaint in writing to the Privacy
Officer at Haven of Hope Counseling. You will not be penalized for filing a complaint.

OTHER USES OF MEDICAL INFORMATION. Other uses and disclosures of medical information not covered by this notice or the laws that apply to us will be made only with your written permission as set out in an authorization signed by you. If you
provide us permission to use or disclose medical information about you, you may revoke that permission, in writing, at any time.
If you revoke your permission, we will no longer use or disclose medical information about you for the reasons covered by your written authorization. You understand that we are unable to take back any disclosures we have already made with your
permission, and that we are required to retain our records of the care that we provided to you.
Privacy Officer Contact Information:

Haven of Hope Counseling
Attn: Privacy Officer
301 West Main Street
Smithville, TN 37166
Phone : (615) 597.4673
Fax : (615) 597.4673
Effective Date of the Notice
April 15, 2009

Click here to read the full declaration.

 Haven of Hope Counseling Client Rights and Responsibilities (615-597-4673)
(updated 10/25/2022)
You have the right:
To be treated with consideration, respect, and full recognition of your dignity and individuality regardless of your state of mind or
condition; and to receive access to care in a timely fashion.
To receive treatment without distinction of race, color, place of birth, language, gender, age, religion and disability and to be protected
by our personnel from neglect, physical/verbal/emotional abuse and all forms of inappropriate exploitation behavior.
To be assisted by our agency in the exercise of your civil rights.
To be free from any requirement for the ease of performing services that are ordinarily performed by staff.
To complete privacy while receiving the services and privacy of your medical, mental health and financial information.
To privacy in the services and the right to keep your personal information confidential, according to the state and federal
confidentiality laws.
To request and receive information about your medical history, review records, make corrections to your medical record, and receive
copies of your records at the Counselor's discretion considering your (or your dependents) best interest. If your counselor disagrees,
you can include a written statement on the record giving reasons for which you disagree.
To receive information in a language you can understand and for free. Language assistance, interpretation and translation services are
provided free of charge and are available in the form of in-person interpreters, sign language and access to telephonic assistance.
To vote, make contracts, buy or sell real estate or personal property, or sign documents, unless these rights are removed by law or a
court. For example, you will not be penalized for missing an advisory appointment in order to vote or conduct business as mentioned
above.
To participate in the development of your individual treatment plans and to receive enough information on the proposed and
alternative interventions regardless of the cost or benefit covered so that you can effectively participate in the making of treatment
decisions. This information may include risks, benefits, consequences of treatment or non-treatment
To participate in or refuse to participate in community activities, including cultural, educational, religious, community, recreational
and vocational activities. Some may be suggested by your counselor, but it will be your freedom to choose.
To make free use of the common area waiting rooms with consideration of the privacy, personal belongings and rights of others.
Have the right to privacy and freedom to use bathrooms when necessary.
Have personal possessions such as books, photos, games with consideration of the rights of others. However, audio or video
recordings of any kind are prohibited unless authorized by counselor or required by the court.
Participate in any decision-making about your behavioral health, including discharge or post-treatment planning.
To provide quality treatment by competent staff members and be informed of the qualifications of your counselor including education,
experience, license or certification.
Make certain preferences on a counselor and receive a copy of the code of ethics that your counselor adheres to.
To refuse to participate in part or in full in treatment or therapeutic activities (unless the court orders participation).
To have your session without concern of it being recorded either in audio or visual apart from:
1) being permitted by custody holder of young child when there is a specific need to better understand what the child says or does.
2)requirement of graduate program in clinical counseling after obtaining a written consent form the client and/or guardian.
3)sessions in “play” areas for counselor/employee liability protection only to be used if action is brought against
employee/counselor.
To be provided with a copy of your basic rights and responsibilities and to have all questions answered to your satisfaction; and to
make recommendations about the agency’s policies about your rights and responsibilities.
To be given information about the Declaration of Mental Health Treatment, or to designate a person to make decisions using a durable
power of attorney for health care.
To be provided with a list of available advocacy services and contact information when requested; and to be informed on how to reach
the counselor in an emergency situation. Two advocacy services in our area are 1. Genesis House (931-526-5197) which provides
emergency housing and counseling for women/children who are victims of domestic violence. 2. Legal Aid in Cookeville can assist in
some situations (931-528-7436).
To voice concerns and complaints about the care and service you receive. You can continue to receive services without fear of
receiving inadequate treatment; and you have the right to terminate the counseling relationship at any time. You may file a
complaint/grievance either orally or in writing at any time by contacting the office manager at the front desk for a complaint/grievance
(over)
form. If needed, an employee can assist in filling out the form. You have the right to also voice grievance to outside representative of
your choice with freedom from any restraint, interference, coercion, discrimination or reprisal. The form can be given to the office
manager, bookkeeper or executive director. A date will be scheduled for you to meet with the supervising counselor or executive
director to discuss the concerns. If there is not resolution, a date will be scheduled for you to meet with the board of directors.
You are responsible:
To provide accurate information to your provider so we can give you the best appropriate counseling services.
To treat health care providers with respect and dignity. To go by our office rules of no smoking, no unlawful drugs, no weapons, no
violence, no disruptive behavior, no child under 12 left unattended and parking only in designated areas. (No parking in the front of
the building.)
To tell your counselor about medication changes, including medications given to you by others.
To tell us when your address or telephone number changes.
To set and keep appointments with your counselor and let us know as soon as possible if you cannot keep an appointment. A 24-hour
notice is requested. Future appointments may be removed from the schedule after missing 2 or more appointments without notice and
could result in a $35 charge.
To pay agreed on counseling fees on day of service, unless other arrangements are made. Let us know if there is a problem in paying.
We do have a sliding fee scale available based on family size and family income.
To participate, to the degree possible, in understanding your behavioral health problems and to develop mutually agreed upon
treatment goals; and to keep your counselor informed of your progress toward meeting your goals.
To terminate this counseling relationship before entering into arrangements with another counselor.

 Welcome to Haven of Hope Counseling. We would like to thank you for choosing us as your behavioral health
care provider and want you to know that we are committed to providing you with the best possible care. We
also need you to understand that payment of your bill is necessary to provide quality care. Because of this, we
have adopted the following financial policy which we require you to read, agree to, and sign prior to receiving
any behavioral health care services from us.
Please note that communication is key and you will need to contact HOHC to inform us of any changes that
may affect your ability to pay so that we may keep your account active and continue services.

Please read and sign in each section stating that you understand and agree to each statement:

 The following information is to be completed by the person being served or the person’s
authorized representative/parent.
The purpose of this document is to inform you, the client, about many aspects of online
counseling services: the process, the counseling, the potential risks and benefits of services,
safeguards against those risks, and alternatives to online services. Please read this entire
document, sign, and return.

A. Process
1) Possible misunderstandings: The client should be aware that misunderstandings are possible
with telephone and video-based modalities such as Doxy.me because nonverbal cues are
relatively lacking. Even with video webcam software, misunderstandings may occur due to
connection problems causing image delays or less than optimal image quality. Counselors are
observers of human behavior and gather much information from body language, vocal inflection,
eye contact, and other non-verbal cues. If you have never engaged in online counseling before,
please have patience with the process and clarify information if you think your counselor has not
understood you well. Also, please be patient if your counselor asks for periodic clarification. All
sessions and messaging are in English.
2) Turnaround time: Using asynchronous (not in "real time") communication such as Doxy.me
entails a potential of “lag” of response. If the client is in a state of crisis or emergency, the
counselor recommends the client contact a crisis line or an agency local to the client. Clients may
also utilize 1-800-SUICIDE or 1- 800-273-TALK (For the deaf or hard-of hearing: 1-800-799-
4TTY).
3) Privacy of the counselor: Although the internet provides the appearance of anonymity and
privacy in counseling, privacy is more of an issue online than in person. Your counselor has
chosen to use Doxy.me as the software provider for web conferencing, and chat communications
between the counselor and clients. The client is responsible for securing his or her own computer
hardware, internet access points, and password security.
The counselor has a right to his/her privacy and may wish to restrict the use of any copies or
recordings the client makes of their communications. Clients must seek the written permission of
the counselor before recording any portion of the session and/or posting any portion of said
session on internet websites such as Facebook or YouTube. Counselors cannot become friends
with clients on social media; such as Facebook, Twitter, etc…

B. Potential benefits:

The potential benefits of receiving mental health services online include
both the circumstances in which the counselor considers online mental health services
appropriate and the possible advantages of providing those services online. For example, the potential benefits of video sessions include the convenience for clients to potentially receive
counseling from anywhere once an internet signal and necessary hardware is secured.

C. Potential risks:

There are various risks related to electronic provision of counseling services
related to the technology used, the distance between counselor and client, and issues related to
timeliness. Confidentiality could be breached in transit by hackers or Internet service providers
or at either end by others with access to the client’s account or computer. People accessing the
internet from public locations such as a library, computer lab, or café should consider the
visibility of their screen to people around them. Position yourself to avoid others’ ability to read
your screen. Using cell phones can also be risky in that signals are scrambled but rarely
encrypted.

D. Safeguards:

The client is responsible for creating and using additional safeguards when the
computer used to access services may be accessed by others, such as creating passwords to use
the computer, keeping their email and chat IDs and passwords secret, and maintaining security of
their wireless internet access points. Please discuss any additional concerns with your counselor
early in your first session so as to develop strategies to limit risk.

E. Alternatives:

Online counseling is a non-acute service and may not be appropriate for many
types of clients including those who have numerous concerns over the risks of internet
counseling, clients with active suicidal or homicidal thoughts, and clients who are experiencing
active manic/psychotic symptoms. An alternative to receiving mental health services online
would be receiving mental health services in person. HOH can and will assist clients who would
like to explore face-to-face options in their area. Please feel free to request a referral at any time
you think a different counseling relationship would be more practical or beneficial for you.

F. Proxies:

HOH requires this consent form to be signed by the legal guardian of any client
seeking services who is under the age of 18. The name and contact information of the legal
guardian will be kept as part of the client’s record.

G. Confidentiality of the client:

Maintaining client confidentiality is extremely important to
HOH and HOH will take ordinary care and consideration to prevent unnecessary disclosure.
Information about the client will only be released with his or her express and written permission
with the exceptions of the following cases: 1) If the counselor believes that someone is seriously
considering and likely to attempt suicide; 2) if the counselor believes that someone intends to
assault another person; 3) if the counselor believes someone is engaging or intends to engage in
behavior which will expose another person to a potentially life-threatening communicable
disease; 4) if a counselor suspects abuse, neglect, or exploitation of a minor or of an
incapacitated adult; 5) if a counselor believes that someone’s mental condition leaves the person
gravely disabled.

H. Records:

HOH will maintain records of online counseling and/ or consultation services.
These records can include reference notes, copies of transcripts of chat and internet
communication and session summaries. These records are confidential and will be maintained as required by applicable legal and ethical standards according to the American Counseling
Association, National Board of Certified Counselors, the State of Tennessee Department of
Mental Health and Substance Abuse Services. The client will be asked in advance for permission
before any audio or video recording would occur on the counselor’s end.

I. Procedures:

The counselor might not immediately receive an online communication or might
experience a local backup affecting internet connectivity. If the client is in a state of crisis or
emergency, the counselor recommends contacting a crisis line or an agency local to the client.
Clients may utilize the following crisis hotlines: 1-800-SUICIDE or 1- 800-273-TALK (For the
deaf or hard-of hearing: 1-800-799-4TTY).

J. Payments:

It is up to the Client to keep HOH informed of any insurance/financial changes.
HOH will bill any insurances that are accepting charges for telephone and/or video-based
modalities. All client credit/debit card payments will be processed through Square. I understand
payment of fees is expected at the time of service. Client agrees to pay for each service at the
time it is rendered. Client understands they are responsible for all charges incurred, insurance
will be filed as a curtesy to the client. Client will notify HOH at least 48 hours in advance if
he/she is unable to keep appointment.

K. Disconnection of Services:

If there is ever a disruption of services on the internet then the
client will need to call your counselor to discuss how to proceed with the session. Your
counselor can be reached at 615-597-4673.

APPOINTMENTS:
COUNSELING: Haven of Hope Counseling is based on an hourly system and functions on a
tight schedule. Even when you are late, the appointment will still end on schedule. Individuals
are expected to be available by phone during the session in case of an interruption in the
teletherapy/video session service.
APPOINTMENTS NOT CANCELLED 48 HOURS PRIOR TO THE MEETING TIME ARE
CHARGED $35.00. If HOH is able to reschedule someone for that time, or your counselor
makes the cancellation, you will not be charged.

CHARGES: (w/LPC=Service with Licensed Professional Counselor.  w/MA=Services with Masters Level Counselor)

Up to 55 Minutes - $110.00 w/LPC; $85.00 w/MA (additional $15 for every 10 minutes over)

Up to 45 minuets - $95.00 w/LPC; $65.00 w/MA

Up to 25 Minutes - $60.00 w/LPC; $55.00 w/MA

Missed appointment without notice - $35.00 (possible dismissal of future appointments if no notice is give for 2 or more appointments)

PAYMENT IS DUE WHEN SERVICES ARE RENDERED. It is the responsibility of the client

to maintain the account up-to-date to assure continuation of services.

Fill out the information below IF:

You have MEDICARE, (we are unable to bill Medicare at this time) and/or

You are uninsured and in need of a Scholarship to help cover the cost of your services.

We are pleased to offer a sliding fee scale when needed.  Please read and sign below each of the following terms then sign and date indicating your agreement.