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Site Policies for In Person Services

Light of Life Counseling Services LLC is Located on the Campus of Grace Fellowship Church of Buckeye (GFCB) – address is further below

* DO NOT COME ON SITE WITHOUT AN APPOINTMENT…no scheduling of new client’s occurs onsite*

Grace Fellowship Church of Buckeye reserves the right to limit access to the church campus regardless of LLCS client status

Be advised there is a school on campus and visitors will be approached by church or school personnel as a security precaution. Inform anyone asking that you have appointment with LLCS.
Please note church and school staff are not LLCS affiliated. Show discretion in sharing personal information with anyone other than an LLCS clinician, as they are not bound by confidentiality law
Please enter the C BUILDING entrance and be seated
If your clinician is unable to meet you immediately, you may alert them via text of your arrival
If 10 minutes have elapsed into your session without being acknowledged by your clinician, it is possible there is an emergency with another client. They will inform you if rescheduling is required.
Please do not come on campus if under the influence of alcohol or a substance
Please be courteous to anyone you meet while on site; laws regarding personal conduct are enforced and poor conduct may result in legal prosecution
This is a smoke free campus
There is a restroom in each of the C building meeting rooms and in the main church breezeway

Please DO NOT BRING any of the following items onto the GFCB Campus

Firearms or objects that may be mistaken as weapons (weapons free zone)
Alcohol, Tobacco products or any other illicit drugs
Animals, unless officially certified service animals (certification may be requested)
Unattended children or individual needing supervision

Please BRING the following items to the first session if not already submitted via the patient portal:

Completed Client Demographic Form (Complete as best as possible)

Complete the Client Intake (as best as possible)
Insurance card (if applicable)
Copies of legal custodial or guardianship paperwork (for minor clients)

Please feel free to contact LLCS should you have any questions. Thank you.

Public Health Emergency (PHE) Office Precautions: Read here

Directions

Address: 6500 S Miller Rd Bldg. C, Buckeye, AZ 85326

Directions: Light of Life Counseling Services is located on the campus of Grace Fellowship Church of Buckeye (GFCB) which is SOUTH OF SOUTHERN AVE on Miller Rd. GFCB is on the west side of Miller Rd.

***If GPS Sends you north of Interstate 10 (I-10), this is incorrect!

***Best place to park is in the south parking lot

Telehealth/Distance Professional Service Policies

Telehealth therapy falls into the broad category of Distance Professional Services as this type of service can be accomplished through different technologies (i.e., Video teleconferencing, Telephonic, Chat or email.
Clients need to understand concerns associated with these service modes and have the right to ask questions about these modalities and to be provided answers in a language they understand
Distance services are not the same as face-to-face meetings; most noticeable is diminished therapist support not being physically located with the client.
A client must identify an emergency contact for each session, and must allow the therapist to notify that contact should concerns for the client’s safety arise
Clients must be physically present in Arizona to participate in distance services requiring the client to confirm their address or location at the session’s start
Distances services provide increased care access and meeting convenience however, they also create potential challenges to confidentiality which must be regularly addressed
LLCS therapists must ensure that the client’s confidentiality is protected and will need to disconnect from the session to prevent breech of client’s confidentiality
Possible interruption, unauthorized access, and technical difficulties are risks inherent in distance services. The therapist or client can discontinue a visit if feels the distance service connection is not adequate for the situation.
Transition to in-person therapy may be necessary for reasons concerning the therapist or client. Reasons include technological limitations, non-securable confidentiality and symptom or developmental appropriateness,
A referral to another therapist may be needed if distance services are deemed inappropriate and travel and scheduling may limit in-person services
The provider will provide directions for session connection through a HIPAA-compliant communication services before the session
If technical issues arise the provider will have access to a secondary HIPAA-compliant telehealth platform or complete the session
Clients do not have the right to willfully change or terminate aspects of the services platform (i.e., video, if video teleconferencing is the selected platform)
Recording of distance service sessions is forbidden without the express written consent of either the therapist or the client
The therapist is not responsible for confidentiality breaches resulting by direct client actions, failure to maintain their equipment’s security software or by technological actions beyond the warranties of the platform provider
Distance services do not negate laws governing appropriate behavior; threats and gestures of violence and lewd conduct may result in legal prosecution
Termination of distance services due to technological difficulties or confidentiality concerns is not automatic grounds for a waiving of service fees. Prior discussion of concerns involving participation concerns, missed, or prematurely terminated sessions or willful termination of video feeds, communicated to the client by the therapist will be taken into fee consideration.
By completing the LLCS registration, the client certifies:

Having read or had this form read and/or had this form explained to them,
That they fully understand its contents including the risks and benefits of distance therapy services.
That they have been given ample opportunity to ask questions and that any questions have been answered to their satisfaction

Information on the Individual completing the Service Request

Information about the person filling out the form either on behalf of the patient or for themselves

Name of the Registering Individual(Required)

First Last

Is the patient a minor under 17 years old?(Required)

Relationship to patient (under 17 years old)(Required)

Relationship to patient (adult)(Required)

Patient's Date of Birth(Required)

Referral #

Case Manager Referral #

State

Name of Courter

Court Docket#

Legal Guardian

Court Case Docket #

Scheduling Service for Minors

You indicated that the patient is a minor. Please attest to the following statements as part of your scheduling request.

Since you are a minor and identified as self-registering for services, are you an emancipated minor?(Required)

I understand I must provide legal documents to show my status as an emancipated minor.

Decision Making Rights(Required)

I attest that I hold "sole" or "full" court ordered decision making rights for the minor I am seeking to enroll in therapy services. I also agree to provide a copy of the court order prior to the intake session.

Informed All Adults With Decision Making Rights(Required)

I attest, I have informed all other adults with decision making rights over the minor of my intention to enroll him/her in therapy services through LLCS.

Court Custodial Order Required(Required)

I understand LLCS may suspend the intake and future services without prior receipt of a copy of the court custodial order and signed consents by all decision-making adults to include forfeiture of deposits

Legal Guardians Must Be Present(Required)

I understand legal guardians must be present for the full intake session

Scheduling Service for Another Adult or a Minor 17+

LLCS recognizes that most efforts by an adult to schedule services for another adult are to assist someone with a busy schedule to register for services. However, please know therapy is ineffective if individuals are pressured to attend

Therapist Will Confirm Patient's Desire For Therapy(Required)

I understand the LLCS therapist must confirm with the patient their desire for therapy services

LLCS Cannot Confirm If Patient Declines Service(Required)

I understand LLCS cannot confirm if an identified patient declines service

Scheduling Services For Myself May Be Beneficial(Required)

I understand scheduling services for myself may be beneficial even if the other individual declines

Patient Information

You indicated the patient is not yourself, please enter the patent’s information.

Patient Name(Required)

First Last

Best Phone for the client (For minors, provide the guardian's phone)(Required)

Email(Required)

For minors, provide the guardian's email

Address (Address where the client resides)(Required)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Emergency Contact Information

As you are identified a minor, you must provide your legal guardian’s contact information to continue registering for services

Are you concerned that your guardian may become upset with your request for services?(Required)

Thank you for providing your guardian’s information. LLCS intake staff will communicate with your guardian to ensure you have permission to seek services. We will do all that we can to ensure you can continue with services.

In an emergency, Arizona Law allows a minor to meet with a therapist without parental consent. Your LLCS therapist can help you connect with additional agencies that can help you get additional help.

Name(Required)

First Last

Relationship to patient(Required)

Role/Title(Required)

Phone(Required)

Your Therapist and Service Request

Service Type(Required)

In Person or Telehealth?(Required)

Briefly Describe Reason for Seeking services (Include examples of Behaviors, statements, or moods)(Required)

Wait Time Agreement(Required)

I understand that this therapist is presently estimating a {{wait time}} week wait time for service intake. This is an estimate and services may begin earlier or later depending on client's scheduling availability.

Patient Availability

1st most desired session appointment day(Required)

Choose a time(Required)

2nd most desired session appointment day(Required)

Choose a time(Required)

3rd most desired session appointment day(Required)

Choose a time(Required)

Service Continuation Agreement(Required)

I understand completing an intake is not a guarantee of LLCS service continuation for the reasons listed:

The intake reveals a patient's need for specialized services beyond LLCS therapist's expertise
The intake reveals a patient need for a higher level of care than is possible in outpatient services
The patient changes their previously identified availability
The patient breaks LLCS Service Policies

LLCS Policies Agreement(Required)

I have read and agree with LLCS Policies

Click here to open LLCS Policies in a new tab

Waitlist Agreement(Required)

I understand that LLCS's waitlists are non-binding, and I may decline services at any time. However, when contacted, I must respond within 2-3 days, or I risk losing my place on the waitlist.

Patient Financial Information

LLCS will be billing the following for payment of patient services(Required)

Were services already coordinated by an Insurance Care Manager?(Required)

Provide the Care Manager's name or Verification code

My Household's Combined Annual Income(Required)

Number of dependents supported by this income(Required)

Insurance Company Name(Required)

Insurance Company Policy ID#(Required)

Active Date(Required)

EAP Benefit?(Required)

EAP Company Name(Required)

EAP Company Phone Number(Required)

Is the patient the Primary Insured?(Required)

Primary Insured Name(Required)

First Middle Last

Primary Insured's Birthday(Required)

Primary Insured Address(Required)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Primary Insured Phone(Required)

Is the Patient the Guarantor of Services?(Required)

Guarantor Name(Required)

First Middle Last

Guarantor Address(Required)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Guarantor Phone(Required)

Patient/Guarantor Financial Agreement

Good Faith Estimate

I understand payor information I provide must be accurate(Required)

I understand the payor information I provide LLCS must be accurate with incorrect information having the potential to impact my desired use of benefits for services

I understand LLCS will provide a good faith estimate for the cost of services before intake scheduling(Required)

I understand LLCS will provide a good faith estimate for the cost of services before intake scheduling. This service estimate supersedes any previously communicated estimate, or anticipated use of my benefits

I understand that proceeding with Intake I (patient/guarantor) becomes ultimately liable for all service fees(Required)

I understand that proceeding with Intake I (patient/guarantor) becomes ultimately liable for all service fees for whatever reason my benefits provider fails to pay for services

Intake Scheduling Deposit Information

When contacted to schedule an intake session, LLCS requires a $75 deposit as insurance Payors do not pay for missed sessions. The deposit must be paid prior to the intake to confirm its scheduling.

Agree to 24-hour notice for intent to cancel or reschedule a scheduled session(Required)

I agree to directly confirm with my LLCS clinician via phone, text, or email of my intent to cancel or reschedule the intake with 24 hours' notice.

Agree to pay $75 Intake deposit(Required)

I agree to pay a $75 intake scheduling deposit (regardless of using insurance) and that I may forfeit this deposit if I do not give my therapist 24 hours' notice to cancel or reschedule the session.

Agree to pay Intake deposit even if I am using EAP benefit(Required)

I understand that I will be required to pay the intake deposit even if I am using an EAP benefit, and that it will be returned to me once I complete the intake.

Agree to second intake deposit of $95 if first intake session is missed(Required)

I agree that LLCS reserves the right to charge a second $95 deposit to schedule a second intake session if the first is missed without 24 hours' notice of cancelation or session reschedule request.

I agree to patient payment responsibility(Required)

I agree that LLCS may apply the intake deposit against any patient payment responsibility (i.e., patient copays, co-insurances, or deductibles) and that it will be returned if there is no confirmed patient payment responsibility.

Intake Session and Portal Access Creation

After receipt of the patient’s service registration is confirmed, the patient’s desired therapist will contact the patient with a tentative intake date. At this time the patient will receive an online patient portal account and must complete the following actions.

I have access to email and the Internet(Required)

Intake Confirmation Through the LLCS-InSync Portal (preferred)(Required)

I understand that to confirm my intake session, I will need to sign onto the LLCS-InSync Portal to complete the following actions:

I must electronically complete the LLCS Information and Consent Packet - Everyone
The LLCS Informed Consent During a Public Health Emergency – Unnecessary for Telehealth
Applicable Patient Adult or Child History
Upload copies of any required custodial or other legal orders
Pay the Intake Deposit online

Intake Confirmation when LLCS-InSync Portal is not available(Required)

I agree that if I cannot complete the consent forms online or pay the deposit, I will:

Bring copies of required custodial orders
I will call my therapist or LLCS office to pay the deposit over the phone
Print the forms and bring the completed forms to the intake session:

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Name

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Registration

Patient Intake

Site Policies for In Person Services

Directions

Telehealth/Distance Professional Service Policies

Information on the Individual completing the Service Request

Scheduling Service for Minors

Scheduling Service for Another Adult or a Minor 17+

Patient Information

Emergency Contact Information

Your Therapist and Service Request

Patient Availability

Patient Financial Information

Patient/Guarantor Financial Agreement

Intake Scheduling Deposit Information

Intake Session and Portal Access Creation

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