Professional Disclosure Statement and Service Agreement – Jennifer Holladay

Qualifications and Experience

I am licensed as a Marriage and Family Therapist in the state of North Carolina. I hold a Masters in Marriage and Family Therapy, issued in 2015 by the Pfeiffer University in Charlotte, NC. The program was accredited by the Commission on Accreditation for Marriage and Family Therapy Education (COAMFTE). My experience as a therapist began in 2013. I have worked with children and families under a Bachelors degree in Social Work since 1995. My experience includes working with individuals, couples and families in a variety of capacities including couple distress, parenting, adoption, infidelity and family preservation. I have received full certification in Emotionally Focused Therapy.

Description of Services & Approach

My approach comes from a belief that people thrive on relationships and connections to other human beings and those relationships are an essential part of healthy living. Healing can happen within self and exponentially within relationships. Therapy is an opportunity for people to explore their relationship to self, each other, and the world in a safe, non-judgmental atmosphere. Together we will look for patterns and behaviors that hinder connection and accomplishing your therapeutic goals. It is important to know that initially therapy can be challenging as difficult areas are addressed and worked through. Therapy can also be extremely rewarding as you struggle to find connection.

I work from a family systems, experiential, attachment perspective called Emotionally Focused Therapy (EFT). EFT recognizes that people get caught in repetitive negative patterns creating negative emotional experiences like anger, sadness, isolation and loneliness. Often, we are unsure how to break free from these negative patterns and we get stuck. Together we will work to understand where the emotions arise and hope to build a strong, safe, loving relationship where connection is enhanced. I work with individuals, couples, and family relationships.

Sessions, Fees, Payment Method & Scheduling

• Initial Assessment Interview lasts ninety (90) minutes. Fee: $295
• Individual Session lasts fifty (50) minutes. Fee: $195
• Extended Individual Session lasts eighty (80) minutes beginning on the hour and ending ten (10) minutes before the half 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: $295

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.

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, Emergencies, eNewsletter 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, 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 permanent record.

If you need to contact me between sessions, please leave a voicemail or email and I will respond within 24 hours. If you contact me on the weekend I will respond on the next business day. If an emergency arises, state clearly in your message and I will respond as quickly as possible. A life-threatening emergency is considered danger to self or others or catastrophic loss. In the event of a life-threatening emergency, contact 911 immediately and then contact me.

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.

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 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.

Other Professional Services

These services 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 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, 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 $900.00 per hour for preparation and attendance at any legal proceeding.

Confidentiality & Special Concerns

I am honored that you have entrusted me with your information. Everything you share in session will be kept in the utmost confidence. This is to the extent in that if we are to come into contact outside of the office, I will not acknowledge you unless you initiate first. I utilize both individual and group supervision in order to best serve you. The supervision team is also bound by the same confidentiality laws and ethical mandates. There are three situations in which I cannot guarantee confidentiality ethically or by law:

• If child or elderly abuse is suspected
• Reasonable suspicion of imminent danger to self or someone else
• Court order

For couple or family counseling, it is important to understand that I have a “no secrets” policy. Our relationship is built on trust and secrets undermine our ability to work together. If a secret is shared, I will help to facilitate sharing the secret within the next two sessions. Child/teen confidentiality is limited to parental consent; however, trust is essential in working with children and teens. I ask that you allow my sessions with them to be confidential unless I become aware that they are in danger. I will do my best to help facilitate conversations between parent and child/teen in order to build and strengthen your relationship. In the case of a child custody dispute, I will assume both partners love their children and want the best for them. For that reason, I will not testify on behalf or against either party. In order to provide you with the best possible care, I utilize both individual and group supervision. The supervisory process is bound by the same confidentiality laws and ethical mandates. 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.

Complaint Procedures

I have the deepest regard for my clients, so if you are dissatisfied with any aspect of our work, please make me aware immediately so that we can work on a resolution. You may also contact my supervisor B. Anne Hancock, Psy.D. at 704-319-5593. If we are unable to resolve the problem, or you feel that your rights as a client have been ethically violated, you can contact the North Carolina Marriage and Family Therapy Licensure Board at (919) 469-8081 or by mail at Post Office Box 5549, Cary, NC 27512.

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.