Welcome!
This document outlines the important details regarding the therapeutic services I offer in my private practice. Please read this information carefully and ask any questions you may have before signing below. By signing this form, you acknowledge that you have read and understood this information and that you have had all your questions answered. If you elect to use your insurance benefits, as described in the section below called Insurance Reimbursement, then by signing this form you are also giving me permission to share your information with your insurance company.
About Me
My name is Sheila M. Kruesel, and I am a licensed alcohol and drug counselor (LADC) in the state of Minnesota.
My license number is 307596. You can verify the details from the MN Board of Behavioral Health and Therapy.
You can find more information about my qualifications and experience on my website at www.charliebrowntherapy.com.
Services Offered
I provide group therapy for [adults (ages 18+) experiencing a variety of challenges, including, but no limited to, life's transitions, addiction, substance use, anxiety and burnout, depression and meaning making.
I utilize CBT, CBT-G, ACT, MI, 12 Step, and DBT as my primary therapeutic approaches.
I do not offer medication management, court-ordered evaluations, or detoxification services.
Evaluation
The first session will involve my evaluation of your needs. This evaluation typically lasts one session.
This initial conversation is designed to ensure alignment. By the end of the session, we will determine whether this is the right therapeutic partnership. If it is, we will begin building a focused, actionable treatment plan.
I will refer you to another therapist if I believe someone else is better suited based upon your needs.
Psychotherapy
Psychotherapy is a collaborative effort that requires active participation from you.
The approach used will vary depending on your needs and it may involve discussing uncomfortable topics.
Therapy is a collaborative process, and while outcomes cannot be guaranteed, extensive research demonstrates that individuals who actively engage in therapy often experience meaningful improvement.
Benefits and Risks of Therapy
Therapy requires an investment of time, money, and energy. Therapy can be a helpful and an effective way to address emotional and behavioral difficulties.
Potential benefits of therapy include improved mood, reduced stress, less career burnout, better coping skills, enhanced relationships, and healthier mental disposition..
However, therapy can also involve some emotional discomfort as you explore challenging issues.
Throughout any therapy sessions, I encourage you to ask questions. Also, feel free to seek a second opinion at any time.
Confidentiality
If you are concerned about confidentiality in any situation, please bring it to my attention.
Fees
Group sessions are typically 120 minutes long.
Additional Fees:
Additional services, including the list below, will be billed at $250 per hour.
Report writing
Telephone conversations at your request
Attendance at meetings with other professionals per your request
Preparation of records or treatment summaries
Time spent performing any other service you may request of me and to which I agree
Tasks under one hour will be pro-rated (meaning the cost will be calculated proportionally to the time spent on the task and not the full hourly rate).
Legal Matters:
You are responsible for my professional time if legal matters require my participation, even if I am subpoenaed.
My fee for legal preparation and attendance at proceedings is $500 per hour.
Payment
I accept online payments via AMEX, VISA, Discovery, and Mastercard.
Payment is due at the time of service unless otherwise agreed upon.
I do accept insurance from (BCBS of MN, Optum (UHG), and Healthpartners.
If you choose to use insurance, please be aware that you are responsible for any copay, coinsurance, or deductible associated with your plan. If your insurance denies your claim, you will be responsible for the total amount of my fees.
There is a $75 cancellation fee for cancellations with less than 1 business days’ notice.
If your account is unpaid after 60 days, I may use legal means, such as the help of a collection agency, to collect payment.
Insurance Reimbursement
Understanding your insurance coverage is important for setting realistic treatment goals.
I will try to help you navigate your insurance benefits and maximize coverage, but you are ultimately responsible for payment.
Your insurer may require authorization before providing reimbursement and may limit the number of sessions that are covered by insurance. Should you request more sessions beyond your insurance coverage, you would be responsible for the total amount of those sessions.
I recommend contacting your insurance company directly and in advance of our first session to understand your specific mental health coverage benefits and any limitations or pre-authorization requirements.
Most insurance companies, require a diagnosis assessment in order to provide coverage as well as additional clinical information (treatment plans, progress notes, etc.). When you sign this form, you are giving me permission to share your information with your insurance company to seek payment for your covered services.
Many choose not to use your insurance for some or all your care. You have the right to pay for services yourself to avoid these limitations and potential privacy concerns associated with using your insurance.
Your Rights
You have the right to participate actively in your treatment and make informed decisions about your care.
You have the right to ask questions and request clarification at any time.
You have the right to terminate therapy at any time. Any unused sessions paid for are non-refundable.
You have the right to seek a second opinion.
Contacting Charlie Brown Therapy
When you contact the office of Charlie Brown Therapy, you are welcome to leave me a confidential message, and I will make every effort to return your call within the [time frame to return call excluding weekends/holidays if desired].
If you cannot reach me and require immediate help, call 911 or call 988.
In case of an extended absence on my part, I will provide you with contact information of a colleague who may be able to provide you with services.
My Responsibilities
I am committed to providing you with competent and ethical psychological care.
I will respect your privacy and confidentiality.
I will discuss the limitations of my expertise and refer you to another provider if necessary.
Agreement
By signing below, you acknowledge that you have read and understood this Informed Consent document, that you have had all your questions answered to your satisfaction, and you consent to the releases of information described above. You agree to participate in therapy voluntarily.