Professional Disclosure Statement and Service Agreement – Sarah Faircloth

Qualifications & Experience

I am a Licensed Clinical Mental Health Counselor Associate in the state of North Carolina. I achieved my Masters in Counseling from Wake Forest University, May 2016. Further, I have a Bachelor of Arts in Psychology from University of North Carolina at Chapel Hill. My counseling experience includes working in hospitals and treatment centers.

Description of Services & Approach

In order for counseling to be effective, a therapeutic relationship must be established. My role is to provide you with support, unconditional positive regard, and guide you through a series of steps towards a closer relationship. Your role is to engage actively and openly within therapy. Real change is possible. The nature of therapy is that particular outcomes are not guaranteed. At times, therapy brings up unpleasant experiences, with the intention of reintegrating these experiences into healthier patterns. I will not work outside the scope of my professional training and would refer you to a qualified professional if needed. Our relationship will be close, however I maintain professional boundaries. As do the rest of the Wellness team, I work from a model of couples counseling called Emotionally Focused Therapy (EFT). EFT is a research-based modality that helps couples understand how they get caught in negative cycles, which can drive a couple apart. I will help you articulate your patterns, your roles in the negative cycle, and the underlying attachment meanings. Working in this way allows couples to move into lasting healthier patterns, and form stronger bonds.

Sessions, Fees, Scheduling, & Cancellation Policy

• Initial Diagnostic Interview lasts ninety (90) minutes. Fee: $285
• Individual Session lasts fifty (50) minutes beginning on the hour and ending ten (10) minutes before the hour unless other arrangements are made. Fee: $195
• 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: $285
• 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: $285

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.

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. Email are for scheduling and cancellation only and will not be retained as a part of your permanent record.

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. your physician) 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 $705 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 hr. 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 and 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 couples requires a special kind of confidentiality. I will not keep secrets from either partner, though I will help you to disclose a secret to your partner if needed. For ongoing professional development and best practice, I have a 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 the couple and your children. 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.

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. Although clients are encouraged to discuss any concerns with me, you may file a complaint against me with the organization below should you feel I am in violation of any of these codes of ethics. I abide by the ACA Code of Ethics. (http://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. Fax: 336-217-9450. E-mail:

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SPECIAL REMINDERS: 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.