BRIAN POWERS, MA LLP PC 18348 Mack Avenue, Ste. 5

Grosse Pointe Farms, MI 48236

Tel: (313) 675-9886

Fax: (313) 216-1840

PowersPsychotherapy.com

INFORMED CONSENT FORM

Name ____________________________________________ Date of Birth______________________

Address ______________________________________ City/State/Zip___________________________

Phone ________________________________ Email ______________________________________

Work/Cell/Other______

SERVICES:

I am pleased to be able to serve you and your family. I provide psychotherapy services for adult individuals and couples. Fees are based on a 45 minute session for individuals, couples or families. Fees are based on the standard and customary reimbursement rates established by insurance providers at a rate of $110-$140 per full session. Sliding scale fees are also offered and are determined prior to the commencement of treatment. You may be billed 100% of your established fee if you do not cancel an appointment at least 24 hours in advance.

Failure to attend two (2) consecutive appointments will result in termination of treatment with no notification, unless there are extenuating circumstances. In addition, frequent cancellations, no-shows, or no face-to-face contact within thirty (30) days may lead to termination of treatment.

FEE FOR SERVICE:

Your fee for each session will be determined by your insurance carrier, depending on your policy benefits. If you are not using insurance your fees are: __________

RECIPIENT RIGHTS – CONSENT TO TREATMENT – CLIENT CONFIDENTIALITY

I consent to mental health treatment. I understand that I will participate in psychotherapy and that I am free to withdraw my consent and discontinue treatment at any time.

Confidentiality of treatment is protected by Federal law and regulations. Violation of the Federal law and regulations is a crime. Suspected violations may be reported to appropriate authorities in accordance with Federal regulations. Communications between a psychotherapist and patient in treatment are privileged and may not be disclosed without your permission, except as required by law. For example, psychotherapists still must report suspected child abuse, and may have to breach confidentiality if you appear to pose an imminent danger to self or others, in order to reduce the likelihood of harm.

Federal law and regulations do not protect any information about suspected child abuse or neglect from being reported under State law to appropriate State or local authorities. Federal law also does not protect information regarding self harm and/or harm to others.

I have read this agreement. I had the opportunity to ask questions which have been answered to my satisfaction. I understand and agree to the conditions specified herein and have been given a copy of this signed agreement.

________________________________________________________________________________

Client’s Name, Printed

________________________________________________________________________________

Client’s Signature Date

_________________________________________________________________________________

Therapist’s Signature Date

BRIAN POWERS, MA LLP PC 18348 Mack Avenue, Ste. 5

Grosse Pointe Farms, MI 48236

Tel: (313) 675-9886

Fax: (313) 216-1840

PowersPsychotherapy.com

CONSENT TO BILL HEALTH INSURANCE

Person Responsible for Account _____________________________

Date of Birth _______________________

In lieu of listing info below, please place snapshot of front and back of insurance card here and sign below:

Front of card

Primary Insurance ________________________________

Insurance Plan ___________________________________

Contract # _______________________________________

Group # _________________________________________

Assignment of Release

I certify that I am/ or my dependent(s) have insurance coverage with the above listed insurance provider and assign to Brian Powers, MA, LLP all insurance benefits, if any, otherwise payable to me for services rendered. I understand that I am financially responsible for all charges not paid by my insurance. I authorize the use of my signature on all insurance submissions.

The above named practitioners may use my health care information and may disclose such information to the above named insurance company and their agents for the purpose of obtaining payment for services and determining benefits. This consent terminates when my current treatment plan is completed or one year from the date of cessation of services.

__________________________________________________________________________________

Client’s Name, Printed

_________________________________________ _______________________________

Client’s Signature Date