Professional Disclosure Statement and Service Agreement – 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

  • Overview and Description of Services

    Anne Hancock, is a Marriage & Family Therapist licensed in the states of North Carolina and California. Dr. Hancock sees individuals, couples and families and specializes in working with distressed couples primarily 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 partners 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, one’s 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 manner to gain self-awareness in current relationships and intergenerational experiences. A genogram (3 generational family history) is constructed, usually within the first two sessions.
    • Cognitive-Behavioral – focusing on the present and interpersonal environments that perpetuate thoughts and behaviors. This modality is directive and actions, negotiations and contracts may be used to help modify cognitive and behavior patterns.

  • Sessions, Fees, Payment Method, Scheduling & Cancellation Policy

    • Initial Diagnostic Interview lasts ninety (90) minutes. Fee: $395
    • Individual Session lasts fifty (50) minutes beginning on the hour and ending ten (10) minutes before the hour unless other arrangements are made. Fee: $295
    • Couple & Family Session lasts eighty (80) minutes beginning on the hour and ending ten (10) minutes before the half hour unless other arrangements are made. Fee: $395

    Any time overage will be prorated in ten (10) minute intervals. Clients pay for services 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 a period of 3 months. Professional services are rendered and charged to the client and not to the insurance company. Clients who wish to submit a statement to their insurance company will receive a statement with appropriate procedure and diagnostic codes. Please note that 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 returned check.


  • Sessions, Fees, Payment Method, Scheduling & Cancellation Policy

    • Initial Diagnostic Interview lasts ninety (90) minutes. Fee: $395
    • Individual Session lasts fifty (50) minutes beginning on the hour and ending ten (10) minutes before the hour unless other arrangements are made. Fee: $295
    • Couple & Family Session lasts eighty (80) minutes beginning on the hour and ending ten (10) minutes before the half hour unless other arrangements are made. Fee: $395

    Any time overage will be prorated in ten (10) minute intervals. Clients pay for services 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 a period of 3 months. Professional services are rendered and charged to the client and not to the insurance company. Clients who wish to submit a statement to their insurance company will receive a statement with appropriate procedure and diagnostic codes. Please note that 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 returned check.


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


  • Confidentiality & Special Concerns

    Information disclosed in session is confidential and may not be disclosed to anyone without written permission from you, the client. However, 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, 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. 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 rare event where I am called on to appear or prepare for legal proceedings, my fee is $750/hr irrespective of which partner/attorney has made the request.


  • Telephone

    Phone sessions are available on request. If you need to contact me between sessions, please leave a message and I will return your call within 24 hours. If an emergency arises, state that clearly in your message and I will respond as quickly as possible. An emergency is considered danger to self or others or catastrophic loss. In the event of a life-threatening emergency, it is in your best interest to contact 911 immediately. Non-emergency calls to my office 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.


  • Registering Complaints

    On occasion, clients have concerns and complaints and are urged to bring them to the therapist’s attention immediately. Clients may also register complaints with the NC Board of Licensure.

  • Date Format: MM slash DD slash YYYY
  • 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.