Professional Disclosure Statement Deborah S. Wages, MA, LCMHC, NCC, BC-TMH Jodi Province Counseling Services Front Desk (336) 818-0733 This information is intended to inform you about my professional background and to describe certain aspects of our therapeutic relationship. Please read it carefully and feel free to ask any questions you may have. Qualifications I graduated with a master’s degree in Clinical Mental Health Counseling from Liberty University in August 2018. I completed my Practicum in Fall of 2017 and completed my Internship I & II in Counseling at Jodi Province Counseling Services in the Summer 2018. I am a nationally certified counselor as well as licensed with the state of North Carolina as a Licensed Clinical Mental Health Counselor (#14582). I am also a Board-Certified Tele-Mental Health provider. I have almost four years of counseling experience. Counseling Background and Process My counseling work has primarily focused on children, adolescents, and adults with concerns related to anxiety, depression, grief and trauma. My primary approach to counseling in an integration of person-centered, mindfulness-based, and cognitive behavioral therapies. My role is to assist you in reaching whatever goals you may have for yourself by providing non-judgmental support and helping to facilitate your journey, whatever form it may take. I strive to empower you and assist you in expanding healthy awareness, rather than to give you advice. Maintaining professional boundaries for both client and counselor is a vital component in the therapeutic relationship, and I will uphold those boundaries in order to ensure an appropriate therapeutic relationship and more positive therapeutic outcome. Length of Service Sessions begin on the hour and last 50 minutes each. The duration of counseling varies widely among clients depending on their needs and preferences. You may choose to terminate therapy at any time, but I strongly suggest that we have a final session together once you decide to terminate so that I am best able to help you prepare for and process the conclusion of our work together. Session Fees We are networked with several major insurance carriers including Blue Cross and Blue Shield, Medcost, Medicaid, Medicare, Cigna, Aetna, Tricare, Magellan, and NC Healthchoice. Co-pays are accepted in the form of cash, check, or credit. We are also credentialed with many local industry’s Employee Assistance Programs (EAP). Please check with your human resource department to determine eligibility. Private Pay Fees: Initial Intake $160.00 Counseling Sessions $140.00 Letters $45.00 FMLA Paperwork $25.00
Missed Appointments If you find that you must cancel or reschedule an appointment, please make an effort to contact the Counseling office at 336-818-0733 at least 24 hours in advance. The Counseling office’s policy is that if 3 appointments are “no-show” (i.e. failing to show up for a scheduled appointment without contacting us) your file will be closed and services will be considered complete. Effects of Counseling Embarking on a counseling journey is a brave undertaking that may challenge you at times. The counseling process may open up levels of awareness that could cause pain and anxiety as you work through them, and the process of change can be a difficult one that could cause disruption or discomfort in your life. While working through this discomfort at your own pace has the potential to yield very meaningful personal benefits, you always have the right to refuse to participate in certain therapeutic techniques. In the event that a psychological emergency should occur, please call 911 or go to nearest Emergency Department. Use of Diagnosis 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 is made 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 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 and may have ramifications in terms of costs of insurance and long-term insurability. Confidentiality I consider my clients’ confidentiality of the utmost importance and will keep confidential anything you say as part of our counseling relationship. However, there are a few rare circumstances in which I may be required to break confidentiality: (a) you give written permission to disclose information to someone else, such as another health professional, insurance company, or family member. (b) I determine that you are a danger to yourself or to others. I you disclose information that leads me to believe a child, disable person or elderly person is being abused or neglected. (d) I am ordered by a court to disclose information. (In unusual cases a client’s involvement in a custody or criminal dispute may lead to me receiving a court order). Divorce and Custody I sometimes work with high conflict families and families of divorce. If you ever become involved in a divorce/custody or other court-related dispute, I want you to be informed about the difference between the clinical and forensic role. In order to avoid dual relationships and conflicts of interest, I will provide your child with clinical services only. I do my best to avoid becoming involved n court related cases as they can erode the client-therapist relationship and may compromise your child’s ability to be honest with me during treatment. In addition, I do not participate in evaluation for adoption home studies or provide evaluations of parental fitness to adoption agencies or government entities. My role is strictly therapeutic and not forensic, meaning I cannot form an opinion on who a person should live with or visit with and who a person should or should not interact with. By signing this document and the end, you agree to and have been informed of the following regarding divorce and separation: • o I am ethically required to do my best to involve and obtain consent for treatment from both parents prior to me seeing your child. Please contact the other parent/guardian and inform them and ask them to contact me. I am happy to split an initial session for the parents in the event that both wish to be separate. • o In the event that the other biological parent’s whereabouts and/or contact information is unknown, let me know. • o I am ethically required to obtain the most up to date and full custody agreement prior to seeing your child. • o That my role is limited to providing treatment and that you and your lawyer cannot ask me to step outside my therapeutic role and step into a forensic role. • o Both parties are required to sign a release of information form in the even that I am subpoenaed. • o You understand that by you and/or your lawyer or judge subpoenaing me, there is a chance that your child’s record will become public knowledge. This is an obvious concern of mine, as I am protective over your child’s privacy and how this may cause him/her distress and distrust of me as their therapist. • o That you will not ask for my participation or recommendations in a custody evaluation, fitness of parent, adoption home study or dependency hearing. • o If I am called into court or receive a subpoena for records, I will charge a $100 retainer upon obtaining a subpoena which will be credit applied to the first hour, including time spent traveling, preparing reports, testifying, being in attendance, and any other case-related costs, then $100 per hour for subsequent hours. Complaints Although clients are encouraged to discuss any concerns directly with me, you may file a complaint against me with either of the organizations below should you feel I am in violation of the American Counseling Association Code of Ethics: (http://www.counseling.org/Resources/CodeofEthics/TPHome/CT2.aspx). North Carolina Board of Licensed Clinical Mental Health Counselors 7D Terrace Way Greensboro, NC 27403 336-217-6007 / Toll Free: 844-622-3572 Email: LCMHCinfo@ncblcmhc.org Gr Acknowledgement and Acceptance of Terms I have read and agree to these terms and will abide by these guidelines. I understand that I am free to ask questions or raise concerns at any point in the therapeutic process.