Welcome to Renewal Christian Counseling Center and thank you for allowing us to assist you along your journey! Please read and fill out this form carefully as it contains information about our professional services and business policies. Should you have any questions, please contact us via email at firstname.lastname@example.org.
It will take you approximately 15 minutes to complete this registration form. We must have these forms completed before services begin. If these forms are not completed before your scheduled appointment time, you may not be seen for services until this form is completed.
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Parent / Legal Guardian Information
Fill out this section if the client is a minor.
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Communicating With You
We may need to communicate with you through telephone, including leaving messages on your voicemail, mail, and email. Communications may include appointment reminders and account billing notifications; we will not communicate clinical information through these channels unless authorized/requested by you.
Communicating With Others
For your privacy, we do not give anyone your information or allow anyone to make changes on your behalf without your permission. Please list anyone you would like to give permission to access your appointment and billing information. This is often your spouse, family member, or caretaker. If you are the parent or guardian of the client who is a minor, please fill out your information below. We recommend "Appointment & Billing Information" contacts to be added for all parents or legal guardians if the client is a minor.
NOTE: This consent does not release private mental health information or diagnosis. This is only permission to access appointment and/or billing information. An additional consent form is required to release private and confidential mental health information.
We take your private health information seriously. While text and email messaging allow us to exchange information conveniently and efficiently, at the same time, we recognize that email and text messaging are not a completely secure means of communication because these messages can be addressed to the wrong person or accessed improperly on your device or during transmission. You are not required to use text messaging or email and this decision will not affect your health care in any way. If you prefer not to authorize the use of email and/or text messaging we will continue to use U.S. Mail or telephone to communicate with you.
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Payment For Services
We accept nearly all major insurance plans. Here are a few: Aetna, Blue Cross Blue Shield, Blue Care Network, Cofinity, Beacon Health, Cigna, Hap, McLaren, Medicaid, Medicare, Tricare, and more!
We also want therapy to be affordable and accessible to all. In order to assist our clients who do not have insurance coverage, we have established a cash sliding fee scale that is applied based on family income levels. You may take advantage of this fee reduction if your family income is below $120,000 per year and you can provide Renewal Center with your 1040 tax report or other proof of income to demonstrate your income level.
Primary Insurance Information
* If applicable. Skip if you're paying out-of-pocket.
Secondary Insurance Information
* If applicable. Skip if none.
Credit Card on File Policy
Payment for Services
Payments are due at the time service is provided. Renewal Christian Counseling Center, like many other healthcare agencies, implemented a credit card on file policy due to the increase in virtual Telehealth appointments to collect payments whether your session is in-person or via Telehealth. The information will be held securely to be used to pay balances on your account such as deductibles and copays.
** NOTE: Fees apart from normal services such as insurance rejections, no-show late fees, bounced checks, etc will NOT automatically be charged. **
Credit Card on File Policy Understanding
Payment for Services
Financial Responsibility Consent and Agreement
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Appointment Cancellation Policy
Required 24-Hour Cancellation Notice
IMPORTANT NOTICE: Please read the following carefully. We want to make sure you are familiar with our appointment cancelation policy to avoid potential issues. We do send appointment reminders to you as a courtesy, but it is ultimately your responsibility to make sure you remember in the case our reminder technology fails or glitches.
24-hour Cancellation Notice: Please contact your office AS SOON AS YOU KNOW that you will be unable to keep a scheduled appointment. Late cancellation notice and appointment no-shows may be subject to a $45 cancellation fee for any appointments that are canceled less than 24-hours prior to the scheduled session or are missed without any notification. The Responsible Party will be required to pay the fee before rescheduling or attending any scheduled future appointments.
Appeals: While we know life is filled with many uncertainties, we understand there may be times when things are simply outside our control. Unexpected illnesses, emergencies, etc. If you find yourself in a situation where you need to cancel your appointment less than 24-hours before your appointment, an appeal form is available if you would like to dispute your charge or case closure. Appeals can be submitted up to 60 days after the date of the missed appointment. Our agency depends financially upon our clients keeping scheduled appointments; therefore, our policy is to close your case if you accumulate 2 "no-shows" within 6 months.
** RECOMMENDATION: If you need to make an appeal, we recommend that you would pay the $45 late notice cancellation fee, even in emergency situations, so you can continue scheduling future appointments. If your appeal is approved, your $45 fee will be reimbursed or can be applied to your account if you choose.
Per our Billing Policy, our Administrative Support Staff are prohibited from scheduling anyone with an outstanding balance. The Responsible Party will be required to pay the fee before rescheduling or attending any scheduled future appointments.
Appointment Cancellation Policy Understanding
Required 24-Hour Cancellation Notice
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Please read this document carefully, as it contains information about our professional services and business policies.
Who Are We
Renewal Christian Counseling Center brings the best of psychotherapy, psychiatric services, and faith-based Christian counseling, together. Renewal is a full-service, CARF accredited, Behavioral and Mental Health and Substance Abuse Outpatient Clinic dedicated to making therapy available and affordable for all, in-person and online. Our mission is to rebuild and bring newness to the individual and his or her relationships through Christ-centered clinical counseling.
Renewal Center is founded and led by Steve Fair, LMSW along with an Advisory Board made of professional, well-respected, community leaders along with our medical team of psychiatric doctors, child and adult psychiatrists, pediatricians, and nurse practitioners. Our licensed and insured therapists, counselors, and psychologists are all Masters and Doctoral-Level practitioners who provide the highest quality and care of all those we serve. To remain unbiased, and to ensure the highest ethical and moral standards, Renewal is accredited and audited by CARF International and follows the American Association of Christian Counselors code of ethics to meet industry and international standards of quality of care with you in mind. Today, with multiple locations, online therapy, and a dedicated team who share the same passion for helping others we're here for you.
We are generally open Monday through Thursday from 8:30:00 AM to 9:00 PM. This varies from therapist to therapist (additional hours may be available upon request). When you call our office number or email email@example.com, you will reach our office, non-clinical, support staff team. Due to your therapist's work schedule, they are often not immediately available by telephone when they are in session. You may ask our office support staff to route your call to your therapist's personal voicemail. Your therapist will return your call at their earliest convenience.
In the case of an emergency, if you are unable to reach your therapist and feel that your situation is life-threatening, you may contact your local 24-hour crisis line at (586) 307-9100 for Macomb County, (800) 241-4949 for Wayne County, (888) 225-4447 for St. Clair County, (989) 631-4450 for Midland County.
You may also call 911 for life-threatening emergencies or if you are having suicidal thoughts or making plans to harm yourself, you can call the National Suicide Prevention Lifeline at 1(800) 273-TALK (8255) for free 24-hour hotline support.
What To Expect
Your first session will be a time of assessment to specify any diagnoses you may have and to specify any treatment interventions that may be helpful to you. Renewal Center has found much success and has seen many come to a place of freedom from their symptoms through the use of Cognitive Behavioral Therapy, Dialectic Behavioral Therapy skills, and other research-based interventions combined with your motivation to change.
Our treatment process will follow this progression:
Initial Assessment: Your therapist will ask many questions with the intent of getting to know you and your struggles, diagnosing your symptoms, and build trust with you. It is normal to feel some discouragement if you define your first session as a therapy session where you will find relief of your symptoms and direction for your decisions. Please bear with us, as we do not want to try to "fix" anything that we together do not fully understand first!
Treatment Planning: This process may start in the first session, but not later than the second. You and your therapist will define together the goals you are working on, the outcomes you desire before therapy concludes and you will be provided with a treatment plan outlining how your therapist will help you reach your goals. Your therapist will ask about your hopes, consider your beliefs, and your desired pace of healing. Your therapist will also be documenting the goals that you agree upon together for treatment and you will be given a copy of this plan unless you specify otherwise.
Treatment: Per insurance codes, most people meet with their therapist weekly, in-person and/or online, for 50-minute sessions. Some more often if in crisis and others much less often. This will be up to you unless your therapist specifies otherwise. You’ll be expected to be present for your session at your scheduled time. Your therapist and/or doctor will remain on schedule due to insurance billing codes. You may be charged extra for sessions longer than 60 minutes as these sessions are billed at a different code with your insurance carrier.
There are many models of therapy that are used at Renewal. Some methods are short-term "Solution Focused Treatment" which can be concluded in as few as 3 sessions. Other forms of treatment can be ongoing long-term for those whose issues are resistant to short-term interventions and for those who do not have a validating support network outside of Renewal Center. Individual sessions, family meetings, joint sessions with other supports present, and group sessions are all common and effective modes of treatment delivery that you and your therapist will decide upon.
Discharge Planning: When the goals you have set begin to be met, you and your therapist will begin planning your transition to help maintain your progress after your therapy work has been completed at Renewal Center. This transition planning should include, without therapy intervention, you having some defined supports that know what interventions you and your therapist have decided upon, a doctor (and psychiatrist if you are on medications), and a crisis or relapse plan. When you are safe and your symptoms are manageable, counseling may decrease to a level where your counselor will help you monitor your progress may be monthly or even quarterly. You may always return to regular sessions if your symptoms return fully after discharge.
In the best interest of our clients, our Medical Director will review your file, and your private health information may be reviewed by a quality assurance committee made up of a multidisciplinary team of professionals who work together for your quality of care.
You may also request a psychiatric review with one of our psychiatric team members or you may be referred to one of them by your therapist if there are any medical or safety concerns. We'll defer to your doctor regarding any medical symptoms if you are not seen by a psychiatrist at Renewal Center. We'll ask that you provide us with your Primary Care Physician's name and address for coordination of care.
The continuation of treatment is at your therapist's discretion. Renewal Center is most willing to work with those who are ready and willing to change. If your therapist or doctor determines you are presenting symptoms that are associated as a high-risk for safety issues and may better meet the criteria for programs that are more intensive, you may be referred to other programs that best fit your mental health needs.
You should also be aware that your contract with your health insurance company requires that we provide it with information relevant to the services that we provide to you. We are required to provide a clinical diagnosis for entry into our Clinical Counseling Program for payment by your insurance company. Please understand, these symptoms will be given a diagnostic code by your therapist and/or your doctor. This information is then sent to the insurance carrier for billing. Medical necessity must be established in order for your insurance company to be billed. Clients that do not present with a diagnosable set of symptoms will be served through our "Coaching and Mentoring" program and will need to pay cash for these services.
Prohibited: Abusive actions or words may also lead to your dismissal from the program. Anyone carrying legal drugs, illegal drugs, prescription meds, as well as weapons, may be asked to leave the premises and even prosecuted. Smoking is prohibited in all areas of this agency. You may contact Michelle Briggs at 586-783-2950 if you wish to regain your rights and privileges that have been restricted.
Children: Seclusion and restraint are prohibited as an intervention for you or your children, except in case of self-defense by our workers, and to support you in handling your child if he/she is escalated to the point of compromising safety.
In the case of an emergency: Maps of our building with emergency routes are located at every room entrance in each of our locations, illuminated exit signs are above exit doors, fire extinguishers are located conveniently and safely throughout the building, and first-aid kits are available at our front desk at your request.
Payment For Services
You will be expected to pay for each session at the time it is held whether it's in-person or telehealth unless we agree otherwise or you have insurance coverage that requires another arrangement (ie. balance to be billed to you upon receipt of the insurance processing). You are responsible for payment for all services you receive, whether or not your insurance reimburses for a portion of the charges.
Responsible Party Advisory: You, the Responsible Party, are liable for all fees not collected from your health insurance provider. If you have requested that your medical insurance be billed for mental health services at Renewal, we will need to exchange information with your insurance company, such as your diagnosis and frequency of treatment. By signing this form, you are releasing Renewal Center and its insurance billing staff to communicate with your insurance provider and bill them for services.
* Responsible Party: Individual Responsible for Financial Liability Incurred for Services
Therapy Rates: Our standard rates are applied according to your insurance co-pays, deductibles, or on a Sliding Fee Schedule that is available upon request. Rates for additional services are also outlined in the Sliding Fee Schedule.
We want counseling to be affordable to all. In order to assist those who do not have insurance coverage, we have established an affordable self-pay sliding fee scale that is applied based on family income levels. You may take advantage of this fee reduction if your family income is below $120,000 per year. You'll just need to provide Renewal Center with your most recent 1040 tax report or other proof of income to demonstrate your income level.
Auto Pay - Credit Card on File Policy: Payments are due at the time service is provided. Renewal Christian Counseling Center, like many other healthcare agencies, implemented a credit card on file policy due to the increase in virtual Telehealth appointments to collect payments whether your session is in-person or via Telehealth. The information will be held securely to be used to pay balances on your account such as deductibles and copays. You will receive a text notification automatically within 48-hours of your scheduled appointment.
* NOTE: Fees apart from normal services such as insurance rejections, no-show late fees, bounced checks, etc will not automatically be charged.
Appointment Cancellation: A $45 fee will be charged for any appointments that are canceled less than 24 hours prior to the scheduled session or are missed without any notification. The Responsible Party will be required to pay the fee before rescheduling or attending any scheduled future appointments.
* An appeal form is available if you would like to dispute your charge or case closure. Appeals can be submitted up to 60 days after the date of the missed appointment. Our agency depends financially upon people keeping the appointments they schedule; therefore, our policy is to close your case if you accumulate two "no-shows" within six months.
Billing: The Responsible Party listed above is liable for payment of services on the day of your session. All unpaid balances will be handled per Renewal's established billing policy and will be turned over to a Designated Credit Bureau if monies are not collected from the Responsible Party within 120 days.
* Our Administrative Support Staff is prohibited from scheduling client sessions for those with an outstanding balance.
Bounced Check: A $25 fee will be charged for each bounced check.
Recipient Rights and Responsibilities
You, the recipient, have the right to receive respectful treatment in a physically and emotionally safe treatment environment without the fear of humiliation, retaliation, or abuse.
You have the right to privacy and the law binds our therapist and doctors to confidentiality with certain exceptions (i.e., child abuse/neglect, a client has the intent to harm self or others).
You have the right to know the financial cost of treatment in advance of receiving services.
You have the right to decide not to enter therapy with any Renewal Center therapist. If you wish, we will provide you with the names of other good therapists that we can refer you to, both internally and outside our agency.
You have the right to ask any questions at any time about what we do during therapy and to receive answers that satisfy you. If you wish, we will explain further any of our treatment modalities to you. You also have the right to refuse any such intervention.
You have the right to end therapy at any time. However, you are expected to pay for any treatment you have already received.
If your therapist wishes to record your session, he/she will request your permission in writing. You have the right to refuse any such request.
You have the right to review your diagnosis and treatment plan at any time, with a few exceptions.
You have the right to education regarding mental health Advance Directives. You have the right to make an Advanced Directive which gives you control of decision making if you were ever in a time of a Mental Health Emergency. The Advanced Directive form can be obtained at our front desk. You have the right to be helped by your therapist in defining this plan together. Download your copy of the Advanced Directive.
You have the right to share your concerns, dissatisfaction with services, and/or if you have had their rights to treatment temporarily revoked or restricted may fill out an appeal form to receive further services at Renewal Center with our Recipient Rights Officer and have your grievance(s) heard by calling our office and asking for Michelle Briggs, (586)-783-2950. You may be asked to submit your concerns in writing so that either the director or a committee can investigate your complaint fully after which they will contact you regarding their findings within 14 days. You may also give input and suggestions via our website or suggestion boxes which are by our front desks.
Treatment Consent and Agreement
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Online Therapy, also known as Telehealth, involves the use of electronic communications to enable mental health professionals to connect with individuals using interactive video and audio communications. Telehealth includes the delivery of psychotherapy, including diagnosis, consultation, treatment, and referral to resources, education, and the transfer of medical and clinical data.
You can continue to meet in-office for most of your appointments, however, we may use Telehealth options when you or your provider are not able to attend appointments in-person when weather or other extenuating circumstances (e.g. COVID-19) prevent you or your provider from being able to attend the appointments in-office. Telehealth appointments will be scheduled and approved at the discretion of your provider. Telehealth may also be used when you're traveling within the state of Michigan, provided that your agrees to this arrangement in advance.
Rights, Benefits, and Risks
I understand that I have the following rights with respect to Telehealth:
Confidentiality: I have the right to keep my personal health information (PHI) private in Telehealth just as I do in face-to-face therapy.
Rights: I understand that I have the right to withhold or withdraw my consent to the use of Telehealth in the course of my care at any time without affecting my right to future care or treatment and that my therapist has the right to accept or deny Telehealth as a valid venue for therapy in the best interest of my care.
Benefits: I understand that I may expect the anticipated benefits such as improved access to care and more efficient evaluation and management from the use of Telehealth in my care, but that no results can be guaranteed or assured.
Risks: I understand that there are risks and consequences from Telehealth including, but not limited to, the possibility of technical issues that are beyond our control and that the transmission of my personal information could be disrupted or distorted by technical failures.
Consequences: I understand that if I late cancel within 24-hours, do not answer the phone call of my therapist, or if I am not present at the video session at the time of the appointment, that I will be assessed a “No Show” which a $45 fee may be the result of my absence per our Financial Responsibility. I understand that it is my responsibility to provide the correct email and mobile number to set up any video conferencing software on my personal technology.
Liabilities: I understand the alternatives to therapy through Telehealth as they have been explained to me, and in choosing to participate in Telehealth, I am agreeing to participate using video conferencing technology and/or telephone therapy. I understand that Renewal Center has contracted with HIPAA compliant technology services for Telehealth, but that there is still a minimal, inherent risk that the security of this technology may be compromised by hackers or other forms of outside influence. If it is found out that there has been a security breach, Renewal clients would be notified immediately.
Crisis: I understand and agree that certain situations, including emergencies and crises, are inappropriate for audio/video computer-based psychotherapy services. If I am in crisis or in an emergency, I should immediately call 911 or seek help from a hospital or crisis facility in my area.
Payment for Telehealth Services
Renewal Christian Counseling Center will bill your health insurance provider for Telehealth services when these services have been determined to be covered by your insurance plan. Payments are due at the time service is provided. We will charge your card on file at the time of your scheduled appointment. If your insurance is not accepted, the Responsible Party agrees to pay out-of-pocket.
Telehealth Consent and Agreement
* BEFORE YOU DECLINE: Depending upon what you and your provider discuss, there are times where a last-minute change to you or your provider's schedule could require a session reschedule (ex: bad weather, childcare canceled, you or a child is mildly sick but can still do therapy from home, etc). In such cases, we can easily switch an in-person appointment to a telehealth appointment. By declining, you will not have this privilege without your consent to use telehealth as a means of therapy. Telehealth sessions could also save you time and money avoiding appeals and fees for late canceling an appointment with less than a 24-hour notice.
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Our Commitment to Your Privacy
Renewal Center is dedicated to maintaining the privacy of your Protected Health Information (PHI) in our mental health records. In conducting our business, we will create records regarding you and the treatment and the services we provide to you. We are required by law to provide you with this notice of our legal duties and the privacy practices that we maintain in our office concerning your PHI. Any revisions to this notice will be posted in a visible location in our offices.
As required by the Privacy Regulations of the Health Insurance Portability and Accountability Act of 1996 (HIPAA). Should you have any questions, please contact us via email at firstname.lastname@example.org. Please review this notice carefully.
If you have any questions about this notice, please contact:
Michelle Briggs, Privacy Officer
100 NB Gratiot Ave.
Mt. Clemens, MI 48043
How We May Use Your Individual Health Protected Information (PHI)
Treatment: Our practice may use your PHI to treat you. For example, we may use your PHI to coordinate health care with your doctor or hospital in case of emergency or internally for clinical supervision purposes.
Payment: We may use and disclose information to your insurance company if you have asked us to bill for third-party reimbursement.
Releases: When you have signed a written release, we may contact the designee without your direct knowledge until the date that release expires. You have the right, though, to change your mind at any point and revoke the release.
Appointment Coordination: Renewal Center may use your PHI to contact you to remind you of an appointment or to reschedule appointment times. For example, we use your phone number and/or email to send you appointment reminders.
Special Circumstance of Disclosure
Public Health Risk: Renewal Center may disclose your PHI to public health authorities that are authorized by law to collect information for the purpose of:
- reporting child abuse or neglect
- preventing or controlling injury or disability
- reporting reactions to drugs or problems with products or devices
- notifying appropriate government agencies and authorities regarding the potential abuse or neglect of an adult (including domestic violence); however, we only disclose if the client agrees or we are required by law.
Lawsuits and Similar Proceedings: Renewal Center may use and disclose your PHI if a response to a court order is mandated. We also may have to disclose your PHI in response to a subpoena or a discovery request.
Law Enforcement: We may release PHI if asked to do so by law enforcement officials:
- regarding a crime victim in certain situations if we are unable to obtain the person's agreement
- concerning a death we believe has resulted from criminal conduct
- regarding criminal conduct at our offices
- in response to a warrant, summons, court order or subpoena
- to identify/locate a suspect, material witness, fugitive or missing person
- in an emergency to report a crime (including the location of victims of a crime, identity, or location of a perpetrator).
Your Rights Regarding Your PHI
Confidential Communications: You have the right to request that we communicate with you about your health and related issues in a particular manner or at a certain location. For instance, you may ask that we contact you at home rather than at work. Please ask your clinician to specify your request.
Requesting Restrictions: You have the right to request a restriction in our use or disclosure of your PHI. We are not required to agree, but if we do then we are bound to our agreement. Talk to our Privacy Officer, Michelle Briggs at (586) 783-2950 if there is information that you wish to be restricted then we are bound to our agreement.
Inspection of Copies: You have the right to inspect and obtain a copy of the PHI that may be used to make decisions about you, including patient records and billing records, but not psychotherapy notes. Contact our Privacy Officer for copies of your records. In limited situations, this request may be denied, if this is not in your best interest as decided by your doctor and/or clinician. Mediation from another health care professional will be made available in this case if requested.
Right To Amend: You may ask us to change your records if you feel that there is a mistake. We can deny your request for certain reasons, but we must give you a written reason for our denial.
You Have The Right To An "Account Of Disclosures": You may ask for a list of all disclosures that were made after April 14, 2003. The list will not include the times that information was disclosed regarding treatment, payment, health care operations, or information given to you or others by your own authorization.
You Have The Right To File A Complaint: If you believe that your privacy rights have been violated, you may file a complaint with our privacy officer Michelle Briggs (586) 783-2950 or with the Department of Health and Human Services at (800) 368-1019.
HIPAA Consent and Agreement
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You've Made It!
Thank you again for choosing Renewal Christian Counseling Center to assist you along your journey! We look forward to hearing your testimony of renewal and freedom! Please read the Service Agreement and sign below then you're all set to fill out any additional forms!
This agreement for psychotherapy between you and Renewal Christian Counseling Center shall govern all professional relations between the parties. It is agreed that any disputes or modifications of agreement SHALL BE NEGOTIATED DIRECTLY BETWEEN THE PARTIES. If these negotiations are not satisfactory, then the parties agree to mediate any differences with a mutually acceptable third-party mediator WHICH CAN BE OUR Advisory Board members, per our client's request. Should this fail to reach a mutually satisfying agreement, all disputes will be submitted to binding arbitration with a certified mediator.
As a consumer/parent/guardian, I understand the rationale for the procedures, risks, consequences and other relevant factors in treatment here at Renewal Center. I acknowledge receipt of the Recipient Rights and Responsibilities that outlines my rights as a consumer of mental health services, and I consent to mental health services at Renewal Christian Counseling Center under the terms and responsibilities listed above.