CAROLINA COUNSELING INC

CAROLINA COUNSELING INC Sandra H. Ritter, PhD, LPCS Sarah M. Deese, MA, LPC Charlotte M. Eure, MA, LPCA Arian J. Fabrikant, MA, LPC Brittiny Ingram, MA, LPCA Lillie Jacobs, MSW, LCSW Shannon M. Lomax, MA, LMFT Christopher R. Lloyd, EdS, LPC Debra P. Martin, MA, LPCA Lorrie J. Miller, PhD, LPC Stephanie G. Pierce, MA, LPC, LCAS Valerie Saucier, MA, SLP-CCC 900 Copperfield Blvd Concord, NC 28025 www.carolinacounseling.vpweb.com 704-721-0000 COUNSELOR-CLIENT SERVICES AGREEMENT and PROFESSIONAL DISCLOSURE STATEMENT Welcome to the practice. This document contains important information about our professional services and business policies. It also contains some summary information about the Health Insurance Portability and Accountability Act (HIPAA), a federal law that provides privacy protections and patient rights with regard to the use and disclosure of your Protected Health Information (PHI) used for the purpose of treatment, payment, and health care operations. HIPAA requires that we provide you with a Notice of Privacy Practices as a stand-alone document. The law requires that we obtain your signature acknowledging that we have provided you with this information prior to actually beginning any services. Although these documents are long and sometimes complex, it is very important that you read them carefully. We can discuss any questions you have about the procedures when we meet. When you sign this document, it will also represent an agreement between us. You may revoke this Agreement in writing at any time. That revocation will be binding on me unless we have taken action in reliance on it; if there are obligations imposed on us by your health insurer in order to process or substantiate claims made under your policy; or if you have not satisfied any financial obligations you have incurred. ABOUT US Sandra H. Ritter, PhD, LPCS is credentialed in North Carolina as a Licensed Professional Counselor and also as a Licensed Professional Counselor Supervisor. She is the CEO of Carolina Counseling Inc. Dr. Ritter received a master's degree (MEd) in community counseling and a doctoral degree (PhD) in counseling and counselor education at the University of North Carolina at Greensboro. Post-doctoral training has been in EMDR (for treating trauma), DBT (for emotional regulation), the Emotional Freedom Technique, and hypnotherapy. Related work experience includes practicum and internship experiences at Guilford County Mental Health, Charter Hospital of Greensboro, staff counselor at Charter Hospital of Greensboro, private practice in Greensboro, assistant professor in the Department of Psychology and Counselor Education at Troy State University (Alabama) and private practice in Concord (since 2004). Clients seen in the office have a wide range of issues, from disruptive behavior in children to couples counseling to anger management, anxiety, and PTSD in adults. When working with children, she often takes a systemic approach so that the family can better understand the changes and create an environment to increase the likelihood for sustainable change. Sarah M. Deese, MA, LPC is credentialed in North Carolina as a Licensed Professional Counselor. She earned her Master's degree in Community Counseling from the University of Counselor-client Services Agreement rev 20161101 Page 1

North Carolina at Charlotte and has experience working with young children, adolescents, families, and adults with a range of issues including behavioral problems in children, anger, depression, anxiety, trauma, and relationship concerns. Work experience includes Intensive In Home team lead, school based therapy, and outpatient community mental health. Postgraduate training and treatment modalities include Cognitive Behavioral Therapy (CBT), Trauma Focused CBT, Motivational Interviewing (MI), and Dialectical Behavior Therapy (DBT). Charlotte M. Eure, MA, LPCA is credentialed in North Carolina as a Licensed Professional Counselor Associate. She earned a master's degree in professional counseling from Liberty University. Field placements included the Hickory Grove Baptist Church counseling center and Genesis... A New Beginning. Related work experience includes Stonewall Jackson Youth Development Center, Grandfathers Homes for Children, Chatham Youth Development Center, and she has been a team lead for intensive in-home services for New Beginnings Youth Facility. Adrian J. Fabrikant, MA, LPC is credentialed in North Carolina as a Licensed Professional Counselor. He earned his Masters of Mental Health Counseling from the Miami Institute of Psychology in Miami, FL. After more than 15 years working in Florida with individuals with developmental delays, autism, Asperger s, adults, children and their families, he relocated to North Carolina. He has been in private practice in Florida, as well as provided services within the Broward County schools. Brittiny Ingram, MA, LPCA is credentialed in North Carolina as a Licensed Professional Counselor Associate. She earned her master's degree in school counseling at Lenoir-Rhyne University. Ms. Ingram is a school counselor at C.C.Griffin Middle School in Harrisburg, NC and works evenings and Saturdays during the school year; she expands her hours when school is not in session. Related work experience includes Time Out Youth (Charlotte), Safe Alliance (Charlotte) and the Rape-Crisis Center (Hickory). Lillie L. Jacobs, MSW, LCSW is credentialed by North Carolina as a Licensed Clinical Social Worker. She earned her Master's degree from The University of Texas in Arlington, and has over 25 years of post graduate mental health service experience. For the past 10 years she has been in private practice providing services for adults diagnosed with depression, anxiety, PTSD, grief, pre-marital, marital and life transition issues. Related work experience include Dept. of Veterans Affairs with extensive training related to PTSD. Additional work experience in hospital ER and community mental health settings. Training and treatment modalities include DBT, CBT, Brief Solution Therapy and motivational counseling Shannon M. Lomax, MA, LMFT is credentialed by North Carolina as a Licensed Marriage and Family Therapist. She earned her Masters in Marriage and Family Therapy from Pfieffer University. She has a wide variety of experience working with children, adults, and couples, both at agencies and in her own private practice. She is also certified in Triple P, Level III. Christopher Lloyd, MS, EdS, LPCA is credentialed in North Carolina as a Licensed Professional Counselor Associate. He earned his master's degree in counselor education from East Carolina University, his EdS at the University of Alabama, and has completed the coursework and associated training to be a registered play therapist. When not at Carolina Counseling, Inc, Mr. Lloyd is a student counselor at Central Piedmont Community College. He Counselor-client Services Agreement rev 20161101 Page 2

is also a licensed school counselor and has worked in an elementary school as well as the Early College High school in Kannapolis. Debra P. Martin, MA, LPCA is credentialed in North Carolina as a Licensed Professional Counselor Associate. She earned her master's degree in Professional Counseling from Liberty University. She has extensive experience interfacing with social workers, foster children, and foster parents; mentoring adolescents; crisis intervention, and working with children, teens, and adults. She has a strong interest in play therapy when working with younger children and enjoys the occasional adult client as well. Lorrie J. Miller, PhD, LPC is credentialed in North Carolina as a Licensed Professional Counselor. She earned her master's degree in Mental Health Counseling form North Carolina State University and her PhD in Counselor Education and Supervision from Texas A&M, Corpus Christi, TX. She specializes in the treatment of mild to severe anxiety, stress management, and emotional intelligence enhancement. She also works with a wide range of other issues including life transitions, behavior management with teens, and more. Most of her clients are mid-teens through adults. In addition to working at Carolina Counseling, Inc., she is the president and COO of Emind Wellness and Training Institute PC. Stephanie G. Pierce, MA, LPC, LCAS is credentialed in North Carolina as a Licensed Professional Counselor and is also a Licensed Clinical Addiction Specialist. She has 20+ years working with mental health and chemical dependency issues of teens and adults. She is licensed both as a counselor and as an addiction specialist. She In addition to working in traditional mental health settings, she has worked in prisons and in substance abuse treatment programs. Born in Belize, she is conversant in Spanish but conducts her sessions in English. Valerie C. Saucier, MS, CCC-SLP is credentialed by North Carolina as Speech Language Pathologist. She has experience working with the pediatric and adult populations in a variety of settings. She specializes in treating children and adults diagnosed with articulation/phonological disorders, expressive and receptive communication delays, feeding/swallowing disorders, social skills/pragmatic impairments, sensory processing disorders, Down Syndrome, Autism Spectrum Disorders, and Traumatic Brain Injury. Valerie provides individual speech-language& swallowing therapy services and is Beckman Oral Motor Assessment & Intervention Certified. SERVICES Counseling and psychotherapy are not easily described in general statements. Services vary depending on the personalities of the counselor and patient, and the particular problems you are experiencing. There are many different methods we may use to deal with the problems that you hope to address. Counseling and psychotherapy are not like a medical doctor visit. Instead, they call for a very active effort on your part. In order for the therapy to be most successful, you will have to work on things we talk about both during our sessions and at home. Counseling and psychotherapy can have benefits and risks. Since therapy often involves discussing unpleasant aspects of your life, you may experience uncomfortable feelings like sadness, guilt, anger, frustration, loneliness, and helplessness. On the other hand, psychotherapy has also been shown to have many benefits. Therapy often leads to better relationships, solutions Counselor-client Services Agreement rev 20161101 Page 3

to specific problems, and significant reductions in feelings of distress. But there are no guarantees of what you will experience. MEETINGS Our first few sessions will involve an evaluation of your needs. During these early sessions, we will be able to offer you some first impressions of what our work will include and a treatment plan to follow, if you decide to continue with therapy. You should evaluate this information along with your own opinions of whether you feel comfortable working with us. Therapy involves time, money, and energy, so you should be very careful about the therapist you select. If you have questions about our procedures, we should discuss them whenever they arise. If your doubts persist, we will be happy to help you set up a meeting with another mental health professional for a second opinion. If we agree to work together after the initial assessment, we will usually schedule one 45-minute or 60-minute session per week at a time we agree on, although sometimes sessions will be more or less frequent. Whenever possible, we prefer to create a standing appointment for your convenience as well as ours. This assures you of a regular time slot that newer clients will need to schedule around. Once an appointment is scheduled (and unless your session is covered by an Employee Assistance Program) you will be expected to pay for it unless you provide 24 hours advance notice of cancellation [unless we both agree that you were unable to attend due to circumstances beyond your control]. It is important to note that insurance companies do not provide reimbursement for cancelled sessions. If you should need to reschedule an appointment, we will try to find another suitable time, although this may mean a delay in your seeing us. It is also important to note that providing adequate notice (24-hour minimum) when you cannot keep an appointment is a courtesy not only to us but also to clients who may want the time slot that you have made available. It is the policy of this office to terminate clients who are inconsiderate of this policy on two occasions in a 13-week period. If such action is necessary, we will provide emergency services only for 30 days in order to allow you time to make other arrangements. CLIENT RIGHTS You have a right To considerate and respectful care which includes freedom form any physical, sexual, fiduciary (financial), or psychological abuse including humiliating, threatening, and exploiting actions; To understand what your problem is, what treatment is recommended and why, who will give the treatment, and what outcome to expect; To be involved in a process of informed choice, informed refusal, and/or expression of choice related to preference of your treatment services, choice of service provider and participation in research projects; To expect that all communications and records pertaining to your care will be treated as confidential; To have continuity of care when you are referred for services outside this agency; to examine and receive an explanation of your bill; to participate in all aspects of your treatment, including development of your treatment plan; to have access to self-help and advocacy support services. Your responsibilities are To be honest in your presentation of your problems and to tell those working with you how you feel about what is happening to you; to be actively involved in the development of your treatment plan that will outline your problems, needs, goals, and expected outcomes; to be considerate of others and their privacy; to present to your counselor any questions, complaints or concerns about your counseling plans or goals so that you may reach an agreement on any problem hindering your progress. Counselor-client Services Agreement rev 20161101 Page 4

If you feel that any of your rights have been denied, you are encouraged to discuss this with your therapist. If you feel that this is not resolve the problem, you may contact the licensing board which corresponds to the type of license held by your provider NC Board of Licensed NC Social Work Certification NC Board of Examiners for Professional Counselors and Licensure Board Speech-Language Pathologists PO Box 77819 PO Box 1043 PO Box 16885 Greensboro, NC 28417 Asheboro, NC 27204 Greensboro, NC 27416 North Carolina MFT Licensure Board 201 Shannon Oaks Circle, Suite 200 Cary, NC 27511 PROFESSIONAL FEES Although we usually have contracted rates with Employee Assistance Programs and insurance programs, there are some instances in which services will not be covered by insurance. Our billing rates are: Initial session: $170; Individual 25-minute sessions: $90; Individual 45-minute session: $120; Family or couples therapy (45-minute): $145; Regardless of type, 60-minute session: $165. Sessions through an employee assistance program are provided at no cost to you. Note: services for Speech- Language Pathology are priced differently. Please check with the speech therapist. In addition to regular appointments, we charge for other professional services you may need, though we will prorate the hourly cost if we work for periods of less than one hour. Other services include report writing, telephone conversations lasting longer than 10 minutes, consulting with other professionals with your permission, preparation of records or treatment summaries, and the time spent performing any other service you may request of us. Generally, the rate charged for these services is $180 per hour, prorated to the portion of the hour that has been used. Exceptions to this include: Copies of records sent to another facility or provided in response to insurance or disability claims: $20.00 plus $0.50 per page, with a minimum charge of $25.00. Collection costs. A collection surcharge of 50% is added to the outstanding balance to offset the costs of using a professional collection service when applicable. Services in conjunction with court issues.* Because of the unpredictability of court-related activities, other clients may need to be rescheduled on relatively short notice, or cannot be scheduled because of the need to prepare for a case. As a result, fees associated with court involvement are generally higher than our other fees. o Preparation time (including submission of records): $220.00/hr. o Phone calls: $220.00/hr. o Depositions: $250.00/hr for time actually in deposition or giving testimony in court. o Time away from office due to deposition or testimony $220.00/hr. o All attorney s fees and costs incurred by us as a result of the legal action. Counselor-client Services Agreement rev 20161101 Page 5

o Filing a document with the court: Actual filing fee plus compensation for time away from office at above rate. o Minimum charge for a court appearance (to be prepaid): $1500.00. o Reschedule fee (if case is rescheduled with less than 72 business hours notice): additional $500.00. *Centore, A. (2012). Why counselors must charge for administrative requests. Counseling Today 55(1), July 2012. Pp. 22-23. Please be aware that we assume that, when you contract for counseling, your intention is to work on your goals in good faith. Because of that, and also because your records contain protected health information, we will not appear in court without either your written consent, or a court order. Please also be aware that, if we are subpoenaed, the testimony we give will be objective and therefore may not be entirely in your favor. Except in the most unusual circumstances, we are unwilling to appear in court. In fact, it is our policy, if subpoenaed, to contact the attorney and explain our record-keeping process, which usually convinces them that we have nothing that would contribute to the case... or that our notes/testimony may be as damaging to the case as it would be helpful. Please bear in mind that the type of notes we keep are primarily process notes required for reimbursement, that address our interventions and your engagement, rather than content notes. As a result, our notes are not likely to be of value in legal proceedings. CONTACTING US Routine matters Due to our work schedules, we are often not available immediately by phone. If you need to reach us between appointments, please call the main office number (704-721-0000) and leave a message. This number does NOT ring in the office but the scheduling assistant checks voicemail several times each day. If your call is about a routine matter such as rescheduling an appointment, she will return the call. If you need to speak with any of the providers directly, she will send us an email and we will respond at the first opportunity, however if it is a day that we are fully booked, we may not have time to return your call until after we finish seeing clients for the day. Please allow up to 24 hours for a response. Urgent matters or confidential communications If you are running late for an appointment with us and want to let your provider know, you may call or text your provider s personal cell phone number that is on the back of your appointment card. If you need to reach us on a weekend, you may either text/call your provider s cell number, or email your provider at the edress on the appointment card. This personal contact information is printed on the back of the appointment cards for your convenient reference. Please use these only if you need to speak with your provider directly. Issues about cancelling or rescheduling appointments will be forwarded to the scheduling assistant and she will contact you on Monday. Please be advised that, although only the individual providers have access to their email accounts, communications via email are not as secure as those through text or voicemail. By signing this document, you give us permission to use email to communicate with you as we consider necessary. We will make every effort to return your communication on the same day you make it, even on weekends and holidays. If you are difficult to reach, please inform us of some times when you Counselor-client Services Agreement rev 20161101 Page 6

will be available, or leave enough information that the dialog can be continued in a series of emails, texts, or voicemails. If you are unable to reach us and feel that you can t wait for us to return your call, call the emergency contact number on your provider s voicemail, contact your family physician, a mental health hotline, or the nearest emergency room and ask for the counselor [psychiatrist] on call. If your provider will be unavailable for an extended time, he or she will provide you with the name of a colleague to contact, if necessary. LIMITS ON CONFIDENTIALITY The law protects the privacy of all communications between a patient and a counselor. In most situations, we can only release information about your treatment to others if you sign a written Authorization form that meets certain legal requirements imposed by HIPAA. There are other situations that require only that you provide written, advance consent. A more complete description of your protection under HIPAA and the way this office may or may not utilize your information is provided in the NOTICE OF PRIVACY PRACTICES. Your signature on this Agreement and the NOTICE provides consent for those activities. PROFESSIONAL RECORDS You should be aware that, pursuant to HIPAA, we may keep Protected Health Information about you in two sets of professional records in order to protect your privacy. One set constitutes your Clinical Record. It includes information about your reasons for seeking therapy, a description of the ways in which your problem impacts on your life, your diagnosis, the goals that we set for treatment, your progress towards those goals, your medical and social history, your treatment history, any past treatment records that we receive from other providers, reports of any professional consultations, your billing records, and any reports that have been sent to anyone, including reports to your insurance carrier. Except in unusual circumstances that involve danger to yourself and/or others or if the record makes reference to another person (unless such other person is a health care provider) and we believe that access is reasonably likely to cause substantial harm to such other person, you may examine a copy of your Clinical Record, if you request it in writing. Because these are professional records, they can be misinterpreted and/or upsetting to untrained readers. For this reason, we recommend that you review them in our presence or have them forwarded to an appropriate professional who can assist you in understanding the content. In most circumstances, we are allowed to charge a copying/processing fee. If we refuse your request for access to your records, you have a right of review, which we will discuss with you upon request. In addition, we may also keep a set of Psychotherapy Notes. These Notes are for our own use and are designed to assist us in providing you with the best treatment. While the contents of Psychotherapy Notes vary from client to client, they are usually quite brief, and can include the contents of our conversations, our analysis of those conversations, and how they impact on your therapy. They also contain particularly sensitive information that you may reveal to us that is not required to be included in your Clinical Record and information revealed to us confidentially by others. These Psychotherapy Notes are kept separate from your Clinical Record. Your Psychotherapy Notes are not available to you and cannot be sent to anyone else, including insurance companies without your written, signed Authorization. Insurance companies cannot require your Authorization as a condition of coverage nor penalize you in any way for your refusal to provide it. Again, if you request these notes sent to anyone, a processing fee will apply. Counselor-client Services Agreement rev 20161101 Page 7

MINORS & PARENTS Children of any age have the right to independently consent to and receive mental health treatment without parental consent and, in that situation, information about that treatment cannot be disclosed to anyone without the child s agreement. While privacy in psychotherapy is very important, particularly with teenagers, parental involvement is also essential to successful treatment and this requires that some private information be shared with parents. It is our policy not to provide treatment to a child under 18 unless parent(s) agree that we may keep information the child shares with us confidential unless the child agrees that it be shared. (We will, however, share impressions and interventions at our own discretion.) Any other communication will require the child s Authorization, unless we feel that the child is in danger or is a danger to someone else, in which case, we will notify the parents of our concern. Before giving parents any information, we will discuss the matter with the child, if possible, and do our best to handle any objections he/she may have. Also, experience has taught us that a child is part of a family system and consequently when a child is the client, sometimes it is important to work with the family system and/or parents as well. Your child s counselor may at times ask to meet with one or both parents, or for the family to try some exercises. BILLING AND PAYMENTS You will be expected to pay for each session at the time it is held, unless we agree otherwise or unless you have insurance coverage that requires another arrangement. Payment schedules for other professional services will be agreed to when they are requested. If your account has not been paid for more than 60 days and arrangements for payment have not been agreed upon, we have the option of using legal means to secure the payment. This may involve hiring a collection agency or going through small claims court which will require me to disclose otherwise confidential information. In most collection situations, the only information we release regarding a client s treatment is his/her name, address, the nature of services provided, and the amount due (including the costs associated with collection). INSURANCE REIMBURSEMENT If you have a health insurance policy, you are responsible for determining what coverage you have for mental health services. Once you have provided us with the necessary information, we will fill out necessary forms and file them with your insurance company, so we can assist you in receiving the benefits to which you are entitled; however, you (not your insurance company) are responsible for full payment of my fees. It is very important that you find out exactly what mental health services your insurance policy covers. You should carefully read the section in your insurance coverage booklet that describes mental health services. If you have questions about the coverage, call your plan administrator. Of course, we will provide you with whatever information we can based on our experience and will be happy to help you in understanding the information you receive from your insurance company. If it is necessary to clear confusion, we will be willing to call the company on your behalf. You may have an insurance plan that limits the number of sessions you are allowed. Such plans often require authorization before they provide reimbursement for mental health services, and are often limited to short-term treatment approaches designed to work out specific problems that Counselor-client Services Agreement rev 20161101 Page 8

interfere with a person s usual level of functioning. If you have such a plan, it is your responsibility to obtain the necessary authorization prior to the first session. You should also be aware that your contract with your health insurance company requires that we provide it with information relevant to the services that we provide to you. We are required to provide a clinical diagnosis. Sometimes we are required to provide additional clinical information such as treatment plans or summaries, or copies of your entire Clinical Record. In such situations, we will make every effort to release only the minimum information about you that is necessary for the purpose requested. This information will become part of the insurance company files and will probably be stored in a computer. Though all insurance companies claim to keep such information confidential, we have no control over what they do with it once it is in their hands. In some cases, they may share the information with a national medical information databank. We will provide you with a copy of any report we submit, if you request it. By signing this Agreement, you agree that we can provide requested information to your carrier. Once we have all of the information about your insurance coverage, we will discuss what we can expect to accomplish with the benefits that are available and what will happen if they run out before you feel ready to end your sessions. It is important to remember that you always have the right to pay for our services yourself to avoid the problems described above. YOUR SIGNATURE BELOW INDICATES THAT YOU HAVE READ THIS COUNSELOR-CLIENT SERVICES AGREEMENT AND PROFESSIONAL DISCLOSURE STATEMENT IN ITS ENTIRETY AND AGREE TO ITS TERMS. Client signature date printed name Other signature (Relationship to client ) Signature date printed name o Sandra H. Ritter, PhD, LPCS Provider s Signature date o Sarah M. Deese, MA, LPC o Charlotte M. Eure, MA, LPC-A o Adrian J. Fabrikant, MA, LPC o Brittiny Ingram, MA, LPC-A o Lillie Jacobs, MSW, LCSW o Shannon M. Lomax, MA, LMFT o Christopher Lloyd, MS, EdS, LPC-A o Debra P. Martin, MA, LPCA o Lorrie J. Miller, PhD, LPC o Stephanie Pierce, MA, LPC, LCAS o Valerie Saucier, MA, SLP-CCC Counselor-client Services Agreement rev 20161101 Page 9