Your therapist, counselor, psychologist, doctor, or other health professional ("Provider") has asked you to read and sign this Consent before you start therapy. Please review the information. If you have any questions, contact your Provider.

 

THE THERAPY PROCESS

Therapy is a collaborative process where you and your Provider will work together on equal footing to achieve goals that you define. This means that you will follow a defined process supported by scientific evidence, where you and your Provider have specific rights and responsibilities. Therapy generally shows positive outcomes for individuals who follow the process. Better outcomes are often associated with a good relationship between a client and their Provider. To foster the best possible relationship, it is important you understand as much about the process before deciding to commit.

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Therapy begins with the intake process. First, you will review your Provider's policies and procedures, talk about fees, identify emergency contacts, and decide if you want health insurance to pay your fees depending on your plan's benefits. Second, you will discuss what to expect during therapy, including the type of therapy, the length of treatment, and the risks and benefits. If your Provider is practicing under the supervision of another professional, your Provider will tell you about their supervision and the name of the supervising professional. Third, you will form a treatment plan, including the type of therapy, how often you will attend therapy, your short- and long-term goals, and the steps you will take to achieve them. Over time, you and your Provider may edit your treatment plan to be sure it describes your goals and steps you need to take. After intake, you will attend regular therapy sessions at your Provider's office or through video, called telehealth. Participation in therapy is voluntary - you can stop at any time. At some point, you will achieve your goals. At this time, you will review your progress, identify supports that will help you maintain your progress, and discuss how to return to therapy if you need it in the future.

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ILLNESS/SICKNESS POLICY

• Only attend in person if you are symptom-free/fever free for 24 hours

• You must follow all safety protocols established by the practice, including:

• Following the check-in procedure;

• Washing or sanitizing your hands upon entering the practice;

• Adhering to appropriate social distancing measures;

• Wearing a mask, if necessary.

 

TELEHEALTH SERVICES

To use telehealth, you need an internet connection and a device with a camera for video. Your Provider can explain how to log in and use any features on the telehealth platform. If telehealth is not a good fit for you, your Provider will recommend a different option. There are some risks and benefits to using telehealth:

• Risks:

• Privacy and Confidentiality. You may be asked to share personal information with the telehealth platform to create an account, such as your name, date of birth, location, and contact information. Your Provider carefully vets any telehealth platform to ensure your information is secured to the appropriate standards.

• Technology. At times, you could have problems with your internet, video, or sound. If you have issues during a session, your Provider will follow the backup plan that you agree to prior to sessions.

• Crisis Management. It may be difficult for your Provider to provide immediate support during an emergency or crisis. You and your Provider will develop a plan for emergencies or crises, such as choosing a local emergency contact, creating a communication plan, and making a list of local support, emergency, and crisis services.

• Benefits:

• Flexibility. You can attend therapy wherever is convenient for you.

• Ease of Access. You can attend telehealth sessions without worrying about traveling, meaning you can schedule less time per session and can attend therapy during inclement weather or illness.

• Recommendations:

• Make sure that other people cannot hear your conversation or see your screen during sessions.

• Do not use video or audio to record your session unless you ask your Provider for their permission in advance.

• Make sure to let your Provider know if you are not in your usual location before starting any telehealth session.

 

IN CASE OF AN EMERGENCY

Please call 911 or go to your nearest emergency room.

Additional Emergency services can be reached through your local community mental health Agency (listed below):

Livingston County: (517) 548-0081

Ingham County: (517) 346-8200

Oakland County: (800) 231-1127

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CONFIDENTIALITY 

All information discussed in session is kept confidential, and not released without written permission from the client. There are exceptional circumstances where information is shared with a third party without the client's permission.

These exceptional circumstances include:

1. If Mid-Michigan Therapy believes that if you, your child, or someone else is in clear and imminent danger of harm we are legally obligated to inform proper authorities in order to help prevent harm from occurring.

2. If you report information that indicates that someone under the age of 18 years old is being abused or neglected; or information that any disabled adult or elderly person is being abused, neglected, or exploited, Mid-Michigan Therapy is legally obligated to notify the proper authorities.

3. If a court subpoena is issued, Mid-Michigan Therapy may be required to disclose information regarding the client.

4. Additionally, you are protected under the provisions of the Federal Health Insurance Portability and Accountability Act (HIPAA). Under HIPAA, client and record information can be released under certain other circumstances, which are outlined in the “Notice of Privacy Practice” document. You are allowed to revoke any written consent for release of information at any time in writing.

 

CHILDREN OF SEPARATED PARENTS:

In such cases where the parents of a minor are separated or divorced, court rulings regarding custody may limit the rights of either parent to participate in psychotherapy without the consent of the other parent. Signing this consent for psychotherapy services indicates that you either:

1. have the consent of the other parent to have your child participate in psychotherapy services, or

2. that you have the sole legal right to bring your child to psychotherapy.

 

RECORD KEEPING

Your Provider is required to keep records about your treatment. These records help ensure the quality and continuity of your care, as well as provide evidence that the services you receive meet the appropriate standards of care. Your records are maintained in an electronic health record provided by TherapyNotes. TherapyNotes has several safety features to protect your personal information, including advanced encryption techniques to make your personal information difficult to decode, firewalls to prevent unauthorized access, and a team of professionals monitoring the system for suspicious activity. TherapyNotes keeps records of all log-ins and actions within the system.

 

COMMUNICATION

You decide how to communicate with your Provider outside of your sessions. You have several options:

• Texting/Email

 (Texting and email are not secure methods of communication and should not be used to communicate personal information. You may choose to receive appointment reminders via text message or email. You should carefully consider who may have access to your text messages or emails before choosing to communicate via either method.)

• Secure Communication 

(Secure communications are the best way to communicate personal information, though no method is entirely without risk. Your Provider will discuss options available to you. If you decide to be contacted via non-secure methods, your Provider will document this in your record)

• Social Media/Review Websites 

(If you try to communicate with your Provider via these methods, they will not respond. This includes any form of friend or contact request, @mention, direct message, wall post, and so on. This is to protect your confidentiality and ensure appropriate boundaries in therapy. • Your provider may publish content on various social media websites or blogs. There is no expectation that you will follow, comment on, or otherwise engage with any content. If you do choose to follow your Provider on any platform, they will not follow you back. • If you see your Provider on any form of review website, it is not a solicitation for a review. Many such sites scrape business listings and may automatically include your Provider. If you choose to leave a review of your Provider on any website, they will not respond. While you are always free to express yourself in the manner you choose, please be aware of the potential impact on your confidentiality prior to leaving a review. It is often impossible to remove reviews later, and some sites aggregate reviews from several platforms leading to your review appearing in other places without your knowledge.)

 

FEES AND PAYMENT FOR SERVICES

Payment for services is due at the time of session. Clients are encouraged to confirm with their insurance company prior to their first session to confirm if they have a copay or deductible to meet. The following are the updated practice fees as of September 2025.

● Private Pay: Private pay sessions are $125

● Insurance Rates (The amount billed to insurance, not indicative of copays or deductible amounts: Intake: $225, 53-60 min: $200, 45 min: $175, 30 min $115, Family Therapy: $225)

Mid-Michigan Therapy accepts cash, checks, and credit cards as a form of payment which is due at the end of each session. Credit card information is stored on file to ensure on-time payment and for payments pertaining to late cancellations or missed appointments. If there is an outstanding balance on your account, Counseling Billing Services may attempt to reach out to you to help manage your account so services may continue. In cases where standing balances are $300 or over, are not being paid or there is not an active payment plan in process, treatment will be paused. To prevent an escalation of the balance and possible negative impacts on a client’s mental health there will be a pause in services to address payment obligations and to either pay off debt or activate payment plans.

 

Your provider will do their best to help you maintain a low balance for the services provided. However, after two attempts are unresponded to by your therapist with no additional sessions scheduled, MMT might utilize a third party to help recover the lost money and zero out your balance

 

NO-SHOW AND LATE CANCELLATION FEES

If you are unable to attend therapy, you must contact your Provider before your session. Sessions canceled within 48 hours will be subject to a $100 cancellation fee. Insurance does not cover these fees.

• Balance Accrual

• Full payment is due at the time of your session. If you are unable to pay, tell your Provider. Your Provider may offer payment plans or a sliding scale. If not, your Provider may refer you to other low- or no-cost services. Any balance due will continue to be due until paid in full. If necessary, your balance may be sent to a collections service.

• Administrative Fees

• Your Provider may charge administrative fees for writing a letter or report at your request; consulting with another healthcare provider or other professional outside of normal case management practices; or for preparation, travel, and attendance at a court appearance. These fees are listed in the fee agreement. Payment is due in advance.

 

INSURANCE BENEFITS

Before starting therapy, you should confirm with your insurance company if:

• Your benefits cover the type of therapy you will receive;

• Your benefits cover in-person and telehealth sessions;

• You may be responsible for any portion of the payment; and

• Your Provider is in-network or out-of-network.

• Sharing Information with Insurance Companies

• If you choose to use insurance benefits to pay for services, you will be required to share personal information with your insurance company. Insurance companies keep personal information confidential unless they must share to act on your behalf, comply with federal or state law, or complete administrative work.

 

COVERED AND NON-COVERED SERVICES

When your Provider is in-network, they have a contract with your insurance company. Your insurance plan may cover all or part of the cost of therapy. You are responsible for any part of this cost not covered by insurance, such as deductibles, copays, or coinsurance. You may also be responsible for any services not covered by your insurance.

When your Provider is out-of-network, they do not have a contract with your insurance company. You can still choose to see your Provider; however, all fees will be due at the time of your session to your Provider. Your Provider will tell you if they can help you file for reimbursement from your insurance company. If your insurance company decides that they will not reimburse you, you are still responsible for the full amount.

 

BORROWED RESOURCES

 At times, your therapist may feel it is in the best interest of a client to borrow a book, or another resource, in order to help them make progress while not in session. It is understood that borrowing a book, or other items, is temporary and should be returned within an agreed upon time frame. Failure to return the borrowed items will cause the client to be charged the price of replacement in order to replace the missing item.

 

COMPLAINTS

 If you feel your Provider has engaged in improper or unethical behavior, you can talk to them, or you may contact the licensing board that issued your Provider's license, your insurance company (if applicable), or the US Department of Health and Human Services.