CONSENT TO TREATMENT
MLL LICENSED CLINICAL SOCIAL WORK SERVICES, PLLC
MARILYN L. LAVES, LCSW-R
CONSENT TO TREATMENT
I hereby permit Marilyn Laves, LCSW-R to provide me with therapeutic services including evaluation, diagnosis and/or other aspects of treatment or treatment planning. I agree to participate, to the best of my ability, in my treatment. Further, I understand that I have the right to voice any concerns to Marilyn Laves, LCSW-R regarding the therapeutic services that I receive. I also understand that should I decide to terminate therapy or change therapists, I have the right to do so at any time.
CONFIDENTIALITY
I understand that the issues discussed in my therapy are confidential, meaning that information that I reveal will not be discussed or shared in any format with others without my knowledge and written consent. My records will not be discussed or sent to others (excluding insurance companies or managed care companies) without a signed release. There are several important exceptions to this confidentiality. They include:
Situations of potential harm to oneself or others, child abuse, sexual abuse and/or neglect; court cases where my records are court ordered; insurance companies seeking information about treatment before making payment.
In such cases, Marilyn Laves, LCSW-R will discuss the situation with me and share any information which is released, whenever possible. I further understand and agree to permit Marilyn Laves, LCSW-R to reveal my name, address and financial information to her billing service.
FINANCIAL POLICIES
Payment or co-payments are due at the time services are rendered. Only cash or checks will be accepted, no credit cards. Please make checks payable to MLL Licensed Clinical Social Work Services, PLLC or Marilyn Laves.
If you do not show up for or cancel your scheduled therapy appointment with at least 24 hours notice, full payment** for the missed session is expected.
** If you have Cigna, you are responsible for the insurance’s allowable rate and not just your co-pay.