Informed Consent Informed Consent Patient Name* First Last Patient Date of Birth* Month Day Year HiddenInformed ConsentWhat does child/adolescent treatment look like at LOA and what is required of me? LOA values a team based approach where parents play an active role in the treatment plan. Therefore, it is required that at least one parent attends each appointment. You will either be actively involved in the whole session or part of the session, depending on clinical recommendations of your LOA therapist but no matter what, your participation will be a key component in the creation and implementation of successful CBT treatment plan for your child so be prepared for hard but important work that will assist your child in moving past stress and anxiety as rapidly as possible. What can I expect from initial visit? The first 2 sessions are devoted to a comprehensive assessment of your problems and the development of a treatment plan. It is recommended thatthe initial assessment sessions are parents only in order to gather as much pertinent information as possible prior to bringing the child/adolescent to appointments. After the initial assessment is completed, the treatment plan will be reviewed and recommendations will be provided regarding which Light On Anxiety therapist will be the best fit based on clinical needs and scheduling requirements. Note: the therapist who conducts the initial assessment may not be the therapist who provides ongoing treatment, but all initial findings will be thoroughly discussed and reviewed with the assigned Light On Anxiety therapist. What will treatment entail? Treatment will include one or a combination of the following: individual therapy (which can include family members), referrals to a psychiatrist for medication evaluation, specialized exposure therapy or referrals to a physician for medical evaluation. Exposure therapy may occur on a weekly basis, or may be required on a more intensive basis when your difficulties are more severe. All therapy we offer is empirically supported and provided to you because it is the treatment determined to be the most effective in assisting you or your child in overcoming anxiety or anxiety-related conditions. What is expected of me? We expect you to come prepared to work hard and play an active role in treatment. We will serve as your anxiety coach and teach you the skills and provide you with the support to move forward in living a vital life. But it is up to YOU to do the hard and transformative work of applying these new skills in your every day life. How frequently will we meet? A treatment plan will be customized to your needs and therefore, after the initial assessment, your therapist will be able to provide you with a recommendation for treatment intensity. When will treatment be completed? Light On Anxiety strives to make treatment as effective and efficient as possible. Therefore progress towards your defined therapeutic goals will be measured frequently. As you move past the challenges that lead you to initiate therapy, your therapist will discuss with you the process of terminating treatment as you become your own anxiety coach. What if I need to take a break from therapy? Clients can miss up to two consecutive sessions and still have their weekly spot held. If a client needs to miss three or more consecutive sessions, clients will be connected with our scheduling department in order to review therapist options upon return from break. What if I need to reach you in between sessions? If you or your child are in a mental health emergency and require immediate assistance, please go to the nearest hospital emergency room and leave a voicemail message for your therapist to notify them of the emergency (312.508.3645). If you are uncertain how to manage a panic attack or an exposure assignment, you are welcome to leave a message for your therapist on their voicemail. Your Light On Anxiety therapist will get back to you with 24 hours on business days. If you believe that you need therapy that provides 24 hour crisis management, please discuss this with your therapist and they will help you find a referral to a program that can best meet your needs. What is your policy on electronic communication? For communication between sessions, we only use email communication and text messaging with your permission and only for administrative purposes unless we have made another agreement. This means that email exchanges and text messages with the office should be limited to administrative matters. This includes things like setting and changing appointments, billing matters, and other related issues. You should be aware that we cannot guarantee the confidentiality of any information communicated by email or text. Therefore, we will not discuss any clinical information by email or text and prefer that you do not either. Also, we do not regularly check email or texts, nor do we respond immediately, so these methods should not be used if there is an emergency. Treatment is most effective when clinical discussions occur at your regularly scheduled sessions. But if an urgent issue arises, you should feel free to attempt to reach out to us by phone. We will try to return your call within 24 hours except on weekends and holidays. If you are unable to reach us and feel that you cannot wait for us to return your call, contact your family physician or the nearest emergency room and ask for the psychologist or psychiatrist on call. If we will be unavailable for extended time, we will provide you the name of a colleague to contact in my absence if necessary. Do you accept insurance? Currently, Light On Anxiety Treatment Center only contracts as an in network provider with Blue Cross Blue Shield of Illinois (BCBSIL) Preferred Provider Organization (PPO), Blue Choice PPO and Aetna. Your insurance will provide a quote of benefits, not a guarantee of payment. While the filing of insurance claims is a courtesy we extend to our in network clients, all charges are your responsibility from the date services are rendered. Reimbursement varies depending upon the level of benefits that you and your employer have chosen. Your degree of coverage is a matter between you and your insurance company and/or your employer. Light On Anxiety cannot guarantee that your insurance will cover my services. You should verify with your carrier that it will be covered and to what extent. You will be expected to pay all co-payments, deductibles, and for uncovered and ineligible services. If your insurance company has not paid a claim within 20 days of submission, you accept full responsibility for payment in full for any outstanding balance. For clients looking to obtain reimbursement from other insurers, we are happy to submit an out of network claim on behalf of the client to facilitate reimbursement of out-of-network mental health claims. Your copay is due at the time of your session. If you do not know your copay amount at the time of session, your therapist will collect the industry standard copay amount of $20 at the time of session and our billing department will make any necesary adjustments upon receiving payment from BCBS. Your insurance company may require us to contact them to discuss your treatment and progress. We are glad to respond to brief requests for information. In the event that extensive information or written reports are requested, Light On Anxiety staff will contact you to discuss the likely fees associated with providing these services. Insurance companies may have different levels of coverage. In addition, if your BCBS member ID begins with CTY we recommend you contact your insurance provider to determine if you need to obtain preauthorization prior to commencing treatment at Light On Anxiety. For all other insurance plans, clients are responsible for paying Light On Anxiety directly and then Light On Anxiety can electronically submit a paid super bill on your behalf to facilitate obtaining out of network reimbursement. If you are interested in having Light On Anxiety submit a superbill to your insurance company, please provide your insurance information. Do you accept Medicare/Medicaid? Light On Anxiety Treatment Center is not a covered provider for Medicare or Medicaid. Therefore you or your legal representative accept full responsibility for payment of all charges. Usual Medicare limits to charges and services do not apply. By choosing to work with Light On Anxiety, you acknowledge that you completely forego the use of these benefits for your treatment at this center and agree that neither you nor any representative will file any claims to Medicare or Medicaid, nor will you ask the provider to do so. You acknowledge that you freely enter this contract with the knowledge of your right to obtain Medicare covered services from providers who have not opted out of Medicare, and understand that you are not compelled to enter into private contracts with providers who have not opted out of Medicare. How much will treatment cost? Light On Anxiety strives to make treatment as short term and cost effective as possible. Light On Anxiety therapists know that it is their job to get you back into your life as quickly as possible. Fees for light on anxiety therapy services are: Master Level Clinician: 25 minute session: $90 40 minute session: $135 55 minute session: $180 Intake sessions (first 2 appointments): $180 each ($360 total) Ph.D Level Clinician: 25 minute session: $130 40 minute session: $195 55 minute session: $260 Intake sessions (first 2 appointments): $260 each ($520 total) Add-on services: Light On Anxiety staff are available for home visits and other out of office exposure based work, when clinically necessary. These services are pro-rated in 15’ increments at the therapist’s hourly rate. Travel time to and from the office is included in the total charge. Light On Anxiety staff are also available via email, text and phone, for between session assistance. In addition, Light On Anxiety staff is available to consult with other providers and write reports. These services will also be pro-rated in 15’ increments at the therapist’s hourly rate. These calls may, or may not, be covered by insurance. What is your cancellation policy? A fee for the missed session is charged for cancellations with less than 24 hours notice. Charges for missed appointments are not covered by insurance and are your responsibility. Are there any limits to confidentiality? The information you share in therapy is confidential and will not be disclosed without your written permission except when you may pose a danger to yourself or others or as required under Illinois and Federal law. If we ever suspect you are at risk to harm yourself or others, we are required to report this to the Firearm Owners Identification (FOID) program. If you disclose information related to suspected child or elder abuse, Light On Anxiety is obligated to report it. If Light On Anxiety receives a court order signed by a judge to release your information, I am obligated to honor it. Light On Anxiety Litigation Policy I agree that I am here for treatment and that I have been advised that if I need an expert witness in my case, I should hire someone specifically for that purpose. I understand that my Light on Anxiety therapist will not serve as a witness in any type of litigation. I agree to advise my attorney that Light On Anxiety will not become involved in any litigation. I agree that should I seek the Light On Anxiety's involvement in such litigation I will be responsible for Light On Anxiety's attorney fees in consulting an attorney to avoid involvement. If ordered by the court to participate in the litigation, either in giving a deposition or testifying or if I voluntarily agree the following rules shall I apply: 1. Fees for time involved in preparing a report(s) for LOA attorney or the court must be paid in advance before such report will be written. 2. The fee for LOA testimony or deposition must be for a 3 hour block of time at $900 for the three hours. Any time exceeding the 3 hours including travel time, shall be billed at the rate of $400 per hour. Fees must be paid at least one week in advance of the testimony being given. If not paid in advance, LOA will not appear to give testimony. 3. If the testimony date is cancelled or rescheduled with less than one business day’s notice, the fee will not be returned or will still be owed. Any further rescheduling will require the payment of another 3 hour minimum fee. Light on Anxiety Child Custody Litigation Policy I hereby confirm I have brought my child to Light on Anxiety to address his/her mental health issues. I understand that the role of Light on Anxiety is to treat mental health issues and that LOA will not become involved in any custody or visitation disputes. I recognize that for my child’s mental health, it is important not to involve the therapist in court proceedings. I therefore agree that as a condition of treatment for my child, I will not seek to have my LOA therapist testify in court, give a deposition, or an affidavit. I understand that the therapist will only become involved when the therapist determines it is necessary to protect the child. I agree to advise my attorney that the treating therapist will not become involved in any custody/visitation litigation. I agree that should I seek the therapist’s involvement in such litigation I will be responsible for the therapist’s attorneys fees in consulting an attorney to avoid involvement, and if ordered by the court to participate in the litigation, I agree to pay one week in advance of any court hearing for a minimum of at least 3 hours of the therapist’s time at the rate of $300 per hour. I understand that if I seek to involve the therapist, he/she may immediately discontinue care with my child. Light On Anxiety In Person Treatment Policy Completion of this health consent form is required prior to initiating in person treatment at LOA or entering a LOA office space, in order to maximize health and safety for all. In order for LOA to provide you with in-person services, the following protocols must be followed by patients/clients and providers: (1) All clients ages 5 and older must be fully vaccinated against COVID-19. (2) Hand sanitizer will be provided at the office entrance and must be used upon entering the office. (3) Social distancing requirements must be met. (4) Patients and providers will be required to wear face coverings or masks while in the office as long as encouraged by the CDC. Note: If you do not have a face covering, one will be provided to you. If at any point during your treatment with Light on Anxiety you become ill, your sessions will be moved to our Web-Based Platform until you have been symptom free for 14 days or can provide a negative test result. We remain committed to following state and federal guidelines and to adhering to prevailing professional healthcare standards to limit the transmission of COVID-19 in our offices. Despite our careful attention to sanitization, social distancing, and other protocols, there is still a chance that you will be exposed to COVID-19 in our office. If, at any point, you prefer to stop in-person services or to consider transitioning to remote services, please let us know. Light On Anxiety Telehealth Treatment Policy Benefits and Risks of Telehealth Telehealth refers to providing services remotely using telecommunications technologies such as video conferencing or telephone. One of the benefits of telepsychology is that the client and clinician can engage in services without being in the same physical location. This can be helpful in ensuring continuity of care if the client or clinician moves to a different location, takes an extended vacation, or is otherwise unable to continue to meet in person. It is also more convenient and takes less time. Telehealth, however, requires technical competence on both our parts to be helpful. Although there are benefits of telehealth, there are some differences between in-person therapy and telehealth, as well as some risks. For example: Risks to Confidentiality Because telehealth sessions take place outside of the therapist’s private office, there is potential for other people to overhear sessions if you are not in a private place during the session. We will take reasonable steps to ensure your privacy, but it is important for you to make sure you find a private place for our session where you will not be interrupted. It is also important for you to protect the privacy of our session on your cell phone or other device. You should participate in therapy only while in a room or area where other people are not present and cannot overhear the conversation. Data Protection The nature of electronic communications technologies is such that we cannot guarantee that our communications will be kept confidential or that other people may not gain access to our communications. We will make every attempt to use updated encryption methods, firewalls, and back-up systems to help keep your information private, but there is a risk that our electronic communications may be compromised, unsecured, or accessed by others. You should also take reasonable steps to ensure the security of our communications (for example, only using secure networks for telehealth sessions and having passwords to protect the device you use for telehealth). Technology Issues There are many ways that technology issues might impact telepsychology. For example, technology may stop working during a session, other people might be able to get access to our private conversation, or stored data could be accessed by unauthorized people or companies. Appropriateness of Telehealth Usually, we will not engage in telehealth with clients who are currently in a crisis situation requiring high levels of support and intervention. Before engaging in telehealth, we will develop an emergency response plan to address potential crisis situations that may arise during the course of our telehealth work. From time to time, we may schedule in-person sessions to "check-in" with one another. We will let you know if we decide that telehealth is no longer the most appropriate form of treatment for you. We will discuss options of engaging in in-person counseling or referrals to another professional in your location who can provide appropriate services. Emergencies and Technology Assessing and evaluating threats and other emergencies can be more difficult when conducting telehealth than in traditional in-person therapy. To address some of these difficulties, we will create an emergency plan before engaging in telehealth services. We will ask you to identify an emergency contact person who is near your location and who we will contact in the event of a crisis or emergency to assist in addressing the situation. We will ask that you sign a separate authorization form allowing me to contact your emergency contact person as needed during such a crisis or emergency. If the session is interrupted for any reason, such as the technological connection fails, and you are having an emergency, do not call us back. Instead, call 911, or go to your nearest emergency room. Call us back after you have called or obtained emergency services. If the session is interrupted and you are not having an emergency, disconnect from the session and we will wait two (2) minutes and then re-contact you via the telehealth platform on which we agreed to conduct therapy. If you do not receive a call back within two (2) minutes, call us on the phone number provided to you. If there is a technological failure and we are unable to resume the connection, you will only be charged the prorated amount of actual session time. Fees The same fee rates will apply for telehealth as apply for in-person therapy. However, insurance or other managed care providers may not cover sessions that are conducted via telecommunication. If your insurance provider does not cover electronic telehealth sessions, you will be solely responsible for the entire fee of the session. Please contact your insurance company prior to engaging in telehealth sessions in order to determine whether these sessions will be covered. Records We will maintain a record of our session in the same way we maintain records of in-person sessions in accordance with our policies. Light On Anxiety's policy regarding treating multiple family members: Light On Anxiety is happy to be of assistance to multiple members within a family. Unless a release of information is signed, information will not be shared between Light On Anxiety therapists. Also, if ever it becomes unhelpful for Light On Anxiety to be seeing multiple family members, Light On Anxiety will provide the appropriate external referrals and assist with a care transition plan. Light On Anxiety (LOA) has asked you to read and sign this Consent For Services Form before you/your child start therapy. Please review the information. If you have any questions, please contact LOA. Generally, when this form uses the words "you" or "your," it is referring to the client who is receiving services at LOA. However, "you" and "your" may also refer to a minor-patient's parent(s), legal guardian or other personal representative. THE THERAPY PROCESS Light On Anxiety specializes in Cognitive Behavioral Therapy (CBT) for anxiety, OCD and related disorders. Our services are practical, short-term and action-oriented. You will participate in empirically-supported, user-friendly exercises to practice thinking new thoughts and engaging in more effective behaviors. The more you work your mental muscles, the more quickly you will rewire your brain to obtain freedom from anxiety. How long does treatment last? - On average, CBT for anxiety treatment is completed within 6-12 months. - After your initial assessment, a treatment plan will be customized to meet your needs. - Your therapist will review your treatment plan with you every 90 days to highlight progress and discuss opportunities. - As you move past the challenges that led you to initiate therapy, your therapist will discuss the process of terminating treatment, including (1) scheduling an annual mental health check-up session, (2) identifying supports to help you maintain your progress and (3) discussing signs of when it may be beneficial to return to active therapy in the future. What is expected of you? - LOA’s CBT methodology requires active, engaged participation in sessions. - In addition to the work completed in session, you and your therapist will identify practice opportunities for you to engage in between sessions. - Consistent, on-time attendance is required to effectively engage in regularly scheduled treatment at LOA. If you are late to or miss more than 1 out of 4 scheduled sessions, the Care Management team will review alternate scheduling options with you. What is expected of parents / legal guardians (for child/adolescent clients)? - Parent / legal guardian participation is a key component of successful implementation of CBT for anxiety treatment plans. - Parent / legal guardian involvement for your child may involve joining for the entire session, part of the session or having separate parent sessions. - The exact format in which you will be involved in your child’s treatment plan will be determined based on information obtained in the intake session and may be adjusted over time, depending on the recommendations of the LOA clinician you are working with. - It is required that at least one parent / legal guardian be available during the time of the session in order to communicate with the therapist on an as-needed basis. IN-PERSON SERVICES & SARS-CoV-2 ("COVID-19") Light On Anxiety remains committed to following state and federal guidelines and adhering to prevailing professional healthcare standards to limit the transmission of COVID-19 in our offices. In order for LOA to provide you with in-person services, the following protocols must be followed by clients and providers: - All clients ages 5 and older must be fully vaccinated against COVID-19. - Hand sanitizer will be provided at the office entrance and must be used upon entering the office. - Social distancing and face coverings will be required in accordance with CDC guidelines. If you do not have a face covering, one will be provided for you. - If at any point during your treatment with LOA you become ill, your sessions will be moved to telehealth until you have fulfilled the applicable CDC requirements for quarantine/isolation or can provide a negative test result. By consenting to in-person treatment you acknowledge that there is still a potential risk of exposure and that you agree to follow the safety protocols outlined above in order to engage in in-person services. In addition, you agree that if your health status changes, you will delay entering an LOA office space/receiving in person treatment until you are no longer experiencing COVID-19 (or any other infectious disease) symptoms and have been symptom-free for the appropriate time frame, per CDC guidelines. TELEHEALTH SERVICES Telehealth services are provided remotely using video conferencing or telephone. To access services, you will need an Internet connection and a device with a camera and microphone. If we determine telehealth is no longer the most appropriate form of treatment for you, we will discuss options such as in-person counseling or referrals to an appropriate external provider in your location. Using telehealth has both risks and benefits: Risks: - Privacy and Confidentiality. As telehealth sessions occur outside the Light On Anxiety office, there is the potential for others to overhear information you are sharing. LOA will take reasonable steps to ensure your privacy, and it is important that you do the same. - Data Protection. You may be asked to share personal information with the telehealth platform to create an account. LOA carefully vets any telehealth platform to ensure your information is secured to the appropriate standard. LOA makes every attempt to keep your information private, but there is a risk that our electronic communications or stored data may be compromised, unsecured or accessed by others. - Technology. At times, you could have problems with your internet, video or sound. If you have issues during a session, you and your therapist will create a plan to move forward, such as changing telehealth platforms, finishing the session via telephone or rescheduling for a later date. - Crisis Management. Assessing and evaluating threats and emergencies can be more difficult when using telehealth than when engaged in in-person therapy. Before engaging in telehealth, we will develop an emergency response plan to address potential crisis situations that may arise during the course of our work. Benefits: - Flexibility. You can attend therapy wherever is convenient for you. - Ease of Access. You can attend telehealth sessions without the need for travel, so less time is required for each appointment. You can also attend therapy during inclement weather or illness. Recommendations: - Only participate in telehealth from a private place where other people are not present and cannot overhear the conversation, and where you will not be interrupted. - Take reasonable steps to ensure the security of our communications (i.e. only use secure networks for telehealth sessions and use a password-protected device). - Do not use video or audio to record your session unless your therapist gives you permission in advance. - Make sure to let your therapist know if you are not in your usual location before beginning a telehealth session. If the telehealth session is interrupted for any reason: - If you are having an emergency, do not call us back. Call 911 or go to your nearest emergency room. Call us after you have called or obtained emergency services. - If you are not having an emergency, disconnect from the session and wait two (2) minutes, then re-connect to the telehealth platform. If we are unable to connect after two (2) minutes, call us on the phone. If we are unable to resume the session, you will only be charged the prorated amount for actual session time. CONFIDENTIALITY The information you share in therapy is confidential and will not be disclosed without your written permission except as required under Illinois and Federal law. If Light On Anxiety must disclose your personal information without your permission, we will only disclose the minimum information necessary to satisfy the obligation. - If we believe you are at imminent risk of harming yourself, we may contact crisis services or law enforcement. - If we believe there is a specific, credible threat of harm to someone else, we are required by law to notify law enforcement. - The Firearm Owners Identification (FOID) program must be notified if we suspect you are at risk to harm yourself or others. - If you disclose information related to suspected abuse or neglect of a minor or elderly individual, we are obligated to report it to the appropriate authorities. - If Light On Anxiety receives a court order signed by a judge to release your information, we are obligated to honor it. RECORD KEEPING Light On Anxiety is required to keep records about your treatment. These records help ensure the quality and continuity of your care, as well as provide evidence that the services you receive meet the appropriate standards of care. Your records are maintained in an electronic health record provided by TherapyNotes. TherapyNotes has several safety features to protect your personal information, including advanced encryption techniques to make your personal information difficult to decode, firewalls to prevent unauthorized access, and a team of professionals monitoring the system for suspicious activity. TherapyNotes keeps records of all log-ins and actions within the system. COMMUNICATION Communication outside of session should be limited to administrative matters. If you have a clinical matter you would like to discuss prior to your next scheduled session, you can schedule an on demand session via the client portal or use the symptom log on the Light On Anxiety website to store the information for your next session. Email communication is used only with your permission and only for administrative purposes. - Light On Anxiety cannot guarantee the confidentiality of any information communicated electronically. - We will not discuss any clinical information via email and ask that you do not either. - If you do send us an email with clinical information, we will save this information in your clinical record and discuss it at your next appointment. - If you have questions regarding scheduling or changing appointments, billing, or other administrative matters, please email our Care Management team at [email protected] If you or your child is experiencing a mental health emergency and require immediate assistance, please call 911 or go to the nearest emergency room. When possible, call Light On Anxiety at (312) 508-3645 to inform our Care Management team of the emergency. If you believe you need treatment that includes 24-hour crisis management, please let us know and we would be happy to assist you in identifying a program that can best meet your needs. FEES AND PAYMENT FOR SERVICES Light On Anxiety is available for sessions in-person and via telehealth (including phone and video conferencing). In-Network Services: - Light On Anxiety contracts as an in-network provider with Blue Cross Blue Shield of Illinois (BCBSIL) Preferred Provider Organization (PPO), Blue Choice PPO and Aetna. - Your insurance will provide a quote of benefits, not a guarantee of payment. LOA cannot guarantee that your insurance will cover our services. - All charges are your responsibility from the date services are rendered. You should verify with your carrier that it will be covered and to what extent. - Insurance may not cover sessions that are conducted via telecommunication. Please contact your insurance company prior to engaging in telehealth sessions in order to determine whether these sessions will be covered. - Reimbursement varies depending upon the level of benefits that you and your employer have chosen. Your degree of coverage is a matter between you and your insurance company and/or your employer. - You will be expected to pay the full patient responsibility amount, including copayments and deductibles. If your insurance company has not paid a claim within 20 days of submission, you accept full responsibility for payment in full for any outstanding balance. - Uncovered and ineligible services will be charged at Light On Anxiety’s private pay rates, and you will be responsible for paying the full amount. Out of Network Services: - For any out of network insurance plan (including Medicare and Medicaid), clients are responsible for paying Light On Anxiety directly at the private pay rate at the time of service. - For clients with out-of-network insurance, Light On Anxiety is able to submit claims electronically, on a monthly basis, to facilitate obtaining out-of-network payment. - We recommend contacting your insurance company to learn about your out-of-network benefits. If you are interested in utilizing this service, please provide us with your insurance information. - Light On Anxiety is not a covered provider for Medicare or Medicaid. By choosing to work with LOA, you acknowledge that you completely forego the use of these benefits for your treatment and agree that neither you nor any representative will file any claims to Medicare or Medicaid, nor will you ask the provider to do so. Private Pay Rates: Light On Anxiety strives to make treatment as short term and cost effective as possible. LOA therapists know that it is their job to get you back into your life as quickly as possible. All clients not utilizing in-network insurance have the right to receive a "Good Faith Estimate". Private pay rates for clients not utilizing in-network benefits, or for ineligible services, are below and are subject to change. Rates for 53 minute sessions: - $180 for Master level clinicians (MA, MSW, LPC, LSW, LCPC, LCSW) - $260 for Doctorate level clinicians (PhD, PsyD) Cancellation Fee: - All appointments canceled with less than 48 hours notice are subject to a cancellation fee of $100. - Charges for missed appointments are not covered by insurance and are your responsibility. Add-On Services: Coordination of Care with External Providers - Coordination of care charges will be prorated for time spent at our hourly rate. - LOA values collaborative care with other providers as it helps to create the most integrated and appropriate treatment plan. - We attempt to keep all collaborative care exchanges as quick and effective as possible—typically about 20 minutes. Report and Letter Writing - Reports and letters can be provided by Light On Anxiety upon client request. - Clients must attend at least 2 sessions before any reports or letters can be written. - Report and letter writing charges will be prorated for time spent at our hourly rate. These charges are not covered by insurance and are your responsibility. - All clients, upon request, can receive a treatment summary including dates of service and diagnosis codes at no charge. Out of Office Services - Light On Anxiety therapists are available for out-of-office services (i.e. school visits, out of office sessions) when clinically necessary. - Charges for travel to and from the office will be prorated for time spent at our hourly rate. These charges are not covered by insurance and are your responsibility. LITIGATION POLICY Light On Anxiety is not available to serve as an expert witness or provide legal perspective on clinical material. LOA therapists will not serve as a witness in any type of litigation. If ordered by the court to participate in the litigation: - You are responsible for Light On Anxiety’s attorney fees. - Fees for time involved in preparing report(s) must be paid in advance. - The minimum fee for LOA testimony or deposition is $900 for 3 hours. Additional time will be billed at the rate of $400 per hour.Consent to Treatment* My signature on this document represents that I have received Light On Anxiety's Consent for Services form and that I understand and agree to the information therein. Further, I consent to use an electronic signature to acknowledge this agreement.Date* MM slash DD slash YYYY Print Name of Patient / Parent / Legal Guardian* Signature of Patient / Parent / Legal Guardian - Consent to Treatment*By signing this form, I consent to treatment. I certify that I have read this Informed Consent and understand and agree to abide by all its terms.