Disclosure

  • Disclosure Statement

    Christian Heart Counseling

    1751 Tower Drive West Stillwater, MN 55082 (651) 439-2059

    Fee Schedule

    $160 per 45 minute Session $240 Initial Diagnostic Session(s)

    Payment is due at time of session. Late payment fee is $10

    Cancellation/Payment Policy:

    We have a 48 business hour cancellation policy. We hold times in our schedules just for you. If you need to cancel for any reason with less than 48 business hours there will be a charge of $100. We will gladly waive the fee if the opening created by your cancellation is filled. You authorize your credit card* to be charged for any late cancellation fee, returned checks or unpaid insurance. We will routinely charge your credit card for unpaid co-pays and insurance. We send statements only on request. Please initial below:

    *Our system verifies the card by charging $2 followed by immediate refund of $2.

  • Consumers of psychological services, or marriage and family therapy services offered by Psychologists, Marriage and Family Therapists, or Licenses Social Workers or Licensed Professional Clinical Counselors licensed by the State of Minnesota have the right: To expect that a therapist has met the minimal qualifications of training and experience required by state law; To examine public records maintained by the board of Licensing Board or Boards which contain the credentials of a therapist; To obtain a copy of the Code of Ethics or Rules and Conduct from the appropriate Licensing Board or Boards; To report complaints to the appropriate Licensing Board by writing or calling: Minnesota Board of Psychology - 2829 University Avenue SE, Suite 320, Minneapolis, Minnesota 55414. Phone: (612) 617-2230; and/or b) Minnesota Board of Marriage and Family Therapy -2829 University Avenue SE, Suite 330, Minneapolis, Minnesota 55414. Phone: (612) 617-2220; c) State of Minnesota Board of Social Work 2829 University Avenue SE, Suite 340, Minneapolis, Minnesota 55414. Phone: (612) 617-2100, d) Minnesota Behavioral Board of Health and Therapy 2829 University Ave SE Suite 210, Minneapolis, MN 55414 (612) 617-2178. To be informed of the cost of professional services before receiving the services; To privacy as defined by rule and law; To be free from being the subject of discrimination on the basis of race, religion, gender, or other unlawful category while receiving services; To have access to their records as provided in Minnesota Statutes, section 144.335, subdivision 2; and To be free from exploitation for the benefit or advantage of a therapist. To refuse treatment at any time.
    1. Our therapists use a blend of relevant therapies and biblically based Christ-centered counseling. Our foundation is built on the belief that healing is a gift from God.
    2. Confidentiality: Information that a client shares with a therapist is completely confidential, except where otherwise specified by law. Information pertaining to a client’s record, or a client’s identity, cannot be released to any individual or agency outside of Christian Heart Counseling without the written consent of the client. For the purposes of gaining greater perspective, case scenarios may be shared within Christian Heart Counseling. I understand that Christian Heart Counseling will use e-mail to communicate between offices and clients and that this entails some risk.
    3. By law, if the therapist determines that the safety of the client is in question or that the client has plans to harm any other person(s), the therapist is required to make a report to the proper authorities and the person(s) mentioned, if appropriate. Also, if the client discloses any information that could be interpreted as physical or sexual abuse to a child or vulnerable adult, the therapist is required to make a report to the proper authorities. A court of law may also require clinical records without a client’s consent.
    4. We reserve the right to use a collection agency to collect overdue payments.
    5. I/we authorize payment of benefits to Christian Heart Counseling for services rendered to myself and/or dependents.
    6. I/we hereby authorize the release of required information to my insurance company.
    7. Benefits quoted from insurance companies are not a guarantee of payment. You agree to be responsible for the costs of services if they are not reimbursed by your insurance company.
    A copy of Christian Heart Counseling’s Privacy Disclosure Statement is available at christianheartcounseling.com and has been offered to you. Please keep in mind we use regular email to communicate with clients and that communications via email over the internet are not secure. Although it is unlikely, there is a possibility that information in an email can be intercepted and read by other parties besides the person to whom it is addressed.

    I have read and understand the information presented in this form: (In case of couple, both should sign)

Disclosure Mobile

  • Disclosure Statement

    Christian Heart Counseling

    1751 Tower Drive West Stillwater, MN 55082 (651) 439-2059

    Fee Schedule

    $160 per 45 minute Session $240 Initial Diagnostic Session(s)

    Payment is due at time of session. Late payment fee is $10

    Cancellation/Payment Policy:

    We have a 48 business hour cancellation policy. We hold times in our schedules just for you. If you need to cancel for any reason with less than 48 business hours there will be a charge of $100. We will gladly waive the fee if the opening created by your cancellation is filled. You authorize your credit card* to be charged for any late cancellation fee, returned checks or unpaid insurance. We will routinely charge your credit card for unpaid co-pays and insurance. We send statements only on request. Please initial below:

    *Our system verifies the card by charging $2 followed by immediate refund of $2.

  • Consumers of psychological services, or marriage and family therapy services offered by Psychologists, Marriage and Family Therapists, or Licenses Social Workers or Licensed Professional Clinical Counselors licensed by the State of Minnesota have the right: To expect that a therapist has met the minimal qualifications of training and experience required by state law; To examine public records maintained by the board of Licensing Board or Boards which contain the credentials of a therapist; To obtain a copy of the Code of Ethics or Rules and Conduct from the appropriate Licensing Board or Boards; To report complaints to the appropriate Licensing Board by writing or calling:Minnesota Board of Psychology - 2829 University Avenue SE, Suite 320, Minneapolis, Minnesota 55414. Phone: (612) 617-2230; and/or b) Minnesota Board of Marriage and Family Therapy -2829 University Avenue SE, Suite 330, Minneapolis, Minnesota 55414. Phone: (612) 617-2220; c) State of Minnesota Board of Social Work 2829 University Avenue SE, Suite 340, Minneapolis, Minnesota 55414. Phone: (612) 617-2100, d) Minnesota Behavioral Board of Health and Therapy 2829 University Ave SE Suite 210, Minneapolis, MN 55414 (612) 617-2178. To be informed of the cost of professional services before receiving the services; To privacy as defined by rule and law; To be free from being the subject of discrimination on the basis of race, religion, gender, or other unlawful category while receiving services; To have access to their records as provided in Minnesota Statutes, section 144.335, subdivision 2; and To be free from exploitation for the benefit or advantage of a therapist. To refuse treatment at any time.
    1. Our therapists use a blend of relevant therapies and biblically based Christ-centered counseling. Our foundation is built on the belief that healing is a gift from God.
    2. Confidentiality: Information that a client shares with a therapist is completely confidential, except where otherwise specified by law. Information pertaining to a client’s record, or a client’s identity, cannot be released to any individual or agency outside of Christian Heart Counseling without the written consent of the client. For the purposes of gaining greater perspective, case scenarios may be shared within Christian Heart Counseling. I understand that Christian Heart Counseling will use e-mail to communicate between offices and clients and that this entails some risk.
    3. By law, if the therapist determines that the safety of the client is in question or that the client has plans to harm any other person(s), the therapist is required to make a report to the proper authorities and the person(s) mentioned, if appropriate. Also, if the client discloses any information that could be interpreted as physical or sexual abuse to a child or vulnerable adult, the therapist is required to make a report to the proper authorities. A court of law may also require clinical records without a client’s consent.
    4. We reserve the right to use a collection agency to collect overdue payments.
    5. I/we authorize payment of benefits to Christian Heart Counseling for services rendered to myself and/or dependents.
    6. I/we hereby authorize the release of required information to my insurance company.
    7. Benefits quoted from insurance companies are not a guarantee of payment. You agree to be responsible for the costs of services if they are not reimbursed by your insurance company.
    A copy of Christian Heart Counseling’s Privacy Disclosure Statement is available at christianheartcounseling.com and has been offered to you. Please keep in mind we use regular email to communicate with clients and that communications via email over the internet are not secure. Although it is unlikely, there is a possibility that information in an email can be intercepted and read by other parties besides the person to whom it is addressed.

    I have read and understand the information presented in this form: (In case of couple, both should sign)

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