Professional Disclosure Statement and Service Agreement – Norena Gutierrez

Name

First Last

Overview and Description of Services

Norena Gutierrez, is a Clinical Mental Health and Marriage & Family Therapist licensed associate in the state of North Carolina. Ms. Gutierrez sees individuals, couples and families and specializes in working with distressed couples primarily from the (EFT) Emotion Focused Therapy perspective. EFT recognizes that partners get caught in repetitive negative patterns creating negative emotional experiences like anger, sadness, isolation, and loneliness. Working as a consultant to the couple or family, she helps members or partners identify the negative patterns and the emotions generated by them. The goal is to help individuals create strong, healthy connections. Other theoretical perspectives used include:

Positive Psychology – focusing on the strengths that enable individuals to thrive and the belief that people want meaningful and fulfilling lives; that they want to cultivate what is best within themselves and enhance their experience of love, work, and play.
Humanistic – focusing on one’s present experience, one’s free choice and the idea that self-awareness leads to choice, responsibility and change.
Family Systems – focusing on the present and paying attention to one’s family of origin in a direct and non-confrontational manner to gain self-awareness in current relationships and intergenerational experiences. A genogram (3 generational family history) is constructed, usually within the first two sessions.
Cognitive-Behavioral – focusing on the present and interpersonal environments that perpetuate thoughts and behaviors. This modality is directive and actions, negotiations and contracts may be used to help modify cognitive and behavior patterns.

Consent*

I have read the above information.

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.

Consent*

I have read the above information.

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.

Consent*

I have read the above information.

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.

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 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.

Consent*

I have read the above information.

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.

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

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

Consent*

I have read the above information.

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.

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.

Complete an Inquiry Form or Call us at 704-319-5593 to Receive a 15-Minute Discovery Call.

We want you to be sure Wellness is the right fit.