Starkville Counseling Associates Counseling for children, adolescents and adults

Would you like to receive a voicemail reminder for your appointments?

By submitting this information I agree for Starkville Counseling Associates staff to leave a discreet message at the source of contact. Required

Is your partner supportive of you seeking counseling?

Payment for services rendered is expected at each session. Acceptable forms of payment include cash, personal check or money order. We offer access to credit card payments on our website through PayPal ®. Accounts 60 days past due are subject to referral to an outside collection agency. In the event that your account is forwarded to an external collection agency, all collections fees will be added to your account. Information such as name, social security number, employer, address, and date of birth of the client and/or billing party are released for collection purposes only.

I understand that my insurance company may require release of information regarding my treatment, and I authorize the release of such information, if applicable. I understand that I am responsible for any charges not reimbursed by my insurance company. I also authorize Starkville Counseling Associates to obtain/release/exchange information with my Primary Care Physician, other healthcare practitioner(s) or as requested by my insurance company for the purpose of service coordination and continuity of care.

I understand that my counselor will not willingly testify in any court proceeding as this role, more often than not, jeopardizes the therapeutic relationship. However, if required by law to appear and/or testify, I understand that I will be charged $150.00 per hour for time spent in activities preparing for a courtroom appearance. I also understand that I will be charged $1000 per day of courtroom appearance – regardless of the time spent in the courtroom and regardless of whether my counselor is able to testify that day or not. Payment for courtroom appearance will be required prior to my counselor’s appearance in court.

CANCELLATION POLICY

There is a cancellation policy, which requires that you cancel your appointment 24 hours in advance to avoid being charged. You may call the office (323-5588), text your counselor’s cell phone or email our office manager or your counselor any time to cancel an appointment. When canceling, please indicate when you would like to reschedule your next session. In the event that your counselor has to cancel a session, he or she will notify you promptly.

I agree to the cancelation policy Required