LCMHCA Professional Disclosure Statement Ashley Dyer MA, LCMHCA, LCAS, NCC Phone: 336-818-0733 Fax: 336-818-0734

Email: Ashley.Dyer.JPCS@gmail.com

Client 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 written statement.

My Qualifications

I received my Master's degree in Clinical Mental Health Counseling from Wake Forest University in May 2022. I earned my B.S. in Elementary Education from Appalachian State University in 2014. During my time as an educator, I taught first grade for one year and fourth grade for four years. I earned licensure in addiction counseling under criteria B from the North Carolina Addiction Specialist Professional Practice Board. Prior to obtaining my LCAS license, I completed the required supervised 6,000 hours to become a Certified Alcohol and Drug Counselor. Upon completing my master's program, I was eligible to apply for my unrestricted LCAS license. I currently hold a Professional Educator License and a provisional license as a Professional School Counselor.

Restricted Licensure and Supervision

I am a Licensed Clinical Mental Health Counselor Associate (LCMHCA: A17608) in North Carolina, and a National Certified Counselor (NCC: 1651381 I am supervised by Dr. Elizabeth Coleman EdD, LCMHCA, NCC, NBCT, she can be reached at 336-818-0733 or by email at rhyskohlman@gmail.com.

I hold an unrestricted license as a Licensed Clinical Addiction Specialist (LCAS-28752 I also hold Professional Educator License and a provisional Professional School Counselor license. (1185533).

Counseling Background

My professional experience includes four years of substance abuse counseling working with adults aged eighteen and up, two years in a private practice, and one year as a school counselor. Before my counseling career, I taught in elementary schools, where I filled an interim position teaching first grade following a retirement, and I taught fourth grade for four years. My eclectic counseling background has allowed me to work with individuals aged two to sixty-six, addressing issues including, but not limited to, behavior problems (at home and school), general anxiety, social anxiety, depression, development of social skills, suicidal ideation, addiction, life changes, and transitions. I have also worked with adolescent and adult members of the LGBTQ+ community.

I have served students and clients from various socio-economic, ethnic, cultural, and religious backgrounds, understanding that each person has unique experiences and challenges to consider when providing counseling services. In the therapeutic process, I work with parents to help children develop healthy, functional relationships within their family and at school, according to their cultural background.

My theoretical orientation is rooted in a person-centered approach, and I utilize a variety of theories and techniques, including motivational interviewing, solution-focused, and cognitive-behavioral methods. Other theories and modalities may be used as needed when appropriate for each client. My goal is to build a strong therapeutic relationship and create a safe and accepting environment where we can work towards the goals you establish. While we will attempt to work toward positive outcomes, there is the possibility that you may experience an increase in symptoms before improvement; however, there is no guarantee of positive outcomes in the counseling process.

Session Fees and Length of Services

Your first session will last approximately one hour. Each subsequent session will last between 45 and 60 minutes. The fees/co-pay is due upon service and can be discussed with our office manager.

The billable fee for an intake session is $210.00. A 45-minute session is $165.00, and a 60-minute session is $195.00. Self-pay clients should speak with office staff concerning rates. Any requested letter is $45.00, and FMLA paperwork is $25.00. Insurance companies do not reimburse for letters or FMLA paperwork. Appointments will be scheduled at mutually agreed-upon times. If you have any questions about billing or insurance, please contact the office. We accept cash, check, and credit card payments.

As a courtesy, we will bill your insurance company, HMO, responsible party, or third-party payer for you if requested. We ask that you pay your co-pay at each session. 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.

Cancellation

It is expected that your session will begin at the agreed-upon time. Any session that begins late 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 your 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 services (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 companies require that a diagnosis must be rendered if the client is going to be reimbursed. 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 it to the health insurance company. Any diagnosis made will become part of your permanent insurance records.

Confidentiality

All counseling services are provided in compliance with NC confidentiality laws, the NC Board of Licensed Professional Counselors, the ethical standards of the National Board of Certified Counselors, and the American Counseling Association. Everything discussed in counseling sessions is voluntary and confidential. Our communications become part of your clinical record, which may be accessible to you upon request. These records include, but are not limited to, contact records, case notes, diagnoses, and copies of all new client forms.

Limitations of Confidentiality The information you share is considered confidential and will not be shared with anyone outside of Jodi Province Counseling Services without your written consent, with the following exceptions:

Information (diagnosis and dates of service) is shared with your insurance company to process your claims.

- If 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 of harming yourself or others.

- Information necessary for supervision with a clinical supervisor. - Required by court order.

Please note that in sessions with multiple clients (e.g., couples, families, groups), confidentiality cannot be guaranteed.

In the event I see you in public, I will not acknowledge you unless you first acknowledge me in order to protect your confidentiality. Any public interactions should be kept to polite interactions and should not contain any information regarding your treatment.

Complaints I abide by the ACA Code of Ethics s(https://www.counseling.org/Resources/aca-code-of-ethics.pdfIf you are dissatisfied or concerned with any aspect of the counseling process, please inform me SO that we can address your concerns. You may also contact my supervisor, Elizabeth Coleman, at 336-818-0733 or rhyskohlman@gmail.com. If your concerns remain unresolved, you may file a complaint against me with the organization below if you feel I am in violation of any of these codes of ethics.

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

Email: Complaints@nbcLCMHC.org

Acceptance of Terms I (we) agree to these terms and will abide by these guidelines.