Patient Consents ~ Privacy ~ Rights

2026 Treatment & Financial Agreement – Counseling Kids and Adults, PLLC. 

By signing or acknowledging this agreement, I authorize Counseling Kids and Adults, PLLC (“CKA”) to provide administrative, billing, and practice management services in connection with outpatient behavioral health services rendered to me and/or my minor dependent(s).

1. I understand that all clinical services, treatment decisions, diagnoses, documentation, medical necessity determinations, and compliance with professional standards of care are provided solely by my assigned clinician (the “rendering provider”), who may be an independently contracted provider. CKA does not control or direct the clinical judgment of the rendering provider and is not responsible for the clinical care provided.
2. I understand that claims may be submitted under CKA’s clinic NPI with the rendering provider identified as the treating clinician when applicable.
3. I confirm I have been offered and can access the following documents at https://counselingkidsandadults.com/consents-privacy-rightsincluding: Informed Consent for Psychotherapy, Privacy and HIPAA Notice of Privacy Practices, Minnesota Client Bill of Rights, Telehealth Consent if telehealth services are used, and Practice Policies regarding appointments, cancellations, and communication.
4. If I use insurance or an employee assistance program, I authorize CKA to submit claims and communicate with my health plan for payment and healthcare operations as permitted by law.
5. I understand that insurance coverage is a contract between me and my insurer and that I am responsible for all copays, coinsurance, deductibles, spenddowns, and services not covered or denied by my plan.
6. Self-pay fees and any patient responsibility amounts are due at the time of service unless otherwise arranged in writing. Fee schedules are available on the clinic website or upon request.
7. I understand that missed appointments or late cancellations may not be billable to insurance and that if I do not cancel at least 24 hours in advance, I may be charged a $100 late cancellation or no-show fee unless prohibited by law or program rules, including certain Medicare or Minnesota Health Care Programs requirements.
8. After two late cancellations or no-shows, services may be suspended or terminated.
9. Returned checks may incur a $30 handling fee.
10. If my account is delinquent due to non-payment for 60 days and no written payment plan is in place, CKA may pursue lawful collection options, including a collection agency or small claims court where permitted.
11. I understand that some clinicians may not be enrolled with Medicare, Medicaid, or Minnesota Health Care Programs or may not be eligible to bill certain plans or services, and that eligibility is determined by the rendering provider’s enrollment status and applicable program rules.
12. Reasonable efforts may be made to verify eligibility; however, I understand that there may be circumstances in which services cannot be billed to my coverage.
13. By signing or acknowledging, I confirm that I have read and agree to this Treatment and Financial Agreement (2026) and that I have been provided access to the linked documents above. Mailing address: Counseling Kids and Adults, PLLC, PO Box 974, Lindstrom, MN 55045, phone 651-755-4276.

Informed Consent for Psychotherapy (2026) – Counseling Kids and Adults, PLLC (CKA), PO Box 974, Lindstrom, MN 55045, 651-755-4276. Welcome to Counseling Kids and Adults, PLLC. This document explains psychotherapy services, your rights and responsibilities, and key business and privacy practices. Psychotherapy is a collaborative process that may include assessment, diagnosis when required, treatment planning, and therapeutic interventions. Early sessions may involve collecting history, discussing goals, and using screening questionnaires. Treatment approaches vary by clinician and may include CBT, DBT-informed skills, solution-focused therapy, family systems, motivational interviewing, humanistic approaches, and other evidence-based methods. Benefits of therapy may include improved coping, mood, relationships, communication, insight, and symptom reduction; risks may include uncomfortable emotions, increased distress, stimulation of difficult memories, relationship changes, or temporary worsening of symptoms. In some situations, a higher level of care may be recommended and options will be discussed. Participation is voluntary and you may stop services at any time; you may request a different clinician and referrals may be provided. Your assigned clinician is the rendering provider and is responsible for clinical services, treatment decisions, documentation, medical necessity determinations, and compliance with professional standards of care; many clinicians are independently contracted and CKA provides administrative and billing support and does not control the clinician’s professional judgment. For minors, consent and access to information are handled according to Minnesota law and clinical standards; if there is joint legal custody, CKA may require consent from both legal guardians before services begin, and if a custody order applies you agree to provide it upon request. CKA clinicians do not provide 24/7 crisis services; if you are in immediate danger or need emergency help, call 911 or go to the nearest emergency room, and in Minnesota you may text MN to 741741 for crisis text support. By signing/acknowledging, I confirm I understand the nature of psychotherapy, the risks and benefits, my right to ask questions, and I consent to treatment under the policies provided by CKA.

Financial, Insurance, Medicare/MHCP, and EAP Terms (2026) – Counseling Kids and Adults, PLLC. I understand that CKA may bill services under the clinic NPI with my clinician listed as the rendering provider when applicable. If I use private insurance, I authorize CKA to submit claims and communicate with my plan for payment and healthcare operations as permitted by law, and I understand insurance coverage is a contract between me and my insurer. I agree to provide accurate insurance/EAP information before services and to notify CKA of changes; if my coverage is inactive, terminated, not effective on the date of service, my plan denies coverage, or my plan later recoups payment due to eligibility issues or coverage changes outside CKA’s control, I understand I may be responsible for the balance, except where prohibited by law or program rules (including Medicare and Minnesota Health Care Programs). Fees range from $50-$350 depending on the service.  If I use an EAP, I understand EAPs often require prior authorization, have limited approved visits, specific billing rules, deadlines, and required information; I authorize CKA to verify EAP eligibility and obtain authorization when possible, and I understand I am responsible for charges if I do not provide accurate EAP information, if authorization is not obtained or is exhausted, if sessions occur outside the EAP authorization window, or if the EAP denies payment due to limitations or requirements, except where prohibited by law or program rules. I understand missed appointments and late cancellations are generally not billable to insurance or EAP. Self-pay fees and patient responsibility amounts (copays, coinsurance, deductibles, and non-covered services) are due at the time of service unless otherwise arranged in writing, and fee schedules are available on the clinic website or upon request. If I do not cancel at least 24 hours in advance, I may be charged a $100 late cancellation/no-show fee unless prohibited by my plan or program rules, including Medicare or Minnesota Health Care Programs requirements. If my outstanding balance reaches $300, future sessions may be placed on hold until payment resumes or a written payment plan is in place, except where program rules require different handling. If payment is not made for 60 days and no written payment plan exists, CKA may pursue lawful collection options where permitted; however, I understand Medicare and Minnesota Health Care Programs have restrictions on billing recipients and collections for covered services, and CKA will follow applicable program rules. Returned checks may incur a $30 handling fee. By signing/acknowledging, I accept these financial and coverage terms and understand that program rules may limit what can be billed to me.

Practice Policies (2026) – Counseling Kids and Adults, PLLC. Appointments are reserved specifically for you. Please cancel or reschedule at least 24 hours in advance; late cancellations/no-shows may be charged a $100 fee unless prohibited by your plan or program rules, including certain Medicare or Minnesota Health Care Programs requirements. Standard psychotherapy appointments are typically 45–60 minutes unless otherwise scheduled; requested changes in appointment length must be discussed in advance. If you arrive late, the session may be shortened to avoid impacting subsequent appointments. CKA clinicians do not provide emergency services; for emergencies call 911 or go to the nearest emergency room, and Minnesota residents may text MN to 741741 for crisis text support. Because clinicians are often with clients, calls may not be answered live; you may leave a confidential voicemail and we aim to return calls within one business day when possible. Portal messaging is the primary method for non-urgent communication; email or text may be used for scheduling only, and confidentiality cannot be guaranteed through standard email/text, so do not use those methods for emergencies or sensitive clinical content. To protect confidentiality and avoid dual relationships, clinicians do not accept client friend/follow/contact requests on social media. Ending services can be a normal part of care; you may end services at any time. Services may be suspended or terminated with appropriate notice due to repeated missed appointments, lack of contact, nonpayment (subject to program rules), or if services are no longer clinically appropriate; referrals may be provided. If no appointment is scheduled for three consecutive weeks and no alternative arrangement is made, the therapeutic relationship may be considered discontinued for clinical and legal purposes.

Notice of Privacy Practices and HIPAA (2026) – Counseling Kids and Adults, PLLC. This notice describes how protected health information (PHI) may be used and disclosed and how you can access your information. CKA and your clinician are required by law to maintain the privacy of PHI, provide this notice, and follow the terms currently in effect; the notice may be updated and the current version is available on request and on the clinic website. PHI may be used/disclosed without your written authorization for treatment, payment, and healthcare operations as permitted by law, including coordination of care, referrals, consultations, billing, claims management, eligibility verification, quality improvement, supervision/training, and administrative functions. PHI may also be disclosed when required or permitted by law, including reporting suspected abuse/neglect, responding to lawful court orders/subpoenas (as applicable), health oversight activities, and to prevent a serious and imminent threat to health/safety. Most disclosures outside treatment/payment/operations require your written authorization, and you may revoke an authorization in writing unless action has already been taken. “Psychotherapy notes,” if maintained as defined by HIPAA, generally require your written authorization for disclosure except in limited circumstances allowed by law. You have rights to request access to your record (excluding psychotherapy notes and subject to limited exceptions), request amendments, request an accounting of certain disclosures, request restrictions (not always required to be granted), request confidential communications, and obtain a paper or electronic copy of this notice. Requests for records must be made in writing; you will receive a response within applicable legal timeframes and may be charged a reasonable cost-based fee where allowed. If you have concerns, contact CKA at 651-755-4276; you may also file a complaint with the U.S. Department of Health and Human Services Office for Civil Rights. By signing/acknowledging, I confirm I have been offered access to this Notice of Privacy Practices.

Telehealth Consent (2026) – Counseling Kids and Adults, PLLC. Telehealth (telemental health) refers to behavioral health services provided through live, interactive video communication. Telehealth may not be appropriate for every situation and is not an emergency service. If you are in immediate danger or need emergency help, call 911 or go to the nearest emergency room; Minnesota residents may text MN to 741741 for crisis text support. Telehealth services may only be provided when both you and your clinician are physically located in jurisdictions where the clinician is authorized to practice at the time of service; at each telehealth session, you will be asked to confirm your physical location and provide a call-back number. Benefits may include improved access, convenience, reduced travel, and scheduling flexibility. Risks and limitations may include technology failures, interruptions, privacy/security risks, and reduced ability to observe certain nonverbal cues or assess safety concerns. You agree to participate from a private location where you cannot be overheard, use a secure and password-protected device when possible, avoid public Wi-Fi when feasible, not record sessions unless both you and the clinician agree in writing, and log out/close the session when complete. You understand that if telehealth is not clinically appropriate or if technology prevents effective care, your clinician may recommend in-person services or other resources. By signing/acknowledging, I consent to receive services via telehealth when offered and clinically appropriate and I understand the risks, benefits, and limitations described above.

Minnesota Client Bill of Rights Acknowledgment – Counseling Kids and Adults, PLLC. Minnesota law provides rights for individuals receiving outpatient mental health services, including the right to respectful and nondiscriminatory care, privacy and confidentiality, participation in treatment planning, the right to request and access records as allowed by law, the right to refuse treatment, and the right to voice grievances without retaliation; no health care facility may require a patient to waive these rights as a condition of receiving services. The full Minnesota Client Bill of Rights is available through the clinic website and/or upon request. If you have a concern, you may discuss it with your clinician or contact the clinic at 651-755-4276 to request information about the internal grievance process. By signing/acknowledging, I confirm I have been offered access to the Minnesota Client Bill of Rights.  

Minnesota Health Care Programs (MHCP) Recipient Notice and Permission (Clinic Form) – Counseling Kids and Adults, PLLC. If I have Medical Assistance, MinnesotaCare, or another MHCP plan, I understand MHCP has specific rules about what services are covered and when a provider may bill a recipient. I understand I will not be billed for covered services in violation of MHCP rules and I will not be billed for a denial caused solely by provider billing or documentation errors. I understand I may be responsible for payment only when permitted by MHCP rules and only after the rendering provider explains why a service is not covered or not billable, discusses covered alternatives when available, and obtains my informed consent using any required MHCP notice, including the DHS-3640 Advance Recipient Notice of Noncovered Service or Item when applicable. I authorize CKA and my rendering provider to communicate with MHCP and managed care organizations for eligibility verification, authorizations, and claims processing as permitted by law. By signing/acknowledging, I confirm I understand MHCP rules may limit billing to me and I consent to the notice and authorization process described above. Click Here to access the form on the MN DHS site.

Minnesota law allows you to inform others of your health care wishes. You have the right to state your wishes or appoint an agent in writing so that others will know what you want if you can't tell them because of illness or injury. The information that follows tells about health care directives and how to prepare them. It does not give every detail of the law.

What is a Health Care Directive?

A health care directive is a written document that informs other of your wishes about your health care. It allows you to name a person ("agent") to decide for you if you are unable to decide. It also allows you to name an agent if you want someone else to decide for you. You must be at least 18 years old to make a health care directive.

Why Have a Health Care Directive?

A health care directive is important if your attending physician determines you can't communicate your health care choices (because of physical or mental incapacity). It is also important if you wish to have someone else make your health care decisions. In some circumstances, your directive may state that you want someone other than an attending physician to decide when you cannot make your own decisions.

Must I Have a Health Care Directive? What Happens if I Don't Have One?

You don't have to have a health care directive. But, writing one helps to make sure your wishes are followed.

You will still receive medical treatment if you don't have a written directive. Health care providers will listen to what people close to you say about your treatment preferences, but the best way to be sure your wishes are followed is to have a health care directive. Visit this website to obtain a health care directive form http://www.honoringchoices.org/health-care-directives

Fees for psychotherapy vary ranging from $50-$350 Depending on the service. If you have a difficult time paying, speak to your therapist and request a payment arrangement and access to a sliding fee scale.