TDNT COUNSELING SERVICES FORMS (View Policies, Guidelines, Informed Consent, Service Agreement, Terms of Service, Emotional Support Animal [ESA] Prescription Letter Request & Other Forms)
Review & Sign to Consent: 1. Client Services Agreement; 2. Informed Consent; 3. Telehealth Consent; 4. Email/Text Consent; 5. Notice of Privacy Policies; 6. Guidelines for Emergency; 7. Release of Information (PHI) Form; 8. Collateral Contact Form; 9. Initial Pre-Consultation & Attendance Policy; 10. No-Show Reminder & Resources 11. Patient Safety Plan
**Not signing these forms #1 thru #11 does not preclude you from receiving services from us or from making payments to us according to our policies, agreement and guidelines. Receiving services from us is not contingent on you signing these forms. You can still receive services and agree with a verbal or written consent outside of the use of these forms.
We do, however, encourage you to sign these for your records (to include in your client or medical records). Please pay special attention to the Client Services Agreement and the Initial Pre-Consultation & Attendance Policy as these two are especially very useful to read before or upon signing up.
To signup for services, please complete the Sign-Up form or Book an appointment with a prepayment of your copay or self-pay amount, whether $1 or more. It is much simpler to fill out the admission Sign Up form and allow us to schedule for you based on your requests on the form. You may also provide this information to us via our secure email, phone or mail. You may also provide this information during our free 10 minute initial consultation, when one is offered to you. You will know you have a free 10 minute consultation when you’ve received an email from us from our email address tdntcounseling@tdntsocialservices.org informing you that you have a free session. Reviewing our forms, websites and asking us any questions you have to our email can prove even more useful.
Once you have signed up for service(s) with your request to schedule a session (appointment) and with your prepayment, you have consented to these policies and guidelines and are considered informed. Please review these forms, policies and guidelines thoroughly; and ask us any questions you may have prior to requesting or agreeing to schedule your session, essentially giving your informed consent.
Please check your email for your private HIPAA-compliant appointment link. Review our Practice Policies online at https://tdntsocialservices.org/tdnt-counseling-services. Click Policies to open, sign and date each form.
We Welcome You to TDNT Counseling Services at TDNT Social Services Inc! We’re always glad when you reach out and schedule a Paid Session with our Independent Practice! This includes a Paid Consultation! It means that you are seeking quality care for your mental health!!! We commend you on this! Our membership authorizes 3rd Party Companies to submit insurance claims for some of our clients. We are however your Clinical Service Provider. Please send any questions you have about our service to our email. We’ll be glad to assist.
Upon booking an initial session, please complete the Sign Up form on our website tdntsocialservices.org/tdnt-counseling-services to Sign Up or schedule your next session. Our standard Self-Pay price is $146.15 per session. We offer more affordable Sliding Scale and Nonprofit Program plans as low as $39.38 per session, based on need and eligibility. Ask Us!
We encourage you to complete the Intake and Consent/Policy forms on our website (also via email). Once you Sign Up, you’ll receive an email confirmation that your session has been scheduled with your HIPAA-compliant session link from tdntcounseling@tdntsocialservices.org.
If we don’t receive your health/EAP insurance and payment card information (your Sign Up form) or your payment for this session, we’ll (unfortunately) not be able to meet for a paid session. Your EAP/health insurance must cover your session to to be valid. Otherwise, you are Self-Pay (out-of-pocket).
Consultations are paid and not free unless you’ve requested this from us directly beforehand and we wrote to you from tdntcounseling@tdntsocialservices.org to confirm that your specific consultation is free before your session.
The Consultation Fee Schedule is as follow:
*for Insurance Pay if clinical work is completed
$1-$3.84 Plus your copay/coinsurance/co-deductible
*for Cash Pay
$39.38 per 7-16 minute sessions
$47.55 per 17-30 minute sessions
$55.96 per 31-38 minute sessions
$64.37 per 39-56 minute sessions
$73.23 per 57-60+ minute sessions
We currently offer a huge DISCOUNT on Consultations to support our community members and encourage them to reach out for help and for mental health support. This Discount is scheduled to last from 5/1/25 to 7/31/25 or longer!! Ask Us! For this period, we are offering all Cash Pay consultation sessions at $39.38 when the sessions lasts between 7 to 45 minutes. Insurance Pay when clinical work is completed is still between $1 to $3.84 Plus your copay/coinsurance/co-deductible, unless we’ve discussed with you that you’d only be charged $1 for that session.
Ask us for any questions you may have! Email tdntcounseling@tdntsocialservices.org.
Some answers about our Sign Up form, which is our Admission form!
So, Service or Treatment is not contingent on you completing the Intake and Consent Forms, or our Policy forms. You can give consent without first completing these forms, although we encourage you to complete those. However, admission or confirmation of appointments is contingent upon you completing our Sign Up form! Please understand that our Sign Up form is our Admission form!!! We do require this form or at least your demographics and payment method details to our email address in order to admit you into our outpatient treatment care and provide you with services. Your demographics are your identifiable information to link your treatment case or treatment account to you; and your payment method details would include your health insurance or EAP insurance details as well as your payment card or bank account to place on file. We have to verify and validate your insurance and other payment details before we can admit you into treatment like other healthcare providers do. We are not an emergency service although we provide mental health crisis sessions. We provide services based on prescheduled tasks, sessions and appointments. Even if we conditioned to provide free services to you, we do require this admission form (Sign Up). It is an admission form and has the required information in order for us to enter you into the system and admit you into treatment. It is not like the Intake or Consent forms. Whenever you cannot complete the Sign Up form yourself for whatever reason, you can always have someone else complete this form on your behalf. We can also have our Therapists help you complete this form in the session before clinical work begins. Please see more information in our FAQs.
ESA Prescription Letter (Housing/Travel)
SOME MORE RESOURCES
Stalking Awareness & Support https://www.stalkingawareness.org/documentation-log/ https://www.stalkingawareness.org/vital-signs/ https://www.stalkingawareness.org/victim-service-provider-resources/ https://www.stalkingawareness.org/risk-and-safety/ Stalking and Harassment Assessment and Risk Profile (SHARP) Tool https://ukcdar.uky.edu/ls/index.php/727369?lang=en
Additional Resources for Emergency:
911 Police/Law Enforcement (Ask for Mental Health Unit)
Your Local Hospital ER/ Your Primary Care Physician_________
Your Support System_________
National Suicide Prevention Hotline: www.suicidepreventionlifeline.org
Crisis Text Line – Text HOME to 741741; www.crisistextline.org ; Call 988
National Suicide Prevention Lifeline – 1-800-273-8255(TALK)
Trans Lifeline – 1-877-565-8860 (for the transgender community)
TrevorLifeline – 1-866-488-7386 (for LGBTQ youth)
Veterans Crisis Line – 1-800-273-8255, Press 1
Essential Community Services United Way – 211
Georgia Department of Family & Children Services – 1-877-423-4746
Florida Department of Family & Children Services – 1-850-300-4323
DFCS Child Protective Services (GA) – 1.855.GACHILD (+1 855-422-4453)
DCF Domestic Violence Hotline (FL) – 1-800-500-1119
Centers For Disease Control and Prevention – 1-800-232-4636
CDC Regional Poison Control Centers – 1-800-222-1222
In the meantime, you enjoy the rest of your day and practice coping tools to help support your mental health on a daily basis. Positive thinking, which leads to positive self-talk, goes a long way! Have a better rest of your day and see you soon! From Our Clinical Staff, LPC, NCC
Suicide Prevention
Pre-written messages to send to trusted contacts from iasp.info:
Reach out: “When you get a chance can you contact me? I feel really alone and suicidal, and could use some support.”
Contact a loved one: “I don’t want to die, but I don’t know how to live. Talking with you may help me feel safe. Are you free to talk?”
Express your feelings: “This is really hard for me to say but I’m having painful thoughts and it might help to talk. Are you free?”
Check in: “I’m struggling right now and just need to talk to someone — can we chat?”
International Association for Suicide Prevention https://www.iasp.info/suicidalthoughts/ Dial/Call or Text 988 or visit 988lifeline.org AFSP suicide prevention https://afsp.org/suicide-prevention-resources/ CDC suicide prevention https://www.cdc.gov/suicide/resources/index.html
Crises Hotlines
24-Hour Crisis Line: (850) 522-4485
Life Management Center https://lmccares.org/service/crisis-hotline/#:~:text=24%2DHour%20Crisis%20Line%3A%20(850)%20522%2D4485&text=Life%20Management%20Center%20crisis%20services,week%2C%20365%20days%20a%20year.
Domestic Violence Resources
National Domestic Violence Hotline Call 800-799-7233
Text BEGIN to 88788 https://www.thehotline.org/
https://www.thehotline.org/get-help/domestic-violence-local-resources/ https://www.domesticshelters.org/
Sexual Assault & Violence
National Sexual Assault Hotline 1- 800-656-4673 RAINN.org https://rainn.org/resources National Sexual Violence Resource Center https://www.nsvrc.org/homepage Sexual Violence Survivors Resources https://www.nsvrc.org/survivors Sexual Assault Kit Initiative https://www.sakitta.org/survivors/ Joyful Heart Foundation https://www.joyfulheartfoundation.org/learn/sexual-assault-and-rape/resources/hotlines-and-more-information
TDNT Social Services, Inc. 