Consent for Treatment

Step 3

Scheduling Appointments and Fees Office Hours and Availability

I, (Client), voluntarily consent for treatment with Carrie T. Ishee, M.A, LPCC, LPAT, ATR-BC, PCC. My right to refuse to consent to admission and treatment was fully explained to me.

Therapy sessions will be arranged with the client and the therapist on the basis of treatment need and scheduling ability. In cases of extreme emergency, special considerations may be applied regarding payment for missed appointments. All payments will be made at the end of each session unless a specific agreement has been made between the therapist and client(s) in writing. Client(s) are required to contact the therapist within twenty-four hours of a scheduled appointment to cancel. The client(s) are expected to pay for any appointments missed when they are not canceled within the twenty-four hours. Fees for services are arranged on a sliding scale based on need and thorough negotiation between the client(s) and the therapist and subject to change based on changes in the financial circumstances of the client(s). The agreed upon fee for services are $110.00 per 50 minute session. Carrie T. Ishee, LPCC, LPAT, ATR-BC, PCC will bill insurance companies directly, but client is responsible for co-pay at time of service. The only insurances taken are BCBSNM and Presbyterian.

Office Hours and Availabiliy

Office Hours: Monday, Wednesday, and Thursday, 9 am-6 pm. Carrie Ishee can be reached at 505-670-0686 during these hours. If she is in session at the time of the call, a confidential message can be left by voice or text message and the call will be returned within twenty-four hours unless otherwise specified on the voice messaging service. After hours Ms. Ishee can be reached at the same number. In case of medical or psychiatric emergency, please call 911 or your medical provider.

I understand that my client records are confidential. Any information regarding the client(s) may be shared with clinical supervisors or therapists who provide back-up clinical support for the sole and expressed purpose of the provision of clinical supervision and with the knowledge and consent of the client(s). Should your case be discussed during clinical supervision, no identifying information will be shared to insure confidentiality.

For purposes of billing, your information will be shared with your insurance company in accordance with HIPPA laws. This information includes only that which is required to bill for my services.

I understand that my records will not be released to any party without my writien permission except under the following circumstances as per the federal Freedom of Information Act, the New Mexico Mental Health Code, and the New Mexico Failure to Warn Statutes: 1. Receipt by Carrie T. Ishee of a valid subpoena from a court of law, 2. Upon disclosure of information by Client of intent of grave self-harm or intent to inflict grave harm onto others, 3. Upon disclosure of information of abuse and/or neglect.

It has been explained to me, and I understand, I have the right to terminate services from Carrie T. Ishee, LPCC, LPAT ATR-BC, PCC at any time

Step 4

Next: Notice of Privacy Practices