Professional Disclosure Statement and Service Agreement – 2-1/2 Day Intensive – Beth McCain

Overview and Description of Services

Beth McCain is a licensed Marriage & Family Therapist in the state of North Carolina. Beth sees individuals, couples and families and specializes in working with distressed couples pri-marily 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 part-ners 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 Beth’s therapeutic training.

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

• The 2 ½ Day Intensive is offered at Wellness Counseling Center in Charlotte NC and generally begins on Friday morning 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 $5,500.00; 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 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 Beth or we will find a mutually agreed upon EFT certified couple therapist in your community. Follow up sessions with Beth last eighty (80) minutes. The fee is $325 and time overage is prorated in ten (10) minute intervals.
• If you need to contact Beth between sessions regarding scheduling, please email or text and she will respond within 24 hours or the next business day if it is the week-end. Email and text are reserved for scheduling and cancellation only and will not be retained as a part of your permanent record. In the event of a life-threatening emergency (considered danger to self or others or catastrophic loss), contact 911 immediately then contact me.
• Clients pay for follow-up sessions after each appointment. 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. A $25 fee is assessed for each declined credit/debit card or re-turned check.

Cancellations for Follow-up Sessions 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. TeleHealth services can 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 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 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. I do not hold secrets and will always endeavor to facilitate difficult conversations between parties. I will always work with you 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.

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.

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. I also under-stand 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 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 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 $750 per hour for preparation and attendance at any legal 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 community you will be receiving this information and you may unsubscribe at any time.

Resolving Complaints

On occasion, clients have concerns and complaints and are urged to bring them to the therapist’s attention immediately. If we 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.

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.