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We are pleased that you have chosen The Family Resource
Center for your clinical services. This agreement will
give you information about our practice operation and
procedures and our professional relationship with you.
The Family Resource Center has been in business for
fifteen years. Our clinical staff and associates have
earned degrees in various professional disciplines including
counseling, psychology and family therapy. The Centers
are staffed by professionals who are licensed and/or
certified in the appropriate therapeutic methods and
domains. Our practice offers both diagnostic and therapy
services to individuals, groups and families and couples.
Many of our clients come to us for help dealing with
issues of loss, trauma, depression, difficulties adjusting
to life events and addictive disorders.
In our practice, we accept only clients who we believe
have the capacity to resolve their own problems with
our guidance and assistance. We believe that as people
become more accepting of themselves and gain the tools
they need to be purposefuland successful, they are more
capable of finding fulfillment and meaning in their
lives. Self-awareness and self acceptance are goals
that sometimes take a long time to achieve. We offer
brief solution oriented therapy services that are directed
towards assisting clients to resolve the issues that
caused them to seek our services. We find that our clients
often require only a few sessions to resolve their presenting
issues. We believe that clients have choices and may
choose to end their counseling relationship with us
at any time. We do not enable our clients to continue
to engage in self destructive behaviors and we will
actively attempt to intervene to assist our clients
to resolve their issues. If counseling is successful,
clients should feel that they are able to face life's
challenges without further assistance and intervention.
We utilize 12 step programs and other self help programs
whenever possible to assist clients to resolve their
issues on a timely and cost effective basis. Please
also note that you can request Christian based counseling
services should you so desire.
Each client has the right
to the following as a client of our professional staff:
- To terminate our professional services without any
moral, legal, or financial obligation to continue
to receive services;
- To ask for and receive referral to another qualified
clinician whenever the choice is made to terminate
our professional services;
- To receive information regarding the procedures
that will be used in your evaluation and therapy process;
- To be informed of your diagnosis and treatment plan
goals and objectives, the clinical plan to meet those
goals and objectives and the financial costs of our
treatment services to you;
- To review your clinical records with your clinician
at any time;
- To have your case information maintained in a confidential
manner as outlined in this Professional Disclosure
Statement;
- To have your records released to others at your
written request or as outlined below in this statement;
- To be treated with respect and dignity according
to the Codes of Ethics that govern our professional
conduct at all times.
Although our sessions are very intimate and personal,
it is important for you to understand that we have a
professional relationship. Our professional Code of
Ethics does not allow us to attend social gatherings
with you, to accept gifts from you, or to accept goods
or services in lieu of payment for services rendered.
We have numerous rules and regulations that govern our
professional conduct with your during the time that
we will be providing professional services to you. We
will be happy to discuss our professional Code of Ethics
with you upon your request.
We will keep everything that you say to us confidential
with the following exceptions: Your requests for us
to tell someone else information that you desire to
have released; you reveal to us that you have knowledge
of unreported child abuse/neglect that must be reported
according to state law; information that you have revealed
to us suggests that you are a danger to yourself ; when
we are ordered by a Court to disclose your information;
or your insurance company requests clinical information
that they are entitled to receive for diagnosis or payment
purposes.
In return for your treatment fee, we agree to provide
professional services to you. Your treatment fees will
vary depending upon your contracted fee schedule with
your fee payor. Our normal session length is 45 minutes.
While it is impossible to guarantee specific results
regarding your treatment program and goals, we assure
you that our services will be rendered in a professional
manner that is consistent with accepted ethical standards
of professional practice. We will bill third party payors
for the remainder of your fees if you request that we
bill your third party insurance company or EAP program.
After each session is completed, contact Ms. Annisa
Vasquez at (281) 444-2678 to schedule your next session
with Dr. Garlock. Please note that her office hours
are on Monday through Thursday, 9:00am-5:00pm and Friday,
9:00am-12:00pm.
Our initial session with you will consist of issue
identification and focusing, a history taking of the
presenting issue(s), a review of your previous efforts
to resolve the presenting issue(s), your expectations
for a solution to the problem issue(s) which is acceptable
to you, the development of a treatment plan to address
your presenting issues and concerns and diagnostic assessment
when needed. Subsequent follow up sessions will focus
on the resolution of your identified issues and helping
you to become independent and to solve the presenting
concerns that brought you to our office. We will utilize
combined individual, couples, family, education, referrals
to specialists when needed, evaluation and counseling
services to assist you to achieve the identified solutions
to the concerns that brought you to counseling. Of course,
we cannot solve your concerns and issues for you, but
it is our goal to increase your own problem solving
which will lead to issue resolution and self satisfaction
and improvement. Your fee for each session is due at
each session unless other financial arrangements have
been made. We are providers for a significant number
of managed care and HMO and EAP companies and we will
accept co-payments for services rendered in accordance
with their established fee schedules and financial policies.
We will file for insurance reimbursement for you. If
payment is not received, it will become your responsibility
to pay for the services that are rendered by our staff
that are not covered by insurance or other third party
reimbursement. Please also note that we will charge
you the session fee if the third party does not pay
for your session due to your not completing paperwork
or documentation that they have requested of you which
has prevented us from being paid for that session. If
requested by you, we will provide you with a receipt
when you pay your session fee.
If you are unable to keep a scheduled appointment,
kindly notify us 24 hours in advance to your scheduled
session. If we do not receive notice of your appointment
cancellation within this time period, you will be responsible
for paying the fee for the session that you missed.
If you are experiencing an emergency situation, please
call our office and either talk with Ms. Annisa Vasquez
or page us directly from our voice mail system that
operates after normal business hours and on weekends.
You may also leave a message at any time on our voice
mail system for Dr. John Garlock. He will return your
call as soon as possible.
Our telephones are answered by Ms. Annisa Vasquez from
9:00am through 5:00pm, Monday through Thursday, and
9:00am through 12:00pm on Fridays. Jessica answers the
telephone on Fridays from 1:00pm to 5:00pm. You may
reach them by calling (281) 444-2678 during these
times. After these hours and on weekends, you may call
this same number and leave a message on our voice mail
system and we will return your call as soon as possible.
Our main telephone numbers are (281) 444-2678
or (281) 367-6651. Our fax number is (281)
444-0368. Dr. Garlock can be reached for emergencies
at (713) 927-3183. Dr. Garlock's email address
is: jagvw@earthlink.net.
We will return your call as soon as possible in non-emergency
situations. Should you encounter an emergency situation,
please call 911 or go to the nearest emergency room
for immediate emergency assistance. You may also
contact us via 713-927-3183. Emergency instructions
are also available on our voice mail when you contact
the main telephone numbers at our office locations.
You can visit our web sites on the internet at:
www.helptochange.com
www.frnewsletter.com
We offer information about our services, maps to our
locations, on line payment for our services, email messaging
to Dr. Garlock, appointment scheduling request services,
self help programs, additional information regarding
Dr. Garlock and his qualifications and experience and
additional information regarding our practice. We encourage
you to visit www.helptochange.com which has all of these
features listed above.
If you want to seek reimbursement for our services
from your insurance company, we will be happy to complete
any necessary forms required by your insurer and submit
them for payment. We will require accurate insurance
billing information at the time of your first session.
If we do not have accurate insurance billing information
at the time of your first session, please be prepared
to pay for your first session yourself as this session
will likely not be covered by your insurance plan. We
will also file claim forms for direct payment for services
rendered to you by Dr. Garlock. Most insurance companies
will reimburse clients for our services, but some will
not. Insurance plans that do reimburse for our services
typically require that clients meet certain annual deductibles
and usually only a percentage of our fee is reimbursable
by insurance. We will be happy to contact your insurance
company or managed care company to determine what benefits
you have for payment for our services at the time that
services are delivered. Please let Ms. Vasquez know
that you would like to have her check your benefits
for you. We file our own insurance claim forms directly
to your insurance company. If payment is not received
as a results of filing for payment with your insurance
carrier or EAP program, it will be your responsibility
to pay the charges.
Third party insurance company payers require that we
diagnose your symptoms to determine that you have a
reimbursable condition for insurance payment purposes.
Most Employee Assistance Programs do not require a diagnosis
for you to receive our services. We will discuss with
you the diagnosis that we plan to submit to your insurance
company prior to the end of your initial session. Any
diagnosis that is rendered will become part of your
permanent record and will be handled with complete confidentiality
by our staff. Please note that your insurance company
has the right to request your records if payment is
being requested from them.
Finally, we often are requested to release information
about you to Primary Care Physicians and other treatment
and care providers. By signing this New Patient Handbook,
please note that you are authorizing us to release information
needed by your insurance company for payment and case
management purposes, your Primary Care Physician or
other care providers to facilitate the continuity of
your care, to coordinate your care and to expedite and
facilitate any referrals to other treating professionals.
We will release information about your treatment and
our services only as needed to assist you and the coordination
of your care.
If you have any questions about any of this information
contained in this New Patient Handbook, please feel
free to discuss it with Dr. Garlock. We look forward
to being of assistance to you in the future. Please
note that signing the last page in this New Patient
Handbook implies your agreement with the information
contained in this handout.
I have read and do understand the material contained
in this New Patient Handbook, which includes the Professional
Disclosure Statement, the Practice Disclosure Statement,
the Welcome to The Family Resource Center letter, and
have completed the Initial Patient Professional Service
Contract Form and the Patient Information Forms as well.
My signature below attests to my knowledge of and understanding
of and agreement with these forms and to my consent
to release case information to my insurance company,
my Primary Care Physician, my Psychiatrist, and to other
treatment professionals I am referred to who require
it, as determined by Dr. John Garlock, in order for
Dr. Garlock to provide treatment and care coordination
services to me. I also understand the scope of and limitations
of Dr. Garlock's practice and agree to have him provide
clinical services within the scope of his practice as
outlined in this document.
I do understand that this information will be sent to
the aforementioned parties to inform them of my initiation
of treatment services and of my monthly progress in
treatment while receiving treatment services at The
Family Resource Center with Dr. John Garlock, LPC. I
do understand that by signing his form I am providing
Dr. Garlock with consent to perform services on mine
or my family members behalf and to file payment claims.
I understand that by clicking continue at the end of
the New Client Registration Forms, I agree with the
information contained in this New Client Handbook and
permit Dr. Garlock to perform all services as outlined
in this Handbook. In addition, I agree to adhere to
all of the procedures and practice and client guidelines
outlined in this Handbook.
Thank you for taking the time to read this New Client
Handbook.
Dr. John Garlock, LPC, LMFT, LCDC, CEAP
New Clients are also required to read and review the
Initial Client Professional Service
Contract and then complete our New Client Information
Form , which can be printed and faxed or submitted
electronically. Please read all of this important
information and initial where you are requested to do
so. We look forward to the opportunity to be of
service to you.
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