Client Counselor Agreement

Client-Counselor Service Agreement

Welcome to Joyful Beginnings Counseling, the practice of Paula Lupinetti-Chadwick, MSW LCSW. This document contains important information about my professional services and business policies. It also contains summary information about the Health Insurance Portability and Accountability Act (HIPAA), a federal law that provides privacy protections and patient rights about the use and disclosure of your Protected Health Information (PHI) for the purposes of treatment, payment, and health care operations. Although these documents are long and sometimes complex, it is very important that you understand them. When you sign the attached document, it will also represent an agreement between us. We can discuss any questions you have when you sign them or at any time in the future.

Counseling is a relationship between people that works in part because of clearly defined rights and responsibilities held by each person. As a client in counseling, you have certain rights and responsibilities that are important for you to understand. There are also legal limitations to those rights that you should be aware of. I, as your counselor, have corresponding responsibilities to you. These rights and responsibilities are described in the following sections.

Appointments: The time scheduled for your appointment is assigned to you and you alone. If you need to cancel or reschedule a session, I ask that you provide me with 24 hours’ notice. You can call or text my cell phone at (609) 346-5953. If you do not cancel your appointment within 24 hours notice, you will be charged a $50 fee. If you miss a session without canceling, or cancel with less than 2 hours notice, you will be required to pay the full fee for the session (this is the full fee paid by both you and your insurance company, not just your copayment). If there are 3 or more no-show visits, we may need to discuss a referral to another clinician. It is important to note that insurance companies do not provide reimbursement for cancelled sessions; thus, you will be responsible for the cancelation fee. In addition, you are responsible for coming to your session on time; if you are late, your appointment will still need to end on time. Your payment is due at the time of your appointment. Cash and check are accepted.

Confidentiality: Your counselor will make every effort to keep your personal information private. If you wish to have information released, you will be required to sign a consent form before such information will be released. There are some limitations to confidentiality to which you need to be aware. Your counselor may consult with a supervisor or other professional counselor in order to give you the best service. In the event that your counselor consults with another counselor, no identifying information such as your name would be released. Counselors are required by law to release information when the client poses a risk to themselves or others, and in cases of abuse to children or the elderly. If your counselor receives a court order or subpoena, she may be required to release some information. In such a case, your counselor will consult with other professionals and limit the release to only what is necessary by law. Additional information regarding your Protected Health Information is available upon request, or available for download on my website at

Record Keeping: Your counselor may keep records of your counseling sessions and a treatment plan which includes goals for your counseling. These records are kept to ensure a direction to your sessions and continuity in service. They will not be shared except with respect to the limits to confidentiality discussed in the Confidentiality section. Should the client wish to have their records released, they are required to sign a release of information which specifies what information is to be released and to whom. Records will be kept for the duration of the client’s treatment and for at least 2 years upon termination. Records will be kept either electronically in an electronic medical record or in a paper file and stored in a locked cabinet in the counselor’s office. Professional Fees You are responsible for paying at the time of your session unless prior arrangements have been made. Payment must be made by check or cash. If I am in network and you will be using your health insurance plan, your benefits will be verified, and you will only be responsible for your co-pay or co-insurance. You will be responsible for whatever your insurance does not cover, including if payment is denied by the health insurance company.

Insurance: If you have a health insurance policy, it will usually provide some coverage for mental health treatment. With your permission, I will file claims and ascertain information about your coverage, and you are responsible for letting me know if/when your coverage changes. You should also be aware that most insurance companies require you to authorize me to provide them with a clinical diagnosis. Sometimes I have to provide additional clinical information which will become part of the insurance company files. By signing the attached Agreement, you agree that I can provide requested information to your carrier if you plan to pay with insurance. If I am not a participating provider, or am out of network for your insurance plan, I will supply you with a receipt of payment for services, which you can submit to your insurance company for reimbursement. Please note that not all insurance companies reimburse for out-of-network providers.

Contacting Me: I am often not immediately available by telephone. I do not answer my phone when I am with clients or otherwise unavailable. At these times, you may leave a message on my confidential voice mail (609-346-5953) if the matter involves questions about your appointment or your insurance. Your call will be returned as soon as possible. You can also text me as it is my cell phone. If you are in crisis/if it is an emergency situation, go to your local hospital, call your local crisis center, or call 911. The county crisis centers for the area are: Burlington County: (609) 835-6180, Camden County: (856) 428-4357, Gloucester County: (856) 845-9100

updated: October 2017