Check the box and then read the following:

Kimberly L. Hillery & Associates, PLLC, believes in providing goal-directed treatment. This means that a treatment goal or several goals are established after a thorough assessment. All treatment is planned with the goal in mind, and progress is made toward accomplishing that goal time-efficiently. Counseling is not an exact science with guaranteed, predictable results, and that guarantee cannot or has not been made concerning my needs. I understand that my therapist will make their best effort to assist me as appropriate.  However, I hereby release my therapist from any liabilities from counseling techniques and/or ordinary professional negligence and/or for actions concerning counseling. As such, I hereby consent to treatment, understanding that I can terminate this contract at my discretion. If you have any questions about the nature of the treatment or anything else about your care, please do not hesitate to ask.  

TREATMENT PLANNING: A treatment plan describing the length, type, and goals of treatment will be developed and signed by you and the counselor no later than 30 days after admission. (No treatment plan will be devised for 1-5 session EAP Model unless otherwise stated). 

FINANCIAL TERMS: Upon verification of health plan/insurance coverage and policy limits, your insurance carrier will bill you, and the carrier will pay me directly. You will be responsible for any applicable deductibles and co-payments. Co-payments must be paid at the time services are rendered. If you are not eligible at the time services are rendered, you are responsible for full payments.  

The established fee for services ($135.00) is due at the time of service unless an agreed-upon plan of payment has been established between this agency and the client. 

CONFIDENTIALITY: Your information is protected by federal law and kept confidential. Information may only be shared if you give written permission, if there is risk of harm to yourself or others, if abuse or neglect is suspected, by court order, during a medical emergency, or for program evaluation. Clients must also respect the confidentiality of others in the program. 

CANCELLED OR MISSED APPOINTMENTS: A scheduled appointment means that time is reserved only for you. If you cannot attend your scheduled appointment, you are encouraged to contact the office and cancel twenty-four (24) hours before your appointment.           

EMERGENCY PROCEDURES: If you need to contact me, leave a message according to the instructions on the phone recording, and your call will be returned within 24 hours. If an emergency arises, please call 911 or present at your local crisis center. 

 ZERO TOLERANCE POLICY:  

1) No alcoholic beverages or drugs are allowed on the premises.  All violators will be asked to leave and may be subject to immediate discharge from the program. (This rule does not apply to medication prescribed for a medical illness.) 

2) Clients will refrain from disruptive and/or violent behavior, threats of violence, and inappropriate language. 3) Weapons of any kind are not allowed on the premises.        

 TREATMENT AGREEMENT: I acknowledge that I am voluntarily authorizing counseling for myself at KIMBERLY L. HILLERY & ASSOCIATES, PLLC, and have been informed of the practices, policies, and procedures as listed below: 

• Program goals and objectives, hours of operation, and fees charged, if any. 

• I have received a copy of my Rights as a Recipient and a Notice of Confidentiality, and I understand. 

• I understand that I will participate in the development of my treatment plan. 

• I have been informed of the program discharge and termination criteria. 

• The program will not certify STD or FMLA under EAP (01/06/26-12/12/26).