Professional Disclosure Statement and Service Agreement – Christina Bronte

Name*

First Last

Overview and Description of Services

I, Christina Bronte, specialize in working with distressed couples, families and young people from an Attachment perspective and use the (EFT) Emotionally Focused Therapy method. EFT recognizes that people get caught in a repetitive negative pattern/cycle creating emotional experiences like anger, sadness, isolation and loneliness. The goal of EFT Therapy is to help people reconnect and create strong, healthy bonds. Through EFT, people are able to identify when they see the negative cycle occurring and when they get stuck. Then, they can start to implement new strategies in order to break those patterns. Other theoretical approaches may be utilized as deemed appropriate. Appropriate referrals will be provided if necessary.

Should you provide written permission, I will also be videotaping the sessions to be used to further contribute to your care. You may withdraw your consent for taping at any time. 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 credentialed professionals according to your needs.

Consent*

I have read the above information.

Confidentiality and Special Concerns

I am honored that you have entrusted me with one of the most intimate part of your lives by focusing on your relationship(s) while in therapy. Everything you share in session will be kept in the utmost confidence. There are four situations in which I cannot hold confidentiality by law:

If child abuse or elderly abuse is suspected
Reasonable suspicion of imminent danger to self or someone else.
Court Order
In the case of a medical emergency, a client's personal information may be provided to medical personnel

To protect you and your confidentiality, should we come into contact outside of the office, I will acknowledge you provided you initiate the interaction.

Consent*

I have read the above information.

Sessions, Fees, Scheduling, & Cancellation Policy

Initial Assessment Interview: (90) minutes. Fee: $295
Individual Session: (50) minutes. Fee: $245
Extended Individual Session: (80) minutes. Fee: $295
Couple and Family Session: (80) minutes. Fee: $295

Any time overage will be prorated in ten (10) minute intervals. Clients pay for services at the end of each appointment and are encouraged to reserve appointments several sessions out in order to ensure availability.

Sessions are 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. Any diagnosis provided to your insurance company becomes a part of your permanent medical record. Acceptable forms of payment are Visa, MC, AMEX, check, and cash. Please note: A $25 fee is assessed for each declined credit/debit card or returned check.

Consent*

I have read the above information.

Working with Minors

If there is reason to believe a minor is placing themself in harm’s way, I may inform the parents to ensure safety. This includes but is not limited to underage drinking while operating a vehicle, leaving the house at night without parental consent and potentially harmful online alliances. My position is parents need this information to keep their children safe.

Consent*

I have read the above information.

Other Professional Services and Legal Concerns

Other professional services are provided at my standard hourly rate and are 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 a legal proceeding, especially in the area of child custody issues, I will not testify for or against either party and I will only participate if ordered by the court. You will be expected to pay for my professional services regardless 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.

Consent*

I have read the above information.

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 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..

Consent*

I have read the above information.

Cancellations, Telephone/Email, Emergencies, and Inclement Weather

Once you schedule an appointment, it belongs to you and a full 48-hour advance notice is required for any cancellation or re-schedule. Without 48 hours’ notice, your full fee will be charged unless the cancellation involves a life-threatening emergency. In the event of a life- threatening emergency, always call 911 or go to your nearest emergency room. Email is for scheduling and cancellation only and will not be retained as a part of your file. You can also leave phone messages and I will return your call within 24 hours or the next business day. 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. You will hear from me directly by phone.

Consent*

I have read the above information.

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.

Consent*

I have read the above information.

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 NC Licensure Board of Social Work at 336-625-1679..

Consent*

I have read the above information.

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

Consent*

I have read the above information.

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

Consent*

I have read the above information.

Name*

First Last

Date*

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*

I agree with the above information.

By consenting here, I am agreeing that I have read this statement fully and am in agreement with all stated.