Payment and co-payments are due at the time of the session by credit care unless other arrangements have been made. Clients with insurance coverage are responsible to turn in receipts to their insurance company. 

Tara Dekkers accepts Blue-Cross Blue Shield Insurance, when applicable, however it is your responsibility to ensure coverage. If the insurance claim is denied, you will be responsible for the $175/session fee.

Thank you!

We are pleased that you have chosen Unveiled Counseling. This form gives you some information about our professional relationship. You are encouraged to ask your counselor any questions regarding his/her background, credentials, professional experience, or philosophy.

CONFIDENTIALITY INFORMATION

Unveiled Counseling is concerned about confidentiality. It is the goal of Unveiled Counseling to provide an environment in which our clients may place their trust and confidence. Under both federal and state law, confidentiality means communication with your counselor and any records pertaining to your identity, evaluation, or treatment will be held in confidence. Where federal and state laws differ, we comply with the stricter standard to ensure that your right to confidentiality is respected at all times. Also, beyond the law, we know that a sense of safety and security are necessary to a process of healing in which our clients are engaged. You have a right to confidentiality.

Your signature at the end of this document indicates consent to use your personal health information for routine practices according to the law for treatment, payment, and health care operations. You may revoke this consent in writing at any time, except to the extent that Unveiled Counseling has taken action relying on this consent.

RIGHTS & RESPONSIBILITIES

Rights
You have a right to be provided with professional and respectful care. You have a right to know your counselor's assessment of the problem, the recommended treatment, and resources available to help deal with your situation.

You also have the right to refuse our suggestions.

Responsibilities
1. To be honest, open, and willing to share your concerns
2. To ask questions when you don't understand or need clarification
3. To discuss any reservations you have about your treatment plan
4. To follow the agreed upon treatment plan
5. To report changes or unexpected events related to your problem
6. To keep appointments whenever possible or to call and cancel within 24 hours prior to your appointment. (See payment information - you will be charged the entire session fee for appointments not cancelled with 24-hour notification)

Remember, you are responsible for your thoughts, feelings, actions, and growth. We are here to help facilitate that growth to the best of our ability.

PAYMENT INFORMATION

The following information is provided to avoid any misunderstanding or disagreement concerning your payment for professional services.

- All professional services are rendered on a private pay, fee-for-service basis.
- Cash, check, or credit card is accepted.
- A $35.00 service charge will be assessed for returned insufficient fund checks. Insufficient fund checks are deposited twice. If the second deposit is also insufficient, a second $35.00 charge will be assessed. After the second insufficient funds deposit, we will only accept cash for payments for services rendered until the insufficient funds check and service charges are paid in full.
- Payment is expected at the beginning of the day of service.

Appointment Cancellation Policy
Twenty-four (24) hour notification is an expected courtesy to the counselor who is reserving time for you and to other clients who are waiting to schedule appointments. You must give 24-hour advanced notification for cancelled appointments. The advanced notice is standard in our profession.

If you miss an appointment without 24-hour notification, you will be charged the entire session fee on the day of your scheduled appointment. If you do not notify us 24 hours in advance when cancelling an appointment, you will be charged the entire session fee on the day of your scheduled appointment.

Unveiled Counseling provides access through the secure portal that is available 24 hours/day to assist you in cancelling appointments in a timely manner.

You must pay for the missed/late cancellation appointment charge in full by your next scheduled appointment. Payment must be timely or we cannot continue to schedule appointments.

COURT PROCEEDINGS

Subpoenas: If a counselor is to receive a subpoena, then the attorney or office staff is required to call the office and set up a time for the subpoena to be served during office hours. A minimum of 72 hours notice of any court appearance is necessary so that schedule changes for clients can be made within a reasonable time frame. Please note: If a subpoena or notice to meet attorney(s) is received without a minimum of 72 hour notice there will be an additional $250 express charge. 

Requests for Records: If a client or legal counsel requests treatment summaries or session attendance documentation, you agree to pay the counselor's regular session fee per hour to research and or complete requested materials. This includes information for legal, disability or insurance purposes. All payments must be processed before the documents are presented. 

The Fee Structure for court appearances/documentation requests is as follows: 

1. Preparation Time (including records submission): $200/hr (billable in 15-minute increments) 2. Phone calls: $200/hr (billable in 15-minute increments) 

3. Depositions: $600/day prepaid for first two hours; $200 for every hour thereafter

4. Time spent on Court premises (with or without testifying): $600/day prepaid for first two hours; $200 for every hour thereafter

5. Compensation for travel to and from court: Counselor's regular session fee per hour

6. All attorney fees and costs that are incurred by the counselor as a result of the legal action 

7. Filing document with the court: $100 

8. The minimum charge for a court appearance: $1000 

A retainer of $1500 is due at least 72 business hours before the scheduled court appearance. The remainder of the costs will be billed after the court appearance and will be due upon receipt. If the counselor is subpoenaed and the case is reset with less than 72 business hours notice prior to the beginning of the day of the scheduled subpoena, trial, then the client will be charged $500 (in addition to original retainer of $1500 for having to appear in court).

MINOR CLIENTS

If the minor child is named in any custody agreement or court order, we will need a copy (digital or paper) of the most recent decree documenting your right to seek counseling for the child(ren) before we can proceed with the child's first session. 

In conflictual situations, our ethical commitment is to seek and promote the well-being and emotional health of the minor client. Any communication and feedback with adults involved are for the benefit of the minor child client. Please feel free to discuss any concerns you have about your specific situation with the counselor at your initial session.

SIGNATURE FOR PROFESSIONAL SERVICES AGREEMENT

I do voluntarily agree to participate in the assessment and counseling as offered by Unveiled Counseling. I am aware that treatment often involves family therapy or education, which will be recommended, if the counselor deems it important to the healing process. I acknowledge that no guarantees have been made to me regarding the outcome of my counseling process. I understand my rights and responsibilities as stated in this document.

I consent to the use of my personal health information for routine practices for treatment, payment, and health care operations according to the laws of the State of Texas and the Federal Government as outlined in the Confidentiality Section of this document and discussed in detail in the Confidentiality Policy and Privacy Practices Brochure.

I have read and agreed to the payment information as stated in this document.

I understand I will be charged the full session fee for appointments that are not cancelled within 24 hours or for appointments I miss altogether.

By my signature below, I accept all the terms and conditions as herein stated.

As a courtesy, I ask that you cancel appointments no later than 24 hours in advance. However, when that is not possible please call or text the therapist as soon as you know at 712-541-2659. In the event of a late cancellation (when 24 hours is not given) a late cancellation fee will be due in the amount of the scheduled session. In the case of a no-show (when a client does not notify before the missed session) you will be charged a no-show fee of $175, the amount of the scheduled session, and will be charged on the day of the scheduled session. The therapist reserves the right to cancel sessions in the case of personal or professional time conflicts but will try to offer a reasonable alternative time of the cancelled appointment.

Issues discussed in therapy are important and are generally legally protected as both confidential and "privileged". However, there are limits to the privilege of confidentiality. 

These limits include:
1. Suspected abuse/neglect of a child, elderly person or a disabled person.
2. When your therapist believes you are in danger of harming yourself, another person or you are 
unable to care for yourself.
3. If you report that you intend to physically injure someone, the law requires your therapist to 
inform that person as well as the legal authorities
4. When your insurance company is involved (e.g. in filing a claim, insurance audits, case review or 
appeals, etc.). In case of unpaid balances on accounts, after 90 days your name and amount 
owed may be released to a collection agency for the purposes of collecting the unpaid balance.
5. If your therapist is ordered by a court to release information as part of a legal proceeding. A 
subpoena for records or testimony does not release confidential information. The order to break 
confidentiality must be given by a judge.
6. When otherwise required by law.
7. You may be asked to sign a Release of Information so that your therapist may speak with other 
mental health professionals, medical professionals, or other individuals important to your 
therapeutic process about your care.
8. If more than one person is involved in therapy (e.g. couples or families), and have individual 
sessions along with couple sessions, the therapist will allow some privacy within individual sessions. However, a no-secrets policy will be observed, such that the therapist will not be expected to keep secrets from the other parties if these secrets are judged to be harmful to the other parties or the therapeutic process.
9. Parents have a legal right to the records of their minor children, but teenagers are usually given more privacy within individual sessions. However, the therapist will strive to help all children and teens talk to their parents about the things that are important to them. The safety and protection of all minor clients will always be paramount.