Kristin Reiners, MA, LPC-S, RPT, NCC Policies and Procedures Missed Appointments/Cancellations First and foremost if you need to cancel an appointment and/or reschedule it must be done 24 hours in advance to avoid a $75.00 missed appointment fee. After 3 missed appointments Kinderton Counseling reserves the right to terminate continued services. I can be reached at 336-745-9719 and check my messages regularly. Extreme circumstances, of course, will be taken into consideration. Inclement Weather KC follows the W-S Forsythe County School weather policy. If schools are closed generally we will be closed. Please call though to make sure as sometimes I will still come into the office to see anyone who would still like to come in. There will be no charges for appointments missed and rescheduled due to weather. Fee Structure and payments 90791: Intake $150.00 90837/90834: Individual Counseling $120.00 Phone calls, written reports, or Correspondence more than 10-15 minutes: $100.00 (per hour pro-rated) Co-pays and deductible payments are expected at the time of service by cash or check. You will receive statements monthly. Balances are expected to be paid within 30 days. After 60 days Kinderton Counseling will turn the balance over to Credit Collections along with a 25% administration fee. Their number is 777-3555. This could adversely affect your credit rating so please be conscious of prompt payments! Thank you! Legal Matters and Fee Structure Please know that I must be fully informed regarding custody situations. If there is custody agreement please provide me with a copy of it for my records along with any supporting documents. If I am ever legally requested for court testimony, understand I am representing the child who is my client not either of the parents. Sometimes my notes will be subpoenaed. I will write summary statements when notes are requested and all parties involved will receive a copy. Phone consultations with lawyers: Written reports and correspondence: Stand by consultation on day of court: In person court appearance: Expert Letter of Recommendation for Judge $150.00 per hour pro-rated $150.00 per hour pro-rated $150.00 per hour pro-rated $250.00 per hour including travel time $100.00 per hour, minimum 3 hours Payments are expected the same as above and the same policies apply. I have read and understand the policies and procedures of Kinderton Counseling. My signature below acknowledges my agreement to adhere to the expectations and I understand my obligations. ----------------------------------------------------------------------------------- ------------------------------------- Signature Date
Kristin Reiners, MA, LPCS, RPT, NCC Professional Disclosure Statement Welcome to counseling. This statement, as prepared for you and required by the North Carolina Board of Professional Counselors, will hopefully answer any questions you have and help you feel more comfortable with the therapy process you are about to begin. Qualifications I earned a Masters in Counseling Psychology from Johns Hopkins University, MD, in 1994. Subsequently I earned 700 Hours in Life Coach Training from the Coaches Institute California in 2000. I worked in the public school system in MD. while completing the requirements and supervision required for the LPC for several years and then in 2005 received my NCC (National Counselor Certification) and LCP (Licensed Professional Counselor) certification. I continued on with my education and in 2009 became an RPT (Registered Play Therapist). In 2010, I moved to NC where I continue my work in the public schools and run a small private practice. I am a member of The American Play Therapy Association (APT), The North Carolina School Counselor Association (NCSCA), and The American School Counselor Association (ASCA). Therapeutic Approach I believe each client is an individual, created by a loving God, with individual needs and responses. With respect to your unique beliefs, temperament, learning style, strengths, and cultural history, I use an eclectic approach using primarily Cognitive- Behavioral Therapy (how thoughts and feelings influence behavior). I also infuse the safety felt in client centered therapy, and problem solving therapies/life coaching such as Rational Emotive Therapy. I believe in a partnership between client and therapist where we collaborate, explore, and brainstorm together. I believe your healing answers lie within you and together we co-design your path. I work with women, children and adolescents quite often incorporating art, biblio-therapy (use of books), imagery, and other expressive modalities to foster freedom of self-expression. Confidentiality I am honored to have your trust prior to, during and after your journey with me is complete. Your therapy sessions are held in complete confidentiality and you will be treated with complete respect. None of your information can be disclosed or discussed without your written consent which I will only ask for if it would benefit you and your progress. I am bound by North Carolina Law and my Professional Code of Ethics. However, there are a couple of exceptions to this rule: 1. If you are a danger to yourself or others I am bound by law to take any action necessary to protect you and to warn and protect anyone I believe could be harmed by your actions. 2. If I suspect Child Abuse/Elder Abuse is occurring- including neglect, I am bound by law to report it to the Department of Social Services. 3. If at any time you are involved in court proceeding I m ay be required release your records. Scheduling I schedule my own appointments by phone (336)745-9719. We will decide together if you would benefit most from weekly or bi-weekly appointments. This can often fluctuate. Each session will be 45-50 minutes in length. Your first appointment will be $120.00 and you are expected to come with your forms in order to maximize your time! Subsequent sessions will be $100.00 and all appointments are payable by cash or check the day of appointment. Please check with your insurance carrier to see what your out of network benefits will be. You are responsible for filing this. Please know that I must put a mental health code on your paperwork and this will be part of your permanent insurance record. Questions or Complaints You have the right to be fully informed. If at any times your have any questions or concerns about me, my qualifications or anything you need me to know about you, please discuss this with me. If you believe I am not in compliance with my professional ethics or professional standards you can contact the North Carolina Board of Licensed Professional Counselors at P.O. Box 1369, Garner, NC. 27529 (919) 661-0820. I have read and understand the Professional Disclosure Statement and in doing so also admit to having read the HIPPA policy and understand my rights to privacy via HIPPA. Client Signature Date Counselor Signature Date
Consent For Treatment I hereby give my consent to my clinician, Kristin Reiners (MA, LCP-S, RPT) to provide evaluation, treatment and/or other services that we may mutually determine to be appropriate. I understand that services will be rendered in a professional manner, consistent with accepted ethical standards. I understand that I will likely gain the most benefit from counseling if I am committed to the process and attend regularly. I also understand that it is not uncommon, over the course of therapy, to temporarily experience increased distress. This is an indicator that important work is underway and significant changes are beginning. I understand that no promises have been made to me as to the results of treatment or any procedures provided by this therapist. In addition, I understand that Kinderton Counseling is dedicated to the development of new counselors and actively supports the profession. Therefore, from time to time, students completing their course of studies will act as Interns and Practicum Pre-Professionals. I may, at times, have an intern or practicum student observing my session or even participating. This student or intern will be fully supervised and under the same oath of confidentiality as my licensed professional. Signing below indicates you I consenting to this possible situation. I acknowledge that I have received and have read the professional disclosure statement and the HIPAA information sheet. I understand that I may ask questions at any time about any of the information given to me, and about treatment options. In addition, I am aware of the constraints involved with confidentiality. I understand that the fee for the initial assessment it $120.00 and $100.00 for subsequent sessions. I have read the fee schedule and understand that I must cancel an appointment at least 24 hours in advance otherwise I will be assessed a $75.00 fee. Payment is due and payable to the therapist at the beginning of each session. Fees may be paid via check or cash. Credit cards will not be accepted. I understand if payments are not made the therapist has the right to stop treatment. I understand that phone calls will be returned to me within a 24 hour period. If I am in an emergency situation I will seek help immediately from an emergency room. Patient signature Date CONSENT FOR TREATMENT OF CHILDREN AND ADOLESCENTS: I give Kristin Reiners consent to treat minor child Signature of Parent or Guardian Date
KINDERTON COUNSELING CLIENT S BILL OF RIGHTS Each client has a right to impartial access to treatment, regardless of race, religion, sex, sexual preference, marital status, veteran status, ethnicity, age or handicap. The personal dignity of each client is recognized and respected in all care or treatment provided. Each client has the right to accept or refuse all or part of his/her care and /or have the expected consequences explained. Each client has the right to expect that all treatment records or information will be kept confidential in compliance with agency policy except as authorized and as required by law. No information/records will be released without written permission of client or other appropriate designee, except to the physician, insurance company or hospital/facility client transferred to. The client will have access to all their health care records. Each client has the right to exercise personal privacy by withholding consent or family s or significant other s participation and to be informed of the possible consequences of that action. Each client has the right to be informed of the nature and purpose of any services rendered and the title of personnel providing that service. Each client has the right to participate in the development of their plan of treatment, evaluate the plan of treatment and voice grievances without fear of negative impact on the service provided and be aware of the process of voicing those grievances. It is the right of each client to receive individualized treatment which includes: o Adequate and humane services regardless of the source of financial support. o Services provided in the least restrictive environment possible. o An individualized treatment plan which is reviewed periodically and as needed. o To be treated by competent, qualified and experienced professional clinical staff who are supervised as appropriate. If at any time during the course of treatment it is felt by client, the family, or surrogate decision maker that a care-related conflict exists between themselves and the agency - they have the right to request the opinion of or have their plan reviewed by a staff consultant or an independent consultant at his/her expense. The client has the right to request a referral for services which the organization does not provide, to be involved in the discharge planning process, and be aware of any aftercare needs. The client will be informed of his/her rights in a language they can understand. Each client has the right to refuse to participate in any research projects without compromising their access to the organizations resources. Each client has the right to be notified of any/all costs of services rendered, the source of the organization s reimbursement, and any limitations placed on duration of services. Each client has the right to make decisions regarding the withholding or resuscitative measures with these decisions respected per agency policy.:the above Bills of Rights have been reviewed with me and any questions I may have had were explained to my understanding. A copy of the Client s Bill of Rights was given to me. Patient/Guardian Signature Date