LCMHC Professional Disclosure Statement

Office: 336-818-0733 Fax: 336-818-0734

This is a statement of your rights and responsibilities for our therapeutic relationship. This document is part of the Standards of Practice of the North Carolina Board of Licensed Clinical Mental Health Counselors as stated in Section 90-343 of the NCBLCMHC Act. The Disclosure Statement is designed to inform you of my professional credentials, types of services offered, fee schedule, and therapeutic orientation and style. Please let me know if you have any questions or concerns about this disclosure statement. You may revoke this agreement in writing at any time.

Client's Rights and Responsibilities As a client, you have the right to choose a counselor/therapist who best suits your needs and purposes. Please be advised that you may ask questions about treatment at any time, and you may also choose to terminate/end therapy at any time by way of a written statement.

I am a Licensed Clinical Mental Health Counselor and a licensed School Counselor for North Carolina. I am currently licensed as a Licensed Clinical Mental Health Counselor (LCMHC) in North Carolina through the North Carolina Board of Licensed Clinical Mental Health Counselors. I am currently employed with Jodi Province Counseling Services LLC. Mrs. Jodi Province can be reached by phone (336-818-0733) or email (jodi.province@gmail.com)

My Qualifications and Education

I received my Master of Arts degree in the area of Psychological Counseling/Agency Counseling from Gardner-Webb University in August of 2000. I am a member of the Psi Chi-National Honor Society in Psychology. I have been a licensed North Carolina School Counselor for over 20 years. In early 2002-2004 I was a Psychology Instructor at Surry Community College. I also have a Bachelor's in Social Work from Appalachian State University.

Counseling Background

As a school counselor, I have over 20 years' experience working with families, children and adolescents, ranging from four- to eighteen-year-olds. I have served students from a variety of socio-economic, ethnic, cultural and religious backgrounds and understand that each person has a unique experience to be considered when providing counseling services. The range of issues presented during my years as a counselor include, but are not limited to, behavior problems (at home and school), physical and sexual abuse, general anxiety, separation anxiety, grief, self-harm, suicidal ideation, divorce, and development of social skills. It is my practice to work closely with parents to help children develop healthy, functional relationships within their family and at school, according to their cultural background.

I have also worked with young adults in the area of career development, college counseling and advising and general mental health issues such as anxiety and depression. My primary theoretical orientation is Cognitive-Behavior Therapy, but I also use Reality, Client Centered, and Solution-Focused Brief Therapy when they are appropriate. These approaches focus on the present, and generally have a problem-solving approach. I also use a strength-based approach which empowers the client to set their own goals and make their own decisions about what is the best solution for any issues. I believe that all clients can reach solutions and achieve goals, with the counselor acting as a guide in the therapeutic relationship.

In the sessions, we often develop short- and long-term goals, and work with those in mind. Occasionally, I will ask that you attempt any homework that I may suggest and discuss your experiences completing those tasks in our following sessions. Often clients that contribute to their therapy by sharing honestly and working in and outside of our sessions will see growth and completion of goals.

Session Fees and Length of Service:

Cash, Check or Credit Card. Your first session will last approximately one hour. Each subsequent session will last between 30 and 60 minutes with the fees ranging between $125-$210. The fees/co-pay are due upon service. All clients are responsible for copayments and coinsurance payments.

Third Party Payers

: As a courtesy we will bill your insurance company, HMO, responsible party or third-party payer for you if requested. We ask that at each session you pay your co-pay. In the event you have not met your deductible, the full fee is due at each session until the deductible is satisfied. If your insurance company denies payment or does not cover counseling, we request that you pay the balance due.

Cancellations:

It is expected that your session will begin at the agreed upon time. Any session that begins after this time due to late arrival (for any reason) cannot be extended beyond the agreed finish time. Please provide 24 hours' notice should you need to cancel or reschedule an appointment. Frequent missed appointments will lead to additional charges that will not be covered by your insurance company or other third-party payers. Three missed appointments without prior notice can result in the termination of service (at the discretion of the counselor

Use of Diagnosis:

Some health insurance companies will reimburse clients for counseling services and some will not. In addition, most will require a diagnosis of a mental-health condition and indicate that you must have an "illness" before they will agree to reimburse you. Some conditions for which people seek counseling do not qualify for reimbursement. If a qualifying diagnosis is appropriate in your case, I will inform you of the diagnosis before we submit the diagnosis to the health insurance company. Any diagnosis made will become part of your permanent insurance records.

Confidentiality:

All communication becomes a part of the clinical record, which is accessible to you upon request. Your verbal communication and clinical records are strictly confidential. You should be aware, however, that legal and ethical requirements specify certain conditions in which it may be necessary for me to discuss certain information about your treatment with other professionals. If you have any questions about these limitations, please ask me about them before we begin our sessions.

Confidentiality will be limited if/when:

Information (diagnosis and dates of service) is shared with your insurance company to process your claims, You and/or your child(ren) report physical or sexual abuse; then, by North Carolina State Law, your counselor is obligated to report this to the Department of Social Services, You sign a release of information to have specific information shared, You provide information that informs your counselor that you are in danger or harming yourself or others, Information necessary for case supervision or consultation, or required by a court order.

Complaints:

Although clients are encouraged to discuss any concerns with me, you may file a complaint against me with the organization below should you feel I am in violation of any of the ACA Code of Ethics which I abide by.

North Carolina Board of Licensed Clinical Mental Health Counselors

P.O. Box 77819 Greensboro, NC 27417

Phone: 844-622-3572 or 336-217-6007 Fax: 336-217-9450

E-mail: Complaints@ncblcmhc.org

Acceptance of Terms I (we) agree to these terms and will abide by these guidelines. Client/Guardian Signature & Date Therapist Signature & Date