Informed Consent for Treatment
Confidentiality and Consent to Use and Disclose Your Health Information
Each treatment that I receive has risks and benefits associated with it. The risks and benefits are described below and
have been explained to me. My signature indicates that I wish to receive this treatment and that I have had these
risks and benefits explained to me.
Informed Consent for Treatment
1. The approach to counseling and psychotherapy will reflect the various evidenced based therapeutic modalities
and is a collaborative effort between the therapist and client. By entering into this therapeutic relationship I am
stating that I am prepared to attend scheduled appointments and partner in the counseling process. It is
expected that I will make the commitment to attend scheduled appointments. I understand that the counseling
time is valuable, and that my counselor is committed to working with me/my child. Repeated cancellations call
into question my commitment to the therapeutic process and impede progress.
2. I have the right to consent to or refuse any service, treatment, or therapy upon full explanation of the expected
consequences of such consent or refusal. A parent or legal guardian may consent to or refuse any service,
treatment, or therapy on behalf of a minor client.
3. My counselor uses a variety of communication to stay in contact including phone, text messaging, and email, if
preferred. However, Katie Wine cannot be reached 24 hours a day and emergencies happen. Emergencies are
never addressed via text messaging and/or emailing. If I am experiencing an emergency, I will contact Netcare
in Franklin County at 614-276-CARE or dial 911.
4. My appointment time has been blocked off for me. I will make every effort to keep my scheduled appointment.
If I am unable to keep my appointment, I know that it is expected to give 24 hour notice. I understand that I will
be charged a late fee of $30 for a late cancelled appointment (less than 24 hours). Direct messages for Katie
Wine can be left by calling 614-306-6563 or emailing at katiewinecounseling@gmail.com.
5. By signing this document I am stating that I understand that treatment goals may not be successfully achieved
should I decide to discontinue treatment against the advice of my own or my child’s therapist.
6. The right to be informed in advance of the reason(s) for discontinuance for service provision, and to be involved
in planning for the consequences of that event, the right to receive and explanation of the reasons for denial of
service, and the right to know the cost of services.
7. I understand that I have the responsibility to provide accurate and complete information in order for treatment
to be appropriate and effective.
8. Katie Wine uses several therapeutic techniques in counseling including but not limited to EMDR (Eye Movement
Desensitization and Reprocessing). This technique can be helpful in some situations with some clients. If
determined by Katie Wine that the use of this technique may be useful to me or my child, information will be
offered and these services and provide opportunities for me to ask questions and obtain additional information
to inform me of their potential risks and benefits. Since therapy often involves discussing unpleasant aspects of
my life, I may experience uncomfortable feelings like sadness, guilt, anger, frustration, loneliness, and
helplessness. On the other hand, mental health services have also been shown to have benefits for people.
Treatment may often lead to better relationships, solutions to specific problems, and significant reductions in
the feelings of distress. But there are no guarantees of what I will experience.
Katie Wine, LPCC-S, LLC
1016 S. High Street, 2nd Floor Columbus, OH 43206 614-306-6563 katiewinecounseling@gmail.com
Confidentiality
The code of ethics of the American Psychological Association and other counseling boards insure that the conversations
you will be having with your counselor will be held in strict confidence. There are, however certain exceptions to this
important rule. The Notice of Privacy Practices explains this information in detail.
1. The child abuse reporting laws of Ohio require my counselor to report to Children’s Services any suspected
physical, sexual, or emotional abuse, neglect or abandonment of any child that is currently under the age of 18
years.
2. My counselor is mandated by law to warn and protect any intended victim if there is reason to suspect bodily
harm on myself or someone else. My counselor reserves the right to inform possible affected parties and/or
make appropriate referrals, if necessary, including contacting the police.
3. Ohio law requires professionals to report elder abuse, neglect, exploitation, or the suspicion of abuse to the
Department of Human Services.
4. If I am involved in a court proceeding and a request is made for information concerning my treatment, my
counselor cannot provide such information without my (or my legal representative’s) written authorization, or a
court order. If I am involved in, or contemplating litigation, I should consult with my attorney to determine
whether a court would be likely to order my therapist to disclose information.
5. If a government agency is requesting the information, my counselor may be required to provide it.
6. If I file a complaint or lawsuit against my counselor, Katie Wine may disclose relevant information about me in
order to defend herself.
7. If I file a worker’s compensation claim, Katie wine may, upon appropriate request, have to provide a copy of my
records or a report of my treatment.
Consulting with Other Therapists and My Attorney
By signing below I agree that Katie Wine may consult with other therapists and other health care providers about my
care. In addition, from time to time, Katie Wine may feel the need to discuss legal issues involving my case with her
consulting attorney. By signing below I consent to these consultations, which will be limited to the amount of
information necessary for Katie Wine to properly address issues that may arise in my therapy.
Health Information
The Notice of Privacy Practices* (NPP) explains in more detail your rights and how we can use and share your
information.
*If you would like a copy of the “Notice of Privacy Practices” which explains this information in detail, one can be
provided to you at your intake appointment. A written copy of the Notice of Privacy Practices will be given to me
upon my request. A copy is also available on the web at www.katiewinecounseling.com/forms
Insurance and Fees
Please review this agreement before signing. By signing this form I agree to abide by the fee agreement. I also
understand that I am financially responsible for the amount of charges not covered by my insurance.
I understand that I am responsible for obtaining necessary insurance authorization / referrals and for confirming
coverage and agree to notify the therapist of any changes in insurance coverage.
By signing this form I acknowledge that if although insurance will be billed directly, that I am responsible for the balance
of my account for services rendered, regardless of any payments or promise for payment by my insurance company or
other third party. Prompt payment is expected from you of any insurance payments made directly to you for counseling
services.
Katie Wine, LPCC-S, LLC
1016 S. High Street, 2nd Floor Columbus, OH 43206 614-306-6563 katiewinecounseling@gmail.com
Payment is expected on the day of service. I understand that if I choose to not submit an insurance claim, I will be
expected to pay full cash fee. The full cash fee for a counseling session is $120.00. The full fee for a counseling session
required by Worker’s Compensation is $180 due to needing extra time for documentation and coordination of care.
By signing below I understand that in the event that myself or my insurance company do not pay for services that Katie
Wine may send my information to a collections agency to collect any balances due. If this occurs, Katie Wine will only
release enough information about me to collect the debt. A collection fee of 20% will be added to the reported debt
amount.
By signing below I consent to the disclosure of necessary information to my insurance company, which is required for
billing (diagnosis, treatment plans, dates of service, and, if required, treatment progress). I also give consent to bill my
insurance company for services rendered and allow a photocopy of my signature to be used.
Individuals have a new right to restrict certain disclosures of Protected Health Information to a health plan where the
individual pays out of pocket in full for the healthcare item or service. I understand that I have this choice in my
treatment.
I choose to self-pay out of pocket: Y____ N_____
Primary Insurance Company: _____________________________________________
Co-Pay Amount: _______________________________________________________
Member ID:___________________________________________________________
Group Number: _______________________________________________________
Contact Information: ____________________________________________________
Is Katie Wine an In-Network Provider? ___________________________________
*Please call your insurance company to verify coverage and copay amount, and if there is a deductible to be met first
Secondary Insurance Company: ____________________________________________
Co-Pay Amount:________________________________________________________
Member ID:___________________________________________________________
Group Number: _______________________________________________________
Contact Information: ____________________________________________________
Is Katie Wine an In-Network Provider? ____________________________________
CANCELLATION POLICY: I understand I will be charged a minimum amount of $30.00 for late cancellations (appointments
cancelled without 24 hour notice) and a fee of $60.00 for a no-show appointment. Clients who do not give a 24-hour
notice for cancellations or who do not keep scheduled appointments may be terminated. I understand that insurance
does not cover “missed appointment” fees.
I understand that I am responsible for filing complaints or suits against my insurance company if they deny or delay
payment on an eligible visit.
I have had the opportunity to discuss this consent with my therapist and do hereby give full voluntary consent/
authorization to the treatment for myself and or my child/family under the conditions set forth.
Legal Proceedings
In the event that Katie Wine becomes involved in legal proceedings as a result of therapy, such as but not limited to
responding to a subpoena or attending a deposition or a hearing, I agree to pay for my fees in connection with such a
proceeding. I also agree that Katie Wine may consult with her attorney on how to best proceed and I agree to pay for
those legal costs. Time for depositions and court may involve preparation time, travel time, and waiting to testify. In
such situations, Katie Wine may request a retainer which will be charged at the normal rate charge at that time for
Katie Wine, LPCC-S, LLC
1016 S. High Street, 2nd Floor Columbus, OH 43206 614-306-6563 katiewinecounseling@gmail.com
therapy ($120/hr). If any money in the retained is not used Katie Wine will refund the balance. In the event that Katie
Wine does not schedule patients in anticipation of a court proceeding and notice of a cancellation of the court
proceeding with in one week of its scheduled date is not received, I agree to pay for time Katie Wine lost with patients
that would have been otherwise scheduled.
By signing below I understand that Katie Wine, LPCC-S is not a forensic psychologist.
Professional Records
The laws and standards of our profession require that Katie Wine keep Protected Health Information about me in my
Clinical Record. If records are requested copied for another provider, legal proceedings, etc., in most circumstances,
Katie Wine is allowed to charge me or my personal representative a copying fee of $2.74 per page for the first 10 pages,
$.57 per page for pages 11 through 50, and $.23 per page for pages 51 and higher, plus the cost of any related postage.
Signature of Agreement:
If I have any questions or concerns about the information presented to me in this form, I can speak with my counselor at
any time.
Signing below indicates that I have read and understand that there are limits on confidentiality, there is a fee and
payment procedure and that I hereby give my consent and permission for all listed above.
My signature certifies that I have either received a copy of the “Notice of Privacy Practices” or waived that right. I
understand that I can obtain a copy at any time from my counselor.
As a minor 14 years of age or older, I understand I am entitled to receive counseling services for not more than six
sessions or thirty- (30) days, whichever comes first, without the consent of my parent / guardian and without that person
being informed. If services extend beyond that point, I will work with my therapist to involve my parent / guardian in my
treatment. Minor Signature ______________________________________
I consent to receive the services for which are outlined above or I consent for my child, who is under the age of eighteen
(18) to receive these services.
Client’s Signature
Date
Parent/Legal Guardian Signature for a minor under 18 years of age
Date
Updated 10/26/2015
Katie Wine, LPCC-S, LLC
1016 S. High Street, 2nd Floor Columbus, OH 43206 614-306-6563 katiewinecounseling@gmail.com