Professional Disclosure Statement and Service Contract for 2½-Day Intensive Session – Nicole Kelly

Overview and Description of Services

Nicole Kelly is a Licensed Marriage & Family Therapist in the state of North Carolina. Nicole sees individuals, couples and families and specializes in working with distressed couples primarily from the (EFT) Emotion Focused Therapy perspective. EFT recognizes that partners get caught in repetitive negative patterns creating negative emotional experiences like anger, sadness, isolation and loneliness. Working as a consultant to the couple she helps partners identify the negative patterns and the emotions generated by them. The goal is to help partners create a strong, healthy connection. Other theoretical approaches may be utilized as deemed appropriate. Appropriate referrals will be given to clients whose need exceeds the scope of Nicole’s therapeutic training.

2½-Day Intensive, Payment Method, Cancellation, Travel, and Follow-up

• The 2½-Day Intensive is offered at Wellness Counseling Center in Charlotte, NC and generally begins on Thursday morning and concludes on Saturday morning unless other arrangements are made. It works best if each person is completely unplugged from home and work demands. Nicole requests mobile devices be turned off during the day while you work.
• The fee is $5250.
• For all Intensives, half (50%) of the fee is due when you reserve the date and is non-refundable. The remaining balance (50%) is due 10 days before the Intensive begins. If for any reason you decide to cancel 11 days or more before your Intensive begins, your remaining balance will not be processed. If, however, you decide to reschedule at the 11-day mark or prior, your remaining balance will be processed according to the terms of the originally scheduled date.
• If you cancel 10 days or less before the originally scheduled start date, your entire payment may be applied to a single rescheduled Intensive date. Please know, the re-scheduled Intensive must be completed within 90 days from the original scheduled date.
• Couples are responsible for their travel arrangements, hotel accommodations, car rental and evening meals, as well as any entertainment or recreational expenses i.e., golf or spa treatments. If you need hotel suggestions, please let us know. There are several nearby hotels to choose from.
• We suggest you think ahead by considering travel insurance or refundable tickets / reservations when booking your hotel and transportation. Life can get complicated and while reschedules and cancellations are rare occurrences, they can happen.
• If you need to contact Nicole, please email her at . In the event of a life-threatening emergency (considered danger to self or others or catastrophic loss), contact 911 immediately then contact Nicole.
• Insurance reimbursement does not apply to the 2½-Day Intensive. It is the client’s re-sponsibility to determine coverage. Visa, MC, AMEX, Discover, check and cash are acceptable forms of payment. A $25 fee is assessed for each declined credit/debit card or returned check.
• After the intensive, couples benefit from on-going follow-up sessions lasting 80-minutes or additional Intensive work. The fee for on-going sessions is $325 and time overage is prorated in 10-minute intervals. Intensives are offered in ½-Day and 1-Day events.

Inclement Weather

In the event of potentially dangerous weather (i.e. snow or tornado warnings), Wellness Counseling Center follows community standards with everyone’s safety in mind. If schools are closing, we are likely to be closed too. Typically, you will hear from Nicole directly or you may call the phone number on the Wellness website for an update. Tele-Health services may also be arranged as an alternative in the event of inclement weather.

Confidentiality & Special Concerns

Information disclosed in session is confidential and may not be disclosed to anyone without written permission from you, the client.

The law requires the following exceptions to client confidentiality:

• Suspicion or evidence of child or elder abuse
• Reasonable suspicion that the client presents a danger to self or others
• Court order
• In the case of a medical emergency, a client’s personal information may be provided to medical personnel.

Please be advised, if you use/file insurance claims for follow-up sessions, therapeutic notes contain diagnosis and become part of the client record in perpetuity. Also, please note that confidentiality cannot be guaranteed in groups. In working with couples and families, free flow of information is imperative. Nicole does not hold secrets and will always endeavor to facili-tate difficult conversations between parties. She will always work with you to help you achieve your goals yet cannot make any outcome guarantees. She will always assume (if applicable) both partners love their children and want the best for them. For that reason, please know, Nicole will not testify on behalf or against either party.

In the unlikely event of Nicole’s leaving or departure from Wellness Counseling Center, you will be offered the opportunity to work with another Wellness therapist or provided referrals to appropriately credentialed professionals according to your needs.

TeleHealth Consent

I understand that Wellness uses HIPAA compliant TeleHealth technology as part of deliver-ing therapeutic services and I have the right to use or refuse this service. The privacy laws that apply to protecting confidentiality and exceptions to confidentiality are the same as in-office therapeutic services. There shall be no recording of sessions by either party. I also un-derstand that we may encounter technical difficulties resulting in service interruptions. If this occurs and we are unable to reconnect within ten (10) minutes, we will connect via phone and discuss whether to continue the session or re-schedule. TeleHealth services can also be used in the event of inclement weather.

Other Professional Services

These are provided at Nicole’s standard hourly rate and prorated in 10-minute intervals. Such services may include but are not limited to: non-legal report writing, preparation of records or summaries, attendance at meetings you have authorized and phone conversations unrelated to scheduling an appointment. Please know that in the unusual event of legal proceedings, Nicole will only participate if ordered by the court and you will be expected to pay for her professional services, even if she is called to testify by another party. Legal proceedings are challenging and complex. As such, Nicole’s fee is $750 per hour for preparation and attendance at any le-gal proceeding.

eNewsletter

Periodically, Wellness Counseling Center distributes an eNewsletter via email containing relationship tips, ideas, and updates that may be helpful to you. As a client and member of the Wellness family, you will be receiving this information, and you may unsubscribe at any time.

Suitability

If at any time Nicole has concerns that the treatment provided to you is not helpful, or that she is no longer a suitable provider for you, Nicole will address those concerns with you. Likewise, if you have such concerns, you are encouraged to share them with her. Ultimately, if either you or Nicole continue to have concerns about whether on-going treatment makes sense, treatment may be terminated with proper referrals provided.

Resolving Complaints

On occasion, clients have concerns and complaints and are urged to bring them to the therapist’s attention immediately. If together you cannot resolve your concern, you may contact Anne Hancock, Psy.D. at 704-319-5593. To learn more about your rights as a client, or if you feel that you have been treated unfairly or unethically and would like to register a complaint, you may contact the North Carolina Marriage and Family Therapy Licensure Board at 919-469-8081.

Special Reminders

A $25 fee is assessed for each declined credit/debit card or returned check.

This Agreement sets forth the entire agreement and understanding of the parties relating to the delivery of services and subject matter above.

I have read these office policies and guidelines.

I have reviewed the Privacy Policy.

I have had the opportunity to ask questions.

I have had my questions answered and I understand them to the best of my ability.