New Patient Contract

Contract, Office Procedures, and Financial Agreement 

CLAY Therapeutic Services

1325 Remington Rd Suite O
Schaumburg, IL 60173
(224) 633-9323

CLAY Therapeutic Services, is a business facility where a number of therapists engage in the practice of mental and behavioral health services delivery (“counseling”). Some therapists are licensed to practice independently and others require supervision. Those who require supervision work under the direction and supervision of a fully credentialed practitioner. Your contract for services is with CLAY Therapeutic Services

Rights and Risks: · Please feel free to ask questions about any aspect of the counseling process. ·You need to be willing to discuss what troubles you and be open to change. · You may remember unpleasant events, arouse intense emotions, and/or alter close relationships. The purpose of counseling is to facilitate your process. · If you have been referred by a court or state agency, you have the right to divulge only what you want included in a report.

Confidentiality: · Information shared will be held in confidence with certain limitations. · Information will not be released without your written consent, except for professional consultation if needed and unless required by law. · Your therapist is required by law to disclose information pertaining to suspected child or elder abuse or neglect; inability to care for one’s basic needs for food, clothing or shelter; and threatened harm to oneself or others. · The courts may in select cases subpoena counseling records. · It is understood that information regarding treatment and diagnosis will be provided to an insurance company if you opt to bill your insurance company for services. · You may want to discuss further limits or exceptions of confidentiality.  Privacy: By signing this contract, I understand that any counseling session in which I participate with co-therapists is for the purpose of improving my care, and not an invasion of my rights of privacy. If my counselor is a Licensed Professional Counselor (LPC), then I understand he/she is working under the direct supervision of a Licensed Clinical Professional Counselor. The supervisor has responsibility for my clinical care, and as such, will have access to my file and will consult with my counselor about my case.

Appointments: · All office visits are by appointment with your therapist directly. Please arrive on time, as you use up your own time when you arrive late for an appointment.  The usual length of an appointment is 53 minutes. · Late cancellation (less than 24 hours before) and/or no-show appointments are charged to the credit card on file for $145. If your appointment is cancelled or missed, contact your therapist for a new appointment time. Insurance companies will not pay for no-show charges or late cancellation charges or for telephone consultations. 

Fees:  · Payments and copayments for services are required at the time services are rendered.   · Your health insurance may help you recover some of your counseling costs. Verify with your company the amounts of coverage for outpatient psychotherapy by licensed professionals.  If your policy requires preauthorization to receive services, this is your responsibility and needs to be handled prior to your first visit. If required preauthorization is not on file, your credit card will be charged for your session. · Regardless of your intention to use insurance, the “Insurance Declaration Form” MUST be on file before services can commence. · By signing this contract, you acknowledge responsibility for payment per hour for any demand on the therapist’s time that occurs under your direction and/or on your behalf. This includes time demands that result from involvement in any legal proceeding. The fees are detailed below.

“Self Pay Clients” as defined in our Insurance Declaration Form are expected to pay their fees at the time services are rendered.  Our office will provide an “insurance ready” receipt upon request. Clients will receive a statement periodically reflecting any balance due on their account, either in paper copy or via email when we are granted permission to do so.  This office will not accept responsibility for collecting insurance claims or for negotiating a settlement on a disputed claim.  Clients and parents/guardians of minor clients are responsible for payment (and insurance claims) on their accounts.  Accounts become delinquent after thirty (30) days. Delinquent accounts may be turned over for collection at the responsible party’s expense.

Phone calls over five (5) minutes will be billed in 15 minute increments, at $40 per 15 minutes. This will not be processed by insurance and will be owed from the client to CLAY Therapeutic Services.  

CLIENT/RESPONSIBLE PARTY ACKNOWLEDGEMENT AND ACCEPTANCE OF TERMS: Any change in my financial or insurance situation I will discuss with my therapist. I have read, understand, and agree to the above policies and the fee schedule on this contract. I have discussed these policies with my therapist if desired and all questions are answered to my satisfaction. I have been offered a copy of these policies and understand a copy is available on line. I hereby authorize CLAY Therapeutic Services and my therapist to abide by my expressed preferences on the Insurance Declaration Form I submitted with this contract. I understand my insurance coverage is a relationship between me and my insurance company and I agree to accept financial responsibility for payment of charges incurred.  I understand that in the event of non-payment, I will bear the cost of collection and/or court costs and reasonable legal fees should this be required. I understand that Co-pays and Deductibles are not negotiable. 

Consent to Treatment and Fee: I hereby agree to full responsibility for all expenses incurred by me and/or on account of this client and hereby assign CLAY Therapeutic Services and all Insurance benefits due to me to the full extent of my financial obligation to Clay Therapeutic Services.  I have read and/or received a copy of CLAY Therapeutic Services Privacy Policy.  A completed Insurance Declaration Form is required for my file.

FEE SCHEDULE I acknowledge and understand the fee schedule, detailed in the table below. I understand that the STANDARD portion of the fee schedule may be submitted to my insurance company for payment if I authorize CTS to do so on my behalf. I understand and accept that I am responsible for copays and deductible amounts.

I understand that that the “ADDITIONAL” portion of the fee schedule is not billable to insurance and will not be paid for by a third party. Any “ADDITIONAL” fees incurred by me or by my dependent child are my sole responsibility.

If a payment is returned or credit card is declined for insufficient funds , the client is responsible for any bank fees assessed within one week, and an alternate method of payment is required. If your account is 90 days past due, you will be forwarded to a collection agency and will be responsible for a 30% fee for the total amount submitted to collections. Continued non-payment will result in a report to the credit bureau and unpaid balances will remain on your credit report until payment is received in full.

In the event that I cancel an appointment with less than 24-hours or fail to attend a scheduled appointment, I hereby authorize CLAY Therapeutic Services., to charge to my credit card the fee of $145. 

Parties consent to electronic contact/communication via third party entities for the purpose of collections. 

If any action is brought to enforce this Agreement, The prevailing party in such arbitration, litigation or controversy shall be entitled to recover from the other party or parties all reasonable attorneys’ fees, expenses and suit costs, including those associated with any appellate or post judgment collections proceedings. This entire agreement shall be governed, construed, and interpreted by the laws of the State of Illinois. Venue for any dispute between the parties shall be in arbitration in Cook County, Illinois.

Good Faith Estimate Table of Services and Fees
Service code (CPT Code)  DescriptionFee for Service (Number of Sessions Will Be Determined as We Progress)
90791Initial Diagnostic Evaluation$220
90834Psychotherapy, 38-52 minutes$140
90837Psychotherapy ≥ 53 minutes (This fee is my hourly rate & used for all prorated calculations as indicated)$185
90839Psychotherapy for a Crisis (30-74 minutes)$190
+90840Psychotherapy for a Crisis (Add on code for each additional 30 mins)$75
90846Family Psychotherapy without Patient Present, 50 minutes$185
90847Family Psychotherapy with Patient Present, 50 minutes$185
90853Group Psychotherapy$100
Case managementLetters, reports, consultations (These are not covered by insurance)Prorated based on the amount of time spent at hourly rate
98966-98968Telephone Assessment & Management  Prorated based on the amount of time spent at hourly rate
98970-98972Online Digital Evaluation & Mgt (Responding to Email & Text Messages)Prorated based on the amount of time spent at hourly rate
Cancelation FeeYour Therapist Requires a 24-Hour Cancelation FeeYou are Responsible for the Fee of the Appointment Missed $145
Production of RecordsWill require 30 days to complete after written authorization$50
Legal FeesSubpoenas, legal consultations, depositions. These will include travel times to and from venues if necessary. $300/hr and can be prorated based on time spent
Total Estimate:This Good Faith Estimate explains your therapist’s rate for each service provided. Your therapist will collaborate with you throughout your treatment to determine how many sessions and/or services you may need to receive the greatest benefit based on your diagnosis(es)/presenting clinical concerns.