Informed Consent

Thank you for choosing Blue Skies Counseling, LLC.  

Today’s appointment will take approximately 45 – 55 minutes.  

 I realize that starting counseling is a major decision and you may have many questions.  This document is intended to inform you of policies, State and Federal Laws and your rights.    

I have earned a Bachelors of Science Degree in Philosophy and Psychology from Illinois State University in Normal, IL and earned a Master’s degree in Mental Health Counseling from Capella University in Minneapolis, Minnesota.  I am licensed in the state of Illinois as Licensed Clinical Professional Counselor.  I have earned a certificate from Illinois Certification Board as a Certified Alcohol and Drug Counselor.  I have more than 15 years’ experience in clinical experience in treating adults and families using individual and family therapy.  

Treatment practices, philosophy and plan limitations and risks will be discussed with you today.  If you have other questions or concerns, please ask and I will try our best to give you all the information you need.

CONFIDENTIALITY AND EMERGENCY SITUATIONS: Your verbal communication and clinical records are strictly confidential except for: 

• information shared with consultants, 
• information, diagnosis and dates of services, shared with your insurance company to process your claims, 
• information you and/or your child or children report about physical or sexual abuse; then by Illinois State Law, I am obligated to report this to the Department of Children and Family Services,
• where you sign a release of information to have a specific information shared 
• if you provide information that informs me that you are in danger of harming yourself or others 
• information necessary for case supervision or consultation and/or when required by law.  

In the unlikely event that Rebecca Lynn is unable to provide ongoing services Tonya Bassett, LCPC, CADC, CCTS may be contacted at 1(309) 831-9558. If an emergency situation for which the client or their guardian feels immediate attention is necessary, please call the local hospital or emergency response personnel. Rebecca Lynn will follow those emergency services with standard counseling and support to the client or the client’s family. Email, text messages and social networking sites are not confidential and Rebecca Lynn may not be able to respond. 

Coordination of Treatment:   It is important that all health care providers work together.  As such, I would like your permission to communicate with your primary care physician and/or psychiatrist. 

 Your consent is valid for one year.  If you prefer to decline consent no information will be shared.  This authorization may be revoked at anytime.  Please provide your consent here.

Consent for Children or Adolescents:  Treatment for children and adolescents must be provided before the appointment here.

Financial Responsibility:  As a courtesy we will bill your insurance company, HMO, responsible or third party payer for you if you wish.  We ask that at each session you pay your co-pay or 50% of the fee.  In the event you have not met your deductible, the full fee is due at each session until the deductible is satisfied.  If your insurance company denies payment or does not cover counseling, we request that you pay the balance due at that time.  If your balance exceeds $300.00 we will need to ask that you pay for services when rendered. After 60 days, any unpaid balance will be charged 1.5% interest a month (18%APR).  In the event that an account is overdue and turned over to our collection agency, the client or responsible party will be held responsible for any collection fee charged to our office to collect the debt owed.  

We ask that every client authorize payment of medical benefits directly to the Blue Skies Counseling LLC.  You may put a credit card on file to pay for charges not covered by your insurance.    

 Lastly, if you need to cancel or reschedule an appointment, please give 24 business hours advance notice, otherwise you will be billed at the hourly rate.  We sincerely appreciate your cooperation and at any time you have any questions regarding insurance, fees, balances or payments please feel free to ask.  You may have a copy of this form if requested.