Cathy Weeg Informed Consent

Cathy Weeg, LPC

Counseling and Therapy Services


Informed Consent/Disclosure Statement

Thank you for choosing this practice. I realize that starting counseling is a major decision and you may have many questions. This document is intended to inform you of my policies, state and federal laws,and your rights. If you have other questions or concerns, please ask and I will try my best to give you all the information you need.

My name is Cathy Weeg. I am a Licensed Professional Counselor. I am also an incorporated business. My business address is 565 University Avenue, Suite #4, Fairbanks, Alaska, 99709. My business phone number is (907) 590-8384. I received my M.S.Ed in Counselor Education from Western Illinois University, December 1993.

My style is very interactive, collaborative and dynamic, emphasizing, but not limited to, Dialectical Behavioral Therapy, Cognitive Behavioral Therapy, and Emotion Focused Therapy. I believe all people have the ability to heal themselves once they began looking inward with objectivity and empathy. I have experience working with adults, couples, children, families, and groups.

I work here at the private practice Monday through Thursday.

In addition, if you attend group therapy services Jennifer Danhauser, LPC, an independent practitioner, will work in conjunction with me. Her phone number is (907) 978-4978. She received her M.S. in Mental Health Counseling from Eastern State University, May 2001. Also Mike Worrall, Ph.D, an independent practitioner, will work in conjunction with me. His phone number is (907) 712-7667. He received his doctorate in Clinical Psychology from the University of Nevada, August 2011.

I also utilize Jennifer Danhauser, LPC and Mike Worrall Ph.D for consultation purposes.

This information is required by the Board of Professional Counselors which regulates all licensed professional counselors. To reach the board by mail, please write the Department of Commerce, Community and Economic Development, Division of Occupational Licensing, P.O. Box 110806, Juneau, Alaska, 99811. To reach the board by telephone, call 907-465-2550.

Service and Pricing

Golden Heart Administrative Professionals, Inc will bill your insurance company for you. Services and pricing are as follows:

Service Length Rate
Initial Assessment Session 1 hour $300
Individual Therapy, Couples Therapy, or Family Therapy 16 to 37 minutes $87.50
38 to 52 minutes $175
53 minutes or longer $225
Group Therapy Group Therapy $175
Court Fees 3 hours or less $175
Any additional hour or portion thereof $175

>As a courtesy, Golden Heart Administrative Professionals, Inc will bill your insurance company, responsible party, or third party payer for you if you wish. If your insurance company denies payment or does not cover counseling, we request that you pay the balance due at that time. After 3 months of receipt of first bill, any unpaid balance will add assessed finance charges. We ask that every client authorize payment of medical benefits directly to Cathy Weeg, LPC. In addition if you join the DBT Skills Group we ask that every client authorize payment of medical benefits to Cathy Weeg, LPC or Jennifer Danhauser, LPC or Mike Worrall, PhD as indicated on your bill.

>If you miss an appointment, you will be charged the cost of the appointment and this will not be billed to your insurance company. Any unpaid balances may be turned over to collections. If this is the case, you are responsible for any collection fee charged. You will be charged $25 for any returned checks.

Assignment of Benefits

I authorize payment by my insurance company to be paid directly to Cathy Weeg, LPC, Jennifer Danhauser, LPC or Mike Worrall, PhD for services rendered. I am aware that the amount I owe may be different specific to which independent practitioner is charging for services rendered. I understand that I am financially responsible for charges applied to the insurance deductible and for all charges limited by the insurance carrier. I authorize Cathy Weeg, LPC, Jennifer Danhauser, LPC, or Mike Worrall, PhD to give copies of any records when needed for payment by my insurance carrier and/or its affiliates. I have received a copy of my fee schedule.

By typing your name below you acknowledge and accept conditions as outlined above in this Informed Consent:

Consent For Payment By Insurance:(Required)
MM slash DD slash YYYY
Client Signature:(Required)

Confidentiality

Client information shared with me is confidential, except in the following circumstances:

  • Information shared with Jennifer Danhauser, LPC for peer consultation
  • Information shared with John Michael Worrall, Ph.D. for peer consultation
  • Diagnosis and dates of services shared with Golden Heart Administrative Professionals, Inc , and your insurance company to collect payments
  • Mandated reporting of abuse of children or adults
  • Threats of suicide or homicide
  • Cases where you have signed a release of information
  • Information released as outlined in the HIPAA Notice of Privacy Practice
  • Online transmission of billing information, such as Kareo by our billing company.
  • Text messages and emails are not encrypted or secure and ARE NOT HIPPA compliant. Your awareness and agreement is necessary to transfer communication in this manner and is not recommended. In addition these messages are considered a part of your records and will be included in your records.
  • Those required by law
  • Records are archived and maintained for a period of 10 years.

Your treatment program may be discussed with other professionals (other then those listed under Treatment in the Notice of Privacy Practices and Client Rights) and, if that occurs, your confidentiality will be maintained. Also, your name and identity will be disclosed only in compliance with AS 08.29.200 of the Statutes and Regulations of Professional Counselors.

Emergency Situations

In case of emergency outside of my normal business hours please contact:

  • Cathy Weeg at (907) 590-8384.
  • The Careline at 1-877-266-4357
  • The National Suicide Prevention Hotline at national suicide prevention lifeline at 1-800-273-8255
  • Call 911 for immediate emergency care or go to the nearest emergency room

By typing your name below you acknowledge and accept conditions as outlined above in this Informed Consent:

Client Consent(Required)
MM slash DD slash YYYY
Signature of Client:(Required)

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