Professional Disclosure Statement and Service Agreement - Nicole Kelly

Name

First Last

Overview and Description of Services

I am a graduate student in Marriage and Family Therapy at Capella University and am completing my practicum and internship experience with Wellness Counseling Center. I have a Bachelor of Arts in Music Therapy from East Carolina University. At Wellness I will be under the supervision of Dr. Anne Hancock, as well as my practicum/internship professor, Dr. Michael Reiter. I will work with couples and individuals using EFT (Emotionally Focused Therapy); a highly regarded and well-researched method for individuals, couples and families. This type of counseling is helpful to people who want to create strong, healthy relationships.

Consent*

I have read the above information.

Restricted

As a requirement of the University’s Graduate Program & EFT approved supervision, I may request permission to audio/video record some sessions to review with my supervisor(s). This means recording our session in order to assess my skills and the quality of your care. Names or any further identifying information will not be revealed. Recordings will be kept in confidence and not transmitted outside the purview of supervision. Only the client may elect to release this information to persons or agencies outside the counseling program. All recordings will be destroyed immediately upon review.

Consent*

I have read the above information.

Sessions, Fees, Payment Method, Scheduling & Cancellation Policy

Individual Session lasts fifty (50) minutes beginning on the hour and ending ten (10) minutes before the hour unless other arrangements are made. Fee: $100
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: $125
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: $125

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

Consent*

I have read the above information.

Confidentiality & Special Concerns

I am honored that you have entrusted me with this vulnerable journey. 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,
Or I am ordered by a court to disclose information.

To protect you and your confidentiality, should we come into contact outside of the office, I will acknowledge you provided you initiate the interaction.

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 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.

Consent*

I have read the above information.

48 hours 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.

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. 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 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 Marriage and Family Therapy board, PO Box 10912, Raleigh, NC 27605, or my Capella University Clinical Supervisor, Michael Reiter Ph.D.

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.

Professional Disclosure Statement and Service Agreement – Nicole Kelly

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

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.