Professional Disclosure Statement and Service Agreement – 2-1/2 Day Intensive – Anne Hancock

B. Anne Hancock, Psy.D.
Licensed Marriage & Family Therapist
309 S. Sharon Amity Rd. Suite 310, Charlotte, NC 28211

North Carolina License # 919
California License # 33106

Name

Overview and Description of Services

Dr. Anne Hancock, is a Marriage & Family Therapist licensed in the states of North Carolina and California. She sees individuals, couples and families and specializes in working with distressed couples primarily from the (EFT) Emotionally 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 create a strong, healthy connection. Other theoretical perspectives used include:

  • Positive Psychology – focusing on the strengths that enable individuals to thrive and the belief that people want meaningful and fulfilling lives; that they want to cultivate what is best within themselves and enhance their experience of love, work and play.
  • Humanistic – focusing on one’s present experience, free choice and the idea that self- awareness leads to choice, responsibility and change.
  • Family Systems – focusing on the present and paying attention to one’s family of origin in a direct and non-confrontational way to gain self-awareness in current relationships and intergenerational experiences. A genogram (3 generational family history) is constructed, usually within the first two sessions.
Consent(Required)


The 2 ½ Day Intensive, Payment Method, Cancellation and Follow-up

  • The 2 ½ Day Intensive is offered at Dr. Hancock’s office in Charlotte NC and generally begins on Friday at 10am and concludes on Sunday at 12pm unless other arrangements are made. It works best if each person is completely unplugged from home and work demands. We request mobile devices be turned off during the day while we work.
  • The fee is $7,750.00; half of the fee is due when you reserve the date and the balance is due 48 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 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 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 on-line or in-person with Anne Hancock or we will find a mutually agreed upon EFT certified couple therapist in your community. Follow up sessions with Dr. Hancock last eighty (80) minutes beginning on the hour and ending ten (10) minutes before the half hour unless other arrangements are made. The fee is $410 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. Scheduling on a quarterly basis means negotiating and reserving appointment times specifically for the client for 3 months. Please note there may be the possibility of insurance reimbursement for follow-up sessions. Insurance reimbursement does not apply to the 2 ½ Day Intensive. If you wish to file a claim, we will provide a statement with appropriate procedure and diagnostic codes. It is the client’s responsibility to determine coverage. Visa, MC, AMEX, check and cash are acceptable forms of payment.

Consent(Required)


Declined Credit Cards / Checks, Cancellation of Follow-up Sessions

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

Also, 48 hours advance notice is required for any cancellation or re-schedule of a follow up session. Without 48 hours notice, full fee will be charged unless it involves a life threatening emergency

Consent(Required)


Confidentiality & Special Concerns

Information disclosed during our work together is considered confidential and may not be disclosed to anyone without written permission from you, the client. However, North Carolina law requires the following exceptions to client confidentiality:

  • Where there is suspicion or evidence of child or elder abuse,
  • Where there is reasonable suspicion that the client presents danger to self or other, and
  • Court order

Please be advised that therapeutic notes contain diagnosis and become part of the client record.  Also, please note that confidentiality cannot be guaranteed in group work. 

During this process I will always work to help you achieve your goals yet cannot make any outcome guarantees. 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.

Consent(Required)


Telephone, Email and Texting

Phone and Zoom sessions are available on request. If you need to contact me between sessions, please leave a voicemail, email or text and I will respond within 24 hours. If you contact me on the weekend I will respond on the next business day. If an emergency arises, state that clearly in your message and I will respond as quickly as possible. A life-threatening emergency is considered danger to self or others or catastrophic loss. In the event of a life-threatening emergency, contact 911 immediately then contact me. Please note: Non-emergency phone calls to my office about issues other than cancellation or scheduling will be considered billable at the standard hourly rate. Email and texting are for scheduling and cancellation only and will not be retained as a part of your permanent record.

Consent(Required)


Registering Complaints

Sometimes clients have concerns and complaints and are encouraged to bring them to Dr. Hancock’s attention immediately. Clients may also register complaints with the NC-MFT Licensure Board.
Consent(Required)


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.

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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.

Consent