Professional Disclosure Statement and Service Agreement – Julie Moore

Julie Moore, M.A.
Wellness Counseling Center PC
Clinical Mental Health Counselor Associate
309 S. Sharon Amity Rd. Suite 310, Charlotte, NC 28211

North Carolina License #A16719

  • Overview and Description of Services

    I am a Licensed Clinical Mental Health Counselor Associate in the state of North Carolina. I received my Master of Arts degree in Clinical Mental Health Counseling from Wake Forest University in May 2021. Additionally, I hold a Bachelor of Arts in Sociology from Wake Forest University. My counseling experience includes working in outpatient behavioral health and community agencies. In order to have an effective counseling relationship, trust and respect must be established. My goal in working with clients is to provide a safe space for individuals and couples to share and grow, though this process can be difficult at times. As does the entire Wellness Counseling Center team, I utilize a couples counseling approach called Emotionally Focused Therapy (EFT), a highly regarded and well-researched model for couples work. This type of counseling will help clients uncover negative relational patterns and the deeper emotions behind them and aims to create healthier and stronger relationships.
  • Sessions, Fees, Payment Method, Scheduling & Cancellation Policy

    • Initial Diagnostic Interview lasts ninety (90) minutes. Fee: $165
    • Individual Session lasts fifty (50) minutes. Fee: $115
    • Extended Individual Session lasts eighty (80) minutes. Fee: $165
    • Couple & Family Session lasts eighty (80) minutes. Fee: $165

    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-hour Advance Notice is Required for any cancellation or re-schedule.

    Once you schedule an appointment, it belongs to you and a full 48 hours advance notice is required for any cancellation or reschedule. Without 48 hours notice, the full fee will be charged unless a life-threatening emergency is involved. 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 closed, 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 may be used in the event of inclement weather and can be arranged as an alternative.
  • 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.
  • Telephone and Other Forms of Communication

    Telephone calls, emails, and texts are reserved for scheduling and cancellation purposes and are not retained as a part of your permanent file. If you need to contact me between sessions, please call or email me and I will get back to you within 24 business hours. In the event of a life-threatening emergency, contact 911 immediately prior to contacting me. Non-emergency calls to the office about issues other than cancellation or scheduling will be considered billable.
  • Confidentiality & Special Concerns

    By law, a vital part of the counseling relationship is that everything you share with me will be kept confidential with the treatment team and myself, with the following exceptions:

    • You direct me in writing to disclose information to someone else,
    • There is suspicion of possible abuse or neglect of a minor or dependent adult, 

    • There is evidence of possible danger to the client or identified others,
    • There is evidence of possible danger of contagion of life-threatening diseases, 

    • Or I am ordered by a court to disclose information.

    Please be advised, if you use/file insurance claims, therapeutic notes contain diagnosis and become part of your client record in perpetuity. For ongoing professional development and best practice, I have a supervisor who also abides by ethical and legal mandates. Please note that in working with couples, families and groups, confidentiality cannot be guaranteed. Therefore, a “no secrets” policy is imperative in couples and family work. I will work with clients to help facilitate difficult conversations. I will also work to help achieve therapeutic goals but cannot make any therapeutic outcome guarantees. 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. Additionally, I will not work outside of my scope of competency and will make referrals when appropriate.
  • 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 $450 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

    Clients are encouraged to discuss any concerns with me. 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 Board of Licensed Clinical Mental Health Counselors P.O. Box 77819 Greensboro, NC 27417 Phone: 844-622-3572 or 336-217-6007
  • 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.
  • 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.