Community Wellness Partners of NC PLLC
809 N. Lafayette St., Suite A, Shelby, NC 28150
1446 E. Gaston St. Suite 101, Lincolnton, NC 28092
Phone: (704) 284-0554
ACKNOWLEDGMENT OF CLIENT'S RIGHTS AND RESPONSIBILITIES
Check I Agree box
if you acknowledge and agree:
I understand that any balance over 60 days past due will incur a 1.5% interest fee,
retroactive to the date of service,
and that it is my responsibility to pay this balance regardless of any expectation on my part of third-party reimbursement. I realize that any money received by Shelby Wellness and Therapy Center, from third parties, over and above my indebtedness will be refunded to me after my account is paid in full, including any interest charges, at the end of treatment, or of the fiscal year, whichever comes last.
I acknowledge that there is no guarantee of results. I am responsible to pay in full, any balance for services rendered regardless of the outcome of therapy. I also realize SWTC may utilize all legal means to collect unpaid balances, and that I may incur further costs associated with the collection of this debt, including but not limited to legal fees and reimbursement for administrative time spent in the collections or court process.
I will be responsible for arriving on time, and for making and keeping all appointments. I realize that if I opt out of reminder text messages/emails/phone calls, I will
receive reminders and that SWTC is not responsible to remind me of my appointments. I understand that insurance companies do not reimburse for missed appointments. Any non-emergency missed appointments or cancellations without a minimum of 24 business-hours’ notice will incur the
entire session fee
(not a co-pay or discounted rate). Business hours are Monday and Wednesday 9am to 5pm, Tuesday and Thursday 9am to 9pm, and two Saturdays per month 9am to 4pm.
I read in the Informed Consent document, or have had explained to me, the potential risks of therapy and by signing below have agreed to all conditions. I understand the limits of confidentiality described in the Informed Consent document. Alternative treatment options have been or will be explained to me in my first appointment to my satisfaction, and I take responsibility to ask any questions I may have regarding this or anything else regarding my treatment. I also realize SWTC is not a crisis service, and I realize I will need to call 911 if I am in a life-threatening emergency.
AUDIO/VIDEO RECORDING PREFERENCES
As a standard practice in the psychotherapeutic context, therapists and therapists-in-training
occasionally audiotape or videotape counseling sessions for purposes of case review with peers
and/or supervisors, or for use in training, research or professional publication.
Therapists and therapists-in-training at Shelby Wellness and Therapy Center (SWTC) may
occasionally choose to tape sessions for the above purposes, with the express understanding that
confidentiality will be protected to the highest professional standard, and that
no identifying client
information would be used in any publications or research without specific consent to this effect.
Recordings of all counseling sessions will be destroyed immediately after its use as stated above, and
become a part of the clients' permanent record.
Clients of SWTC have the right to decline audio and/or video taping of counseling sessions; this is
a condition of treatment. Please sign below indicating your understanding of this policy, and
your preference regarding the occasional use of audio/video tapes for the above stated purposes.
this box if you
to have any appointments taped at this time.
this box if you understand the audio/video taping policy and
give your consent
to have your counselor occasionally record your sessions.
Client or legal Guardian Signature: