Initial Consent for Treatment and Professional Services

This document contains important information about our professional services and business policies. It also contains summary information about the Health Insurance and Portability Accountability Act (HIPAA), a federal law that provides privacy protections and patient rights with regard to the use and disclosure of Protected Health Information (PHI) used for the purpose of treatment, payment, and health care operations. HIPAA requires that we provide you with a Notice of Privacy Practices. The Notice, which we provide to you during our initial meeting, explains HIPAA and its application to your personal health information in greater detail. The law requires that we obtain your signature acknowledging that we have provided this information by the end of your session. You may revoke this Agreement in writing at any time. That revocation will be binding on me unless we have taken action in reliance on it; if there are obligations imposed on me by your health insurer in order to process or substantiate claims made under your policy; or, you have not satisfied any financial obligations you have incurred.

Counseling Services 

Psychotherapy is not easily described in general statements. It varies depending on the personalities of the therapist and client.  Depending on your presenting issues, we may draw on a variety of methods to help you regain balance and begin to pursue a more meaningful, fulfilling life. It is important to understand that psychotherapy is not like a medical doctor visit. Instead, it calls for very active effort on your part in which you work collaboratively with the therapist. You will need to practice the things we talk about. Psychotherapy can have a variety of potential benefits and risks. Since therapy often involves discussing unpleasant aspects of your life, you may experience uncomfortable feelings like sadness, guilt, anger, frustration, loneliness, and helplessness. On the other hand, therapy often leads to better relationships, solutions to specific problems, and a significant reduction in feelings of distress. But, there are no guarantees. Our first few sessions will involve evaluation of your needs. By the end of the evaluation, we will be able to offer you some first impressions about what our work will include and suggest a treatment plan to follow. You should evaluate this information along with your own opinions to decide if you feel comfortable working with me. Therapy involves a large commitment of time and energy, so you should be very careful when you select a therapist. If you have any questions about our procedures, we should discuss them as they arise. For therapy to be successful, it is critical that you share any doubts, misgivings, or dissatisfaction that you feel about our counseling relationship. If your doubts persist in spite of our efforts to address them, we will be happy to help arrange a meeting with another mental health professional in order to get a second opinion. 

Meetings 

The theoretical approaches and counseling strategies we facilitate in session are dependent upon specific individual characteristics and the types of issues that you present. We typically begin by facilitating person-centered empathic approaches, increasing your awareness and growth through exploring, clarifying, and identifying goals for therapy. Experiencing change and personal growth can be difficult but we will invite you to pay attention to what your mind, body, and spirit are communicating to you. Basically, we invite you to be open to the idea that you can be an active participant and observer of your own unique life experiences and achieve optimal levels of mind, body, and spiritual wellness.

We respect and am open to all ethnic, racial, gender, lifestyle, disability, and cultural differences. We believe that it is important to establish a good trusting relationship and working alliance in a safe environment so that you can disclose issues that may be of a very personal nature. After establishing a good working alliance we begin facilitating interventions using a variety of counseling approaches that may include, but are not limited to, Rational Emotive Behavioral Therapy, Acceptance and Commitment Therapy, DialecticalBehavioral Therapy, Transactional Analysis, Re-decision Therapy, mindfulness approaches, motivational enhancement, twelve-step facilitation, cognitive-behavioral techniques, gestalt therapy, solution-focused, other holistic counseling and wellness types of therapies.  

Professional Fees 

Our hourly fee is $120. In addition to weekly appointments, we charge this amount for other professional services you may need. Other services include: report writing; telephone conversations lasting longer than 10 minutes; consulting with other professionals with your permission; preparation of records or treatment summaries; and, any other service you may request of me. If you become involved in legal proceedings that require my participation, you will be expected to pay for our professional time, including preparation and transportation costs, even if We are called to testify by another party. Because of the difficulty of legal involvement, we charge $200.00 per hour for preparation and attendance at any legal proceeding.  Once an appointment hour is scheduled, you will be expected to pay for it unless you provide 24 hours advance notice of cancellation. $100 fee for late cancellations and no-shows. 

Contacting Us 

Office hours after Monday thru Friday from 8AM and 4PM through voice and text. Voice mail and text messages are monitored frequently seven days a week. We will make every effort to return your call on the same day. If you are unable to reach us and feel that you can't wait for us to return your call, go to the nearest hospital emergency room and ask for the mental health worker on call. 

Professional Records 

The laws and standards of my profession require that we keep treatment records. These records are kept in locked files. Before others can see these records, you must sign a written Release of Information form. You are entitled to review a copy of your records unless We believe that seeing them would be emotionally damaging, in which case we will send them to a mental health professional of your choice. Because these are professional records, they can be misinterpreted and/or upsetting to untrained readers. We recommend that you review them in my presence so that we can discuss the contents. Clients will be charged an appropriate fee for any time spent preparing information requests. In most circumstances, we are also allowed to charge a copying fee of $.25 per page. 

Limits on Confidentiality
The law protects the privacy of all communications between a client and a therapist. In most situations, we can only release information about your treatment to others if you sign a written Release of Information form that meets certain legal requirements imposed by HIPAA. There are other situations that require only that you provide written, advance consent. Your signature on this Agreement provides consent for those activities, as follows: (1) We may occasionally find it helpful to consult other mental health professionals about a case. During a consultation, we make every effort to avoid revealing the identity of my patient. The other professionals are also legally bound to keep the information confidential. If you don't object, we will not tell you about these consultations unless we feel that it is important to our work together. We will note all consultations in your Clinical Record which is called "PHI" in my Notice of Therapist's Policies and Practices to protect the Privacy of Your Health Information; (2) Disclosures required by health insurers or to collect overdue fees are discussed elsewhere in this Agreement; (3) If we believe that a patient represents an imminent danger to his/her health or safety, We may be obligated to seek hospitalization for him/her, or to contact family members or others who can help provide protection. 

There are some situations where we are required to disclose information without either your consent or authorization: (1) If you are involved in a court proceeding and a request is made for information concerning the professional services that we provided you, such information is protected by the therapist-patient privilege law. We cannot provide any information without your written authorization, with exception of a court order from a superior judge. If you are involved in or contemplating litigation, you should consult with your attorney to determine whether a court would be likely order our agency to disclose information; (2) If a government agency is requesting the information for health oversight activities, we may be required to provide it for them; (3) If a patient files a complaint or lawsuit against me, we may disclose relevant information regarding the patient to defend ourselves; (4) If a patient files a worker's compensation claim, and my services are being compensated through worker's compensation benefits, we must, upon appropriate request, provide a copy of the patient's record to the patient's employer or the North Carolina Industrial Commission. 

There are some situations in which we are legally obligated to take actions which we believe are necessary to attempt to protect others from harm, and we may have to reveal some information about the patient's treatment. These situations are unusual in our practice: (1) If we have cause to suspect that a child under 18 is abused or neglected, or if we have reasonable cause to believe that a disabled adult is in need of protective services, the law requires that we file a report with the County Director of Social Services. Once such a report is filed, we may be required to provide additional information; (2) If we believe that a patient presents an imminent danger to the health or safety to self and of another person(s), We are required to disclose information in order to take protective actions, including: initiating hospitalization, warning the potential victim, and/or calling the police. 

If such a situation arises, we will make every effort to fully discuss it with you before taking any action, and we will limit my disclosure to what is necessary. While this written summary of exceptions to confidentiality should prove helpful in informing you about potential problems, it is important that we discuss any questions or concerns that you may have, now or in the future. The laws governing confidentiality can be quite complex, and we are not attorneys. In situations where specific advice is required, formal legal advice may be needed. 

Dual Relationships

This is a therapeutic relationship. Counselors do not engage in dual relationships with clients. This includes business relationships and social relationships-in person or online. This general guideline is in accordance with confidentiality standards and helps avoid unwanted social introductions and/or breaches of privacy. 

Social Networking 

We will not directly solicit or accept friendship or other requests via social media platforms. We take this measure to safeguard your confidentiality.

Patient Rights
HIPAA provides you with several new or expanded rights with regard to your Clinical Records and disclosures of protected health information. These rights include: requesting that we amend your record; requesting restrictions on what information from your Clinical Record is disclosed to others; requesting an accounting of most disclosures of protected health information that you have neither consented to nor authorized; determining the location to which protected information disclosures are sent; having any complaints you make about my policies and procedures recorded in your records; and, the right to a paper copy of this Agreement, the attached Notice form, and my privacy policies and procedures.

Billing & Payments 

You will be expected to pay for each session at the time it is held, unless we agree otherwise or unless you have insurance coverage that requires another arrangement. We accept debit or credit cards, and payments can be made via cash or check. There is a $25 fee for each returned check, as well as any bank fees incurred. Payment schedules for other professional services will be agreed to when they are requested. If your account has not been paid for more than 60 days and arrangements for payment have not been agreed upon, we have the option of using legal means to secure the payment. This may involve hiring a collection agency or going through small claims court, which will require me to disclose otherwise confidential information. In most collection situations, the only information we release regarding a patient's treatment is his/her name, the nature of services provided, and the amount due. If such legal action is necessary, its costs will be included in the claim.

Insurance Reimbursement 

In order for us to set realistic treatment goals and priorities, it is important to evaluate what resources you have available to pay for your treatment. If you to use your health insurance policy, it will usually provide some coverage for mental health treatment. You-not your insurance company-are responsible for full payment of our fees. It is important that you find out exactly what mental health services your policy covers. Call the customer service number on the back of your insurance card and discuss benefits and out-of-pocket costs with your plan administrator. 

Due to the rising costs of health care, insurance benefits have increasingly become more complex. It is sometimes difficult to determine exactly how much mental health coverage is available. "Managed Health Care" plans such as HMO's and PPO's often require preauthorization before they provide reimbursement for mental health services. These plans are often limited to short-term treatment approaches designed to work out specific problems that interfere with a person's usual level of functioning. It may be necessary to seek approval for more therapy after a certain number of sessions. While much can be accomplished in short term therapy, some patients feel that they need more services after insurance benefits end. 

ATTENTION: You should also be aware that your contract with your health insurance company requires that we provide personal/confidential information relevant to the services that we provide to you to include a clinical diagnosis and additional clinical information such as treatment plans and progress notes or even copies of your entire Clinical Record. This information will become part of your permanent health record and insurance company files and will probably be stored in a computer. Though all insurance companies claim to keep such information confidential, we have no control over what they do with it once it is in their hands. In some cases, they may share the information with a national medical information databank. By signing this Agreement and using your health insurance, you agree that we can provide requested information to your carrier.

Once we have all of the information about your insurance coverage, we will discuss what we can expect to accomplish with the benefits that are available and what will happen if they run out before you feel ready to end our sessions. It is important to remember that you always have the right to private pay for our services and avoid the problems described above and have upmost privacy and confidentiality.

Agreement to Participate in Services

If you have any questions, please feel free to discuss them before signing this form. Your signature below indicates that you have read this Agreement, that you agree to abide by its terms during our professional relationship, and that you acknowledge that you have received the HIPAA Notice form described above. 

Our practice recommends private pay fee for service. Fee for service requires no diagnosis, gives you total confidentiality, and allows you to determine the type, length, and content of your treatment. It is a great benefit for you to approach this as a valuable professional service for you and your family.  Clinical Hour 53-55 Minutes $77.00

MISSED APPOINTMENT FEE: Patients will be expected to pay for their session when not cancelled at least 24 hours in advance and will be charged to your card on file.

Payment:

At the time of your appointment, you may pay for your session (e.g., co-pay, co-insurance, or full session fee) with a credit card, debit card. We do not offer any scholarship or sliding scale services.

The benefits of paying out-of-pocket:

Depth -Mental health issues are often complex and based on multiple underlying causes. Brief, symptom-focused treatments do not usually address these underlying issues, leaving patients vulnerable to relapse after treatment has ended.  When you private-pay for therapy, the duration of treatment is dictated by your individual needs. You and your therapist are free to explore and work through any underlying causes, making symptoms less likely to return after therapy has ended.

Quality of the Relationship - How much do you trust someone after only knowing them for five or ten hours? Typically, not very much. Learning to trust someone enough to let them in takes time. Therapists have long known, and volumes have been written about navigating the early trust-building phase of therapy so that the often more impactful later phases of treatment can be reached. This is where lasting change is often achieved. When you pay out-of-pocket, you give both you and your therapist a chance to build the trust that will be so vital in helping you to work through difficult issues that may lie further down the road.

Increased Value - Like anything in life, therapy has more emotional and psychological value when it requires some level of sacrifice to obtain. Budgeting and paying for therapy out of one's own pocket makes the relationship more significant. It carries more weight because of the patient's personal investment in the process.  Moreover, paying privately adds dimensionality to the treatment. Issues of affordability, sustainability, and worth must be negotiated and addressed - providing rich opportunity to explore self-worth, trust, dependency, and many other facets of a person's relationship with themselves and others that might otherwise get overlooked. Negotiating and working through the practicalities and psychological dimensions of payment and cost can significantly increase the depth and effectiveness of therapy.

HIPAA NOTICE OF PRIVACY PRACTICES

As required by the Privacy Regulations Promulgated Pursuant to the Health Insurance Portability and Accountability Act of 1996 (HIPAA) 

THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY. 

This Notice of Privacy Practices describes how we may use and disclose your protected health information (PHI) to carry out treatment, payment or health care operations (TPO) and for other purposes that are permitted or required by law. It also describes your rights to access and control your protected health information. "Protected health information" is information about you, including demographic information, that may identify you and that relates to your past, present or future physical or mental health or condition and related health care services. 

Uses and Disclosures of Protected Health Information: Your protected health information may be used and disclosed by our organization, our office staff and others outside of our office that are involved in your care and treatment for the purpose of providing health care services to you, to pay your health care bills, to support the operation of the organization, and any other use required by law. 

Treatment: We will use and disclose your protected health information to provide, coordinate, or manage your health care and any related services. This includes the coordination or management of your health care with a third party. For example, we would disclose your protected health information, as necessary, to a home health agency that provides care to you. For example, your protected health information may be provided to a healthcare provider to whom you have been referred to ensure that the provider has the necessary information to diagnose or treat you. 

Payment: Your protected health information will be used, as needed, to obtain payment for your health care services. For example, coverage may require that your relevant protected health information be disclosed to the health plan to obtain approval for coverage. 

We may use or disclose your protected health information in the following situations without your authorization: as Required By Law, Public Health issues as required by law, Communicable Diseases, Health Oversight, Abuse or Neglect, Food and Drug Administration requirements, Legal Proceedings, Law Enforcement, Criminal Activity, Inmates, Military Activity, National Security, and Workers' Compensation. 

Other Permitted and Required Uses and Disclosures Will Be Made Only with Your Consent, Authorization or Opportunity to Object, unless required by law. 

You may revoke this authorization, at any time, in writing, except to the extent that your physician or this organization has taken an action in reliance on the use or disclosure indicated in the authorization. 

Your Rights: Following is a statement of your rights with respect to your protected health information. 

You have the right to inspect and copy your protected health information. Under federal law, however, you may not inspect or copy the following records; psychotherapy notes; information compiled in reasonable anticipation of, or use in, a civil, criminal, or administrative action or proceeding, and protected health information that is subject to law that prohibits access to protected health information. 

You have the right to request a restriction of your protected health information. This means you may ask us not to use or disclose any part of your protected health information for the purposes of treatment, payment or healthcare operations. You may also request that any part of your protected health information not be disclosed to family members or friends who may be involved in your care or for notification purposes as described in this Notice of Privacy Practices. Your request must state the specific restriction requested and to whom you want the restriction to apply. 

Our organization is not required to agree to a restriction that you may request. If our organization believes it is in your best interest to permit use and disclosure of your protected health information, your protected health information will not be restricted. You then have the right to use another Healthcare Professional. 

You have the right to request to receive confidential communications from us by alternative means or at an alternative location. You have the right to obtain a paper copy of this notice from us, upon request, even if you have agreed to accept this notice alternatively, e.g., electronically. 

You may have the right to have our organization amend your protected health information. If we deny your request for amendment, you have the right to file a statement of disagreement with us and we may prepare a rebuttal to your statement and will provide you with a copy of any such rebuttal. 

You have the right to receive an accounting of certain disclosures we have made, if any, of your protected health information. 

We reserve the right to change the terms of this notice and will inform you by mail of any changes. You then have the right to object or withdraw as provided in this notice. 

Complaints: You may complain to us or to the North Carolina Board of Licensed Professional Counselors if you believe your privacy rights have been violated by us. You may file a complaint with us by notifying our privacy contact of your complaint. We will not retaliate against you for filing a complaint. 

We are required by law to maintain the privacy of, and provide individuals with, this notice of our legal duties and privacy practices with respect to protected health information, if you have any questions concerning or objections to this form, please ask to speak with our President in person or by phone at 910-777-1189. 

Associated companies with whom we may do business, such as an answering service, billing and accounting services  are given only enough information to provide the necessary service to you. No medical information is provided. 

We welcome your comments: Please feel free to call us if you have any questions about how we protect your privacy. Our goal is always to provide you with the highest quality services.