223-D Commerce Street, Greenville, NC Phone: (252) Fax: (252)

Transcription

1 James A. Barbour, MS, LPC, LCAS, CSI, CHt Web: D Commerce Street, Greenville, NC Phone: (252) Fax: (252) JAMES A. BARBOUR, MS, LPC, LCAS, CSI, CHt Licensed Professional Counselor Licensed Clinical Addiction Specialist Clinical Supervisor Intern Clinical Hypnotherapist PROFESSIONAL DISCLOSURE STATEMENT Thank you for selecting me as your counselor or consultant. This document is designed to inform you about my credentials and background and to ensure that you understand our professional relationship. I earned dual Master s degrees in Rehabilitation Counseling, and Substance Abuse and Clinical Counseling in 2009 from East Carolina University in Greenville, North Carolina. I have been a professional counselor for more than five years. I have three years of experience as an Associate Professional prior to being a Licensed Professional Counselor or a Licensed Clinical Addictions Specialist. I obtained my hypnosis certification from American Society of Clinical Hypnosis in I am a Licensed Professional Counselor (LPC # 7996) I am a Licensed Clinical Addiction Specialist (LCAS # 1668) I am a Clinical Supervisor Intern I received Hypnotherapy Certification in COUNSELING SERVICES OFFERED/THEORETICAL APPROACHES People can make better decisions if they have enough information and understanding about how counseling works. Here are some aspects of counseling and therapy as I perceive and practice it: Counseling requires your active involvement including efforts to change and challenge self-defeating thoughts, feelings, and behaviors. You will be asked to work both in and out of the counseling sessions. There are no instant, painless, or passive cures, no magic pills. Instead there will be homework assignments and other projects. Most likely, you will need to work on improving stress management, belief systems, relationships, and your general lifestyle if counseling is to be successful. Sometimes change will be relatively easy but more often change takes much effort, time, and persistence. It is not uncommon that some psychological and behavior patterns have been reinforced for 20 to 30 years and will not change with insight alone. These entrenched thinking and behavior patterns will usually require much focused time and effort. I utilize an approach in which treatment is based in sound, evidenced-based practices indicated for Professional Disclosure Statement - 1 P a g e

2 treatment of symptoms. Theoretically, I rely heavily on cognitive and behavioral counseling theories, Gestalt counseling/therapy, Transactional Analysis, Redecision Therapy, Reality Therapy, and Hypnosis Therapy. These are well established, researched and respected therapies. I provide counseling services to children, adolescents and adults with mental health concerns as well as substance abuse disorders. Among other mental health concerns I provide services to help individuals and their families treat and/or manage the cause and symptoms of depression, anxiety, panic, phobia, conduct/behavioral disorders, trauma, grief, and substance use. I also provide treatment for relationship problems and career issues. I refer individuals to other mental health and rehabilitation professionals when appropriate. Mental health counseling and therapy can involve both benefits and risks. Potential benefits include becoming free from self-defeating and sometimes self-destructive behavior (e.g. substance abuse, negative self-talk); developing more satisfying relationships with other people; becoming happier and more loving; and living a healthier lifestyle. Risks might include experiencing uncomfortable feelings or difficulties with friends and family members during the counseling and/or rehabilitation process. Personal growth often involves change. Sometimes these changes in our usual ways of functioning and relating involve considerable stress. Major life changes like divorce and changing jobs or careers, although extremely distressful in the short run, may be the conclusion you arrive at as a potential. For example, a goal of counseling may not be to keep a dysfunctional marriage together at all costs. Sometimes it is in the best interest of both spouses and other family members to separate. CONFIDENTIALITY I regard the information you share with me with the greatest respect, so I want us to be clear about how it will be handled. Generally, I will tell no one what you tell me. The privacy and confidentiality of our conversations, and my records, is a privilege of yours and is protected by state law and profession s ethical principles, in all but a few circumstances. There are two circumstances in which I cannot guarantee confidentiality, legally and/or ethically: 1. When I believe you intend to harm yourself or another person; and 2. When I believe that a child or elder person has been, or will be, abused or neglected. In rare situations, professional counselors can be ordered by a judge to release information through a court order. Otherwise, I will not tell anyone anything about your treatment, diagnosis, history, or even that you are a client, without your full knowledge and usually a signed Release of Information Form. As a Professional Counselor I seek ongoing consultation from professional peers who are part of my process team. These individuals are also bound by the same confidentiality agreement stated for you here. Audiotaping and/or Videotaping. An important part of professional growth involves me being able to visit and review my work. I am able to do this by making a recording and listening to or watching previous sessions. When I do this, I better serve the needs of clients. All recordings are secured. You will find that recording does not affect our practice session so long as you and I are comfortable. If you wish, we can Professional Disclosure Statement - 2 P a g e

3 turn off the recorder at any time. EXPLANATION OF DUAL RELATIONSHIPS Although our sessions may be very intimate psychologically, it is important for you to realize that we have a professional relationship rather than a social one. Our contact will be limited to sessions you will arrange with me. Please do not invite me to social gatherings, offer me gifts, or ask me to relate to you in any way other than in the professional context of our counseling sessions. You will be best served while I am seeing you for counseling and therapy if our relationship stays strictly professional and if our sessions concentrate exclusively on your concerns. You will learn a great deal about me as we work together during your counseling experience. However, it is important for you to remember that you are experiencing me in my professional role. LENGTH OF SESSION, CANCELLATION POLICY AND OFFICE HOURS I assure that my services will be rendered in a professional manner consistent with accepted ethical standards. Sessions are approximately 60 minutes in duration. If you are unable to keep an appointment please call to cancel or reschedule at least 24 hours in advance at (252) If you fail to cancel a scheduled appointment, we cannot use this time for another client and you will be billed for the entire cost of your missed appointment. A full session fee is charged for missed appointments or cancellations with less than a 24-hour notice unless it is due to illness or an emergency. A bill will be mailed directly to all clients who do not show up for or cancel an appointment. Thank you for your consideration regarding this important matter. Please note that it is important not to guarantee any specific results regarding your counseling goals. Often, counseling and treatment goals change with increased understanding. Your counseling, treatment, or rehabilitation goals will likely be modified throughout the counseling process as you so desire. However, counseling and rehabilitation goals will always be your goals. Together we will work to achieve the best possible results for you. Office hours are Monday through Friday 10am to 7pm and by appointment only. Professional Disclosure Statement - 3 P a g e

4 FEES/METHODS OF PAYMENT FOR COUNSELING In return for the following fee (please see fee schedule below), I agree to provide counseling services for you. Initial Session 60+minutes - $ Individual/Couples/Family Session 60 minutes - $ Group Session* 2-4 people - $65 per person 5-8 people - $50 per person 9 or more - $40 per person I charge $ per day that I am subpoenaed for a court hearing; and $ per day for being on-call for court teleconference. My policy is that you pay for each session at the beginning of each session. Cash or personal checks are acceptable forms of payment. I also accept credit cards (Visa, MasterCard, Discover, and American Express). *Group rates will vary per group topic offered and per number of participants. FEES/METHODS OF PAYMENT FOR HYPNOSIS For standalone service of Hypnosis, or Emotional Freedom Technique the same fee schedule applies. Please note that your insurance provider may not cover these services and you are responsible and not your insurance company for paying the fees agreed upon. Smoke Cessation 3 sessions = $280 Professional Disclosure Statement - 4 P a g e

5 BILLING/INSURANCE REIMBURSEMENT I am currently on the Blue Cross Blue Shield of North Carolina network provider list. I am also on the MedCost network provider list. I am not on any other network provider list. Therefore, if I am not on your insurance company s provider list, please remember that you are responsible and not your insurance company for paying the fees agreed upon. Some health insurance companies will also reimburse clients for my counseling services and some will not. Those that do reimburse usually require that a standard amount be paid by you before reimbursement is allowed (deductible), and then usually only a percentage of my fee is reimbursable. You should contact a company representative to determine whether your insurance company will reimburse you and about what schedule of reimbursement will be used. However, please remember that you are responsible and not your insurance company for paying the fees agreed upon. Health insurance companies often require that I diagnose your mental health condition and indicate that you have a mental disorder or a mental illness before they will agree to reimburse you. In the event a diagnosis is required, I will inform you of the diagnosis I plan to render before I submit it to the health insurance company. Any diagnosis made will become part of your permanent insurance records. CRISIS PROCEDURES If it is an after-hours crisis please contact me at (252) Community crisis numbers include Real Crisis Intervention at (252) or Mobile Crisis Unit at (866) If you are experiencing a life threatening emergency, PLEASE DIAL 911. Professional Disclosure Statement - 5 P a g e

6 COMPLAINT PROCEDURES If you are dissatisfied with any aspect of our work, please inform me immediately. This will make our work together more efficient and effective. If you think that you have been treated unfairly or unethically, by me or any other counselor, and cannot resolve this problem with me, you can contact the North Carolina Board of Licensed Professional Counselors at P.O. Box 77819, Greensboro, NC 27417, , for clarification of client s rights as I ve explained them or file a complaint. If you have any questions, feel free to ask. Please sign and date this form. A copy for your records will be returned to you. I will retain a copy in my confidential records. _ Counselor s Signature James A. Barbour, MS, LPC, LCAS, CSI, CHt _ Date Client s Signature Date Parent Legal Guardian Date Professional Disclosure Statement - 6 P a g e