Clinical Services Program Forms

Jewish Family & Children's Service

10950 Schuetz Road

St. Louis, MO 63146

WELCOME LETTER AND SERVICE AGREEMENT

For over 137 years, Jewish Family & Children’s Service (JF&CS) has provided families in the St. Louis community with the resources they need to meet the challenges of everyday living. Our services are specifically tailored for children, couples, families, adults and the elderly experiencing problems with daily living, as well as those with extremely serious physical and emotional difficulties. Our staff is committed to providing the highest quality services while recognizing your right to privacy and confidentiality.

FEES

The Agency’s fee to provide counseling, case management, and/or mental health services is $110 per hour. Fees for psychological, educational, vocational, and/or behavioral assessments are determined by type of assessment. A sliding fee scale for services is based upon need and is available should you not be able to meet the cost. The remainder will be subsidized using funds provided by the United Way and the Jewish Federation. If you choose to use the Agency’s sliding scale, it is your responsibility to demonstrate your financial situation (e.g., assets, income and outstanding debts). If your financial situation changes, your fee will be adjusted accordingly.

INSURANCE

If you have insurance and it covers our services, at your request we file a claim with your insurance company. Unless arranged otherwise, all insurance payments must be assigned to JF&CS. You are responsible for your deductible and co-pay. Combined insurance and sliding scale payments in excess of $110 will be refunded to you upon the termination of services. If you choose not to use your insurance, your fee will be $110 per hour and you will be unable to submit your visits in the future for insurance reimbursement.

PAYMENT

Payment is required before the start of each appointment, although billing is possible based upon prior arrangement with the Agency. If payment is due for more than two sessions, we will be unable to provide further counseling or other Agency services until your account is made current. If you need to contact your provider by phone to discuss something other than scheduling a visit, the Agency reserves the right to bill you for this time. If your conversation with your provider is at least 15 minutes, but less than 30 minutes, you will be billed 1/2 the hourly rate set for you. If your conversation is in excess of 30 minutes, you will be billed the full hourly rate. If your insurance prohibits billing for phone sessions (e.g., Medicare), you will be asked to schedule a visit with your provider.

CANCELLATIONS

If cancellation of an appointment is necessary, we request 24 hours notice so that your appointment time can be made available for another client of JF&CS. Cancellations without adequate notice will be charged at your regular fee with the exception of emergency situations as determined by the Agency. Either way, we request that you call the Agency, if possible, to let us know about your inability to make an appointment.

CONFIDENTIALITY

All clients of our Agency have a right to confidentiality and privileged communication, with a few limited exceptions. Missouri law dictates that if any individual intends harmful acts or dangerous action against others or against themselves, it is the Agency’s duty to break confidentiality with the client to ensure that the client and others are safe. Every effort will be made to resolve the issue before a breach of confidentiality takes place. If the Agency has reason to believe that a child or vulnerable adult is being physically abused, sexually abused, or neglected, we are mandated to report the incident to the proper authorities.

CASE RECORD

A case record is assembled documenting the services you receive at the Agency. You have the right to access your case record and obtain a copy of its contents. The original case record is the property of the Agency and will remain secured in the Agency in accordance with State law. You will be charged 15 cents per page plus a $10 handling fee to cover the costs of copying your case record and you must present yourself at the Agency with identification to obtain a copy. The Agency has 30 days to prepare a copy of your case record from the date of written request.

LEGAL PROCEEDINGS

On occasion, clients call upon mental health providers to participate in legal proceedings (e.g., custody, divorce, etc.). It is this Agency’s policy that its staff only involves themselves in legal proceedings when ordered by the court. The Agency strongly believes that involving its staff in legal proceedings should be avoided because of the potential for it to negatively affect the therapeutic relationship and the potential for opening up the client to unnecessary scrutiny. Other than a mandate from the court, you will be charged for any time the Agency uses to deal with legal proceedings.

GRIEVANCE POLICY

Should the need arise, as a client of the Agency, you may: (1) file a grievance; (2) have access to information in your written record; or (3) refuse or discontinue treatment.

l have read and been offered a copy of this letter. I have read and been offered a copy of Client Rights and Responsibilities. By signing below, I agree to receive services from Jewish Family & Children’s Service and agree to the aforementioned conditions for obtaining services from Jewish Family & Children’s Service.

□Yes □No I consent to have emails sent to me by agency staff regarding appointment times, service paperwork, or other non-treatment related issues.

I understand that my therapist does not provide therapy by email. I agree that if I have a crisis situation outside regular office hours, I will call Behavioral Health Response or Life Crisis, go to the emergency room, or call 911. I will not use email to advise my therapist of the crisis.

Client: _________________________________ Date: ______________

Witness: ______________________________ Date: ______________