Caleb Baker Counseling PLLC Informed Consent
Counseling and expectations:
Active participation during and between sessions will maximize the client's benefit. Client participation is always voluntary, however, termination sessions are recommended when a client is ready to terminate the counseling relationship.
Counseling is client-centered, and each individual will experience the counseling process in their way. As with any treatment, therapy comes with risks. Change can be uncomfortable or disrupt existing relationships. However, treatment aims to help clients work through these feelings. Treatment does not guarantee the elimination of presenting symptoms. The client is ultimately responsible for change or non-change.
During the counseling process, the counselor will gather information about the client including history and current life situations. The counselor will work to provide a safe environment free from judgment and build a therapeutic rapport with the client. The client and counselor will work together to form treatment goals. The counselor will use interventions and suggest other resources as appropriate to assist in behavioral, cognitive, and effective change. EMDR is the primary treatment modality used with Caleb Baker, M.Ed., LPC, however, additional modalities will be implemented depending on the client and their situation(s).
It is typical to be seen once a week or every two weeks. The length of counseling service varies depending on issues, goals, diagnosis, etc. The length of counseling is determined collaboratively between the counselor and the client.
Confidentiality and Limits of Confidentiality:
The law protects information that is shared between a counselor and a client. Any information you disclose to me during treatment or I obtain while providing care is confidential unless the client permits us to disclose such information verbally or written. Counselors follow HIPAA and state PHI laws.
Exceptions to Confidentiality:
The counselor may break confidentiality to protect the safety and welfare of individuals. If the counselor assesses that a client is a clear and imminent danger to self or others, the counselor may utilize police resources, call 911, notify emergency contacts, etc. If there is a reason to suspect that child or elder abuse has occurred, the law requires that the counselor report to appropriate authorities within 24 hours. If a client files a complaint or lawsuit, relevant information will be disclosed as needed to defend ourselves in the litigation process. If the counselor or medical records are subpoenaed, the counselor is compelled to respond. If a client is using insurance to pay for services, the insurance provider (as the payor) has the right to request medical records from the counselor. If the clinician becomes incapacitated or dies, records may be accessed through Jennifer Fanelli, Nina Moreno, Carrie Jones, Jill Rios, Leticia Sanchez, or Chelsea Morrow–all of whom are LPCs in this office.
Child and Adolescent Confidentiality:
Counselors adhere to the Licensed Professional Counselor board guidelines regarding confidentiality and minors. “Parents have the right to receive progress reports on their child’s counseling. However, personal information shared by a child during an individual session will be kept confidential unless it involves imminent danger to the child or someone else.” - Texas State Board of Examiners of Professional Counselors. When applicable, both parents will have an equal opportunity to communicate with me and receive the same information. When a minor has parents who are divorced or separated, I am required to obtain a copy of the divorce decree or custody agreement.
Couples Counseling and Confidentiality:
When a couple comes in for therapy, the couple and not the individual is the client. I will uphold the right to confidentiality within the unit. However, the counselor will maintain the integrity of the unit by not keeping secrets from either individual in the unit. Should one or both individuals within the couple decide to end couples therapy, the counseling relationship will terminate also. I do not bill insurance for couples counseling.
Communication:
Texting is used only to confirm appointments. Counseling cannot be conducted via texting.
While the client is welcome to text the counselor, the client is doing so under the understanding that:
● Texting is not HIPPA-secure.
● The counselor is not required to reply to the text unless it pertains to scheduling and is done during the counselor's business hours.
The counselor is not obligated to respond to texts, calls, and/or emails if they are conducted outside of normal business hours. The counselor will respond to a communication from the client within 48 business hours of the initial receipt of the communication. If the client is in crisis, they are encouraged to call a crisis line or 911.
Professional Boundaries:
Counselors have the ethical responsibility to not develop personal friendships, social networking, or business relationships with clients or their immediate family members. In regards to this, ethical responsibility is not limited to the duration of treatment. If interactions with clients or their families are unavoidable, the counselor will take appropriate steps to maintain professional boundaries and confidentiality.
Cancellation and No-Show Policy:
Commitment to counseling appointments is important. I understand that emergencies and illnesses do arise and there is not always 24 hours' notice. A late cancellation is 24 (business hours) or less notice. A no-show is a missed appointment without notice. The fee for a late cancellation or no-show is $50. If the counselor agrees that there is an emergency or special circumstances, the counselor may waive the fee. The counselor will continue to offer text reminders the day before the appointment as a courtesy but this is not required of the counselor. If you believe you have an appointment the next day and have not received a text reminder, please text/call to confirm. Thank you for your cooperation in this matter.
The counselor will notify the client by text or voicemail if the counselor must reschedule an appointment. Reasonable efforts will be made by the counselor to show the same 24-hour courtesy that is expected of the client but can not be guaranteed.
Inclement weather resulting in local school closures will automatically be canceled to protect the safety of the client and counselor. Telehealth may be offered as an alternative on inclement weather days.
If the client no-shows for their scheduled appointment and has not made concerted efforts to reschedule with the counselor within one week of the scheduled appointment, the client will be terminated from counseling services.
Fees for Services:
Individual, 53-60 minutes: $135
Extended Session, Past 60 minutes: $2/minute, in addition to the base rate
Couple/Family, 53-60 minutes: $160
I’m using Ivy Pay to take credit cards. It works with credit, debit, HSA, and FSA cards. It’s HIPAA-secure, keeps our therapy confidential, and makes payment easy for you and me. All I need is your mobile number.
Insurance: For clients who have policies with BCBS, United Healthcare, Aetna, Optum, and Cigna: I am using Headway to process claims, copays, fees, and deductibles for these insurances. Headway will ask for client, payment, and insurance information. There is also a privacy practices agreement that requires acknowledgment.
Copy of records: $25 plus $1 per page. If the chart is large, the option for a treatment summary is available for $25.
Legal Proceedings: A $2000 retainer is due within 48 hours of the subpoena being served. The person who signs the informed consent is responsible for payment to the counselor regardless of who issues the subpoena. The retainer will cover $250/hour and this includes any preparation, transportation, consultations, and participation/attendance at legal proceedings. Additional expenses the retainer may include (but are not limited to) are paid for by the counselor’s attorney and travel expenses if the court is outside of Potter or Randall County. If expenses go beyond the retainer, the counselor will itemize and charge the person signing this consent. The counselor may use the credit card on file to charge for court-related expenses.
According to the No Surprises Act passed by the U.S. Congress and in effect for January 2022, Good Faith Estimates (listed above) must be provided to all patients. Disclaimers: There may be additional items or services that are recommended as part of your treatment that will be scheduled separately and are not reflected in the good faith estimate. Information provided in the good faith estimate is only an estimate and actual items, services or charges may differ from a good faith estimate. Also, a good faith estimate does not require the private pay patient to obtain psychotherapy or other services from this counselor. As a courtesy, for patients who are using insurance and provide their insurance information to the provider 7 business days before the appointment, I will look up benefits and give you a good faith estimate of your portion of the payment to the provider. I obtain this information directly from the insurance companies and occasionally I am misinformed by the insurance. Your counselor is not responsible for any misinformation provided by the insurance. It is recommended that patients also check their insurance benefits before their appointment.
**I may use your credit card on file for any unpaid balances. If I am unable to process your card, you will be billed for any past-due balances you may owe. Accounts with balances more than 90 days old may be referred to collections for processing. I reserve the right to temporarily suspend scheduling further appointments if an outstanding balance is not paid and/or payment arrangements are not made or complied with. Referrals to appropriate services will be made as requested. Payments are due at the time of service. In the event the client is a minor, the person who brings the client to the appointment is responsible for payment. It is not the counselor’s policy to get involved with custody and payment disputes for a minor client. If a charge is disputed, the client agrees that confidentiality may be broken in order to effectively resolve disputed charges.
Counselor’s Information:
Caleb Baker M.Ed., LPC
License # 83098
NPI: 1215698261
521 SW 8th Ave
Amarillo, TX 79101
806-570-6100
calebbaker444@gmail.com
Crisis Hotline
Local: 806-359-6699
Text 741741
Call 988
Texas Behavioral Health Executive Council
George H.W. Bush State Office Bldg.
1801 Congress Ave., Ste. 7300
Austin, Texas 78701