Client Form

Contract

This is a contract for services with Carolina Counseling Co, PLLC.  In order to begin therapy, you must consent to the following:

Consent to Treatment

I voluntarily consent to receive therapy services provided by Carolina Counseling Co, PLLC. I understand that if I am not seen for 60 days or longer, my case will be considered inactive and I will be terminated. I understand that I may resume therapy by calling Carolina Counseling at: 984-329-2754.I understand that this consent to service will be valid and remain in effect as long as I attend sessions through Carolina Counseling Co, PLLC, unless revoked by me in writing, with written notice provided to Carolina Counseling Co, PLLC. I understand that all communications with Carolina Counseling Co, PLLC are confidential and that no information about my session will be released without my written authorization and the written authorization.

Client Rights and Responsibilities 

You have a right to confidentiality. The only exceptions are: the reporting of child abuse as required by law, reporting of clients potential danger to self or others, reporting of clients grave mental disability (i.e.,inability to properly care for self, due to severe disability) or when ordered by a court of law to release

Information. Fees to appear in court are not discussed in this document, and are separate from session rates. Information about court fees can be provided upon request. As a client, you have the right to choose a therapist. If you work with me, you have a right to raise questions about my therapeutic approach and to request a referral if you believe you might make better progress with another therapist. In addition if for some reason treatment is not going well or not progressing, I may suggest you see another professional in addition to or instead of me. To assure quality of care, it is your responsibility to keep me fully up to date about any changes in your feelings, thoughts, and behaviors, and to cooperate with treatment to the best of your ability.

Benefits and Risks of Therapy 

As with any treatment, there are some risks as well as many benefits with therapy. You should think about both the benefits and risks when making any treatment decisions. For example, in therapy, there is a risk that clients will, for a time, have uncomfortable feelings. Clients may recall unpleasant memories. Clients may uncover problems with people important to them. Family secrets may be told. Therapy may disrupt a marriage (although my approach is to enhance relationships, not harm them). At times, a client’s symptoms may temporarily increase after beginning treatment. Most of these risks are to be expected when people are making important changes in their lives. Finally, even with our best efforts, there is a risk that therapy will not work for you. While you consider these risks, you should also know the benefits of therapy have been shown by scientists in hundreds of well-designed research studies. Therapy can help people feel less depressed or anxious. Clients’ relationships and coping skills may improve greatly. Their personal goals and values may become clearer. And they may grow in many ways.

No Secrets Policy 

I understand that the therapist may work with multiple members of my system. In relational (couples or families) cases, the therapist may need to share information learned in an individual session (or a session with only a portion of the treatment unit being present) with the entire treatment unit- that is, the family or the couple, to effectively serve the unit being treated. This “no secrets” policy is intended to allow the Therapist to continue to treat the couple or family by preventing, to the extent possible, a conflict of interest to arise where an individual’s interest may not be consistent with the interests of the unit being treated.

Seeing Each Other in Public 

If your therapist were to see you outside of therapy (e.g., the grocery store), they will protect your confidentiality by not acknowledging that they know you, however, you are free to initiate communication if you choose to do so.

Termination of Service 

Your therapist may terminate therapy with you in the following situations: 1.) you fail to pay the set fee; 2.) you are not cooperating with the appropriate treatment recommendations; 3) there is a discovered conflict of interest. 4.) you fail to provide adequate notice of canceling your sessions 3 consecutive times in a row. 5.)The practice is moving or closing.

Multiple Relationships 

The therapist can only be your therapist. It is unethical for a therapist to be a close friend or socialize with a client. Even though you are free to invite the therapist, they will not attend your family gatherings, such as parties or weddings. The therapist will not celebrate holidays or give you gifts, and they may refuse gifts from you.

Record Keeping 

The therapist keeps very brief records, noting only that you have met with them, your name(s) and signed disclosure statement, the session date and fee for service.

Confidentiality 

As a client in counseling, you have certain rights that are important for you to know about. There are also certain limitations to those rights of which you should be aware. As a client of a therapist, you have privileged communications under state law. With the exception of the situations listed below, you have the right to have information you share with me held in strict confidence; that information includes the fact that you are seeing me. The privilege is yours, not mine, and cannot be waived without your consent. I will always act to maximize your privacy even when you waive your right to confidentiality. The following situations are exceptions to your right of confidentiality. If I believe that you are likely to do harm to yourself or to another person, I am required by law 1. to take steps to protect you and/or the other person. If I believe that you may be physically or sexually abusing or neglecting a minor child or 2. vulnerable adult, or if you report information to me about the possible abuse or neglect of a child, I am required by law to report this to Children’s Protective Services, a state agency. If you are currently in litigation or become involved in litigation during the treatment process 3. or file a complaint against someone for malpractice, I may be asked to disclose information regarding your therapy as part of that process. Although I will request your consent to release information, I can be legally obligated by subpoena or court order to turn over my records and testify. Nevertheless, please inform me as soon as you know that you are likely to be in such a legal situation; so that I can exercise due caution so as to protect your privacy.

Disclosures may also be made if (a) you sign a written authorization permitting disclosure; (b)4. you file a complaint against me; (c) a contracted third-party agent contacts you by mail or phone to receive payment for a balance due that exceeds 90 days.

CANCELLATION POLICY 

As many of you are already aware, we are in the midst of a mental health crisis. Last minute cancellations hurt 3 people: You, your therapist, and another client, who could have potentially utilized your time slot. Therapy sessions are scheduled in advance and are a time reserved exclusively for clients. When a session is canceled without adequate notice, we are unable to fill this time slot by offering it to another current client, a client on the waitlist, or a client with a clinical emergency.

Clients who wish to cancel or reschedule an appointment must do so 24 hours prior to the day of their scheduled appointment time. Otherwise the full session fee will be charged. For example, if your appointment is 2pm Tuesday, you would need to let us before 2pm Monday to avoid the cancellation fee.

SCHEDULING FOLLOW UP APPOINTMENTS & PAYMENTS

You will be provided with the recommended course of therapy and sessions at the conclusion of your first appointment. Payments will be processed 24 hours prior to your appointment.

Professional Fees

 Payment of our professional fees is required in the following installments, and must be paid on request:

FEES FOR THERAPY

– $175 paid in full-per 55-minute Couples or Individual therapy session.

– Charges will go through 24 hours prior to each session via Ivy pay, a HIPAA compliant payment processor, to which you have consented to hold your payment information.

Please Note: the first Initial Ivy pay charge will go through upon the date of Ivy pay set up.

Acknowledgement

I understand and accept the contract terms as stated above. I understand by signing this form, I am opting out of using my insurance.  I understand that it is my responsibility to track my scheduled sessions and I will not receive a reminder from the therapist. I understand the above fee policy and agree to pay the above amount for the services being rendered and understand my payment will be processed 24 hours prior to my scheduled appointments. I understand that I forfeit a refund if I do provide notice of cancellation or request to reschedule to my provider 24 hours prior to my reserved appointment slot. I understand I am opting out of using my insurance. I understand insurance requires a diagnosis. I understand if I were to elect to receive the service of couples therapy, I understand that a couple cannot be diagnosed. I understand I cannot use the payment of sessions towards my deductible and my therapist will not provide superbills for reimbursement purposes. I have been given the opportunity to read this agreement and all related documents in full and in my own time. I have also been offered the opportunity to have any matters contained therein explained or clarified, prior to entering into this agreement.

I agree with the terms and conditions outlined above.