Last Revised: 09/17/2020
This document contains information about my professional background as well as the services offered, prices, and your rights in this process. Please review the document carefully. If you agree to the terms below, please sign and return the form to me. If you have any questions about any of the information in this document, I will be happy to discuss them at our next session.
My Education: I am a graduate student of the Mental Health Counseling Program in the Addictions track from The University of North Carolina at Charlotte. I will be graduating from the program in 2021. I obtained my B.S. in Psychology from The University of North Carolina at Charlotte, in 2016.
My Qualifications: I began working with clients during my graduate, practicum experience, at The University of North Carolina at Charlotte. I have roughly 1 year of professional counseling experience. Throughout this time, I have worked with children, adolescents, and adults. I have worked mostly with adolescents, with a variety of mental health issues. Some include, addiction, grief and loss, depressive and anxiety disorders, and impulsive disorders. The population I work with are adolescents and adults with addictions, families, children, and those with mental health disorders.
It is a challenge to come and commit to counseling, so thank you for your bravery and willingness! As your counselor, it is my job to create a safe space for all to heal and to help improve the quality of your life. My theoretical orientation is not specific to one belief. I use a variety of techniques and concepts from various theories while staying true to my core orientation of Psychoanalytic, Gestalt and Person-centered theories. From the Psychoanalytic Theory, I believe that we all are driven by our conscious and unconscious mind and memory. I believe our thoughts and memories control most of our lives. Once we begin to uncover hidden or unconscious thoughts, we become more aware of ourselves, our motivation and drive.
I have core beliefs in these theories. However, I strongly believe that all people are different. What is effective with one person may not be as effective for someone else. Knowing this, I will pull from different techniques and theories depending on the need of each client.
Though you are seeking help from me, I want to help foster an open, therapeutic relationship. As I strive to make you feel more empowered and comfortable, please feel free to inform me if you do not feel my services have been effective. Honesty and openness benefit relationships, including the therapeutic relationship. It is my job to help you. I desire to do so, to the best of my ability. What you put into this process, you will also receive. I commit to putting in the time and effort to conduct positive change and I hope that you will do the same.
Restricted Licensure: I am a 2021 Candidate for Master of Arts in Counseling (Addictions Concentration) intern. Therefore, I am under the supervision of a Licensed Professional Counselor Supervisor by the name of Ms. Asha Sims. Her License # is S4135. She is the owner of Ashakti Wellness &Yoga, LLC. Ms. Asha Sims, MA, LPCS, RYT-200 can be reached at email@example.com or 980.202.1183.
Appointments: We can schedule our appointments via phone or in person at the end of a session. We can also schedule a standing appointment. I generally recommend that 50-minute sessions be scheduled at least biweekly to support the continuity and depth of our work together. If, however, this is not workable for you I am open to other arrangements based on your needs.
Payment: I accept cash and credit cards. Fees are due at the end of each session. I currently do not accept insurance.
Use of Diagnosis: I currently do not accept insurance. However, some health insurance companies will reimburse clients for counseling services and some will not. In addition, most will require that a diagnosis of a mental-health condition and indicate that you must have an “illness” before they will agree to reimburse you. Some conditions for which people seek counseling do not qualify for reimbursement. If a qualifying diagnosis is appropriate, a counselor must inform you of the diagnosis before it is submitted to the health insurance company. Subsequently, any diagnosis made will become part of permanent insurance records.
Confidentiality: All of our communication becomes part of the clinical record, which is accessible to you upon request. I will keep confidential anything you say as part of our counseling relationship, with the following exceptions: (a) you direct me in writing to disclose information to someone else, (b) it is determined you are a danger to yourself or others (including child or elder abuse), or (c) I am ordered by a court to disclose information.
Electronic Communications Policy: If you decide to email or text me at firstname.lastname@example.org or 336-963-0159, please be advised that electronic mediums such as email and text messages are not secure. I cannot guarantee the confidentiality with these forms of communication.
Emergencies: In a crisis situation, you may need assistance before an appointed session. If this is the case, please call 911. You may also contact your local emergency room for assistance.
Termination: Termination of therapy should not occur by telephone. Completion is an essential part of the process. For this reason, I strongly suggest that we use one to three sessions to conclude our work in therapy. However, if at any time, you find that this therapeutic process is not meeting your needs, you have a right to request a change in direction or discontinue treatment. If more than 60 days have passed since our last contact and I have not received any contact from you, I will accept that as your notice that you no longer wish to continue counseling and that our therapeutic relationship is terminated.
Complaints: Although clients are encouraged to discuss any concerns with me, you may file a complaint against me with the organization below should you feel I am in violation of any of these codes of ethics. I abide by the ACA Code of Ethics (http://www.counseling.org/Resources/aca-code-of-ethics.pdf).
North Carolina Board of Licensed Professional Counselors
P.O. Box 77819 Greensboro, NC 27417
Phone: 844-622-3572 or 336-217-6007
Acceptance of Terms: We agree to these terms and will abide by these guidelines.