Policies and Fees
Consent to Treatment Agreement
Policies, Client Privacy Rights, Service Information, Fees
Thank you for choosing La Bella Luce, LLC as your provider of the professional services described in this agreement. We are committed to using our best efforts towards your treatment being successful. Please understand that payment of your bill is considered a part of your treatment. The following is a statement of your consent to treatment and our financial policy, which you are required to read and sign before receiving any treatment. All clients must complete our information form before seeing the clinician.
Confidentiality:
I have been informed that all client information and records provided during a session will be kept confidential except under circumstances as detailed in the applicable provisions of the Wisconsin Statutes, Wisconsin Administrative Code, or federal laws and regulations or with the following exceptions: a court order, or threats of physical harm to self or another individual. In these instances the practitioner is bound by law and ethics to report the situation to the appropriate authorities. Information about your minor child will not be released without your written permission. All client accounts are the sole property of La Bella Luce, LLC and are maintained in strict confidence, to the extent consistent with applicable state and federal laws and professional standards.
I further authorize my practitioner to discuss the material from my sessions or my confidential files on an anonymous basis with an appropriate mentor for purposes of consultation, education or support. All such information will be handled professionally and confidentially. I further understand that such discreet discussion enables my practitioner to better serve me and increases his/her effectiveness in my sessions.
Release:
I hereby knowingly and voluntarily release and covenant not to sue Lynn Luebben or La Bella Luce, LLC for any alleged or actual negligence in providing any services or treatments to me. This release does not apply to any alleged or actual willful misconduct by Lynn Luebben or La Bella Luce, LLC in providing me with any services or treatments.
Minors:
All information pertaining to minors will be released to their parents or legal guardians upon their written request, unless it would adversely affect the therapeutic process. The adult accompanying a minor and the parents (or guardians of the minor) are responsible for full payment of the professional fees. In divorce situations, the parent who brings the child to the appointment is responsible for payment of charges regardless of any provision in a divorce decree. If payment responsibility issues exist, they must be resolved between the parents.
Fees and Payment:
Our practice is committed to providing the best treatment reasonably achievable for our clients and we charge what are usual and customary fees for our area. Fees charged for all sessions in accordance with the fee schedule. The session is 45-50 minutes in length. Pay Pal payment is accepted in lieu of cash or check if providing distant services. Each check that is returned because of insufficient funds will result in a charge to you of $25.00 plus bank charges. At this time we do not file insurance claims. Receipts will be provided for you to submit to your Flex account or insurance company.
FULL PAYMENT FOR SERVICES RENDERED ARE DUE AT THE TIME OF SERVICE. WE ACCEPT CASH AND CHECK OR PAY PAL.
Treatment:
La Bella Luce, LLC will provide each client with specific, complete and accurate information regarding the treatment that they receive. As a client, I understand that outpatient mental health or behavioral health services, and/or alternative medicine and complementary energy-based approaches may be used. There are multiple alternatives that may be used including (but not limited to): Healing Touch, Reiki, Ama Deus Techniques which are all gentle, complementary energy-based approaches to health and healing that can assist the human body in its natural ability to heal. I fully acknowledge and understand that this is accomplished through the use of contact and/or non-contact methods. Bibliotherapy, religious care, community support, holistic healing, and/or aromatherapy are methods which may be incorporated in the treatment. I acknowledge being informed that complementary and integrative therapy are not intended to replace any currently prescribed medical treatments as ordered by my physicians or other medical practitioners, nor does it replace any other medical care I have or may be advised to seek by them. I have been informed that my practitioner will neither diagnose nor prescribe for any non-mental health condition that I might have. I acknowledge that she does not make any specific claims regarding results for the sessions that I receive.
All clients are required to sign their treatment plan.
- Psychotherapy treatment shall be done in the following modes – individual, couple, family, or group.
- Integrative energy techniques are accomplished by contact and/or non-contact modalities.
- If you would like to receive a different treatment mode, transfer to another therapist, or seek treatment elsewhere, you are free to do so at anytime.
- You are free to withdraw this consent at anytime and to terminate services.
Possible Outcomes, Benefits and Side Effects:
The overall goals of behavioral health, integrative and complementary treatments at La Bella Luce, LLC include (but are not limited to) improvement in mental health or physical health, reduction in pain, anxiety and stress, improvement in family functioning, improvement in inter-personal relationships, social functioning, employment functioning, resolution of legal distress and/or reduction of substance use concerns. As clients participate, many difficult and stressful issues might be addressed. At times, side effects of treatment might include a temporary increase in negative symptoms. We encourage you to discuss this situation with your primary treatment provider as these issues arise.
Emergencies:
I understand that La Bella Luce, LLC does not provide emergency services of any kind and in the event of a medical or mental health emergency, I will need to contact my health care provider or Emergency Medical Services through 911 or my local police or fire departments.
Cancellations and Changes of your Appointment Time:
Unless canceled, at least 24 hours in advance, our policy is to charge you for missed appointments at the rate of a normal office visit. You will be billed directly. Please help us to serve you better by keeping scheduled appointments.
Medical Supervision:
It is required by the applicable State of Wisconsin codes that all mental health clients have in their file a referral from an M.D. or psychologist. La Bella Luce, LLC will send a referral letter to be signed by your medical doctor or an approved clinical psychologist and require that it be returned.
Statement of Agreement:
By signing below I acknowledge that I have read, understand, consent to and agree to the above policies and conditions. We have discussed the nature of the services to be provided including information on holistic complementary and integrative energy-based therapy, along with traditional psychotherapy. I fully understand my practitioner’s qualifications and agree to allow physical contact and/or non-contact treatment. I understand it is my responsibility to maintain a relationship with a medical doctor or psychologist, if I so desire. I have discussed these policies with the practitioner and all questions have been answered to my satisfaction. Finally, I have been offered a copy of this agreement to take with me if I desire.