Professional Disclosure Statement and Service Agreement – Nicole Kelly

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.

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.

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.

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

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.

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.

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.