Policy Agreement

Form

Since 2014, Light of Life Counseling Services LLC remains true to it’s founder, Ulises Gonzalez’s mission, to provide excellent and affordable mental health services to the residents of Buckeye and the outer regions of Maricopa County.

1. Legal guardians of minor clients must be present for the entire intake session. 1. Legal guardians of minor clients must be present for the entire intake session. a. I attest I have sole court ordered decision making rights for the minor I am enrolling in LLCS services. b. I attest I have informed all other Adults (actively engaged or estranged) with shared decision-making rights of my intent to enroll the minor in LLCS services. c. I will provide copies of custodial agreements and signed consents by all decision-making parties before the intake session. d. I acknowledge that intake and future services will be suspended until consents copies are provided, with deposits forfeited.

2. Intake appointment generally last one hour, but may require additional sessions to accommodate for special needs or if testing is determined necessary 2. Intake appointment generally last one hour, but may require additional sessions to accommodate for special needs or if testing is determined necessary a. I acknowledge a $75 /Hr deposit is required to schedule an intake session. b. I acknowledge the deposit will be credited toward insurance required copays, co-insurances, or deductibles, unless forfeited due to late cancellation (see below) c. I understand the intake session does not guarantee LLCS service continuation but is required to determine presence of specialized services needs beyond the therapist’s expertise.

3. LLCS requires clients provide 24-hour notice directly to their therapist of their intent to cancel or reschedule intake sessions or forfeit intake deposit fees. 3. LLCS requires clients provide 24-hour notice directly to their therapist of their intent to cancel or reschedule intake sessions or forfeit intake deposit fees. a. I agree to contact my LLCS therapist directly with over 24 hours’ notice to cancel or reschedule an intake. If less time is given, I acknowledge I may forfeit any deposits b. I acknowledge LLCS may require a new $100 (non-refundable) intake rescheduling fee regardless of previously collected deposits. c. I understand that LLCS reserves the right to send any unpaid account balance beyond 90 days to a collection agency.

Email

Phone

Name of Child's Other Guardian

Other Guardian Phone

Other Guardian Email