Diana Muschiol – Professional Disclosure Statement and Service Contract

Fee Changes

Appointment gaps five (5) weeks or more may be subject to any fee change Diana has had. You will always be informed in advance.

Billing

If at any time the payment card on your account is not able to process your fee, our billing department will send an email requesting that you contact us by phone with an updated card. Future sessions may be paused until your account is current.

Our Philosophy on Attendance

We view therapy as a process of developing a sense of awareness about oneself and how our actions impact others, especially those we love. People who are willing to make therapy a priority tend to experience greater growth and quicker positive change. Therapy tends to be most helpful to people who view their appointments as an important and valuable component of their lives.

For individuals and for couples in particular, we have learned that consistency matters more than frequency. To get traction and favorable momentum toward change, we encourage clients to schedule the first 6-10 appointments as close together as calendars and budgets allow. Then space out the appointments as determined with your therapist, i.e. every 2 weeks or 3 weeks. Occasionally, long-term clients like to schedule ‘tune-up’ sessions every other month or even quarterly as a preventative measure.

At Wellness we have a 48-Hr Cancellation and reschedule policy designed to protect and respect both the client and the clinician’s time.

Please read the following carefully:

48-Hour Cancellation / Reschedule Policy

Once you schedule an appointment, it belongs to you and a full 48-hour advance notice is required for any cancellation or reschedule. Without 48 hours’ notice, the full fee will be charged unless a life-threatening emergency is involved.

Maintaining a Consistent Therapeutic Relationship

In our therapeutic model, consistency matters more than frequency. Therefore, we invite you to consider what works best for you and your current lifestyle. Outside the 48-Hour mark cancellations and rescheduled appointments are acceptable. However, if a client cancels or reschedules three (3) or more appointments in one calendar year, Wellness reserves the right to pause therapy, evaluate and: a) place the client on waitlist for future sessions or b) refer out with proper referrals provided. Should you experience work or lifestyle changes, please bring this to Diana’s attention or our Client Liaison. If you have any questions, please bring this up during your initial consultation.

One Person Can’t Make It

In the event one partner cannot attend an appointment, the other partner may attend individually. All efforts will be made to keep things even and we will offer the other partner an individual session before continuing as a couple.

Telehealth

In some cases, depending on the therapist, when in-office sessions are not possible, Telehealth services can be arranged as an alternative.

Late Arrivals

If you arrive late for your appointment, the session will still end at the scheduled time. The full fee will be charged regardless of the length of the session.

No-Shows

If you fail to attend your scheduled appointment without any notice, you will be charged the full fee for the missed session. Repeated no-shows may result in termination of services.

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 closed, we are likely to be closed too. Typically, you will hear from Diana directly or you may call the phone number on the Wellness website for an update. In some cases, Telehealth services may be available as an alternative.

Confidentiality & Special Concerns

The 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 danger to self or other
• 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, 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. Diana will not hold secrets and will always endeavor to facilitate 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, Diana will not testify on behalf or against either party.

In the unlikely event of Diana’s leave 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 delivering 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 without written consent. I also understand 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. In some cases, Telehealth services can also be used in the event of inclement weather.

Other Professional Services

These are provided at Diana’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 Diana 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, Diana’s fee is $750 per hour for preparation and attendance at any legal proceeding.

Telephone

If you need to contact Diana in between sessions, please leave a message and she will return your call within 24 hours. In the event of a life-threatening emergency, contact 911 immediately. An emergency is considered danger to self or others or catastrophic loss. Non-emergency calls about issues other than cancellation or scheduling will be considered billable.

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 community, you will be receiving this information, and you may unsubscribe at any time.

Suitability

If at any time Diana has concerns that the treatment provided to you is not helpful, or that she is no longer a suitable provider for you, Diana 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 Diana 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 their 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.