Professional Disclosure Statement and Service Agreement – Norena Gutierrez

Sessions, Fees, Payment Method, Scheduling & Cancellation Policy

• Initial Diagnostic Interview lasts ninety (90) minutes. Fee: $165
• Individual Session lasts fifty (50) minutes beginning on the hour and ending ten (10) minutes before the hour unless other arrangements are made. Fee: $125
• 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: $ 165
• 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: $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 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. Once you schedule follow-up sessions the appointment 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. 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 closing, 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 can also be arranged as an alternative in the event of inclement weather.

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 $495 per hour irrespective of which partner/attorney has made the request.

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 unless specifically authorized by the client. 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

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.

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