PDF Version

You've Already Taken the Biggest Step ...

Coming to counseling is a big step for many people. We recognize the courage and determination it takes to decide to deal with the issues you are facing. Because counseling depends on honest, two-way communication, we want to explain what you can expect from us, as well as what we will expect of you, while you are in counseling at ACCFS.

Emergencies

• ACCFS does not have staff to provide 24-hour crisis/emergency intervention.
• You may not be able to contact your counselor directly in time of crisis/emergency.
• If you are experiencing a life-threatening emergency (e.g., feeling suicidal), dial 911 or go to your local emergency room.
• If you live in Central Illinois you can call one of the following Emergency Response Service (ERS) numbers: Peoria County ERS 309-671-8084; Tazewell/Woodford County ERS 309-347-1148; McLean County ERS 800-662-HELP or 309-827-4005.

Confidentiality and Release of Information

• At ACCFS we work to provide you with a safe, private atmosphere and secure confidentiality.
• You have the right to have your treatment information kept private. However, there are certain situations, as required by law, in which your counselor is required to break confidentiality. your counselor will go over a separate confidentiality form with you prior to starting the first session. Please read it carefully and feel free to ask your counselor questions if you have any concerns.
• If you would like your counselor to speak with someone about your treatment (e.g., physician, minister, family member, etc.), you will need to give your permission in writing. Simply ask your counselor to fill out a Release of Information form. You can revoke your Release of Information at any time.

Consent for E-Mail Correspondence

E-mail is simple and efficient way to communicate and exchange information. During your time in counseling at ACCFS, e-mail exchanges with your therapist may be helpful for issues such as rescheduling an appointment or providing a brief update on events/issues. While there are benefits to corresponding through e-mail, you need to be aware of, and agree to, the following provisions:

• ACCFS cannot guarantee the confidentiality of the information on your computer that you send or receive via e-mail.
• If other people in your home or office have access to your e-mail account, they may have access to your sent and/or received e-mails.
• If you change your e-mail address or would like messages sent to a different e-mail account, you are responsible for informing your counselor at ACCFS.

Insurance

• ACCFS does not participate in any managed-care insurance plans and does not bill insurance companies.
• If you decide to submit a claim to your insurance carrier, you are responsible for turning in all paperwork.
• At times, after a claim is submitted to an insurance company, they contact our office to obtain information about the diagnosis, treatment plan and licensure of the counselors. If you submit a claim for mental health care provided by ACCFS to your insurance carrier and they contact us for more information, you give ACCFS permission for us to release any information necessary to file that claim.

Fees For Counseling

• The ACCFS standard rate for services is $110 per 50 minute session.
• No one will be denied services because of inability to pay. Apostolic Christian Counseling and Family Services is a not-for-profit 501(c)(3) agency.
• Clients are asked to assess their ability to pay based on their convictions and circumstances. Individual circumstances may make it unfeasible to pay the recommended amount or make it possible to pay above the recommended amount.
• The fee schedule is established to help cover the costs to operate this service. In order to ensure that services are available for those unable to pay, clients are asked to pay up to their ability.
• The fees listed below are discounted from standard professional counseling fees because they are subsidized by the Apostolic Christian Church of America.
• You have a responsibility to pay the fee that you agree upon and to let your counselor know about any problems with payment of fees.

1. Individuals with dependents 2. Couples and Families 3. Minors living with parents Annual Income Fee per Session $ 0 – 30 K $10 $31 – 40 K $20 $41 – 50 K $35 $51 – 60 K $60 $61 – 70 K $90 $71 K + $110

Individuals with NO dependents Annual Income Fee per Session $ 0 – 20 K $20 $21 – 30 K $40 $31 – 40 K $70 $41 – 50 K $90 $51 K + $110

Consent for Treatment

If you are a current counseling patient and have lost your form, or have been directed here to print, sign and return the "Consent To Treatment" form, please use the PDF Version of this form.

• You have the right to choose among various treatment options that can be used to deal with your issues.
• You have the right to know the risks and benefits of any counseling techniques used in your treatment.
• You have the right to know the clinical guidelines used in providing and managing your care.
• You have the right to know your counselor’s education/training, licensure and clinical specialties.
• By entering into this counseling arrangement you give consent to be treated by your counselor.

Updated 3-5-07