Rob Jackson, MS
Licensed Professional Counselor – Colorado #
3187
Licensed Mental Health Counselor – Washington # LH00006817
Licensed Professional Counselor – Mississippi # 0142
National Certified Counselor # 20259
Qualifications/Experience:
I’m pleased you have selected me as your counselor. This document is designed to inform you about my background and to insure that you understand our professional relationship.
I am licensed by the states of
Nature of Counseling:
I hold a Master of Science degree in clinical psychology and have been a professional counselor since 1986.
Although our sessions may be very intimate emotionally and psychologically, it is important for you to realize that we have a professional relationship rather than a personal one. Our contact will be limited to the paid sessions you have with me. Please do not invite me to social gatherings, offer gifts, or ask me to relate to you in any way other than in the professional context of our counseling sessions. You will be served best if our relationship remains strictly professional and if our sessions concentrate exclusively on your concerns. You will learn a great deal about me as we work together during your counseling experience. However, it is important for you to remember that you are experiencing me only in my professional role.
Referrals:
If at any time for any reason you
are dissatisfied with my services, please let me know. If I am not able to
resolve your concerns, you may report your complaints to the Colorado State
Grievance Board at (303) 894-7766, the Washington Department of Health (360)
236-4902, The Mississippi State Board of Examiners for Licensed Professional
Counselors (888) 860-7001 or the National Board for Certified Counselors in
Fees,
Cancellations and Insurance Reimbursements:
In return for my fee, I agree to provide professional counseling services for you. The fee for each online and/or telephonic session will be due and payable before the session. Personal checks made to “Rob Jackson” are acceptable for payment, and may be mailed to my address. Checks drawn on credit card accounts are not acceptable, but payment can be made with credit cards through www.PayPal.com. In the event you will not be able to keep a telephone appointment, you must notify me 24 hours in advance. If I do not receive advance notice by telephone or email, you will be responsible for paying for the session that was missed.
Some health insurance companies will reimburse clients for my professional services and some will not – none to my knowledge, will reimburse for online and/or telephone counseling. In all cases, most insurance companies will require that I diagnose your mental health condition and indicate that you have an “illness” before they will agree to reimburse you. Some conditions for which people seek counseling do not qualify for reimbursements. If a qualifying diagnosis is appropriate in your case, I will inform you of the diagnosis I plan to render. Any diagnosis made will become part of your permanent insurance records.
If you wish to seek reimbursement for my services, please inform your health insurance company. Because you will be paying me at the time of service, any later reimbursement from the insurance company should be sent directly to you. Please do not assign any payments to me.
Those insurance companies that do reimburse for counselors usually require that a standard amount be paid (a “deductible”) by you before reimbursement is allowed, and then usually only a percentage of my fee is reimbursable. You should contact a company representative to determine whether your insurance company will reimburse you and what schedule of reimbursement is used.
Our firm will complete and mail one insurance claim form each month for as long as you are in treatment at no additional cost to you. In the event your insurance company requires additional paperwork or telephone contact, the time will be prorated at the hourly rate of $25.00. Reasonable charges for copies and postage will also be charged to you.
Records
and Confidentiality:
All of our communication becomes part of the clinical record, which is accessible to you on request. I will keep confidential anything you say to me, with the following exceptions: a) you authorize me [with a written release form] to tell someone else, b) I determine that you are a danger to yourself or others, c) you disclose knowledge or suspicion that a minor, handicapped, or elderly person is suffering abuse or neglect, d) you disclose that a therapist has treated you unethically, and/or e) I am ordered by a court to disclose information.
By your signature below (please sign both copies, keep one for your files and return the other copy to me), you are indicating that you have read and understood this statement, and/or that any questions you have had about this statement have been answered to your satisfaction.
________________________________ ______________________________
Counselor’s Signature and Date Client’s
Signature and Date
5585 Erindale Drive, Suite 207
Colorado Springs, CO 80918