Jennifer Danhauser Informed Consent

Jennifer Danhauser, LPC

Counseling and Therapy Services


Informed Consent/Disclosure Statement

Thank you for choosing this practice and congratulations for taking the next step in improving you. I realize that starting counseling is a major decision and you may have many questions. This document is intended to inform you of my policies, state and federal laws, and your rights. If you have other questions or concerns, please ask and I will try my best to give you all the information you need.

My name is Jennifer Danhauser. I am a Licensed Professional Counselor (LPC) as provided by the State of Alaska Board of Professional Counselors, which has been maintained since January 12, 2004. I am also a National Counselor Certified (NCC) as provided by the National Board for Certified Counselors, which has been maintained since August 15, 2001. I have my M.S. in Counseling Educational and Developmental Psychology, having graduated from Eastern Washington University. I have been a member of the American Counseling Association in good standing since January 1, 2000. My business is Jennifer Danhauser, LPC, LLC and address is 565 University Avenue, Suite #4, Fairbanks, Alaska, 99709. My business phone number is (907) 978-4978.

My training is focused in Dialectical Behavioral Therapy (DBT), Prolonged Exposure Therapy (PET) and Eye Movement Desensitization and Reprocessing Therapy (EMDR). DBT uses a strong Cognitive Behavioral approach along with mindfulness, which offers a compassionate and scientifically sound treatment for those who have struggled to reach or maintain a life worth living. PET and EMDR are both treatment approaches focused specifically for trauma including Posttraumatic Stress.

I bring my dedication and experience into each session. My therapy process involves genuineness, respect, warmth, acceptance and empathy. I will help you gain a clear understanding of the process of change and empower you to make effective changes to accomplish your goals. Validation of your experiences and recognizing when acceptance is needed will also be part of the process.

Most of my private practice experience is with adults both in individual and group settings.Working with teens is on a case by case basis. I work Monday through Friday with varioushours between 9am and 7:30pm. Of note, the 5-7:30pm hours are reserved for DBT skills group training.

In addition, if you are in crisis while this clinician is unavailable or if you choose to attend group therapy services, Cathy Weeg, LPC and Mike Worrall, PhD., independent practitioners, may work with you and bill for services rendered. Cathy’s business phone number is (907) 590-8384. She received her M.S.Ed in Counselor Education from Western Illinois University, December 1993. Mike’s business phone number is 907-712-7667. He received his doctorate in Clinical Psychology from the University of Nevada, August 2011. Please check your insurance company specific to these independent practitioners as some may be in or out of network with your insurance.

This information is required by the Board of Professional Counselors which regulates all licensed professional counselors. To reach the board by mail, please write the Department of Commerce, Community and Economic Development, Division of Occupational Licensing, P.O. Box 110806, Juneau, Alaska, 99811. To reach the board by telephone, call 907-465-2550.

Service and Pricing

Golden Heart Administrative Professionals, Inc will bill your insurance company for you. Services and pricing are as follows:

Service Length Rate
Initial Assessment Session 1 hour $300
Individual Therapy, Couples Therapy, or Family Therapy 16 to 37 minutes $87.50
38 to 52 minutes $175
53 minutes or longer $225
Group Therapy Group Therapy $175
Court Fees 3 hours or less $175
Any additional hour or portion thereof $175

As a courtesy, we will bill your insurance company, responsible party, or third party payer for you using Golden Heart Administrative Professionals, Inc. If your insurance company denies payment or does not cover counseling, we request that you pay the balance due at that time. After 3 months of receipt of first bill, any unpaid balance will accrue assessed finance charges. We ask that every client authorize payment of medical benefits directly to Jennifer Danhauser, LPC, Cathy Weeg, LPC or Mike Worrall, PhD. as indicated in your bill.

If you miss an appointment, you will be charged the cost of the appointment and this will not be billed to your insurance company. Any unpaid balances may be turned over to collections. If this is the case, you are responsible for any collection fee charged. You will be charged $25 for any returned checks.

Assignment of Benefits

I authorize payment by my insurance company to be paid directly to Jennifer Danhauser, LPC, Cathy Weeg, LPC or Mike Worrall, PhD. for services rendered. I am aware that the amount I owe may be different specific to which independent practitioner is charging for services rendered. I understand that I am financially responsible for charges applied to the insurance deductible and for all charges limited by the insurance carrier. I authorize Jennifer Danhauser, LPC, Cathy Weeg, LPC or Mike Worrall, PhD. to give copies of any records when needed for payment by my insurance carrier and/or its affiliates. I have received a copy of my fee schedule.

By typing your name below you acknowledge and accept conditions as outlined above in this Informed Consent:

Consent For Payment By Insurance:(Required)
MM slash DD slash YYYY
Client Signature:(Required)

Confidentiality

Client information shared with me is confidential, except in the following circumstances:

  • Information required by your insurance company such as diagnosis and dates of services, etc. will be shared with our billing provider to collect payments
  • Mandated reporting of abuse of children or adults
  • Threats of suicide or homicide
  • Cases where you have signed a release of information
  • Information necessary for consultation including Cathy Weeg, LPC and Mike Worrall, PhD. for peer consultation and collaboration
  • Information released as outlined in the HIPAA Notice of Privacy Practice
  • Those required by law
  • Online transmission of information, such as Kareo, used by billing company.
  • Text messages and emails are not encrypted or secure and ARE NOT HIPPA compliant. Your awareness and agreement is necessary to transfer communication in this manner and is not recommended. In addition these messages are considered a part of your records and will be included in your records.
  • Files are stored primarily on computer with a backup server. Other printed files are kept locked per HIPPA standards.
  • Records are archived and maintained for a period of 10 years.

Your treatment program may be discussed with other professionals (other than those listed under Treatment in the Notice of Privacy Practices and Client Rights) and, if that occurs, your confidentiality will be maintained. Also, your name and identity will be disclosed only in compliance with AS 08.29.200 of the Statutes and Regulations of Professional Counselors.

Emergency Situations

In case of emergency outside of my normal business hours please contact:

  • Fairbanks Crisis Hot Line at 452-4357
  • Fairbanks Community Behavioral Health Center On-Call Service at 452-1575
  • Call 911 for immediate emergency care or visit the F.M.H. emergency room
  • Crisis Text Line online: crisistextline.org or Text: 741741
  • National Suicide Prevention Lifeline at 1-800-273-8255

By typing your name below you acknowledge and accept conditions as outlined above in this Informed Consent:

Client Consent(Required)
MM slash DD slash YYYY
Signature of Client:(Required)

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