Right to Receive a Good Faith Estimate
Federal Law requires as of January 1, 2022 that I provide you with this information.
You have the right to receive a “Good Faith Estimate” explaining how much your medical care will cost. Under the law, health care providers need to give patients who don’t have insurance or who are not using insurance an estimate of the bill for medical items and services. You have the right to receive a Good Faith Estimate for the total expected cost of any non-emergency items or services. This includes related costs like medical tests, prescription drugs, equipment, and hospital fees. Make sure your health care provider gives you a Good Faith Estimate in writing at least 1 business day before your medical service or item. You can also ask your health care provider, and any other provider you choose, for a Good Faith Estimate before you schedule an item or service. If you receive a bill that is at least $400 more than your Good Faith Estimate, you can dispute the bill. Make sure to save a copy or picture of your Good Faith Estimate. For questions or more information about your right to a Good Faith Estimate, visit www.cms.gov/nosurprises or call me at 980-253-9841.
Informed Consent for Telemental Health Counseling
I consent to engaging in telehealth counseling (counseling through the medium of electronic devices). I understand that telehealth counseling includes therapy/counseling, diagnosis and treatment, and transfer of personal medical and mental health data via audio and video or data communication. The laws that protect the confidentiality of my medical information also apply to telehealth counseling. This includes all policies which you reviewed and signed in the original disclosure/consent paperwork at the onset of treatment.
• I understand that there are risks from distance counseling include, but are not limited to, the possibility (despite my therapist’s efforts of using a HIPAA compliant service) that: sessions could be disrupted or distorted by technical issues, and the transmission of my medical information could be intercepted by unauthorized persons.
• I understand that I am responsible for the confidentiality and privacy of my own environment. While convenience is a benefit of using mobile devices for telehealth counseling, it is important to find a confidential environment and use a private, secure wifi connection wherever I am located.
• I understand that Telemental health services may feel different than face-to-face therapy and may not be appropriate for everyone. If my counselor believes I would be better served by another form of psychotherapeutic service (e.g. in-person), I will be referred to someone who can accommodate this service. My counselor and I will keep in communication about how distance counseling is going and modify as need.
• In emergencies, in the event of disruption of service, my therapist may communicate with me by phone or secure messaging in the client portal. I understand that SMS text messaging (e.g., through my cellular provider) and non-encrypted email are not secure and should not be used to convey protected health information.
• Location information should be provided to my counselor if I am not at home in case there is an emergency.
• If I am facing an emergency situation that could result in harm to me or to another person; I am not to wait for a telehealth counseling session. Instead, I agree to seek care immediately through a local health care counselor or at the nearest hospital emergency department or by calling 911.
Professional Disclosure Statement
* Master of Arts in marriage and Family Therapy from Indiana Wesleyan University (Dec 2002) * Licensed Clinical Mental Health Counselor in North Carolina, License #6477 * National Certified Counselor, #76731 * Licensed Professional Counselor in Pennsylvania, License #PC004299 (inactive status)
Experience and Counseling Approach
* Counseling professionally since 2003, following the completion of graduate school. * Clientele: Individuals, couples, and families of all ages, children through elderly. Also: groups, classes, and workshops. * Therapeutic Issues: I am experienced in counseling areas such as, but not limited to, depression/mood, anxiety, trauma, sexual abuse, grief/loss, relationship problems, identity issues, career guidance, personality issues, and adjustment. * Therapeutic Approach: I use the approach to counseling I believe will work best with the client’s situation and needs. My varied approach includes, yet is not completely limited to: Gestalt Emotion Focused Therapy Family systems Experiential Cognitive-behavioral Pyschoeducational Psychodynamic EMDR
I consider the whole person body, mind, and spirit, in the counseling process. I offer counseling from a Christian perspective, however, it is up to you how much we include spirituality in your counseling process. My approach includes processing thoughts, emotions, and behaviors. I also use expressive/experiential therapies such as art, music, writing, and play.
Nature of Counseling
Session Length: 45-52 minutes. The first session, family sessions, or emergency sessions, groups, workshops, or classes may be longer. Occasionally I may do a 30 minute session as needed.
Counseling Process: Counseling works best when you are actively involved in the changing process both in and out of sessions. Sometimes change may come quickly and smoothly through acquiring a new perspective; however, usually counseling is a slow, gradual process and can include times of struggle as well as times of significant growth. Achieving your desired goals in counseling may also be aided by activities outside of session, such as reading, exercises, writing, or other projects which I may encourage in the counseling process.
Professional Limits, Ethics, and Confidentiality
It is important that we maintain professional relationship, so while our sessions may be very connecting, our sessions will concentrate on your concerns and remain professional in nature. Examples of professional limits: * I will make referrals to other counselors or professionals for situations outside of my treatment limits * Avoid texting * Avoid social networking with past/current clients * I do not approach clients in public
I regard the information you share with me (our conversations and my records) with respect to your confidentiality. My permanent records include, but are not limited to, session notes, correspondence, and diagnostic impressions. Diagnoses may change over time as new information is gathered or as change occurs in the individual. The records are protected by state law and counseling ethics in most circumstances. However, legally and ethically, confidentiality is limited in the following circumstances:
* When there is reason to believe there is intent to harm yourself or another person * There is reason to believe there is abuse or neglect of a child or elder adult reportable by law * When ordered by a judge to release information * Requested information by an insurance company or collections agency for services rendered * At times, a case may be brought up in consulting with other professionals to ensure quality counseling services. This is done with regard to ethical and legal standards of professional conduct.
Outside of these exceptions, our relationship is completely confidential.
Telehealth sessions are conducted on a HIPAA-compliant platform via video. There are many benefits to the use of telehealth technology for our sessions, such as convenience, comfort of your own space, flexibility of location and schedule. Telehealth also brings unique challenges, such as technology failures, online security, and video quality making it difficult to see visual cues and hear voice intonations correctly, and misunderstandings because of these issues. When technology fails, we troubleshoot in the moment and may need to switch platforms or devices during session if problems persist. To prevent some of the challenges, it helps to make sure there is a strong internet signal, adequate lighting, a private and comfortable environment protected from distractions. Specific information and instructions are in the Telemental Health Consent form. Also, if you are submitting out-of-network to insurance, it is important that you check with your insurance company about reimbursement for telehealth sessions.
Legal Use of Client Records
Situations may be presented in which a client’s counseling records may seem helpful in a legal case (i.e. custody, divorce, or other legal proceedings). I believe counseling should remain a safe place to express yourself. While I am an advocate in terms of your mental, emotional, relational, and spiritual well-being through the counseling process, my role is neutral in the courtroom.
Legal involvement can jeopardize your security in counseling regarding confidentiality, the counseling process, and counseling relationship. It also confuses the role of the counselor. The legal process may be harmed as well, as what is said and done in counseling may be misconstrued or used against you. Any information you provide to a lawyer or court regarding your counseling can be used unfavorably. Fees will be assessed for any work done, letters, phone calls, or otherwise.
To obtain what is needed for court proceedings, a formal, objective evaluation done by a licensed provider specifically trained for these circumstances. The court, your lawyer, or I may refer you to a trained professional.
It is important that we maintain the role of the counseling for personal well-being, not for legal advocacy.
Fees and Payments
* Fees for standard services are expected at the time of service. Sessions are charged to the credit card on file at each session unless other arrangements are made. * A standard counseling hour is 45-52 minutes. Sometimes a 1.5 hour session is needed or desired, and I also offer intensive sessions (2+ hours) for deeper, more concentrated sessions. The standard fee for sessions is $130/hour. * Alternative payment agreements made are to be followed according to the agreement for services to continue. * Fees for additional services such as assessments, correspondence, or otherwise will be explained prior to the service being administered. Fees for legal situations are 1.5 times the standard rate. * Advanced notice is required for cancellations. Any appointment not cancelled by 24 hours before the appointment will incur a fee of $100 if cancelled late or not showing to appointment. * Adjustments may be made to the discretion of the therapist in some circumstances.
Insurance: Some insurance companies will reimburse for my services. If you wish to seek insurance reimbursement, I will provide the necessary completed forms for out-of-network reimbursement. It is the client's responsibility to contact the insurance company regarding reimbursement questions or concerns.
Dissatisfaction and Complaints
It is important to me to know what you are thinking and feeling about the counseling process as it progresses, so I can serve you to the best of my ability. If you are dissatisfied with any aspect of our work, I want to know so we can discuss how to resolve the situation and make appropriate adjustments.
If you feel you have been treated unethically and we are not able to resolve the problem, you may contact the Board for clarification of client’s rights or to make a formal complaint:
North Carolina Board of Licensed Clinical Mental Health Counselors (NCBLCMHC) P.O. Box 77819 Greensboro, NC 27417 844-642-3572
If you have any questions regarding this document or related issues, please ask. You may have a copy for your records.