Professional Disclosure Statement and Information Regarding Counseling Practice

Margaret (Marge) W. Maycock, MA, LCMHC

Jodi Province Counseling Services

Appalachian State University, Boone, NC

May, 1981 BA Major: Psychology Minor: Sociology, English

Appalachian State University, Boone, NC

Licensed Mental Health Counselor - -1996, North Carolina License Number 2404.

License in Psychology (Masters level) State of Tennessee (1988) by Health Related Boards, Nashville, Tennessee

Thirty eight years of counseling experience.

General Areas of Competence and Populations Served in Mental Health Practice as well as

Children (age five and older), adolescents, and adults having depression or anxiety.

All ages of individuals suffering from Panic Disorder or Post Traumatic Stress Disorder.

All general areas of counseling need for ages five through elderly population, including oppositional defiant disordered youth and their families, families where violence is present.

Individuals with severe and persistent mental illness

Couples with mental difficulties

Addiction issues as well as dysfunctional family of origin issues.

Victims of trauma and sexual abuse.

Mindfulness training as it relates to mental and physical functioning.

Individuals who have mental illness, personality disorder, brain or neural conditions as well as linkage to non-therapy related support systems.

Dialectical Behavioral therapy.

Insight oriented and solution focused therapies.

Session Fees and Length of Service

All therapy sessions, individual, marital, family or group therapy sessions will last between 50

minutes to an hour and a half.

My therapeutic orientation and techniques are based in humanistic and cognitive psychology and counseling.

The initial fee for the first intake therapy session is $165.00. The hourly rate for all other sessions is $145.00. We accept the hourly rate paid by Medicare. We will be willing to consider lowering your fee on a case by case basis if you are experiencing financial hardship. Once you have met your insurance deductible, we will accept copays for "specialist" and the allowed amount as paid for by your insurance company. We are credentialed with most insurance panels. Clients with Medicare may only be seen by therapists who have LCSW or Ph.D. certifications. We will accept payment by cash, check, and credit cards.

All clients who attend counseling sessions will have an appropriate diagnosis and corresponding code. This is a part of best practice protocol for counseling and will be explained to you. This provides a description of your presenting issues for which you are receiving counseling and is not meant to undermine your status as a person. Some health insurance companies will reimbuse clients for counseling services and some will not. In addition, most will require a diagnosis of a mental health condition and indicate that you must have an "illness" before they will agree to reimurse you. Some conditions for which people seek counseling do not qualify for reimbursement. If a qualifying diagnosis is appropriate in your case, I will inform you of the diagnosis before we submit the diagnosis to the health insurance company. Any diagnosis made will become part of your permanent insurance records.

Your clinical record is privileged communication between me, the therapist, and you, the client. The only exception to this would be in the event that you present a danger to yourself or others, a court order by a judge, or if there is a national security issue at stake. Substantial evidence of child or elder abuse will also waive rights of 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.

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 Clinical Mental Health Counselors; P.O. Box 77819; Greensboro, NC 27147; Phone: 844-622-3572 or 336-217-6007; Fax: 336-217-9450; E-mail: Complaints@ncblcmhc.org.

We agree to these terms and will abide by these guidelines.