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CONSENT FOR TREATMENT

Melissa Parenteau, MA, LPC Hill Country LPC
Psychotherapist Fredericksburg, Tx 78624
512-762-6841

I, , voluntarily consent to enter into a therapeutic and professional relationship with Melissa Parenteau, MA, LPC. I understand that this consent for treatment will be valid and remain in effect as long as I attend sessions with Melissa Parenteau unless revoked by me in writing.

OFFICE POLICIES AND PROCEDURES

Payment in full is due at the time of service. Office charges for therapy are based upon a rate outlined in the Non-Traditional Fee Payment Agreement for a 45 to 50 minute appointment. Longer sessions are charged at a prorated fee.

I understand that any fees related to foreseen or unforeseen legal actions that require Melissa Parenteau to reproduce records, produce written reports or participate in depositions or court appearances will be my responsibility and will be paid in advance. These fees are substantially higher than therapy fees and are usually not covered by insurance, regardless of who files the subpoena or initiates the legal action.

I understand that appointments may occasionally need to be cancelled. If appointments are not cancelled 24 hours in advance so another client may use my time, I agree to pay the entire fee for the missed appointment. I understand that this policy applies to any appointments missed without notification, as well as to late cancelled appointments.

I understand that Melissa Parenteau does not file insurance claims for our work together. It is my responsibility to file all insurance claims and to secure pre-authorization if required by my plan. Mrs. Parenteau will complete any reports required by my insurance plan without any additional charge to me.

If I am in crisis and believe that I am a danger to myself or to others, I agree to telephone the MHMR Crisis Line at 512-472-4357 (472-HELP), to call 911 or go to the nearest hospital emergency room and allow them to treat me.

I understand that my therapist is available by telephone at 512-762-6841 during normal working hours, 9:00 AM until 5:00 PM Monday through Friday. Messages will be returned within 24 hours.

I understand that I may be seen by my therapist during scheduled appointments only. No walk-in psychotherapy appointments are available.

My signature below indicates that have read the Consent for Treatment and Office Policies and Procedures and have had my questions answered to my satisfaction so that I fully understand the document. I will be given a copy of this completed form upon request.

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Signed by Melissa Parenteau M.A., LPC
Signed On: January 3, 2026

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October 12, 2023 10:41 am CDT

CONSENT FOR TREATMENT Uploaded by Melissa Parenteau M.A., LPC - melissa@hillcountrylpc.com IP 98.97.82.54