CONSENT TO TREAT

In order for a Revive clinician/counselor/coach to perform treatment and services, clients must acknowledge and accept Revive's terms of service. Please read each section and initial, then sign and date at the bottom of the form.

Note: If your are receiving counseling or coaching as a couple or family, each person needs to complete their own Consent to Treat form.

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THE PROCESS

Revive Center for Wellness takes a collaborative approach when providing services to each client.  Therapy, counseling, and coaching work best when they are voluntary and a client chooses to participate in order to address the issues that may be affecting their quality of life.  The treatment goals and therapeutic approach will be discussed, reviewed, and revised periodically while in sessions with your therapist, counselor, or coach.

Therapy and Counseling clients can expect that the first 4-6 sessions will primarily focus on the client's history and the events that lead the client to seek the services of a professional.  During this initial period, the therapist or counselor will discuss what the client hopes to achieve from the experience, and together with the client will set goals. After the initial period, the client and provider will begin to actively work towards achieving the agreed upon goals.  

Health, Fitness, and Nutrition clients can expect a similar approach as therapy and counseling, however, the initial information gathering and goal-setting period is usually less than what is required for therapy.

It is important to understand that therapy, counseling, and coaching are only effective and successful when the client is a willing participant and is committed to the process.  Periodically, clinicians/coaches will check in with clients to explore issues of effectiveness of the current approach.  If a client feels that counseling or coaching has not been effective or is not meeting their needs, they should discuss this issue with their clinician or coach so that their provider can make adjustments to their approach or explore alternate treatment options.

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SESSIONS

Sessions are to be scheduled in advance directly with your therapist, counselor, or coach.   Sessions are scheduled for 55 minutes, and each provider is responsible for using their discretion when allocating the breakdown between therapeutic activities and administrative tasks, such as collecting payments and booking future sessions.

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FEES

Clients are responsible for making full payment to their Provider on their portion of the cost for services rendered at the time of service.  

Revive accepts multiple forms of payment: 
• Check (Payable to “Revive Center for Wellness”)
• Paypal (Send to: Payment@ReviveCenterForWellness.com)
• Venmo (Send To: @Revive-CenterForWellness)
• Credit Card  

In order to streamline the payment process and reduce the session time spent in administrative activities, Revive asks all clients to complete the Payment Options form, which allows Revive to keep payment preference information on file.  There will be a $25 service charge assessed for bounced checks.  Clients will be unable to schedule future sessions while they have an outstanding balance for services rendered.

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CANCELLATION POLICY

Twenty-four hours notice is required for cancellations.  If proper notice of cancellation is not given, at your provider’s discretion, you will be charged the full session fee.  Providers will take emergencies and extenuating circumstances into consideration.

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CANCELLATION DUE TO WEATHER/NATURAL DISASTERS/GLOBAL FACTORS

Revive recommends that each Provider follow the schedule of the local public school district, when determining whether to hold in-office appointments.  If the public school district of the town where you’re scheduled to receive treatment has been closed due to weather or natural disaster, then Revive recommends Providers cancel their in-office sessions at that treatment facility.

In order to maintain both safety and the continuity of care, Revive offers virtual teletherapy sessions that utilize a free and secure online platform as an alternative to in-office appointments.

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INSURANCE

Each Provider is independently paneled with insurance carriers.  If you are interested in submitting to insurance as in-network, please inform your provider of your insurance plan and they will let you know if it is one that they currently accept.  If you  are submitting for in-network benefits, you will only be responsible for paying copays and deductibles as specified by your plan.  If your Provider does not accept your insurance be advised that some insurance companies will reimburse for sessions with non-participating providers as an “out of network provider”.  It is the client’s responsibility to inquire with their insurance company regarding the fees and reimbursement offered to them through their insurance plan. However, Revive will process the out-of-network claim for clients.  Clients submitting for out of network benefits are responsible for making full payment at the time of service, and their benefits reimbursement will be mailed to them directly from their insurance carrier.

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CONFIDENTIALITY

Confidentiality is an important part of the Client-Therapist relationship (known as the therapeutic alliance) and Clients should all be aware of their rights and the exceptions to those rights.  Confidentiality is mandated by The Privacy Rule within the HIPAA Laws, it states that any information shared between the Client and the Therapist/Counselor during a session falls within Doctor-Patient Privilege.  There are a number of exceptions to the rule, below are the main exceptions (other less common exceptions do exist)

   • A reasonable belief exists that the Client is abusing or neglecting a child, elder, or vulnerable adult, or if the Client provides information about someone else who is.  Providers are legally obligated to inform Child Protective Services or Adult Protective Services.
   • A reasonable belief exists that the Client is in imminent danger of harming him/herself or another person.  Providers are legally obligated to alert the appropriate authorities.
   • A reasonable belief exists that someone is neglecting, abusing, or at risk of imminently harming the Client.  Providers are legally obligated to notify the appropriate authorities.

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EMERGENCIES

In case of emergency or crisis where immediate intervention is needed, clients should contact 911 or go to the nearest emergency room, and provide them with their provider’s contact information.

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SUPERVISION OF CHILDREN

In order to ensure the safety of both the client and the provider, it is expected that parents and/or guardians of children will remain present while the child is in a session.

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LEGAL MATTERS

Revive and its providers do not participate in legal matters, including but not limited to trials, hearings, and testimonies.  If Revive or its providers are mandated to participate in a legal matter, the right of doctor/patient confidentiality will be exercised.

CUSTODY OF MINORS

In regard to minors, where matters of custody are concerned, please upload or provide documentation regarding the custody arrangement so appropriate consent to treat can be ascertained.

Maximum file size: 516MB

ACKNOWLEDGEMENTS

The signatures below indicate that you have voluntarily agreed to enter into therapy.  The information contained in this form has been discussed with you and understood by all participating members of therapy.  Concerns about these items may be discussed at any point in the therapeutic process.

Client Full Name *

Parent/Guardian Name (If Minor)

Clinician Assigned to Client *

Date *

Signature *

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