Welcome to Unbroken Family Counseling

INFORMED CONSENT AND CONTRACT FOR SERVICE Consent to treatment. I voluntarily consent to behavioral health services for myself, or for the minor named in this registration for whom I am the parent or legal guardian. I understand that counseling can bring benefits and also risks, that progress depends on many factors, and that no particular outcome is guaranteed. Sessions and cancellations. Sessions run 40 to 60 minutes. I agree to give at least 24 hours' notice to cancel or reschedule. Late cancellations (less than 24 hours' notice) and no-shows are charged 50% of the session fee. Fees. The initial session fee is $300 and each session after that is $250. I am responsible for all charges for services, whether or not my insurance pays for them. Insurance. The practice is in network with BCBS, Aetna, Humana, UHC, Medicaid plans, Medicare Part B, and Cigna. The practice is out of network for Tricare. Emergencies. The practice does not provide emergency services. In an emergency I will call the police (911) or go to the nearest emergency room, and then contact my therapist. Communication. The office can be reached at 630-300-8928 and info@unbrokenfamilycounseling.com. By signing, I authorize the practice to contact me by text message and email, to send me a link to the client portal, and to send me newsletters. To opt out of any of these I must complete a communication change form.

HIPAA NOTICE OF PRIVACY PRACTICES Your information is confidential. What you share in counseling and your records are protected health information. They are released only with your written authorization, except as described below. Exceptions. Information may be disclosed without your authorization: when there is a risk of serious harm to you or others, or suspected abuse or neglect of a child, elder, or person with a disability; in response to a subpoena or court order; when your insurer requests information needed to pay for services; and within the practice for clinical supervision, billing, and scheduling. Couples and family counseling. In couples or family counseling, information is not shared with other family members without the consent of the person it concerns. Minors. Services for a minor require the permission of the minor's parent or legal guardian. By signing, I acknowledge that I have received and understand this Notice of Privacy Practices.

CREDIT CARD AGREEMENT I authorize the practice to keep the credit or debit card I provide on file and to charge it for recurring sessions unless I give at least 24 hours' notice of a cancellation. I authorize charges to this card for copays, deductibles, coinsurance, any balance my insurance does not cover, and the 50% late-cancellation and no-show fee. Card payments are processed by Helcim, the practice's payment processor. My card is entered in Helcim's secure payment window and stored in the Helcim Card Vault; the practice does not see or keep my full card number or security code. I authorize the practice to initiate charges to my stored card, through Helcim, for the amounts described above, without my further signature for each charge. Charges appear as "Professional services" with an invoice number; a receipt is available on request. I may dispute a charge by contacting the office. This authorization remains in effect until I revoke it in writing.

CONSENT TO AUDIO RECORDING OF SESSIONS (AI NOTE ASSISTANT) What this is. With my permission, my clinician may make an audio recording of my therapy sessions (in person or by telehealth). The recording is used only to produce a written transcript, and the transcript is used only to help my clinician write a first draft of the session note. My clinician reviews, edits, and signs every note; the AI never signs or finalizes anything. Who processes it. The recording and transcript are processed by Google Cloud (Speech-to-Text and Vertex AI) under a HIPAA Business Associate Agreement with the practice. They are not used to train AI models, are encrypted in storage and in transit, and are never shown in the client portal. How long it is kept. The audio is deleted automatically after the transcript is made (or within the number of days the practice has set). The transcript is deleted automatically after the note is signed unless the practice's retention setting keeps it longer. The signed note becomes part of my record. All-party consent. Illinois law requires the consent of everyone in the conversation. Before each recording my clinician will ask everyone present for verbal consent, and anyone may decline. If anyone declines, the session is not recorded. My choice. This consent is voluntary. Declining does not affect my care in any way. I may withdraw it at any time by telling my clinician or the office; withdrawal stops future recordings. Minors. For a client under 18, a parent or legal guardian signs this consent; the minor is also asked for verbal assent in each session. I have read this form, my questions have been answered, and I consent to audio recording of my sessions as described above.