You do not need a referral to begin mental health counseling or therapy services with us. We welcome you to reach out directly to schedule an appointment.

However, for the following specialized services, a referral from your primary care provider is required:

Transcranial Magnetic Stimulation (TMS)

Speech Therapy

Psychological Testing and Autism Evaluations

This helps ensure coordinated care and proper documentation for insurance and clinical purposes. If you have questions or need help obtaining a referral, our team is happy to assist.

Your Privacy Matters—Understanding Confidentiality at LifeThrive

At LifeThrive, your privacy is a top priority. Everything you share with your clinician is kept confidential and protected by law. We believe that trust is the foundation of effective care, and we are committed to honoring that trust.

However, there are a few specific situations where we are legally required to break confidentiality to ensure safety and comply with mandated reporting laws. These include:

If you disclose plans to harm yourself or someone else

If there is suspected abuse or neglect of a child, elderly person, or vulnerable adult

If we are ordered by a court to release records

If there is a medical emergency that requires coordination of care

If you disclose abuse by a licensed health professional

These exceptions are rare, and when possible, we will discuss them with you before any action is taken. Our goal is always to protect your well-being while following the law and ethical standards.

Dear Patient/Guardian,

We are pleased to welcome you to our clinic for your first appointment with our practice. During your initial visit, we will get to know you better and discuss your health needs.

Here’s what you can expect:

1.) Psychological/Medical History Review

To ensure you receive the most appropriate and personalized care, your visit begins with a comprehensive review of your psychological and medical history—conducted by one of our trained intake specialists. This process helps us assess a wide range of conditions and determine which services best support your well-being.

Please bring all current medications in their original bottles. This allows us to create a complete and accurate picture of your health, including any existing conditions, medications, and family health background.

Following your intake, you will be scheduled with your regular provider to begin your care journey with a plan tailored to your needs.

2.) Getting to Know You

During your intake, we want to understand you as a person—beyond just your psychological and medical history. Feel free to share information about your family life, hobbies, spirituality, and exercise habits.

Knowing what matters to you helps us tailor care plans that align with your preferences and lifestyle.

3.) Health Concerns

If you have specific concerns or needs, we encourage you to share them during this visit. Whether it’s emotional, behavioral, developmental, or relational—we’re here to listen and support.

4.) Matching You With the Right Provider

After your intake, we schedule your initial appointment with a provider whose expertise and approach best align with your needs and preferences. We take into account your clinical goals, communication style, and any specific requests to ensure a strong therapeutic fit from the start.

5.) Assessing the Provider-Patient Relationship

When you meet with your provider, we encourage you to reflect on the connection. Do you feel heard and understood? Is there good eye contact and confidence in communication?

We value building strong, trusting relationships. If at any time you feel your needs aren’t being met, you’re welcome to reach out to our Patient Outreach Coordinator, who can help you transition to a different provider or address any concerns.

6.) Next Steps

At the end of your visit, you and your provider will discuss next steps and identify a time in their schedule that works best for you. We recommend establishing a recurring appointment time to ensure consistency and reserve that time slot for your care.

Prioritizing your health is essential—and we’re honored to walk alongside you on your wellness journey.

Assessment Structure

Multiple Sessions: The psychological assessment consists of several parts, each conducted on a separate day. This approach ensures thorough and accurate results.

Appointment Scheduling: It is imperative that you do not schedule any additional appointments on the same day as your psychological testing. Insurance may not cover multiple appointments on the same day, and you would be responsible for the full charge.

Session Duration: Each session will last approximately two hours.

Intake and Test Determination: The specific screeners you will undergo will be determined upon completion of the initial intake session.  When you meet to review the results of the screeners, it will be determined if you meet medical necessity to meet with the psychologist and what testing is recommended.

Assessment Phases

Phase One:

EEG (Electroencephalogram)

Biopsychosocial Assessment

Behavioral Component

Assessment from Adaptation

Autism Screening

ADHD Screening

Note: Phase One is a screening process to understand your needs better.  The results of these individual assessments will be reviewed, and additional recommendations may be made for Phase Two. Once we determine that you meet the medical necessity, you may be placed on a waitlist.  If placed on a waitlist you will be called in the order you were placed on the waitlist to meet with the psychologist. The expected wait time is between 3 months and 1 year.

Phase Two:

Personality Inventory

Cognitive Evaluation

Autism Diagnostic Exam

Any additional testing deemed medically necessary by the psychologist

Note: Phase Two is the psychological assessment where you will work with one of our psychologists. You will be provided with a comprehensive psychological evaluation that meets your specific needs.

We want every patient to feel safe, heard, and supported throughout their care. If you ever have concerns about your provider or feel that something isn’t working for you, please reach out to our Patient Outreach Coordinator. You may request a change in provider at any time.

Unless there is a clinical reason that prevents us from making the change, a new provider will be recommended by the Director to ensure continuity of care and emotional safety.

We rely on your feedback to improve your experience—management cannot address concerns we aren’t aware of. Your voice matters, and we’re committed to making adjustments that support your healing journey.

CONSENT FOR TELEHEALTH CONSULTATION

I understand that my health care provider wishes me to engage in a telehealth consultation.

My health care provider explained to me how the video conferencing technology that will be used to affect such a consultation will not be the same as a direct client/health care provider visit due to the fact that I will not be in the same room as my provider.

I understand that a telehealth consultation has potential benefits including easier access to care and the convenience of meeting from a location of my choosing.

I understand there are potential risks to this technology, including interruptions, unauthorized access, and technical difficulties. I understand that my healthcare provider or I can discontinue the telehealth consult/visit if it is felt that the videoconferencing connections are not adequate for the situation.

I have had a direct conversation with my provider, during which I had the opportunity to ask questions in regard to this procedure. My questions have been answered and the risks, benefits and any practical alternatives have been discussed with me in a language in which I understand.

CONSENT TO USE THE TELEHEALTH BY PracticeQ/Google Meet's SERVICE

Telehealth by PracticeQ/Google Meets is the technology service we will use to conduct telehealth video conferencing appointments. It is simple to use and there are no passwords required to log in. By signing this document, I acknowledge:

Telehealth by  PracticeQ/Google Meets is NOT an Emergency Service and in the event of an emergency, I will use a phone to call 911.

Though my provider and I may be in direct, virtual contact through the Telehealth Service, neither  PracticeQ/Google Meets nor the

Telehealth Service provides any medical or healthcare services or advice including, but not limited to, emergency or urgent medical services.

The Telehealth by  PracticeQ/Google Meets Service facilitates videoconferencing and is not responsible for the delivery of any healthcare, medical advice or care.

I do not assume that my provider has access to any or all of the technical information in the Telehealth by  PracticeQ/Google Meets Service – or that such information is current, accurate or up-to-date. I will not rely on my health care provider to have any of this information in the Telehealth by  PracticeQ/Google Meets Service.

To maintain confidentiality, I will not share my telehealth appointment link with anyone unauthorized to attend the appointment.

By signing below, if you are signing for your child, you also attest to and certify that you are the Parent/Legal Guardian of the Minor Client, and that you have current and unrevoked legal authority to grant permission and consent to the above listed practice permitting the Minor Client to use the PracticeQ/Google Meets Software and Services.

YOU AGREE, THAT IF AND WHEN YOU NO LONGER HAVE SUCH AUTHORITY, YOU WILL IMMEDIATELY NOTIFY THE MINOR CLIENT PRACTICE IN WRITING.

If you are a parent or guardian, please state your child's name here: _____________________________________

By signing this form, I certify:

That I have read or had this form read and/or had this form explained to me.

That I fully understand its contents including the risks and benefits of the procedure(s).

That I have been given ample opportunity to ask questions and that any questions have been answered to my satisfaction.

HIPAA & Notice of Privacy Practices

LifeThrive is committed to maintaining and protecting the confidentiality of the individual’s PHI. LifeThrive is required by federal and state law, including the Health Insurance Portability and Accountability Act (“HIPAA”), to protect the individual’s PHI and other personal information. LifeThrive is required to provide the individual with this Notice of Privacy Practices regarding their specific policies, safeguards, and practices. When LifeThriveE uses or discloses an individual’s PHI, LifeThrive is bound by the terms of this Notice of Privacy Practices, or the revised notice of Privacy Practices, if applicable. 

I. My Pledge Regarding Your Personal Health Information:

I understand that health information about you and your health care is personal. I am committed to protecting health information about you. I create a record of the care and services you receive from me. I need this record to provide you with quality care and to comply with certain legal requirements. This notice applies to all of the records of your care generated by this mental health care practice. This notice will tell you about the ways in which I may use and disclose health information about you. I also describe your rights to the health information I keep about you, and describe certain obligations I have regarding the use and disclosure of your health information. I am required by law to:Make sure that protected health information (“PHI”) that identifies you is kept private.Give you this notice of my legal duties and privacy practices with respect to health information.Follow the terms of the notice that is currently in effect.I can change the terms of this Notice, and such changes will apply to all information I have about you. The new Notice will be available upon request, in my office, and on my website. 

II. How I May Use and Disclose Your Health Information:

The following describes the ways LifeThrive may use and disclose PHI. Except for the purposes described below, LifeThrive will use and disclose PHI only with the individual’s written permission. The individual may revoke such permission at any time by writing to LifeThrive'S: Compliance Officer.

For Treatment: We may use and disclose PHI for the individual’s services. For example, LifeThrive may disclose PHI to doctors, nurses, technicians, or other personnel, including people outside LifeThrive, who are involved in the individual’s medical care and need the information to provide the individual with medical care.

For Payment: We may use and disclose PHI so that or others may bill and receive payment from the individual, an insurance company or third party for the treatment and services the individual received. For example, we may tell the individual’s insurance company about a treatment the individual is going to receive to determine whether the individual’s insurance company will cover the treatment.

For Health Care Operations: We may use and disclose PHI for health care operation purposes. The uses and disclosures are necessary to make sure that all LifeThrive patients receive quality care and to operate and manage our office.

Appointment Reminders, Treatment Alternatives, and Health Related Benefits and Services: We may use and disclose PHI to contact the individual to remind them that they have an appointment with LifeThrive. We also may use and disclose PHI to tell the individual about treatment alternatives or health-related benefits and services that may be of interest to the individual.

Research: Under certain circumstances, LifeThrive may use and disclose PHI for research. For example, a research project may involve comparing the health of patients who received one treatment to those who received another, for the same condition. LifeThrive will generally ask for the individual’s written authorization before using the individual’s PHI or sharing it with others to conduct research. Under limited circumstances, we may use and disclose PHI for research purposes without the individual’s permission.

Incidental Use and Disclosure: We are not required to eliminate every risk of an incidental use or disclosure of your PHI. Specifically, a use or disclosure of your PHI that occurs as a result of, or incident to an otherwise permitted use or disclosure is permitted as long as I have adopted reasonable safeguards to protect your PHI, and the information being shared was limited to the minimum necessary.

III. Special Situations in Which I May Disclose PHI Without Your Consent:

As Required by Law: We will disclose PHI when required to do so by international, federal, state, or local law.To Avert a Serious Threat to Health or Safety: We may use and disclose PHI when necessary to prevent a serious threat to the individual’s health and safety or the health and safety of others. Disclosures, however, will be made only to someone who may be able to help prevent or respond to the threat, such a law enforcement or potential victim.  For example, we may need to disclose information to law enforcement when a patient reveals participation in a violent crime.Law Enforcement: We may release PHI if asked by a law enforcement official if the information is: (1) in response to a court order, subpoena, warrant, summons or similar process; (2) limited information to identify or locate a suspect, fugitive, material witness, or missing person; (3) about the victim of a crime even if, under certain very limited circumstances, LifeThrive is unable to obtain the individual’s agreement; (4) about a death LifeThrive believes may be the result of criminal conduct; (5) about criminal conduct on LifeThrive premises; and (6) in an emergency to report a crime, the location of the crime or victims, or the identity, description or location of the person who committed the crime.Abuse or Neglect: We may disclose your PHI to a state or local agency that is authorized by law to receive reports of abuse or neglect. However, the information we disclose is limited to only that information which is necessary to make the required mandated report.Essential Government Functions: We may be required to disclose your PHI for certain essential government functions. Such functions include but are not limited to: assuring proper execution of a military mission, conducting intelligence and national security activities that are authorized by law, providing protective services to the President, making medical suitability determinations for U.S. State Department employees, protecting the health and safety of inmates or employees in a correctional institution, and determining eligibility for or conducting enrollment in certain government benefit programs.

Business Associates: We may disclose PHI to any business associates that perform functions on our behalf or provide LifeThrive with services if the information is necessary for such functions or services. All of LifeThrive's business associates are obligated to protect the privacy of the individual’s information and are not allowed to use or disclose any information other than as specified in our contract.

Lawsuits and Disputes: If the individual is involved in a lawsuit or a dispute, LifeThrive may disclose PHI in response to a court or administrative order. LifeThrive also may disclose PHI in response to a subpoena, discovery request, or other lawful request by someone else involved in the request or to allow the individual to obtain an order protecting the information requested.

Health Oversight: I may disclose PHI to a health oversight agency for activities authorized by law, such as audits, investigations, and inspections. Oversight agencies seeking this information include government agencies and organizations that provide financial assistance to the program (such as third-party payors) and peer review organizations performing utilization and quality control. If we disclose PHI to a health oversight agency, we will have an agreement in place that requires the agency to safeguard the privacy of your information.

Psychotherapy Notes: If kept as separate records, we must obtain your authorization to use or disclose psychotherapy notes with the following exceptions. We may use the notes for your treatment. We may also use or disclose, without your authorization, the psychotherapy notes for my own training, to defend myself in legal or administrative proceedings initiated by you, as required by the APPLICABLE STATE AGENCY or the US Department of Health and Human Services to investigate or determine my compliance with applicable regulations, to avert a serious and imminent threat to public health or safety, to a health oversight agency for lawful oversight, for the lawful activities of a coroner or medical examiner or as otherwise required by law.

IV. You Have the Following Rights with Respect to Your PHI:

The Right to Request Limits on Uses and Disclosures of Your PHI: You have the right to ask me not to use or disclose certain PHI for treatment, payment, or health care operations purposes. I am not required to agree to your request, and I may say “no” if I believe it would affect your health care.

The Right to Request Restrictions for Out-of-Pocket Expenses Paid for In Full: You have the right to request restrictions on disclosures of your PHI to health plans for payment or health care operations purposes if the PHI pertains solely to a health care item or a health care service that you have paid for out-of-pocket in full.

The Right to Choose How I Send PHI to You: You have the right to ask me to contact you in a specific way (for example, home or office phone) or to send mail to a different address, and I will agree to all reasonable requests.

The Right to See and Get Copies of Your PHI: Other than “psychotherapy notes,” you have the right to get an electronic or paper copy of your medical record and other information that I have about you. I will provide you with a copy of your record, or a summary of it, if you agree to receive a summary, within APPLICABLE TIME FRAME (CHECK STATE/FEDERAL LAWS) of receiving your written request, and I may charge a reasonable, cost-based fee for doing so.

The Right to Get a List of the Disclosures I Have Made: You have the right to request a list of instances in which I have disclosed your PHI for purposes other than treatment, payment, or health care operations, or for which you provided me with an Authorization. I will respond to your request for an accounting of disclosures within APPLICABLE TIME FRAME (CHECK STATE/FEDERAL LAWS) of receiving your request. The list I will give you will include disclosures made in APPLICABLE TIME FRAME (CHECK STATE/FEDERAL LAWS)  unless you request a shorter time. I will provide the list to you at no charge, but if you make more than one request in the same year, I will charge you a reasonable cost-based fee for each additional request.

The Right to Correct or Update Your PHI: If you believe that there is a mistake in your PHI, or that a piece of important information is missing from your PHI, you have the right to request that I correct the existing information or add the missing information. I may say “no” to your request, but I will tell you why in writing within APPLICABLE TIME FRAME (CHECK STATE/FEDERAL LAWS).

The Right to Get a Paper or Electronic Copy of this Notice: You have the right get a paper copy of this Notice, and you have the right to get a copy of this notice by e-mail. And, even if you have agreed to receive this Notice via e-mail, you also have the right to request a paper copy of it. (This notice will be available in your client portal).

Right to Get Notice of a Breach: LifeThrive is committed to safeguarding the individual’s PHI. If a breach of the individual’s PHI occurs LifeThrive will notify the individual in accordance with state and federal law.

Right to Request Restrictions: Individuals have the right to request a restriction or limitation on the PHI LifeThrive uses or disclose for treatment, payment, or health care operations. Individuals also have the right to request a limit on the PHI we disclose to someone involved in the individual’s care or the payment for the individual’s care, like a family member or friend.To request a restriction, the individual must make their request, in writing, to the Department in which their care was provided. LifeThrive is not required to agree to the individual’s request unless the individual is asking us to restrict the use and disclosure of the individual’s PHI to a health plan for payment or health care operation purposes and such information the individual wishes to restrict pertains solely to a health care item or service for which the individual has paid Mindful Way Out-of-pocket in full. If we agree, we will comply with the individual’s request unless the information is needed to provide the individual with emergency treatment or to comply with law. If we do not agree, we will provide an explanation in writing.

Out-of-Pocket Payments: If the individual pays out-of-pocket (or in other words, the individual has requested that LifeThrive not bill the individual’s health plan) in full for a specific item or service, the individual has the right to ask that the individual’s PHI with respect to that item or service not be disclosed to a health plan for purposes of payment or health care operations, and we will honor that request.

Informed Consent for Treatment and Practice Policies

Please remember to cancel or reschedule 24 hours in advance. You will be responsible for the entire fee if cancellation is less than 24 hours.

Informed Consent for Treatment and Practice Policies

General Information:

The therapeutic relationship is unique in that it is a highly personal and at the same time, a contractual agreement. Given this, it is important for us to reach a clear understanding about how our relationship will work, and what each of us can expect. This consent combined with the Privacy Practices and Practice Policies will provide a clear framework for our work together. Feel free to discuss any of this with your provider. Please read and indicate that you have reviewed this information and agree to it by filling in the checkbox at the end of this document.

What is Therapy?

Therapy is a service provided by a qualified mental health therapist.  Although each session and individual’s perception of therapy may be unique, you can expect a few things to be consistent: a nonjudgmental and empathetic environment to openly discuss challenges, fears, hopes, and goals, and appropriate and qualified analysis of relationship and individual wellness. Psychotherapy requires the active participation of both the client and the therapist. In order to receive the greatest benefit from treatment,  it is recommended that you take time to reflect on the topics and suggestions given during sessions.

Counseling is not always easy. You may find yourself having to discuss very personal information. You could find those conversations difficult and embarrassing, and you might be very anxious during and after such conversations. Counseling is intended to alleviate problems, but sometimes, especially at first, and as you get to the root of the things, you may feel them even more acutely than in the past. Your therapist may suggest for you to do some things that might, initially, make you feel awkward or uncomfortable. Sometimes counseling requires trying new ways of doing things. You will always be free to move at your own pace. Your therapist may challenge you and your old ways of thinking and doing things, but we cannot make any promise about the results you will experience.

The Therapeutic Process:

You have taken a very positive step by deciding to seek therapy. The outcome of your treatment depends largely on your willingness to engage in this process, which may, at times, result in considerable discomfort. Remembering unpleasant events and becoming aware of feelings attached to those events can bring on strong feelings of anger, depression, anxiety, etc. There are no miracle cures. We cannot promise that your behavior or circumstance will change. We can promise to support you and do our very best to understand you and repeating patterns, as well as to help you clarify what it is that you want for yourself.

How long will therapy last?

Therapy appointments usually last approximately 45 minutes. Sessions may last from a few weeks to several months. The course of therapy depends on the presenting concerns, your commitment to change, and may also be impacted by the number of sessions covered by insurance. In general, we consider our job to “work ourselves out of a job.” We will be in ongoing dialogue about your needs, progress, and recommended duration of counseling. You are invited at any time to ask questions about your therapist’s methods or direction of your counseling.

Social Media and Telecommunication: 

Due to the importance of your confidentiality and the importance of minimizing dual relationships, Staff at LifeThrive do not accept friend or contact requests from current or former patients on any personal social networking site (Facebook, LinkedIn, etc). We believe that adding patients as friends or contacts on these sites can compromise your confidentiality and our respective privacy. It may also blur the boundaries of our therapeutic relationship. If you have questions about this, please bring them up when with a member of the management team at LifeThrive and we can talk more about it.

SmartScribe software use:

You provider may elect to use SmartScribe Software during your session to help with clinical documentation of treatment.

Documentation: will be used to support the creation of medical notes based on conversations during you appointment. The notes created will be part of the medical record. The transcript of the session never becomes part of your medical record.

Quality Assurance: The collected data may be used for quality assurance and continuous improvement at LifeThrive

Compliance with Laws: SmartScribe Corp. and the healthcare facility will comply with all applicable federal, state, and local laws and regulations, including HIPAA, in the collection, use, and disclosure of this information.

Electronic Communication: We cannot ensure the confidentiality of any form of communication through electronic media, including text messages. If you prefer to communicate via email or text messaging for issues regarding scheduling or cancellations, we will do so. While we may try to return messages in a timely manner, we cannot guarantee immediate response and request that you do not use these methods of communication to discuss therapeutic content and/or request assistance for emergencies.

Contacting your Provider:

In the event of an emergency, please call 911 or go to your local emergency room. For non-emergent needs you may leave a message on our confidential voicemail or send your therapist an email. Please refrain from discussing topics other than scheduling or billing information outside of our face to face interactions.

Outside Communication with LifeThrive staff. If one of our LifeThrive Team-members see you or a family member accidentally outside of the office, we will not acknowledge you first. Your right to privacy and confidentiality is of the utmost importance to us, and we do not wish to jeopardize your privacy. However, if you acknowledge us first, we will be more than happy to speak briefly with you, but feel it appropriate not to engage in any lengthy discussions in public or outside of the therapy office.

Confidentiality:

In accordance with the standards set forth by the State of Illinois and HIPAA, the information you provide to LifeThrive will be treated as strictly confidential, meaning that we will not share information you have provided us with unauthorized individuals. However, there are exceptions, including those situations which we are required by law to report, such as: suspected abuse to a child and /or dependent adult, harm or threat to self or others. While these situations are rare, you should be aware of the possible occurrence as well as the protective actions required of your therapist. These actions may include notifying the potential victim, notifying the police, seeking appropriate hospitalization for the client, and/or contacting family members or others who can help provide protection.

There may be times when your therapist will need to consult with another professional in order to adjust or improve their therapeutic approach. In these consultations, we will make every effort to avoid revealing your identity. The consultant is also legally bound to keep the information confidential. Unless you object, we will not necessarily inform you about these consultations. All clinicians on staff participate in group consultation, and clinicians that are not yet licensed to work independently receive supervision by a fully licensed clinician.

Counseling and Treatment of a Minor:

LifeThrive requires this “Terms of Services and Policies” document to be completed by both parents or legal guardians of a minor. A minor is identified as a client under the age of 18. If applicable, custody or guardianship documentation such as a parenting agreement must be provided to LifeThrive prior to the initial appointment. Please note that at the age of 12, a minor has certain rights to their file that may affect what information can be communicated or released outside of treatment. You may speak with your clinician if you have any concerns or questions about this.

PRACTICE POLICIES

Please remember to cancel or reschedule 24 hours in advance. You will be responsible for the entire fee if cancellation is less than 24 hours.

Session Fees & Payments Expectations for private pay patients or out of network benefits:

The fee for the initial sessions (diagnostic assessments) is $200.  Subsequent treatments are billed as follows:

$180 per billable hour for counseling 

$350 per billable hour for psychological services

$350 per billable hour for Occupation Therapy

$350 per billable hour for Speech Therapy

$350 per TMS session

$250 to see a MD or Nurse Practitioner

Session Fees & Payments Expectations for sessions billed through your insurance:

Many do not understand that a provider bills your insurance, it is the insurance company that has established the rates the provider must charge the patient. Further our contracts with your insurance company dictates that we are not able to adjust the fee’s or write off a balance.

Acceptance of Insurance and Client Responsibility:

If you have insurance coverage. We will be happy to submit claims to receive payment directly from them if we have a contract with your insurance or third party payer. In that case, LifeThrive will submit claims according to the contract terms with your insurance. If you prefer LifeThrive will also provide you with a superbill and any other information you may need so that you may submit your own insurance claims and be reimbursed by your carrier. Your copay or co-insurance is due at the time of your visit. If there is a problem collecting payment from your insurance or managed care company for the balance, you remain responsible for payment of the fee. If we have not received payment from your insurance or third party payer within 8 weeks of any counseling session, we will bill you directly for past and for ongoing visits. If your carrier does not pay, you will be responsible and failure to pay will necessitate termination of counseling and a referral to another provider.

We will attempt to submit claims to insurance companies that we are not in network with, as well as submit to secondary insurance payers. LifeThrive makes no guarantee of success and you will be responsible if we have not received payment from any out of network claims or secondary claims within eight weeks of the submission date, we will bill you directly for past and for ongoing visits. We will be happy to provide a superbill in these cases to aid in your own submission for reimbursement.

It is in your best interest to verify the details of your health insurance policy and share that information with LifeThrive staff. Staff at LifeThrive may assist you in verifying your coverage and submit your claims to the insurance company. However, you remain responsible for knowing your insurance benefits. You also remain personally responsible for deductibles, co-payments, co-insurance, non-covered, ineligible, or unauthorized services. It is recommended that you verify your coverage 24-hours prior to the first appointment to be sure that your therapist is a covered provider, and these services will be covered.

Some insurance companies will often require advance authorization before they will provide reimbursement for mental health services. It is your responsibility to make sure you are taking proper steps to obtain reimbursement from your insurer; this includes keeping track of your authorized visits. If your insurance company limits the number of sessions you are allowed per calendar year/contract year/lifetime or limits the dollar amount paid out, you are expected to maintain documentation, as payment may become your responsibility if you exceed this number. *Please note maximum visits or dollar amounts may include all mental health services, not just for those rendered at LifeThrive.

You should also be aware that most insurance agreements require your therapist to provide a clinical diagnosis. This information will become part of the insurance company files. And. in all probability, some of it will be computerized. All insurance companies claim to keep such information confidential, but once it is in their hands, we have no control over what they do with it. It is important to remember that you always have the right to pay for services directly and avoid the reporting and complexities associated with insurance coverage.

If you experience any changes in your insurance coverage, it is your responsibility to notify your clinician and our administrative staff prior to your session. In the event that the insurance information that you have provided us is incorrect, resulting in the denial of a claim, you will be subject to a $25 insurance resubmission fee. An example of this is if your coverage has ceased or changed and you fail to notify us before your session.

Sliding-Fee-Scale:

If you are unable to afford the cost; Laws do allow us to provide a sliding fee scale that allows us to adjust charges. Need has to fall within federal guidelines for poverty and be held to a standard for all patients. If at any time you feel that you are unable to afford the cost that your insurance company states you owe, please reach out to our staff at (618) 283-2222 to request and complete a sliding-fee-scale.

Canceling or Rescheduling:

If you need to cancel or reschedule your appointments, please provide 24-hours-notice with the office staff at (618) 283-2222. Your counselor will not be able to cancel your appointments. Failure to provide the practice a 24-hours notice of cancellation will result in you being charged a fee equivalent to our out of pocket session fee for the services you were scheduled to receive. If you are late by 15 minutes or more and have not contacted your therapist, we will assume you are not coming. Unfortunately, your insurance company does not pay claims for missed appointments.  LifeThrive will take utilize one of two options.  

1) Patients who fail to give a 24 hour notice of cancelation are at risk for termination due to non-compliance in treatment.  You will be discharged from care due to non-compliance or 

2) You will have to pay the fee for a late cancellation or missed appointment yourself prior to your next session. No-show/Late Cancel fees are never fun for your clinician to charge, but it is a way for us to maintain our income and to validate the worth of our time. We appreciate your understanding and adherence to this policy. This fee is the full cost of your scheduled appointment.  

Non-Compliance of Treatment.

Patients who are deemed to be non-compliant with treatment may be discharged from a treatment program or from the practice.

Reasons for noncompliance include failing to complete prescribed services and failing to attend appointments regularly.

If Termination occurs you will need to reestablish care. You may have to be scheduled with a new provider if your provider is no longer accepting new patients. To reestablish care the treatment team must meet and determine the ability to be compliant with treatment. Insurance is not responsible for this cost and is billed as private pay, at a rate of $180 per hour. Upon scheduling a charge will be placed to your credit card to cover the cost in advance. If you feel like you are unable to pay this cost, you may schedule an appointment with billing to discuss you need for assistance with the cost. This is not a guarantee of assistance.

Attendance of Sessions:

If you decide to end the session early or if you are late to session you are responsible for the cost of this time. We are unable to bill insurance if you are not present for the session. This is necessary because a time commitment is made to you and is held exclusively for you. it is a way for us to maintain our income and to validate the worth of our time. We appreciate your understanding and adherence to this policy. This fee is $50per 15 minute increment.

Medical Records:

Medical Records can be requested by a patient at the patient's cost. This includes the time to prepare records at $25 per 15-minutes required to complete the task and the cost per page to print. This charge must be paid prior to receiving records. If requested by an attorney, or in a disability case then the attorney or requesting agency will receive the bill and must pay for the records prior to release. Or it must be paid by the patient directly.

Cost per page:

Pages 1-25 are billed at a $0.56 per page. Pages 26-50 are billed at $0.37 per page. Pages 50+ are billed at $0.19 per page.

If we quested with a valid release of information from a medical provider the charges will be written off.

We will need a 30 day notice to complete the medical request.

Report Requests:

If you have a request for your therapist to prepare a report, sign a document, or write a letter, please be advised that you may be charged a fee of $50 per 15-minutes required to complete the request. Your therapist will make reasonable efforts to limit this information to the minimum necessary to accomplish the intended purpose of the request. Your therapist reserves  the right to decline these requests.

Court Testimony:

It is our practice to not become involved in any custody, visitation, or legal disputes. It is important that you seek appropriate and qualified legal advice regarding divorce or custody arrangements. 

If you become involved in legal proceedings that require our participation, you will be expected to pay for any professional time one of our staff spend on your legal matter, even if the request comes from another party.  [Lifethrive charges $400 per hour for professional services I am asked or required to perform in relation to your legal matter].

Invoices and Patient Payment:

An invoice on any unpaid balances will be created on a weekly basis. Please remember that an invoice only states the balances currently owed. This is not a final bill as your insurance carrier may still have outstanding claims that are being processed.

There are two ways to receive notice of the invoice. The first way is through the patient portal. If enabled by you a message will be sent directly to your phone notifying you of the invoice with the current amount due. The second way is by keeping an updated valid email on file in your simple practice patient portal. It is your responsibility to ensure that the settings are correct for the method of your choosing. LifeThrive team members will be happy to help if you reach out. You may also follow the link for further instructions on the Mobile app.

No less than 24 hours after receiving the invoice your debit/credit card that you have on file will be debited. If you are unable to pay the bill you may reach out to one of our dedicated billing specialists to discuss payment plans. You must complete the payment plan document for the payment plan to be valid and follow through on your payments as agreed.

Returned fee or Credit Card charge disputes:

There is a $25 service charge for personal checks returned for any reason. There is also a $25 charge for any disputes made in regards to credit card charges. Payment plans may be made at my description and pending individual circumstances. In order to schedule an initial appointment with our clinicians. We require that a credit card be put on file.

Late Payment Fees and Collections:

Please be advised that we will charge 10% interest at 30 days and 60 days past due.  At 90 days a 22% fee will be added to cover the cost of sending your balance to collections, or to an attorney to obtain payment. If you are unable to pay your bill please contact the billing office to set up payment arrangements and avoid adverse consequences to failure to pay.

We will continue to attempt payment on a weekly basis until your balance is paid in full.

Suspension or Termination of Services:

Occasionally, your therapist may elect to discontinue treatment services provided. This may happen when your therapist observes no substantial progress is being made or other factors are interfering with their ability to help you. Additionally, if you do not keep a scheduled appointment and do not call within one week, your therapist will assume you have chosen to terminate counseling at that time. Future considerations of re-engaging in counseling will need to be initiated by you.

Failure to comply with the statements of this services contract may also lead to termination of services.

If you fail to keep a valid credit card on file and have a balance for longer than 1 week after receiving the invoice in your email.

If your account shows a balance of $250.00 or more, services will be suspended until the balance is paid or a payment plan is established.

If you are unable to afford services your therapist will make a referral to an outside agency for you to receive treatment.

Payment Policies

Please read and completely fill out the form below.

Before your first scheduled session, you are required to have a valid credit card on file.

For private pay clients and for any co-pays, co-insurances or deductibles that are not captured by a separate service, I utilize my electronic health record system (IntakeQ) that is HIPAA and PCI Compliant. There is a form below to capture your CC information.

By completing and signing this Payment Agreement, you are indicating that you understand and agree to provide a valid credit card number, with expiration date, for payment of future therapy sessions, appointments or other fees.

Your signature indicates you understand that if you do not attend a scheduled appointment your credit card will be charged the regular session fee unless you cancelled your appointment at least 24 hours in advance, for cancellations with less than 24 hours' notice, the full cost of the appointment will be charged. For missed appointments with no notice given, the full cost of the appointment will be charged.  

I further understand that I may also be discharged from care due to non-compliance of treatment.  This is the result of canceling with less then 24 hour notice or failing to attend an appointment.

I understand that this authorization will remain in effect until I cancel it in physical writing, (not through electronic means) and I agree to notify LifeThrive in writing of any changes in my account information or termination of this authorization.

I further understand that cancelation of the use of a card without providing a new credit card on file may result in termination of care due to failure to provide valid form of payment.

Your credit card number will be kept on file throughout treatment and will be charged for your copay and deductible. It is expected that your session be paid for by or at the time of service, unless other arrangements have been made. LifeThrive reserves the right to cancel a session if payment is not made. 

Your signature indicates that you may be charged for other services such as, extended phone calls, consultation on your behalf, and other services rendered on your behalf. 

Except for regular cost of a session mentioned earlier, prior to any charges to your card an invoice will be emailed to the main email listed on the account. Please ensure you have a valid and correct email on file to receive the invoices. It is your responsibility to monitor your email for expected charges. 

No less than 24 hours after the invoice is sent to your email the charges will occur. If you are unable to make the payment, please contact us at (618) 283-2222 to schedule a dedicated time with one of our billing specialists to discuss payment or set up a payment plan. If payment arrangements are not made and/or a payment plan completed and signed by you by the scheduled time then charges will occur without notice.

EXAMPLES: Other professional services include report writing, telephone conversations lasting longer than 15 minutes, attendance at meetings with other professionals you have authorized, preparation of treatment summaries, and the time spent performing any other service you may request of me. All these services are charged at a prorated rate of $200/hour in 15 minute increments.

If you become involved in legal proceedings that require my participation, you will be expected to pay for any professional time I spend on your legal matter, even if the request comes from another party.  [Lifethrive charges $400 per hour for professional services I am asked or required to perform in relation to your legal matter].

Your signature indicates that you are an authorized card user for the card you are placing on file.  (If you are not an authorized user a police report may be made due to fraudulently using a credit card)

If you are using your insurance for receiving therapy, you will be asked to fill out a separate authorization to bill insurance. It is your responsibility to know your benefits and to pay for your sessions.

If a session is not covered due to lapse of benefits or change in carrier, and you do not notify us of this change, you will be charged our current full fee. Please review the insurance payment form for more information.

If you are paying out-of-pocket, or using "out of network benefits" you will be charged:

$200 per initial intake 

$180 per billable hour for counseling 

$350 per billable hour for psychological services

$350 per billable hour for Occupation Therapy

$350 per billable hour for Speech Therapy

$350 per TMS session

$250 to see a MD or Nurse Practitioner

If a dispute is filed with the bank and is not found in your favor, charges will result in a $25 fee added to your account.

I certify that I am an authorized user of this credit card and will not dispute these scheduled transactions with my bank or credit card company as long as the transactions correspond to the terms indicated in this authorization form. I acknowledge that credit card transactions could be linked to Protected Health Information.

A cancelled appointment hurts three people: you, your therapist, and another client who could have potentially used your time slot. Therapy sessions are scheduled in advance and are a time reserved exclusively for you. We reserve for you a full hour of our time for the session and clinical notes. If a client cancels with less 24 hours it is unlikely that we will be able to fill that time slot, and we lose an entire hour from our work schedule.

When a session is cancelled without adequate notice, we are unable to fill this time slot by offering it to another current client, a client on the wait list, or a client with a clinical emergency. Without a cancellation fee policy in place, your therapist will lose money or the opportunity to schedule another client if you late cancel or do not show up.

LifeThrive's cancellation policy is this: Clients can cancel or reschedule an appointment anytime if they provide 24 hours notice. If you cancel an appointment with less than 24 hours notice, or fail to show up, you will be charged the full cost of the appointment or discharged for non-compliance from all providers at LifeThrive.

This cancellation policy is not a penalty or a punishment. Most clients understand this. Very rarely, there will be a client who will feel that he or she is being punished when they are charged a late cancellation fee or discharged for non-compliance. We want to make sure that you don’t feel this way, if someday you miss an appointment.

It is likely, if you are in counseling long enough, at some point you might forget about an appointment, or something will come up in your schedule that will result in you missing an appointment. Maybe you’ll need to work late, or your car will break down, or something unavoidable will come up. Therefore, (example: we provide one “freebie” per 12-month period).

Some examples of emergencies are car accidents, deaths in the family or extreme illness of you or a family member. Work issues do not constitute emergencies. This cancellation policy also applies even if missing the appointment was an unintentional act.

Also, if you are more than 15 minutes late to your appointment time, it will be treated like a late cancellation.

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Your FULL FEE will be charged or discharge for non-compliance when you miss or cancel an appointment without giving 24 hour notice.

This means that if an appointment is scheduled for 3:00 pm on a Tuesday, notice must be given by 3:00 pm on Tuesday at the latest. 

While it is a time commitment, this is for your personal growth and consistency is key in order to achieve this.

If you are a weekly client and you miss three scheduled appointments within a two-month period, the therapeutic relationship may be terminated and appropriate referrals to other practices will be offered, or your regularly scheduled appointments, which are offered as a convenience, may be cancelled.

If you are a bi-weekly client and you miss two scheduled appointments in a three-month period, the therapeutic relationship may be terminated and appropriate referrals to other practices will be offered, or your regularly scheduled appointments, which are offered as a convenience, may be cancelled.

(OPTIONAL) Finally, I do offer text and email reminders. This is done as a courtesy and only if you consent to receive such communication by providing us with your email address and cell number. It remains your sole responsibility to keep track of and timely attend all scheduled therapy appointments, whether you receive the text or email reminder.

Purpose

By signing this agreement, I acknowledge that I have read and understood the policies outlined below. I agree to comply with the treatment plan, attend scheduled appointments, and follow safety guidelines.

Policies

Appointment Attendance:I will attend all scheduled appointments promptly.If I need to cancel or reschedule, I will provide at least 24 hours’ notice.

Missed Appointments:

I understand that missing appointments without notice may result in reduced priority for future appointments and discharge of care from all providers at LifeThrive

Late Cancellations:

I will cancel appointments at least 24 hours in advance.Late cancellations (within 24 hours) may incur the same penalties as a missed appointment.

Safety Guidelines:

I will follow safety instructions provided by healthcare professionals.Non-compliance with safety measures may impact my treatment.

Consequences

1) You will be billed for the full rate of the appointment scheduled.

2)  Or you may be immediately discharged from care with all providers at LifeThrive.  If discharge occurs, I understand that to re-establish care a care-team-meeting must occur.  The cost of this meeting will need to be paid at time the appointment is scheduled.  

Purpose:

The Care Team Meeting aims to assess the appropriateness of continued care. The patient, healthcare provider, and relevant team members will participate.

Scheduling and Payment:

The patient must pay a fee of $180 upon scheduling the Care Team Meeting. The fee covers administrative costs associated with the meeting. By signing this policy, the patient agrees to this payment, which is not billable to insurance.

Meeting Agenda:

Review the patient’s history, treatment plan, and non-compliance incidents. Discuss alternative approaches, patient education, and potential solutions. Determine whether continued care is appropriate.

Outcomes:

If continued care is deemed appropriate, a revised treatment plan may be established. If not, the patient will be formally discharged.

Authorization to Bill Insurance

I understand that LifeThrive will check my eligibility as a courtesy. 

It is my ultimate responsibility to ensure that LifeThrive or any of its providers are in-network with my insurance.

I understand it is my responsibility to understand my insurance benefits, including any deductibles, co-pays, or co-insurance amounts.

I certify that I am requesting the services of LifeThrive for myself or my minor child, for the purposes of mental health evaluation, recommendations, and treatment. 

I certify that I have been advised and have received a copy of my rights to confidentiality.  I understand that these rights will be respected and upheld. I understand that disclosure of information suggesting harm or the threat of harm to myself or any other person—by myself or my child—requires notification of the appropriate authorities and/or agencies as mandated by law.  

I request payment of authorized insurance benefits or subsidies made, on my behalf, payable to LifeThrive for any services provided to me.

I authorize any holder to release to my insurance company medical information about me needed to determine benefits or the benefits payable for related services, regulatory compliance, state audit or quality assurance purposes. 

I understand that LifeThrive will submit my insurance claims ON MY BEHALF, and that I will be responsible for any deductible, co-payments, co-insurance or any fees that are not covered by my insurance at the time services are rendered. This includes if there are changes in your insurance plan, or a lapse in coverage.

I understand that I will receive a monthly statement if my account has a balance due.  I understand that LifeThrive cannot accept responsibility for collection of my insurance claim or for negotiating a settlement on a disputed claim and that I am responsible for payment of my account. 

I understand that there is a 24 hour cancellation policy and if I fail to appear for a scheduled appointment, I will be responsible for the FULL contracted fee with my insurance.

Dear Parents,

This agreement outlines the rights of both parents to access their children’s medical records, in accordance with applicable laws and regulations, until a court orders otherwise.

1. Parental Rights to Access Medical Records

Both parents have the right to access their children’s medical records as their personal representatives. This access is granted under the Health Insurance Portability and Accountability Act (HIPAA) Privacy Rule, which generally allows parents to obtain medical information about their minor children unless state or other applicable laws provide otherwise.

2. Exceptions to Parental Access

There are specific situations where a parent may not be considered the minor’s personal representative under the Privacy Rule:

When the minor consents to medical care and parental consent is not required by law.

When the minor receives medical care at the direction of a court or a court-appointed person.

When the parent agrees that the minor and the healthcare provider may have a confidential relationship.

3. Professional Judgment and State Laws

In cases where state or other applicable laws are silent on a parent’s right of access, healthcare providers may use their professional judgment to grant or deny access to the minor’s medical information. Additionally, access may be denied if the provider believes that treating the parent as the child’s personal representative could endanger the child.

4. Confidentiality and Safety

Healthcare providers may choose not to treat a parent as the child’s personal representative if they reasonably believe that the child has been or may be subjected to domestic violence, abuse, or neglect.

5. Court Orders

This agreement remains in effect until a court issues an order that modifies or revokes these rights. If such an order exists, a copy must be provided to our staff. Without this documentation, our staff will not be held liable for granting access to medical records based on the terms outlined in this agreement. Both parents are encouraged to stay informed about any legal changes that may affect their access to their children’s medical records.

By signing below, both parents acknowledge their understanding of these rights and agree to abide by the terms outlined in this agreement.

NOTICE TO PATIENTS: This practice serves all patients regardless of ability to pay. Discounts for essential services are offered based on family size and income. For more information, please contact the front desk. Thank you.