Provider Services Agreement and Consent For Care

  • JP Counseling & Associates, LLC

    Provider Services Agreement and Consent For Care


    Welcome and congratulations on taking the first step toward positive change. We look forward to working with you and helping you with healing and growth.

    This Services Agreement and Consent for Care (hereinafter “Services Agreement”) contains important information about our professional services and business policies. Please read it carefully. It is important that you have a clear understanding of why you are receiving services and how we are attempting to assist you with your care. If you are uncertain at any time regarding your treatment, please contact us immediately. This Services Agreement explains the office policies, procedures, and practices. You will be asked to sign indicating that you have read, have understood, and accept the Services Agreement and any and all other documents JP Counseling & Associates, LLC has included.

    The counseling process is not easily described in general statements. It varies depending on the personalities of the counselor and the client, their dynamics together, and the issues being explored. There are many different methods we have been trained to use as counselors to help you deal with the reasons you came to therapy. It is our philosophy to always be kind and respectful, but also to be direct and honest. Counseling requires a very active effort on your part. For therapy to be most successful, you will have to work on things we talk about both during our sessions and outside of them.

    Counseling has both benefits and risks. Significant benefits include better relationships, solutions to specific problems, and reductions in feelings of distress. Since therapy often involves discussing difficult or unpleasant aspects of life, you may also experience uncomfortable feelings like sadness, guilt, anger, frustration, loneliness, or helplessness. Each individual’s experience is unique, and any services offered will be tailored to suit the client’s needs.

    Our first sessions will involve evaluation of your needs and motivation for counseling, as well as an evaluation of your level of comfort working with us. Therapy involves a large commitment of time, money, and energy and, therefore, you should be very judicious about the therapist you select. If you have questions about our procedures or philosophy, we should discuss them whenever they arise.

    If at any time you do not think we are a good fit to continue working together, we will be happy to help you set up a meeting with another mental health professional. The counseling process is voluntary and can be terminated at any time by either party via written request. If we decide to terminate the counseling relationship, we will do our best to explain the reasons why and to make a referral to another clinician. JP Counseling & Associates, LLC will consider your written revocation request as binding so long as you have satisfied all financial obligations.

    JP Counseling & Associates, LLC reserves the right to change the practices described or terms of this Services Agreement at any time. If changed, you may receive a new Services Agreement electronically.


    Therapy sessions vary in length, usually from 45-55 minutes, based on several issues, including insurance. Initially, sessions are scheduled weekly but frequency may vary.


    Once an appointment session is scheduled, you will be expected to provide 24 hours advance notice of cancellation. If you do not follow this procedure, you will be charged $40 for the session. Insurance will not pay or reimburse for late cancelled or no show sessions, and you agree that payment will be your responsibility.


    Fees for services may vary depending on contracts with insurance and other payers. You can ask us to see our rates. In addition to regular appointments, we charge $150 for other professional services you may need, although we will break down the hourly cost if we work for periods of less than one hour. Other services include report writing, telephone conversations lasting longer than 10 minutes, attendance at meetings with other professionals you have authorized, preparation of records of treatment summaries, and the time spent performing any other service you may request of us. Insurance will not pay or reimburse for these additional service fees, and they will be your responsibility.
    If you become involved in legal proceedings that require our participation, you will be expected to pay for our professional time and the expense of our cost to attend even if we are called to testify by another party. Because of the intensity of legal involvement, we charge $400 per hour for preparation, attendance, and travel at any legal proceeding.

    Insurance companies require information about you in order to authorize or pay for services. This information may include a clinical diagnosis, treatment plans, or progress updates. By signing this Agreement, you agree that we can provide requested information to your insurance company or funding source that will pay for the service.

    If you utilize our services as an out-of network provider, you may be able to seek reimbursement at the level of your health insurance company’s out-of-network policy. In any case, you will be expected to pay us directly and receive any reimbursement you are due directly from your insurance company. We are willing to work to assist you in getting reimbursements, including filling out relevant portions of any claim forms and talking with insurance representatives.


    Due to our work schedule, we are often not immediately available by telephone. When we are unavailable, our telephone is answered by a voicemail which we monitor frequently. We will make every effort to return your call within 24 hours, with the exception of weekends and holidays. If you are difficult to reach, please inform us of times when you will be available for us to return the call. If you are unable to reach us and feel that you cannot wait for us to return your call, contact your family physician, nearest emergency room, or call 911. If we will be unavailable for an extended time, we will provide you with the name of a colleague to contact in case of an emergency.


    The laws and standards of our profession require that we keep Protected Health Information (PHI) about you in a Clinical Record. This includes information about your reasons for seeking therapy, a description of the ways in which your problem impacts your life, your diagnosis, the goals that we set for treatment, your progress towards those goals, your medical and social history, your treatment history, any past treatment records that we receive from other providers, reports of any professional consultation, your billing records, and any reports that have been sent to anyone. You are entitled to receive a copy of your records, or we can prepare a summary for you instead. Because these are professional records, they can be misinterpreted and/or upsetting to untrained readers. If you wish to see your records, we recommend that you review them in our presence so that we can discuss the contents. Patients will be charged an appropriate fee for any professional time spend in responding to information requests.


    A juvenile age 14-18 can consent to outpatient mental health examination and treatment for him/herself without parental consent. A parent or legal guardian of a juvenile under age 18 can also provide consent without the juvenile’s consent.


    The law protects the privacy of all communication between a patient and a counselor. In most cases, we can only release information about your treatment to others if you sign a written authorization form that meets certain legal requirements imposed by the Health Insurance and Portability and Accountability Act (HIPAA). There are other situations that require written, advanced consent, such as professional consultations. Your signature on this Services Agreement provides consent for consultation with other health and mental health professionals. During these consultations, we make every effort to avoid revealing the identity of the client. The other professionals are also legally bound to keep the information confidential.

    There are some situations in which we are legally permitted or required to disclose information without either your consent or authorization. These situations include the following:

    • If you are involved in a court proceeding and a request is made for information concerning the professional services we provided to you, such information is protected by the privilege law. We cannot provide any information without your written authorization or a court order. If you are involved in, or contemplating, litigation, you should consult with your attorney to determine whether a court would be likely to order us to disclose information. If a government agency is requesting the information for health oversight activities, we may be required to provide it for them.
    • If you file a complaint or lawsuit against us, we may disclose relevant information regarding your treatment for our defense.
    • If an appropriate request is made regarding a worker’s compensation claim for you, we may be required to provide otherwise confidential information to your employer.

    There are some situations in which we are legally obligated to take actions that we believe are necessary to attempt to protect you or others from harm, and that may require us to reveal some information about treatment. These situations are rare in our practice but include the following:

    • If we have reason to believe that a child, elder, or disabled person is being abused.
    • If we believe a client presents a serious, specific, and immediate threat of serious bodily injury regarding a specifically identified or a reasonably identifiable victim and that he/she is likely to carry out the threat.
    • If we believe a client seriously threatens to harm him/herself.

    If any of these situations should arise, we will make every effort to fully discuss it with you before taking any action whenever possible, and we will limit disclosure to only what is necessary.

    Because our staff are experts in the field of mental health, they may conduct trainings for students, trainees, practitioners, or the community. At times, we may use your de-identified information for teaching purposes as permitted by the Privacy Rule under HIPAA utilizing the Safe Harbor Method of De-identification.

    While this written summary of exceptions to confidentiality should prove helpful in providing you with information about potential problems, it is important that we discuss any questions or concerns that you have now or in the future.


    Unless we agree otherwise, you are expected to pay for each session at the time it is held. Payment for other professional services will be agreed to when services are requested. If your account has not been paid for more than 60 days, and arrangements for payment have not been agreed upon, we have the option of using legal means to secure the payment. These legal means may involve hiring a collection agency, going through small claims court and/or filing a claim in Magistrate Court, all of which may require us to disclose otherwise confidential information. In most collection situations, the only information we release regarding a patient’s treatment is his/her name, the nature of the services provided, and the amount due. If such legal action is necessary, all costs of such legal action will be included in the claim.



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Our Services 

  • Individual counseling for adults, adolescents and families
  • Group therapy
  • Substance use evaluation, treatment and referral
  • DOT SAP Evaluations
  • Sliding scale rates available
  • Payments by cash, check or charge
  • Evening and weekend appointments available
  • Telehealth available for Pennsylvania, Ohio, West Virginia and Florida residents

Our Team

Jill Perry, MS, NCC, LPC, CAADC, SAP

Jennifer Oaks, MS, LPC, CAADC

Hayley Shawger, MA, NCC, LPC, CCTP

Linda Hicks, LCSW

Christina Bertocchini-Guay, MA, LPC

Krista Shae Lion, MA, NCC, CADC

Josh McGee, MA, NCC, LPC

Bill Phillips, Operations Manager