Professional Disclosure Statement and Service Agreement – Courtney Costa

Overview and Description of Services

Courtney specializes in working with distressed couples primarily from the (EFT) Emotion Focused Therapy perspective. EFT recognizes that partners get caught in repetitive negative pattern cycle creating emotional experiences like anger, sadness, isolation and loneliness. The goal of EFT Couples Therapy is to help partners reconnect and create a strong, healthy connection. Through EFT, couples will be able to identify when they see their cycle occurring and then 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.

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 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 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 not acknowledge you unless you initiate.

Sessions, Fees, Payment Method, Scheduling & Cancellation Policy

• Initial Assessment Interview lasts ninety (90) minutes. Fee: $215
• Individual Session lasts fifty (50) minutes. Fee: $155
• 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: $215

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.

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 $645 per hour for preparation and attendance at any legal proceeding.

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.

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 hour’s notice, your full fee will be charged unless the cancellation involves a life-threatening emergency. Email is for scheduling and cancellation only and will not be retained as a part of your file. Please 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.

eNewsletter

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

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

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

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.