Professional Disclosure Statement and Service Agreement – Sheila Mull

Overview and Description of Services

I, Sheila Mull am a licensed Marriage & Family Therapist in the states of North Carolina and South Carolina. I see individuals, couples and families and specialize 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 and the relationship, I help partners identify the negative patterns and the emotions generated. The goal is to help partners create a strong, healthy connection. Other theoretical approaches may be utilized as deemed appropriate. Appropriate referrals will be given to clients whose need exceeds the scope of my practice and therapeutic training.

Sessions, Fees, Payment Method, Scheduling & Cancellation Policy

• Initial Diagnostic Interview lasts ninety (90) minutes. Fee: $265
• Individual Session lasts fifty (50) minutes beginning on the hour and ending ten (10) minutes before the hour unless other arrangements are made. Fee: $175
• 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: $265
• 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: $265

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.

48-hour advance notice is required for any cancellation or re-schedule..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 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 ConsentI 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.

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:

• Suspicion or evidence of child or elder abuse
• Reasonable suspicion that the client presents danger to self or others
• Court order
• In the case of a medical emergency, a client’s personal information may be provided to medical personnel.

It is required by law that I inform you that sexual intimacy between a practitioner and a client is prohibited. 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. In cases where children are involved, I will always assume 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 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.

Other Professional Services

These are provided at my standard hourly rate and 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 and phone conversations unrelated to scheduling an appointment. Please know that in the unusual event of legal proceedings I will only participate if ordered by the court and you will be expected to pay for my professional services, even if I am called to testify by another party. Legal proceedings are challenging and complex. As such, my fee is $795 per hours for preparation and attendance at any legal proceeding.

Telephone

Telephone calls, emails and texts are reserved for scheduling and cancellation purposes and will not be retained as a part of the client’s permanent file. If you need to contact me between sessions, please leave a message and I will return your call within 24 hours. In the event of a life-threatening emergency, contact 911 immediately then contact me. Non-emergency calls to my office about issues other than cancellation or scheduling will be considered billable.

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.

Registering Complaints

On occasion, clients have concerns and complaints and are urged to bring them to the therapist’s attention immediately. 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 Licensure Board at 919-469-8081. To contact the South Carolina Board of Examiners for Licensure of Professional Counselors, Marriage and Family Therapists and Psycho-Educational Specialists, call 803-896-4658.

SPECIAL REMINDER: 48-hour advance notice is required for any cancellation or re-schedule. 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.