Professional Disclosure Statement and Service Agreement – Stephanie Davis

Stephanie Davis, MA
Licensed Clinical Mental Health Counselor (NC #A12625 )
National Certified Counselor (NC #629589)
Wellness Counseling Center
309 S. Sharon Amity Rd. Suite 310, Charlotte, NC 28211

  • This document is designed to inform you about my background, ensure that you understand our professional relationship, and document your understanding and consent to treatment.
  • Qualifications and Experience

    I am a Licensed Clinical Mental Health Counselor (M.A., UNCC), National Certified Counselor and Professional Educator (M.Ed. UNCC) and School Counselor in the State of North Carolina. In addition to my employment with Wellness Counseling Center, I am currently employed as a Licensed Professional School Counselor providing counseling services to children and adolescents.

  • Description of Services and Approach

    My services and modalities include clinical comprehensive assessments, Creative Expressive Therapy, CBT (Cognitive Behavioral Therapy), EFT (Emotionally Focused Therapy), Mindfulness, educational support planning as well as parent and family consultations. I have specialized training and experience as a Child-Centered Play Therapist and I am an advocate and ally of the LGBTQ community.

    I provide counseling services to clients dealing with some of the following issues: situational adjustments, grief and loss, anxiety, social skills, self-esteem, anger-management, depression, gender identity exploration and special education needs including working with individuals diagnosed on the Autism Spectrum, ADD (Attention Deficit Disorder) and ADHD (Attention Deficit Hyperactivity Disorder).

    My theoretical approach to counseling is integrated. I use a holistic approach in which individual’s physical, emotional, mental, spiritual, and social areas are assessed and explored. At Wellness, services are provided in a genuine, supportive environment of empathy and unconditional positive regard. This provides a safe place to explore; a place where clients can safely share thoughts, feelings, behaviors and reactions. During Child-Centered Play Therapy sessions, children and adolescents may use a variety of toys and expressive arts media as we incorporate creative therapeutic activities such as art, music, journaling, bibliotherapy and cinematherapy.


  • Sessions, Fees, Scheduling, & Cancellation Policy

    • Initial Diagnostic Interview lasts ninety (90) minutes. Fee: $250
    • Individual Session lasts fifty (50) minutes. Fee: $235
    • Extended Individual Session lasts eighty (80) minutes. Fee: $250
    • Parent / Family Session lasts eighty (80) minutes. Fee: $250

    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 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.


  • Contact Between Sessions

    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 then contact me. Emails are for scheduling and cancellation only and will not be retained as a part of your permanent record. Please Note: Out of office non-emergency contact will be billed at the prorated session rate.


  • 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.

  • Other Professional Services and Legal Concerns

    Other professional services are provided at my standard hourly rate and are 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. physician or teacher) and phone conversations unrelated to scheduling an appointment. Please know that in the unusual event of a legal proceeding, especially in the area of child custody issues, I will not testify for or against either party and I will only participate if ordered by the court. You will be expected to pay for my professional services regardless if I am called to testify by another party. Legal proceedings are challenging and complex. As such, my fee is $750 per hour for preparation and attendance at any legal proceeding.


  • Cancellations, Emergencies 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. 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’re 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.


  • Confidentiality & Special Concerns

    Everything you share with me will be kept confidential with the treatment team and myself; this is standard professional practice. There are exceptions to confidentiality. I am obligated to disclose if: 1. You are in danger of harming yourself or others. 2. There is any suspicion of child or elder abuse. 3. You direct me in writing to disclose to someone else or if I am ordered by a court to disclose. Working with individuals, parents and families requires a special kind of confidentiality. I will not keep secrets although I will help disclose secrets if/when needed. For ongoing professional development and best practice, I work with a treatment team and in-house supervisor who also shares confidentiality by ethical and legal mandates. I will not testify in a court of law for custody cases, out of the best interest for children and family. 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.


  • 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.


  • Complaint Procedures

    In case of complaints or if you feel that your rights have been violated or that professional ethics have been violated, please let me know right away. Clients are encouraged to discuss any concerns with me and/or the CEO of Wellness Counseling Center first. You may file a complaint should you feel I am in violation of any of these codes of ethics. I abide by the ACA Code of Ethics. (https://www.counseling.org/Resources/aca-code-of-ethics.pdf) North Carolina Board of Licensed Clinical Mental Health Counselors, P.O. Box 77819, Greensboro, NC 27417. Phone: 844-622-3572 or 336-217-6007.


  • 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.

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  • 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.