Service Agreement

Good Faith Estimates

You have the right to receive a “Good Faith Estimate” explaining how much your medical and mental health care will cost.

Under the law, health care providers need to give patients who don’t have insurance, or who are not using insurance, an estimate of the expected charges for medical services, including psychotherapy services.

You have the right to receive a Good Faith Estimate for the total expected cost of any non-emergency healthcare services, including psychotherapy services.

You can ask your health care provider, and any other provider you choose, for a Good Faith Estimate before you schedule a service.

If you receive a bill that is at least $400 more than your Good Faith Estimate, you can dispute the bill. Make sure to save a copy or picture of your Good Faith Estimate.

For questions or more information about your right to a Good Faith Estimate, visit

Psychological Services

Psychotherapy is not easily described in general statements. It varies depending on the personalities of the psychotherapist and patient, and the particular problems you are experiencing. There are various methods your psychotherapist may use to deal with the problems that you hope to address. Psychotherapy is not like a medical doctor visit. Instead, it calls for active involvement on your part. In order for the therapy to be most successful, you will have to work on things you talk about with your psychotherapist, both during your sessions and at home. Psychotherapy can have risks and benefits. Since therapy often involves discussing unpleasant aspects of your life, you may experience uncomfortable feelings like sadness, guilt, anger, frustration, anxiety and helplessness. Your problems may temporarily worsen after the beginning of therapy. For instance, individuals seeking treatment for anxiety often notice an increase in symptom severity during the first several weeks of therapy as they learn new ways of managing their anxiety. Finally, even with best efforts, there is a risk that therapy may not bring you your desired outcomes. On the other hand, psychotherapy is well-documented to have many benefits. It often leads to better relationships, solutions to specific problems, and significant reductions in feelings of distress. But there are no guarantees of what you will experience. The first few sessions will involve an evaluation of your goals and needs. By the end of the evaluation, your psychotherapist will be able to offer you some first impressions of what your work together will include and a treatment plan to follow, if you decide to continue with therapy. You should evaluate this information along with your own opinions of whether you feel comfortable working with your psychotherapist. Therapy involves a large commitment of time, money and energy, so please be careful about the psychotherapist you select. If you have questions about your psychotherapist’s procedures, you and your psychotherapist should discuss them whenever they arise. You may, at any time, refuse treatment, request a change in treatment approach, or ask for a referral elsewhere. There are circumstances in which your psychotherapist may not be the most appropriate provider for your psychological services. This may occur if your concerns are outside the scope of your psychotherapist’s training or expertise, if your working together would create a conflict of interest, or if your psychotherapist’s approach to therapy appears not to be working after a reasonable amount of time and effort.

Supervisory Disclosure

If your psychotherapist is a limited licensed provider, he or she will be under the supervision of a fully licensed provider of the appropriate discipline as required by state law. To ensure that you receive the highest standard of care, the supervisor will routinely monitor and review the clinical work of your psychotherapist. The privacy of your identity, communications, and Clinical Record will be maintained by the supervisor as delineated in the Confidentiality section of this Agreement. At your first session, your psychotherapist will provide you with the name and contact information of his or her supervisor.


Your psychotherapist will normally conduct a diagnostic evaluation that will last from one to three sessions. During that time, you can both decide if your psychotherapist is the best person to provide the services you need in order to meet your treatment goals. If psychotherapy is begun, your psychotherapist will usually schedule one 45-60 minute session per week at a time you both agree on. However, you and your psychotherapist may decide to meet for a different length of time, and/or more or less frequently.

Professional Fees

Sessions are billed at $80 to $650 depending upon the complexity and length of the visit. If you have insurance benefits, session fees will be billed to your insurance and reduced to the rates we have agreed to as a contracted provider to your insurance company. If you have questions about your coverage, you should contact your insurance company. Other services such as written reports, travel time, review of records, communication with other professionals, and services provided by telephone may be charged at an hourly rate as determined by your psychotherapist. If you become involved in legal proceedings that require your psychotherapist’s participation, you will be expected to pay for all of their professional time, including preparation and transportation costs, even if they are called to testify by another party. Legal involvement may be charged at an hourly rate as determined by your psychotherapist. If you have special financial needs, please discuss these with your psychotherapist.


When you call the office number (616-988-3433), or email, you will reach our non-clinical office staff team. Due to your psychotherapist’s work schedule, they are often not immediately available by telephone. Generally, they will not answer the phone when they are in session. When unavailable, most psychotherapists route their calls to a personal voicemail that they monitor and your psychotherapist will make every effort to return your call on the same day you make it, with the exception of weekends and holidays. If you are unable to reach your psychotherapist and your situation is a non-emergency, you may contact the office by telephone or email. If you are unable to reach your psychotherapist and feel that your situation is life threatening, contact your family physician or the nearest emergency room. If your psychotherapist will be unavailable for an extended time, they should provide you with the name of a colleague to contact, if necessary.


The law protects the privacy of all communications between a patient and a psychotherapist. In most situations, we can only release information about your treatment to others if you sign an Authorization form that meets certain legal requirements imposed by state law and/or HIPAA. However, your signature on this Agreement provides consent that we may disclose information in the following situations:

There are some situations where we are permitted or legally required to disclose information without either your consent or Authorization:

In any of the above situations, we will make an effort to discuss it with you before taking action and we will limit our disclosure to what is necessary.

In the event that support group sessions are provided, you are expected to keep materials shared in the group confidential. We cannot be held responsible for a breach of confidentiality on the part of group members.

While this written summary of exceptions to confidentiality should prove helpful in informing you about potential disclosures, it is important that you discuss any questions or concerns that you may have now or in the future with your psychotherapist. The laws governing confidentiality can be quite complex. In situations where specific advice is required, formal legal advice may be needed.

Patient Rights

HIPAA provides expanded rights regarding Protected Health Information (PHI). You can provide a written request to 1) amend your Clinical Record; 2) request restrictions on what information in your Clinical Record is disclosed to others; 3) request an accounting of most disclosures of PHI and where they were sent; 4) request that any complaints you make about our policies and procedures be recorded in your record, and 5) receive a printed copy of this Agreement and our privacy policies.

Minors & Parents

Michigan patients under 18 years of age who are not emancipated, and their parents, should be aware that the law may allow parents to examine their child’s treatment records. They should also be aware that Michigan patients over 14 years of age can consent to (and control access to information about) their own treatment, although that treatment cannot extend beyond 12 sessions or 4 months. While privacy in psychotherapy is very important, particularly with adolescents, parental involvement is also essential to successful treatment. Therefore, it may be your psychotherapist’s policy to request an agreement from any patient between 14 and 18 years of age and his/her parents allowing the psychotherapist to share general information with parents about the progress of treatment and the child’s attendance at scheduled sessions.

In certain cases, the psychotherapist’s responsibility to your child may require involvement in conflicts between parents. By signing the consent form, you agree that the psychotherapist’s involvement will be strictly limited to that which will benefit your child. This means, among other things, that you will treat anything that is said in session with the psychotherapist as confidential. Neither parent will attempt to gain advantage in any legal proceeding from treatment with your child. You agree that in any such proceedings, neither parent will ask the psychotherapist to testify in court, whether in person or by affidavit. You also agree to instruct your attorneys not to subpoena the psychotherapist or to refer in any court filing to anything that has been said in treatment. If the psychotherapist is required to testify, the psychotherapist is ethically bound not to give any opinion about either parents’ custody or visitation suitability. If the psychotherapist is required to appear as a witness, the party responsible for the psychotherapist’s participation agrees to reimburse at a rate to be determined with the psychotherapist in advance for time spent traveling, preparing reports, testifying, being in attendance, and any other case-related costs.

Payment for Services

You will be expected to pay for each session at the time it is held, unless we agree otherwise or you have insurance coverage that requires another arrangement (ie. balance to be billed to you upon receipt of the insurance processing). You are responsible for payment for all services you receive, whether or not your insurance reimburses for a portion of the charges. “No show” or “late cancel” appointments may also be billed to you. If there have been no payments on your account for more than 60 days and arrangements for payment have not been agreed upon, we have the option of using legal means to secure the payment. This may involve hiring a collection agency or going through small claims court, which will require us to disclose otherwise confidential information. In most collection situations, the only information we release regarding a client’s treatment is his/her name, the nature of services provided, and the amount due.

We do not anticipate collections procedures, but have established this policy so that all clients are clear as to our office procedure. If you have questions about fees, payments or your balance, please speak directly with your psychotherapist, contact us via email at, or call us at either office number (616-988-3433).

Insurance Reimbursement

Many health insurance plans provide coverage for necessary mental health treatment when you see a licensed psychotherapist. It is your responsibility to know the limitations and restrictions to your insurance benefits. Note that many policies may only cover a limited number of sessions each year, may have restrictions on the licensure of the psychotherapist you see, and may or may not provide payment for a psychotherapist considered to be out of network with your health insurance plan. We will complete forms and provide you with whatever assistance we can in helping you receive the benefits to which you are entitled; however, you (not your insurance company) are responsible for full payment of fees. It is important that you find out exactly what mental health services your insurance policy covers. Grand Rapids Counseling Services does not provide services through Medicaid, regardless of whether you are eligible for said benefits.

Please check your coverage carefully prior to your first session. Of course, our staff will provide you with whatever information we can based on our experience and will be happy to help you in understanding the information you receive from your insurance company. You can call the number on your insurance card and ask the following questions:

You should also be aware that your contract with your health insurance company requires that we provide it with information relevant to the services that we provide to you. We are required to provide a clinical diagnosis. Sometimes we are required to provide additional clinical information such as treatment plans or summaries, or copies of your entire Clinical Record. In such situations, we will make every effort to release only the minimum information about you that is necessary for the purpose requested. This information will become part of the insurance company’s files and will probably be stored in a computer. Though all insurance companies claim to keep such information confidential, we have no control over what they do with it once it is in their possession. In some cases, they may share the information with a national medical information databank. We will provide you with a copy of any report we submit, if you request it. By signing this Agreement, you agree that we can provide requested information to your carrier.

Once we have all the information about your insurance coverage, you may discuss with your psychotherapist what you can expect to accomplish with the benefits that are available and what will happen if they run out before you feel ready to end your sessions. You always have the right to pay for services yourself to avoid the problems described above (unless prohibited by contract), and we are also able to provide you with a statement which you can submit to your insurance company directly for reimbursement.

Telehealth Services

Telehealth involves the use of electronic communications to enable Grand Rapids Counseling Services’ mental health professionals to connect with individuals using interactive video and audio communications.

Telehealth includes the practice of psychological health care delivery, diagnosis, consultation, treatment, referral to resources, education, and the transfer of medical and clinical data.

If you and your psychotherapist agree to schedule any telehealth appointments, you understand that you have the following rights with respect to telehealth:

Payment for Telehealth Services

Grand Rapids Counseling Services will bill insurance for telehealth services when these services have been determined to be covered by an individual’s insurance plan. In the event that insurance does not cover telehealth, the individual wishes to pay out-of-pocket, or when there is no insurance coverage, payment will be expected at the time of service unless otherwise agreed upon.

Communication Consent

Email and text messaging allows health care providers to exchange information efficiently for the benefit of our patients. At the same time, we recognize that email and text messaging are not a completely secure means of communication because these messages can be addressed to the wrong person or accessed improperly while in storage or during transmission. If you would like us to send you email and/or text messages that contains your health information, please complete and sign this Consent below. You are not required to authorize the use of email and/or text messaging and a decision not to sign this authorization will not affect your health care in any way. If you prefer not to authorize the use of email and/or text messaging we will continue to use U.S. Mail or telephone to communicate with you.