Shenikka Moore, LICSW

Telephone: (202) 779-1828

Email: goldenlifecounseling@gmail.com Website: www.goldenlifecounselingandcoaching.com

INFORMED CONSENT AND PRACTICE POLICIES

Thank you for choosing Golden Life Counseling & Coaching, LLC for your mental health care and assessment services. We believe
that the therapist-client relationship is strengthened when there is a clear understanding between both parties as to their rights and
obligations. We ask, therefore, that you review and sign the following statement of our Informed Consent and Practice Policies prior
to receiving treatment. If you have any questions about our treatment or payment policies, please do not hesitate to ask.
I, ________________________________________________consent to, understand, and agree that:
Treatment Policy:
• I understand and acknowledge that there are many different methods GOLDEN LIFE COUNSELING&COACHING, LLC
may use to address my problems/issues that I hope to address. I also understand and acknowledge that therapy is not like a medical
doctor visit and that it may call for a very active effort on my part such as working on things talked about both during sessions and at
home;
• I understand and acknowledge that therapy can have benefits and risks. Since therapy often involves discussing unpleasant
aspects of your life, you may experience uncomfortable feelings like sadness, guilt, anger, frustration, loneliness, helplessness, etc. On
the other hand, therapy has also been shown to have benefits for people who go through it. Therapy often leads to better relationships,
solutions to specific problems, significant reductions in feelings of distress, etc. But there are no guarantees of what I will experience.
• I have had the opportunity to discuss the risks and benefits of proposed treatment and therapeutic courses of treatment,
together with available alternatives, with the counselor or health professional to my satisfaction;
• I have the right to consent to or refuse any proposed therapeutic course of treatment;
• Golden Life Counseling and Coaching will provide the best care possible consistent with the prevailing standards of the
counseling practice but has made no assurances or guarantees as to the results of treatment; and
• Subject to the foregoing, the counselor of GOLDEN LIFE COUNSELING&COACHING, LLC and its clinical and
technical employees may administer any assessment and/or treatment deemed advisable for my care and treatment.
• I understand that information discussed in therapy is for therapeutic purposes and is not intended for use in any legal
proceedings involving any person. I agree not to subpoena any GOLDEN LIFE COUNSELING&COACHING, LLC
clinician, staff, and/or associate to testify for or against any party and/or to provide records in a court action. If
GOLDENLIFE COACHING&COACHING is required to participate in a court hearing, you will be expected to pay for
professional time even if another party compels me to testify.

Confidentiality Policy:

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Contents of all therapy sessions are considered to be confidential. Both verbal information and written records about a client cannot be
shared with another party without the written consent of the client or the client’s legal guardian. • By signing this document, you
agree to the below limits of confidentiality and understand their meanings and ramifications. Noted exceptions that are required by
law to disclose confidential information to appropriate authorities are as follows:
1. Duty to Warn and Protect: When a client discloses intentions or a plan to harm another person, the mental health
professional is required to warn the intended victim and report this information to legal (and military, when applicable) authorities. In
cases in which the client discloses or implies a plan for suicide, the health care professional is required to notify legal authorities and
make reasonable attempts to notify the family of the client.
2. Abuse of Children and Vulnerable Adults: If a client states or suggests that he or she is abusing a child (or vulnerable
adult) or has recently abused a child (or vulnerable adult), or a child (or vulnerable adult) is in danger of abuse, the mental health
professional is required to report this information to the appropriate social service and/or legal (and military) authorities.
3. Domestic Abuse (Military): If a Mental Health care professional believes that domestic abuse is occurring, they may be
required to report this information to the appropriate civilian and/or military authorities.
4. Prenatal Exposure to Controlled Substances: Mental Health care professionals are required to report admitted prenatal
exposure to controlled substances that are potentially harmful.
5. Minors/Guardianship: Parents or legal guardians of non-emancipated minor clients have the right to access the clients’
records.
6. Insurance Providers (when applicable): Insurance companies and other third-party payers are given information that they
request regarding services to clients. Information that may be requested includes type of services, dates/times of services, diagnosis,
treatment plan, and description of impairment, progress of therapy, case notes, and summaries.
Payment Policy and Fees:
GOLDEN LIFE COUNSELING&COACHING, LLC is a private business which relies solely on income from clients and their
insurers. In order to provide the best possible healthcare at the lowest possible cost, we need your assistance and agreement to our
payment policies: Insurance
• By signing this document, you agree to assign to GOLDEN LIFE COUNSELING&COACHING, LLC any
and all
healthcare benefits to which you are entitled under any policy of insurance (assessment/diagnostic interview, psychotherapy,
interactive psychotherapy, or any other insurance or benefit plan) and authorize, to the extent permitted by law, payment of those
benefits directly to Golden Life Counseling & Coaching, LLC, if applicable.
• Golden Life Counseling &Coaching will protect the privacy of your health information and will not use it
or disclose it
except in a manner that is permitted by state and federal law, as more fully described in the GOLDEN LIFE
COUNSELING&COACHING, LLC Notice of Privacy Policies that has been made available to you. By signing this document, you
consent to and authorize our use and disclosure of your health information in accordance with the Notice of Privacy Policies and
applicable law.
• If your healthcare and /or assessment services are covered by an insurance company with which we
participate, Golden Life Counseling & Coaching, LLC will submit a claim to your insurance company on your behalf.
However, you are required and, you agree to pay at the time of service, any required co-payments, co-insurance, and/or
deductibles, as well as charges for services not covered by insurance, outstanding balances, and delinquent accounts within
thirty (30) days of an invoice.
• If your healthcare services are covered by an insurance company with which we do NOT participate,
GOLDEN LIFE

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COUNSELING&COACHING, LLC will send/provide you with an itemized Statement/Invoice. However, you are required and, you
agree to pay at the time of service any charges for these services as well as any outstanding balances and delinquent accounts.

Self-Pay
• If you do not have (or choose not to use your) healthcare benefits and/or are a “self-pay” client, you are required and, you
agree to pay at the time of service, all charges as well as any outstanding balances and delinquent accounts. See “Fee Schedule”
below.
Fee Schedule
• Fees are dependent upon the service you receive. A receipt may be provided to you for your records and/or to submit for
possible insurance reimbursement. Payment is due at the time of each session, unless we have made other firm arrangements.
Initial Session (55-60 min.) $150
Individual (50-55 min.) $125
Couple/Family (55-60 min.) $135
Group (60-75 min) $60
(Effective January, 2017)

Collections and Non-Sufficient Funds

• In the event the account is turned over to an attorney for collection, you agree to pay interest charges, all costs and

reasonable attorney’s fees allowed by the law.

• You agree that, in the case of a returned check, or non-sufficient funds and/or declined credit/debit transaction, you will be
responsible to pay the original amount of the charge, plus a $50.00 fee.

Cancellation Policy:
Scheduled Appointments
You are required to attend your appointment on time. If you are more than 15 minutes late, you may be asked to
reschedule your appointment and you will be charged the late cancel/no show fee.

• By signing this document, you agree to provide at least 24 hours’ notice to cancel or reschedule an appointment.
• You agree that if you cancel or reschedule your scheduled appointment less than 24 hours before your appointed time
appointment or are a “no show,” you will be responsible to pay a $75.00 fee. In the case of an emergency, this fee may be waived at
the discretion of GOLDEN LIFE COUNSELING&COACHING, LLC.
• I understand that these fees are not covered by insurance and will be paid directly to GOLDEN LIFE
COUNSELING&COACHING, LLC.
• No-showing or cancelling appointments with less than 24 hours notice more than 2 times may result in discontinuing of
services at the discretion of GOLDEN LIFE COUNSELING&COACHING, LLC.
• Clients are generally seen weekly or less frequently as acuity dictates and you and I agree. You may leave me a
voicemail but I can’t guarantee that I will be available immediately. I only return calls during regular business hours,
Monday through Friday. In the event of an emergency you may call your primary care physician, your psychiatrist, the
local emergency room, the suicide crisis hotline 1-800-273-8255 or 911.

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Termination of Counseling
Counseling is voluntary. Both you and GOLDEN LIFE COUNSELING&COACHING, LLC reserves the right to transfer/terminate
services at any time, for any reason, however it is recommended that adequate notice is given to allow for discharge planning.
GOLDEN LIFE COUNSELING&COACHING, LLC will make every effort to provide referrals if termination is requested by either
party.

Clinical Emergencies and Inclement Weather

• I have been informed and agree to, that on unforeseen occasion(s), GOLDEN LIFE COUNSELING&COACHING, LLC
may need to address clinical emergencies, which may interfere with scheduled appointment(s). As such, GOLDEN LIFE
COUNSELING&COACHING, LLC will use its best offers to offer a mutually convenient appointment to reschedule.
I understand that, in the case of inclement weather or office closure, GOLDEN LIFE COUNSELING&COACHING, LLC
may offer telephone counseling or reschedule scheduled appointment(s) as an alternative.

Social Media Policy

I do not accept friend or contact requests from current or former clients on any social networking site (Facebook, LinkedIn, etc).

Sick Policy
In cases where myself or clients who are sick or contagious, a video session may be requested to avoid the spread of germs to either
party.

Email/SMS Text Message

If you need to contact me between sessions, the best way to do so is by phone or direct email at goldenlifecounseling@gmail.com for
quick, administrative issues such as changing appointment times. I prefer using email only to arrange or modify appointments as email
is not completely secure or confidential. If you choose to communicate with me by email, be aware that all emails are retained in the
logs of your and my Internet service providers. While it is unlikely that someone will be looking at these logs, they are, in theory,
available to be read by the system administrator(s) of the Internet service provider. You should also know that any emails I receive
from you and any responses that I send to you become a part of your legal record. I understand that SMS messages are even less
secure than e-mail, and the same conditions apply.
I understand that for this reason I am advised me not to send sensitive information via email or SMS message.
I will provide you information for a HIPPA compliant secure platform for emails that contain sensitive or confidential information.
.
I acknowledge that I have read, understand, and will adhere to the Informed Consent and Practice Policies.

Client (or Parent/Guardian) Date

____ I do not wish to receive a copy of the Informed Consent and Practice Policies