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

  • QUALIFICATIONS/EXPERIENCE

    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.


  • DESCRIPTION OF SERVICES

    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, PAYMENT METHOD, CANCELLATION AND FOLLOW-UP:

    • 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 $1950; 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 with me 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 $285 and time overage is prorated in ten (10) minute intervals.
    • Clients pay for follow-up sessions after each appointment and are encouraged to schedule on a quarterly basis. 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.

  • CANCELLATIONS FOR FOLLOW-UP SESSIONS, eNEWSLETTER, EMERGENCIES AND INCLEMENT WEATHER.

    Once you schedule follow-up sessions the appointment belongs to you and a full 48 hours advance 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 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 me directly or you may call the phone number on the Wellness website for an update.

    Periodically, Wellness Counseling Center distributes an eNewsletter via email containing relation-ship 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.


  • OTHER PROFESSIONAL SERVICES

    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 $350 per hour for preparation and attendance at any legal proceeding.


  • CONFIDENTIALITY AND SPECIAL CONCERNS

    I regard the information that you share with me with the greatest respect. It is important that you know that I am ethically and legally required to maintain your privacy. I utilize both individual and group supervision in order to best serve you. The supervision team is also bound by confidentiality laws and ethical mandates. The primary reasons for limitations to client confidentiality are: (1) where there is a reasonable suspicion that you present danger to yourself or others; (2) where there is suspicion of child or elder abuse; and (3) court order. Otherwise, the only way I would share information about your treatment, history or even that you are a client with me would be with your clear permission accompanied by a signed release of information form. For couples counseling, I have a “no secrets” policy. Our relationship 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. I will always assume (if applicable) both partners love their children and want the best for them. For that reason, please know, I will not testify on behalf or against either party. 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.


  • COMPLAINT PROCEDURES

    In all professions there is an avenue whereby you can register a concern if you feel your rights as a consumer have been violated or that there has been a breach of ethical standards. If you are dissatisfied with any aspect of our work, please inform me immediately. You may also contact my supervisor Anne Hancock, Psy.D. at 704-319-5593. If we are unable to resolve the problem, or to learn more about your rights as a client you can contact the North Carolina Marriage and Family Therapy Licensure Board at (919) 469-8081.

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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.