Sliding Scale/Fee Adjustments - To qualify for a reduced rate, you must show proof of annual income for all immediate family members living in your household. Applicants should provide a copy of any accepted income verification materials (i.e., recent federal tax return, IRS Form W-2 or 1099, or two current pay stubs. I reserve the right to periodically adjust my fees and withdraw this benefit at any time and you will be informed in advance of such a decision.
Cancellation Policy - Appointments may be scheduled, rescheduled, or cancelled by phone or text. Except for emergency situations, you are required to give 24-hour notice to cancel or reschedule an appointment. Up to 2 missed appointments will be charged at $50.00 each ($20 for group therapy After 3 missed appointments I will bill the standard rate (i.e., $110, or $40 for group therapy I reserve the right to terminate our professional counseling relationship after three consecutive absences. Dire emergencies (i.e. hospitalization, accident, death in the family) are addressed on an individual basis. Since your insurance will not pay for any portion of a missed appointment. you will be responsible for the full cancellation fee.
Emergency Situations - If you are out of town, sick, or need additional support, phone sessions are available. I cannot guarantee 24/7 availability though. After office hours, you may leave a voicemail at (910)777-5575 (ext. 101) and I will return your call within 24 hours. During medical or life-threatening emergencies, including emotional or behavioral crises, please go to the nearest hospital emergency room or call/text 9-1-1. You can also call the New Hanover County crisis line at (877) 685-2415, dial the National Suicide Prevention Lifeline 24/7 at 1-800-273-TALK (8255) or text HOME to 741741 to connect with a crisis counselor through the crisis text line.
Confidentiality - I make it a priority to keep your confidentiality and privacy protected, except when:
(a) You sign a release form authorizing me to disclose information to a given person, agency, or institution,
(b) It is clear and present that you intend to do harm to yourself or somebody else,
(c) There is evidence or reasonable suspicion of abuse and/or neglect of someone related to you who is a minor child, elderly, or disabled adult,
(d) I receive a court order directing me to disclose information pertaining to your treatment.
Anyone else who needs access to your records will need your consent. Verbal authorization will not be sufficient, except in emergency situations. I cannot disclose any information outside the treatment context without a written authorization from each person competent to surrender this privilege. You may refuse to sign such a waiver, but this can potentially hurt your ability to received treatment or its outcome.
Use of Diagnoses - A diagnose is important for treatment planning, record keeping, and to indicate medical necessity as required by some insurance carriers to reimburse for services. If a qualifying DSM 5/ICD 10 diagnosis is indicated, it will become part of your permanent records with your health insurance company. I will inform you before submitting documents to your health insurance company or third parties. Please understand that some insurance plans do not cover behavioral health treatment and that certain conditions do not qualify for insurance reimbursement.
Satisfaction - It is impossible to guarantee any specific results regarding your treatment because the outcome depends on your work as well as mine. Together, however, we will work to achieve the best possible results. If you are unhappy with any aspect of your treatment, please let me know immediately.
Follow Up: I may conduct follow-up calls three to six months after your treatment ends or your involvement with the agency is discontinued. The purpose of these calls is to discuss whether the gains made during your treatment have been maintained or receive feedback regarding your experience with our agency. You can choose to opt out of these calls.
Termination - Both the length and intensity of your treatment will determine when it is appropriate to end our therapeutic relationship. Your progress and readiness to move away from therapy, as well as the effectiveness of treatment can facilitate this process. Situations where I notice lack of commitment or there is an unresolved conflict/impasse may prompt my decision to discontinue services. However, I will not do so without first discussing my decision with you and exploring possible solutions. I am able to provide you with a list of qualified therapists in the area that can potentially work with you.
Questions or Complaints - I encourage you to discuss any concerns with me personally. If you believe you have been treated unfairly or unethically in the therapy process and cannot resolve the problem with me, you may file a complaint against me to: The North Carolina Board of Licensed Clinical Mental Health Counselors. P.O. Box 77819, Greensboro, NC 2741. Telephone: 844-622-3572 or 336-217-6007Fax: 336-217-945Email: complaints@ncblcmhc.org
More information about the American Counseling Association Code of Ethics and my professional responsibilities can be found at www.counseling.org/Resources/aca-code-of-ethics.pdf.
Acceptance of Terms - By signing below you are agreeing to the terms and guidelines of this statement and acknowledging that you have been given an opportunity to discuss it prior to committing to treatment.