Policy Agreement

1. Legal guardians of minor clients are required to be present for the full duration of the intake session. 1. Legal guardians of minor clients are required to be present for the full duration of the 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.

Enter your full name to indicate agreement with the items mentioned above

Email address

Phone number

Name of Child's Other Guardian

Other guardian's email

Other guardian's phone

Will you be attending services in person or via Telehealth? Will you be attending services in person or via Telehealth? I will be attending services via Telehealth I will be attending services in person at the LLCS Buckeye site

Policy agreement Policy agreement I attest that I understand and agree to follow LLCS policies regarding Intake Scheduling, Telehealth/On Site Services

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LLCS Telehealth Service Policies

All Telehealth session scheduling is completed directly between the client and their attending therapist once registration is completed and deposits are collected.
Clients are to monitor their emails to sign onto the session platforms using the most recent telehealth link provided by their LLCS therapist
Scheduling a minor’s teletherapy sessions using the adult’s email and device is preferred.
Recording of telehealth sessions is strictly forbidden without the express written consent of the LLCS President and may constitute immediate termination of services and possible prosecution by LLCS.
Client’s must use telehealth in a privacy protective location. LLCS therapist may pause (or end) sessions when the client’s privacy is compromised, or until restored.
All clients must give verbal or written consent for others to participate in sessions. The LLCS therapist may terminate the session due to concerns involving consent.
Use of media editing technology designed to alter or mask screen images, sound or time recordings is expressly forbidden without LLCS therapist consent and may result in termination of services.
If telehealth technology is inoperable, transition to cell phone use upon agreement by both therapist and client is acceptable. The LLCS therapist must agree with session termination to avoid a late cancellation fee.
Ongoing failure of telehealth technology is not grounds for accommodation to in-person services. LLCS therapist will provide referrals to professionals offering in-person services if a suitable and stable service platform cannot be found.
On occasion, LLCS therapists may provide telehealth services to a client located out of state. Continuation of such services must be coordinated with that state’s Behavioral Health governing board. Services must be paused until approval is received.
Exhibitionism, the use of threatening gestures and images or display of sexually explicit materials is expressly forbidden. Such actions may result in service termination or reporting to law enforcement for possible prosecution.
Failure to comply with the above mentioned LLCS Policies is grounds for assignment of client out-of-pocket expense (circumstances involving shortened or missed sessions) or service termination if behavior continues.

LLCS Site Policies for In-Person Services

COVID-19 and other Infectious disease Informed Consent: Read here

LLCS is located on the campus of Grace Fellowship Church of Buckeye (GFCB), and Grace Fellowship Academy (GFA); expect to be approached by staff as a security precaution.
No scheduling occurs on-site. DO NOT COME ONTO THE CAMPUS WITHOUT A SCHEDULED APPOINTMENT.
Church and school staff are not affiliated with LLCS. Only share personal information with your LLCS clinician
Please BRING the following items to the first session (if not submitted online):

Completed Client Demographic Form
Insurance card (if applicable)
Copies of legal custodial or guardianship paperwork (for minor clients)

Please enter the C BUILDING, be seated and text your therapist of your arrival. *There is a restroom in each of the meeting rooms
If 10 minutes into your session you are not acknowledged, it is possible your therapist is involved in a client emergency. Feel free to depart, your therapist will reach out to reschedule.
Please DO NOT BRING

alcohol or illicit substances, or arrive under their influence (drug free school zone)
firearms or objects resembling weapons (weapons free school zone)
tobacco product (Smoke Free campus)
animals, unless officially service certified (certification may be requested)

Please be courteous to anyone you meet while on site
Grace Fellowship Church reserves the right to limit campus access to anyone, and to report such actions to law enforcement.

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

***Some GPS locate the church north of the freeway…This is incorrect!

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

Upon Arriving

Be advised there is an school on campus and visitors may be approached by church or school personnel as a security precaution. Inform anyone asking of your 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 you are 10 minutes into your session without being acknowledge 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
This is a smoke free campus
There is a restroom in each of the C building meeting room and in the main church breezeway

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

Firearms or any 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)

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

Please BRING the following items to the first session:

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 contact LLCS as soon as possible should you have any questions. Thank you.

Types of Intakes

One hour

Explanation of informed Consent (state mandated)
Roughly 15 min for gathering personal History
Possible completion of intake assessment
Intake completed in 2 sessions and less expensive

Two hour

Explanation of Informed Consent (state mandated)
Roughly 75 min for gathering personal History
Completion of intake assessment
Completion of Treatment Plan
Intake completed in 1 session but more expensive

Additional information

If you desire to complete your intake in 1 hour, please only register and pay for 1 hour
All fees will be applied as a credit to any Insurance Deductibles, Copays, or Coinsurance, or against any insurance non-covered services or missed session fees.
This fee is Refundable/Transferable if a request for cancellation/rescheduling is received and confirmed with 24 hours advance notice