Professional Disclosure Statement

I am a 1983 Master’s level graduate of Ball State University’s Clinical Counseling Psychology Program in Muncie Indiana. I am licensed to provide counseling in Indiana (#39000101A), Missouri (#2023031437) and counseling and clinical supervision in North Carolina (#S8874)I have certifications as a Nationally Certified Counselor (#50377), as Certified Clinical Mental Health Counselor (#50377) and as a Board Certified TelMental Health Provider (BC-TMH #877)

Fees for your appointments will be billed to your insurance company or to you directly if you do not have insurance or choose to sign a waiver declining the option to use your insurance. Couples relationship counseling appointments are not billable to insurance and are private pay only at $150.00 per session..

Fees

90791 Intake appointment $200.16, 90837 52 - 60 mi app $168.61, 90834 25-52

app $116.76, 90832 17 - 27 app $116.76. 90846 & 90846 apps for family with or without pt $150.00.

Invoices will be emailed via Square Up and can be paid using a credit card or HSA card.

During the counseling process all information will be confidential with the following exceptions: If you believe you are a danger to yourself or someone else. If you have given me written permission to disclose information. In the case of abuse to a child or an adult, confidentiality will be waived. If the information is court ordered. If you desire to seek payment for services via managed care medical insurance company forwhich the disclosure of confidential information may be required for reimbursement. In the event that an accusation of misconduct is made a right to confidentiality is waived.

When situations arise where information must be shared, only pertinent information will be shared and as much as possible you will be advised before the information is shared. In the event the client is a minor, parents or legal guardianship may be induced in the counseling process as appropriate however steps will be taken to communicate with the best interest of the client in mind.

If at any time you have concerns about your counseling experience please let me know. If you feel that your concerns have not been adequately addressed contacting the following is an option:

North Carolina Board of Licensed Clinical Mental health Counselors Box 77819, Greensboro NC. 27417. PH 844-622-3572

LCMHCinfo@ncblcmhc.org.   web address:  ncblcmhc.org

Please be aware if you are seeking counseling support for the treatment of disordered eating, or it is determined that you are exhibiting symptoms of disordered eating you may be asked to engage in regular medical monitoring. Your medical provider may be asked to check your blood pressure and hard rate as well as order bloodwork. This information is necessary to ensure you are healthy enough to participate in outpatient counseling and may be monitored on an ongoing basis. You may be required to work with a dietician who has experience providing nutritional supports for persons with disordered eating to continue in counseling if there are symptoms of disordered eating. In the event that medical follow along and dietician services are recommended as a part of counseling- choosing to not utilize the medical monitoring and/ or dietician services may result in the discontinuation of counseling services and referral elsewhere.