Professional Disclosure Statement and Service Agreement – 1-Day Intensive – Jennifer Holladay

Jennifer H. Holladay, MA
Licensed Marriage and Family Therapist, North Carolina License #1851
Wellness Counseling Center
309 S. Sharon Amity Rd. Suite 310, Charlotte, NC 28211


    I am licensed as a Marriage and Family Therapist in the state of North Carolina. I hold a Masters in Marriage and Family Therapy, issued in 2015 by the Pfeiffer University in Charlotte, NC. The program was accredited by the Commission on Accreditation for Marriage and Family Therapy Education (COAMFTE). My experience as a therapist began in 2013. I have worked with children and families under a Bachelor’s degree in Social Work since 1995. My experience includes working with individuals, couples and families in a variety of capacities including adolescence, parenting struggles, adoption transition, infidelity, couple distress, and family preservation. I have received full certification in Emotionally Focused Therapy.


    I envision our therapeutic relationship to be a collaborative effort. I will be invested in your personal growth and within the scope of my training I will provide guidance to our times together. Likewise, I expect you to be invested in your personal growth during and between sessions. In addition to talk therapy, you may engage in homework assignments, exercises, writing and other projects. Therapy has no guarantees, and there are no instant, painless, or passive cures. I will seek to provide you with support as you pursue your goals and work towards them. In order to best serve and protect you, our relationship will be professional rather than social in nature.

    I use an integrative approach, practicing primarily from a family-systems perspective, utilizing Emotionally Focused Couples Therapy. I will draw from other approaches when deemed appropriate. If your needs as a client exceed the scope of my therapist training, appropriate referrals will be provided.


    • The 1 Day Intensive is offered at the Wellness Counseling Center in Charlotte, NC and generally begins at 9 or 10 am and concludes between 4 and 5 pm unless other arrangements are made. It works best if each person is completely unplugged from home and work demands. I request mobile devices be turned off during the day while we work.
    • The fee is $2300; half of the fee is due when you reserve the date and the balance is due 24 hours before the Intensive begins. If, for any reason you decide to cancel, your deposit is fully refundable up to 10 days prior to the scheduled start date, less a $250 administrative fee. If you cancel less than 10 days prior to the scheduled start date, your deposit may be carried over and applied to a rescheduled time.
    • Couples who are visiting from out of town are responsible for travel arrangements, hotel accommodations, car rental and meals, as well as any entertainment or recreational expenses i.e., golf or spa treatments. If you need some hotel suggestions, please let us know. There are several nearby hotels to choose from.
    • After the intensive, most couples benefit from regular follow-up sessions. This can be arranged via telehealth (NC residents only), in person, or we will find a mutually agreed upon EFT certified couples’ therapist in your community. Follow up sessions with me last eight (80) minutes beginning on the hour and ending ten (10) minutes before the half hour unless other arrangements are made. The fee is $305 and time overage is prorated in ten (10) minute intervals.
    • Clients pay for follow-up sessions after each appointment and are encouraged to reserve appointments several sessions out, in order to ensure availability. Please note there may be the possibility of insurance reimbursement for follow-up sessions. Insurance reimbursement does not apply to the 1 Day Intensive. If you wish to file a claim for follow-up services I will provide a statement with appropriate procedure and diagnostic codes. Please note that any diagnosis communicated to an insurance company may become a part of your permanent record. It is the client’s responsibility to determine coverage. Visa, MC, AMEX, check and cash are acceptable forms of payment. Please note: A $25 fee is assessed for each declined credit/debit card or re-turned check.
    • If you need to contact me between sessions, please leave a voicemail or email and I will respond within 24 hours. If you contact me on the weekend I will respond on the next business day. Email is for scheduling and cancellation only and will not be retained as a part of your permanent record. If an emergency arises, state clearly in your message and I will respond as quickly as possible. In the event of a life-threatening emergency (considered danger to self or others or catastrophic loss), contact 911 immediately then contact me.


    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 ap-ply to protecting confidentiality and exceptions to confidentiality are the same as in-office thera-peutic services. There shall be no recording of sessions by either party. 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. TeleHealth services can also be used in the event of inclement weather.


    Once you schedule follow-up sessions the appointment belongs to you and a full 48 hours ad-vance notice is required for any cancellation or re-schedule. Without 48 hours’ notice, full fee will be charged unless the cancellation involves a life-threatening emergency. In the event of potentially dangerous weather (i.e. snow or tornado warnings) Wellness Counseling Center fol-lows community standards with everyone’s safety in mind. Typically, you will hear from me di-rectly or you may call the phone number on the Wellness website for an update. Telehealth Services may be used in the event of inclement weather and can be arranged as an alternative.

    Periodically, Wellness Counseling Center distributes an eNewsletter via email containing rela-tionship 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.


    These are provided at my 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 with other professionals (i.e. your physician) and phone conversations unrelated to scheduling an appointment. Please know that in the unusual event of legal proceedings I will only participate if ordered by the court and you will be expected to pay for my professional services, even if I am called to testify by another party. Legal proceedings are challenging and complex. As such, my fee is $900 per hour for preparation and attendance at any legal proceeding.


    I am honored that you have entrusted me with your information. Everything you share in sessions will be kept in the utmost confidence. This is to the extent that if we are to come into contact outside of the office, I will not acknowledge you unless you initiate first. I utilize both individual and group supervision in order to best serve you. The supervision team is also bound by the same confidentiality laws and ethical mandates. There are three situations in which I cannot guarantee confidentiality ethically or by law:

    1) If child or elderly abuse is suspected.

    2) Reasonable suspicion of imminent dangers to self or someone else.

    3) Court Order.

    For couple or family counseling, it is important to understand that I have a “no secrets” policy. Our rela-tionship is built on trust and secrets undermine our ability to work together. If a secret is shared, I will help to facilitate sharing the secret within the next two sessions. Child/teen confidentiality is limited to parental consent; however, trust is essential in working with children and teens. I ask that you allow my sessions with them to be confidential unless I become aware that they are in danger. I will do my best to help facilitate conversations between parent and child/teen in order to build and strengthen your rela-tionship. In the case of a child custody dispute, I will assume both partners love their children and want the best for them. For that reason, I will not testify on behalf or against either party. In order to provide you with the best possible care, I utilize both individual and group supervision. The supervisory process is bound by the same confidentiality laws and ethical mandates. In the unlikely event of my 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.


    I have the deepest regard for my clients, so if you are dissatisfied with any aspect of our work, please make me aware immediately so that we can work on a resolution. You may also contact my supervisor B. Anne Hancock, Psy.D. at 704-319-5593. If we are unable to resolve the problem, or you feel that your rights as a client have been ethically violated, you can contact the North Carolina Marriage and Family Therapy Licensure Board at (919) 469-8081 or by mail at Post Office Box 5549, Cary, NC 27512.

  • SPECIAL REMINDER: 48-hour advance notice is required for any cancellation or reschedule. Without 48-hour notice, the full fee will be charged unless a life-threatening emergency is involved.

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

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  • 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 had the opportunity to ask questions.

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