PROFESSIONAL DISCLOSURE STATEMENT Information and Consent

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1 Molly Casebere, M.S., LPC, NCC Licensed Professional Counselor, North Carolina (License # 8518) Nationally Certified Counselor (Certification # ) PROFESSIONAL DISCLOSURE STATEMENT Information and Consent Thank you for seeking counseling services with me. The following will provide you with background information and also details of what our professional counseling relationship will look like. Please don t hesitate to ask any questions you may have. Education and Experience I received my Master s Degree (M.S.) in Counseling and Educational Development, with a specialization in Student Development in Higher Education, from the University of North Carolina at Greensboro in I have received certification from the National Board for Certified Counselors (#239857) which demonstrates that I have met certain standards in education, knowledge, and experience. I am also currently licensed as a Professional Counselor (LPC #8518) in the state of North Carolina. In addition, I previously obtained a M.S. in Exercise and Sport Science, with a specialization in Sport and Exercise Psychology, from the University of North Carolina at Greensboro in I have been a practicing counselor since 2008 and have additional sport psychology consultation experience. The populations I am most competent in serving include adolescents and adults. Particular subjects that may be addressed may be developmental in nature, adjustment struggles, personal and career issues, as well as athletic performance enhancement. I have experience working with clients experiencing anxiety, depression, low self-esteem, relationship issues, sexual orientation concerns, substance use and abuse, identity development, adjustment and transition issues, bipolar disorders, personality disorders, previous abuse (emotional, physical, and sexual), and eating disorders. If I do not have the experience or training necessary to competently address your concerns, I will refer you to anther mental health care provider who can adequately do so. Counseling Philosophy and Client Responsibilities The relationship between me, as a counselor, and my clients is one of respect, trust, and cooperation. Establishing personal rapport is vital to any successful relationship and must be accomplished in the early stages of counseling in order to foster growth. If a quality helping relationship is not established, little, if any progress will be made due to lack of trust. You and I will work collaboratively to determine the goals for counseling and decide on an appropriate treatment plan. I utilize a variety of counseling theories and techniques depending on what best suites each individual client. These often include Cognitive Behavioral Therapy, Acceptance and Commitment Therapy, Reality Therapy, and Solution-Focused Therapy among others. It is possible that you may experience some emotional discomfort or even an increase of unpleasant symptoms during the counseling process. This is a common experience and is often necessary for growth in achieving your long-term goal. Counseling requires effort from both and/or all parties involved. I feel that it is your responsibility to do your best to try to improve or make changes, while it is my responsibility to listen, educate, and help implement behavior change. I consider my role as facillatory. I can try to help as much as possible, but you must be willing to put forth the work and effort in order to be successful in creating meaningful change. I believe that much of your growth will occur outside of our sessions, which is why I often utilize homework assignments. It is your responsibility to complete these mutually agreed upon tasks in order to maximize progress. I believe that each individual is capable of making the positive changes they want to see in their life. I also believe that each individual is responsible for his or her actions.

2 Dual Relationships The counseling relationship is a contractual, professional relationship and will remain just that. Although sessions are psychologically intimate, the therapeutic relationship is not social. It is critical that the professional relationship be based on respect, safety and trust. Therefore, it is in your best interest that contact with me be limited to counseling sessions or telephone conversations necessary to your therapy. Confidentiality Imperative to our relationship is the importance of confidentiality. Your case records will remain safely locked at all times and will not be disclosed to anyone, including another professional or family member, without your express written consent. Anything told to me, except for the following exceptions will be kept in complete confidentiality: Abuse of Children or Elderly Persons: If a mental health professional reasonably believes that a child under the age of 18 or an elderly person is being abused or neglected, s/he is legally obligated to report this situation to the appropriate state agency. Imminent Harm to Self: If a mental health professional reasonably believes that you are in imminent danger of physically harming yourself (including significant alcohol and/or drug abuse) and if you are unwilling or unable to follow treatment recommendations, s/he may have to make an involuntary referral to a hospital and/or contact a family member or other person who may be able to help protect you. Imminent Harm to Others: If a mental health professional reasonably believes that you are seriously threatening physical violence against another person, or if you have a history of physically violent behavior, and if s/he believes you are an actual threat to the safety of another person, s/he may be required to take some action (such as contacting the police, notifying the other person, seeking involuntary hospitalization, or some combination of these actions. Peer Supervision: In order that I may provide you with the best services possible, and in accordance with professional ethics, I may, at times, participate in peer supervision/consultation with other Licensed Professional Counselors (LPC s) so that I may receive feedback about treatment strategies and other ways in which I may be most effective as your counselor. Please note that even in these colleague consultations I will not reveal your identity without your express written consent. Court Order: In rare circumstances Professional Counselors can be ordered by a judge to release information regarding treatment, diagnosis and history. In situations where a client maintains an unpaid balance on their account without having made special arrangements, the account will be turned over to the Credit Bureau, resulting in identification as a client. Fees Fees for professional services are dues at the time of each session. The fee for an initial Intake interview is $ Standard fee for each subsequent session is $ per session. Cash, personal checks, and Visa or Master Card are acceptable forms of payment. If I am summoned to court on your behalf you are responsible for paying my hourly fee for any time spent in transcribing records requested by you, time in court, including, but not limited to, travel, meals, and any wait time prior to actual court appearance. Insurance Triad Counseling and Clinical Services, LLC will file insurance claims on your behalf. If you have a deductible it is our policy to collect the entire fee for the session and any subsequent sessions until your deductible has been met. However, once the deductible is met you are only responsible for your portion of the fee thereafter. If your insurance benefits state that you are responsible for a set co-pay or co-insurance, you will only be required to pay that amount on the date services are rendered. Should your insurance program have special arrangements, please discuss this with our Insurance Coordinator. Please remember that my professional services are rendered to you, not the insurance company. In accepting my services you also accept the responsibility of paying for these services should your insurance company pay only a part of the fee or deny the claim altogether. A minimum of 50% of the service fee is expected at the time of service if the co-payment is not known.

3 When insurance is utilized for therapy services, clients should be aware of the limits of confidentiality and the fact that filing for insurance requires a diagnostic statement to be placed in your insurance records. The forms must be signed by you in order to authorize the release of confidential information. If you wish to be informed of the diagnosis before it is submitted to your health insurance company, please make me aware of this, and I will discuss the diagnosis fully with you. Typically, insurance companies require the following information: diagnosis, dates of service, the type of service you received (i.e. individual, group, family, etc.), and the name of the client. Some managed care companies require additional information. Thus, you may not have the extent of confidentiality that you might otherwise expect. Signing this agreement authorizes the release of information to your insurance company. Length of Sessions, Missed appointments/cancelations Sessions will last for minutes and the number of sessions will be determined on a case-by-case basis. If you cannot keep your appointment, you should notify me as soon as possible. There is no charge if a cancellation is made at least 24 hours in advance, however, you may be charged for a cancellation within 24 hours of the scheduled appointment. You will be charged for a missed appointment that is not cancelled. Insurance companies will not pay for missed appointments; therefore you will be responsible for the session fee. In the case of a cancelled or missed appointment, there is no guarantee that I will be able to reschedule on short notice, though I will try my best to accommodate. Therapist Cancellations/Vacations I will make every effort to inform you as soon as possible if I need to cancel an appointment. In the event of inclement weather, illness, or other emergency, we may re-schedule for another suitable time. I will inform you at least one week in advance of scheduled vacations. If I am out of town, you may leave a message for me at (office). Client Emergencies If you have a severe crisis and are unable to contact me, please call the Guilford Center for Behavioral Health and Disability Services at (during business hours), (after hours), High Point Behavioral Health ( ), Moses Cone Behavioral Health ( ) or the Guilford County Emergency number (911). If you are outside of Guilford County, please call the emergency number for the county where you are. Office Staff Samantha Dabbs is the Office Manager for Triad Counseling and Clinical Services, LLC. Her office hours are 9:00am-4:30pm Monday-Thursday and 9:00am-12:30pm on Fridays. Tori George is the Office receptionist for Triad Counseling and Clinical Services, LLC. Her office hours are 8:30-4:30Monday-Thursday. Inquiries about accounts and insurance should be directed to either member of the staff, should you have a concern. Use of Mind-altering Drugs or Alcohol No smoking is allowed in the building. Please do not appear for a session under the influence of any mind-altering drug, including alcohol. Should the situation occur, the therapy session will not take place and you will be charged in full for the session. Such an occurrence may be considered grounds for termination of therapy Complaints If you are not satisfied with my services for any reason please do not hesitate to bring it to my attention. If we cannot work together to remedy the problem, a complaint may be reported to North Carolina Board of Licensed Professional Counselors, PO Box 1369, Garner, NC I look forward to working with you.

4 By signing this document, you acknowledge that you have read, understand, and agree to these conditions concerning counseling services. Client Signature: Date: Counselor Signature: Date:

5 Client Information Form The information requested on this form is confidential. You may choose to omit any item and discuss it with me in person. Date: Who referred you? Client Full Name: Nickname: Address: City: State: Zip: Home Phone: Work Phone: Cell Phone: Please indicate where we may leave a message for you. at home at work cell phone Date of Birth: Age: Social Security #: Emergency Contact: Name: Relationship: Phone: Employment History/Education History What is the highest level of education? High School Associate s Degree Bachelor s Degree Graduate School Employer: Occupation: How long? Current job satisfaction: Strongly Dissatisfied Dissatisfied Satisfied Strongly Satisfied Current Household Income: Under $30,000 $30,000 to $45,000 $45,000 to $60,000 Over 60,000 Relationship Information What is your current relationship status? Single Married Separated Divorced Widow/Widower Spouse/Partner Name: Date of Birth: Age: Employer: Occupation: Please list information about your previous marriages/ significant relationships: Name of partner: Start Date: End Date: Name of partner: Start Date: End Date: What are your current living arrangements? Personal Health History Have you been diagnosed with any medical conditions? No Yes If yes, please describe: Have you been hospitalized for mental illness or chemical dependency? No Yes If yes, please describe:

6 Please describe your current medications: Current medication Dose Frequency Reason for medication Prescribing Physician Please describe your previous counseling history: Dates of service Counselor s name Reason for services Outcome Briefly describe your reason for seeking counseling services: Reason for seeking counseling services Please describe your symptoms: Symptom Checklist Never Somewhat Moderately A lot 1. Feeling hopeless 2. Feeling anxious or worried 3. Loss of interest 4. Heart pounding or racing 5. Feeling nervous or shaky 6. Feeling fearful 7. Feeling angry or irritable 8. Overeating/binge eating 9. Sexual difficulties 10. Restlessness 11. Feeling sad 12. Repeated unwanted thoughts

7 13. Difficulty concentration 14. Stomach or intestinal distress 15. Self-injury 16. Difficulty falling asleep 17. Difficulty staying asleep 18. Difficulty at home 19. Difficulty at school or work 20. Suicidal or homicidal thoughts 21. Have you ever attempted suicide? No Yes 22. In the past 6 months, how often have you missed work due to physical or mental health? 23. How many alcoholic drinks have you had in the past week? 24. Have you felt bad or guilty about your alcohol or drug use? No Yes 25. Have you felt like you should cut down on your drinking or drug use? No Yes 26. Have others criticized your alcohol or drug use? No Yes Family History Where were you born? Where you were raised? What are the spiritual/religious practices of your family? What is your current religious/spiritual preference? Are your parents married? Yes No Is your mother remarried? Yes No Is your father remarried? Yes No Please provide a family description: Relative (Mother, Father, Siblings, Children, etc) Name Deceased (yes/no) Location Relationship (excellent, good, fair, poor) Physical/ Mental Illnesses

8 Insurance and Payment Information All professional services rendered are charged to the client. I understand that this office files my insurance as a courtesy and the bill is my responsibility. Therefore, I am responsible for all fees, including services not covered by insurance, unless expressly noted otherwise. It is customary to pay for services when rendered unless arrangements are made in advance. Who is financially responsible for the bill: Name Address City, St, Zip (if different) Name of Insurance Policy Holder Social Security of Policy Holder Date of Birth Release of Information : I hereby authorize Triad Counseling and Clinical Services, LLC to release any information necessary to process insurance claims concerning my diagnosis and treatment and I authorize payment of medical/psychological benefits to Triad Counseling and Clinical Services, LLC. I understand that Triad Counseling and Clinical Services, LLC, is ethically and legal required to report to legal authorities information I give about ongoing abuse of children, disabled and elderly persons and imminent physical danger I present to myself or others because of psychological factors. I have read, understand and accept the above terms and conditions. Client s Signature (Parent/Guardian) Date

9 Triad Counseling and Clinical Services, LLC 5603 B. New Garden Village Dr. Greensboro, NC and 232 Woodrow Ave High Point, NC CONSENT TO DISCLOSE INFORMATION FOR TREATMENT, PAYMENT OR HEALTH CARE OPERATIONS & ACKKNOWLEDGEMENT OF PRIVACY PRACTICES I hereby consent to the use or disclosure of my individually identifiable health information ( protected health information or PHI), excluding psychotherapy notes, by Triad Counseling and Clinical Services, LLC (Provider) in order to carry out treatment, payment, or health care operations (TPO). My specific authorization must be obtained for disclosure of my PHI, including summary of psychotherapy notes, for purposes other than TPO, except in special situations. I have reviewed the Notice of Privacy Practices for a more complete description of the potential disclosures of such information. I have the right to inspect and obtain a copy of my medical/mental health records, although I understand the Provider has the right to deny such request under certain circumstances. I have the right to have a denial to inspect reviewed by a reviewing official. A reasonable fee may be charged for providing a copy of my records. I have the right to request amendments to the information in my medical/mental health records, although I understand the Provider has the right to deny such request. I have the right to request an accounting of disclosures of my PHI for purposes other than TOP and those for which I provided authorization. I may submit a written privacy complaint to 5603 B New Garden Village Dr. Greensboro, NC or to the U.S. Secretary of the Department of Health and Human Services, without any action being taken by the Provider against me without any change in my treatment. Provider reserves the right to change the terms of its Notice of Privacy Practices at any time. If the terms of the Notice of Privacy Practices are changed, I may obtain a copy of the revised Notice by requesting a copy. I retain the right to request that the Provider further restrict how my protected health information is used or disclosed to carry out treatment, payment, or health care operations. The Provider is not required to agree to such requested restrictions; however, if the Provider does agree to by requested restriction(s), such restrictions are then binding on the Provider. At all times, I retain the right to revoke this Consent. Such revocation must be submitted to the Provider in writing. The revocation shall be effective except to the extent that the Provider has already taken action in reliance on the Consent. The Provider may refuse to treat me if I (or authorized representative) do not sign the Consent portion of this form (except to the extent that the Provider is required by law to treat individuals). If I (or authorized representative) sign the Consent portion and then revoke Consent, the Provider has the right to refuse to provide further treatment to me as of the time of revocation (except to the extent that the Provider is required by law to treat individuals). I CONSENT TO THE RELEASE OF PROTECTED HEALTH INFORMATION FOR TREATMENT, PAYMENT, AND HEALTH CARE OPERATIONS. I DO NOT CONSENT TO THE RELEASE FOR PROTECTED HEALTH INFORMATION FOR TREATMENT, PAYMENT, AND HEALTH CARE OPERATIONS. I HAVE HAD AN OPPORTUNITY TO REVIEW THE PROVIDER S NOTICE OF PRIVACY PRACTICES. Date: Signature of Patient (or authorized representative) Please Print Name Representative s Authority to act on behalf of the Patient: For Office Use only: Acknowledgement of Privacy Practices was not obtained because:

10 8/5/09 CONSENT FOR RELEASE OF MENTAL HEALTH INFORMATION This form is used to be able to discuss or release information to you (or your child s) primary care doctor only, in order to coordinate treatment. If you wish for information to be release to the primary care doctor only, please fill in the name of that doctor, check by the authorization line and sign and date the form. If you DO NOT wish for information to be released to the primary care doctor, check by the decline line and sign and date the form. Patient Name: Date of Birth: mo day year Mental Health Provider Name: Primary Care Physician Name: Primary Care Physician Address: Street City, State Primary Care Physician Phone: I authorize the release of relevant treatment information to the provider named above. I understand that these records are confidential and cannot be disclosed without my written authorization, except as otherwise provided by law. My consent may be revoked at any time, and expires one year from the date signed. I decline the release of treatment information to my Primary Care Physician. Signature of Patient of Legal Guardian Date Relationship to Patient

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