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Therapy Appointment & Safe Space Policy

Archer Angels Family Services, LLC requires a minimum of 48 hour notice to cancel or reschedule your appointments. The session fee will be charged to applicable parties (privately insured) if the session is cancelled in less than 48 hours from the scheduled appointment time. Session fees will be charged for “No Call/No Shows”. Privately Insured clients will be charged the same amount their insurance company is contracted to pay this provider for the session. Private Non-Insured “Out-of-Pocket” paying clients will be charged a flat fee of $100.00.


No-Shows are missed appointments without prior notice or cancellation. Excessive and consistent cancellations or “No Shows” may lead to the termination of therapy. A discussion with your therapist and the signing of a “Treatment Contract” may be required to continue. After 2 no-show appointments, you and your therapist will re-evaluate the need for treatment at this time. After 3 no-shows, the therapist reserves the right to transfer or close your case.


Outreach therapy sessions and Telehealth Distance Counseling held away from the office service site can only be provided in a safe and secure environment. To maximize productivity, the space where therapy is held must be private, quiet, neat and safe. This requires that when service providers visit your home the following be put away:

  Substances (alcohol or non-prescription drugs, and no smoking of cigarettes)

  Weapons (legally registered or unregistered weapons)

  Pets (can be put in another room)

  Additional friends and relatives that will not participate or are not needed for treatment

  Profanity (no swearing)

Session Fees & Copayments:

Returning clients, who are required to make copayments by their insurance company, must leave at least one credit/debit card payment method on file. Invoices will be mailed out quarterly after the payment source on file has been charged. It is the client’s responsibility to monitor fees charged to credit/debit card on file. Copayments and session fees must be available to be paid at the beginning of the session. No fees will be refunded once received. Please notify your provider immediately if you recognize a billing discrepancy. It is our priority to provide quality services and resolve any billing concerns immediately.

Patient Records: All requests for patient records must be made in writing. Please allow upto 10 business days to receive your file.

I have read and agree to the terms of these policies stated above. I understand that my failure to comply with these policies can result in the suspension or termination of counseling services: This authorization expires 90 days after case closure or one year from date signed.


I understand that Archer Angels Family Services, LLC and it’s Business Associates complies with the HIPAA/Federal Confidentiality Regulations (42 CFR Part 2). This protects the confidentiality of my record preventing it’s contents from being disclosed without my consent unless otherwise provided for in the Regulations or by statue.

I understand that my information may be accessed by other individuals or organizations that are not subject to privacy protection laws. These parties include law enforcement, state agencies, school districts, Department of Children and Families, municipal offices and others authorities not covered by HIPAA Laws. I understand that I may obtain or inspect a copy of my information that will be used or disclosed pursuant to this authorization. I hereby release Archer Angels Family Services, LLC and its officers, employees, agents, directors, business associates, subcontractors, and volunteers from all legal responsibilities and liabilities that may arise from the release of such protected information in accordance with this directive.

I understand that the authorization of disclosure of my personal information is voluntary. I can refuse to sign or revoke this release form at any time. Authorization of disclosure is not conditional of me receiving treatment or benefits. I understand that information disclosed pursuant to this authorization may be subject to re-disclosure by the recipient and no longer protected by Federal Confidentiality Regulations; however the recipient may be prohibited from disclosing substance abuse information (45 C.F.R. Part 160 and 164).

I understand that I may revoke this authorization by providing a statement in writing, at any time. With the exception that this revocation will not have any effect on action(s) taken by Archer Angels Family Services, LLC prior to written notice of revocation being received by the provider regarding this authorization.

I herein expressly and voluntarily authorize the disclosure of the above information to those persons or agencies listed above. This authorization will expire 90 days after this case closes or one year after the signature date of this document.

I have read and understand the terms of this authorization. I have had an opportunity to ask questions about the use or disclosure of my information.


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