Cheryl A. Byk, LCSW & Counseling Associates



                                            Parent Reunification Terms of Treatment
 
                                                    Initial Evaluation = $200.00 – Subsequent Session = $150.00

I have chosen to receive treatment services from Cheryl A. Byk, LCSW, LLC and  understand that my therapist, Cheryl A. Byk, LCSW, BCD may not disclose any current or future information from our sessions unless a Release of Information Statement is signed by me, or unless I am in danger of doing bodily harm to myself or others. Confidentiality laws are in effect on both a State and Federal level.

If you have health insurance coverage, your insurance carrier will NOT be billed as this is not a covered benefit. You will be responsible for the full cost of each session at the time services are rendered. The full fee will be charged for appointments missed or cancelled without 24 hours notice. This charge will apply regardless of whether or not a courtesy confirmation call was received. Missed appointment fees are due prior to the next scheduled session.

Appointments are scheduled in advance and must be agreed upon by both parties. Continuity of treatment must be maintained with sessions scheduled no greater than (2) weeks apart. Preparation of any documentation, will be an additional charge that must be paid in advance prior to being released to the court.

Both parties agree to discuss any intent to terminate services with Cheryl A. Byk, LCSW, BCD prior to discontinuing treatment, or consultation with legal counsel. I understand that a voice-mail number, 609-971-8989, is available to reach my therapist 24 hours a day. In case of emergency and when a quick response is necessary, I understand that I should call the psychiatric emergency screening service (P.E.S.S.) at 1-866-904-4474, or my local hospital Emergency Room.

I certify that I have read, understand, and agree to abide by the terms listed above. Any disregard of these terms will result in discontinuation of any further services.

 

             ______________________________                                                                                                  _________________
                       Client Signature                                                                                                                        Date

             ______________________________                                                                                                  _________________
                      Client Signature                                                                                                                         Date

              ______________________________                                                                                                 __________________
                           Witness                                                                                                                                  Date

                                                                  Client Information and Informed Consent

 I have chosen to receive treatment services from Cheryl A. Byk, LCSW, LLC. My choice has been voluntary, and I understand that I may terminate therapy at any time. Cheryl A. Byk, LCSW, LLC may not disclose any current or future information from the sessions unless a Release of Information Statement is signed by me, or unless I am in danger of doing bodily harm to myself or others. Confidentiality laws are in effect on both a State and Federal level.

                                                                            Fee Agreement and Provisions of Service:

Initial Evaluation = $150.00                                                                                              Individual, Couples or Family Sessions = $130.00

If you have health insurance coverage, your insurance carrier will be billed for services rendered by Cheryl A. Byk, LCSW, LLC. Claims will be submitted on an assigned basis and payment will be sent directly to me. INSURANCE COVERAGE IS NOT AGUARANTEE OF PAYMENT. If your insurance company denies a claim for any reason, you will be responsible for the full cost of those services. If you elect to process your own insurance claim(s), you are aware that you are responsible for payment in full at the time of service. Any outstanding balance over 30 days will be charged a $10 late fee. Any outstanding balance over 60 days will be submitted to collections and I, hereby, agree to pay a collection fee of 25%.


I understand that appointments are scheduled in advance and require regular attendance to ensure optimum therapeutic benefit. The full fee will be charged for appointments missed or cancelled without 24 hours notice. This charge will apply regardless of whether or not a courtesy confirmation call was received. Co-payments are due before the beginning of the session. Missed appointment fees are due prior to the next scheduled session.

I understand that if insurance coverage is paying for the treatment, my records may be released to my insurance company, and to my primary care physician for case management and coordination of treatment.


I understand that a voice-mail number, 609-971-8989, is available to reach my therapist 24 hours a day. In case of emergency and when a quick response is necessary, I understand that I should call the psychiatric emergency screening service (P.E.S.S.) at 1-866-904-4474, or my local hospital Emergency Room.

I certify that I have read, understand, and agree to the terms described above.

                                   ______________________________                                                                        _________________
                                             Client Signature                                                                                              Date

                                   ______________________________                                                                        _________________
                                                  Witness                                                                                                        Date



Call Us:  609-971-8989