Informed. Consent
Informed Consent, Rights & Responsibilities Form
Welcome!
Please read through this introduction to my practice.
Treatment Process
The purpose of counseling is to help you achieve your personal goals and gain greater insight into your life through a process of exploration in therapy. You and I will work together to identify treatment goals and options. The length of time in therapy will vary according to individual needs and will be discussed throughout the course of your care. You are encouraged to talk as openly as possible about the problems you are experiencing so that I can better assist you in treatment planning.
Therapy has both benefits and risks. Risks may include experiencing uncomfortable feelings such as sadness, guilt, anxiety, anger, frustration, loneliness, helplessness and relapse. At the same time, benefits of therapy have been shown to decrease feelings of distress, increase satisfaction in interpersonal relationships, lead to greater personal awareness and insight and increase skills to manage stress and resolutions to specific problems. There are no guarantees about what will happen, however often improvement begins after the first session. Therapy requires an active effort on your part. In order to be most successful, you will be encouraged to work on issues we discuss outside of sessions. Prior to the first session you will be asked to complete introductory paperwork. In our first session, you will be asked to share your reasons for counseling and your current situation. You will be asked questions about your family as well as your own history. You will be asked to identify your strengths. You and I will make a treatment plan focusing on your behavioral health needs within the first two sessions and the frequency of your sessions will be based on your individual assessment.
Professional Orientation and Training
I received a Master's degree in Counseling from NDSU in 1991. I am a Licensed Professional Clinical Counselor (LPCC) in North Dakota since 1991 and I am a Licensed Clinical Mental Health Counselor in North Carolina since 2020. My focus since 2000 has been in adolescent and adult individual mental health therapy. I have special interests and training in the areas of shame, trauma and grief, women's issues, and family. I use a strengths based approach in my work and believe in respectful treatment of all my clients. I see myself as a partner with you in your own process of self discovery and learning. I am responsible for providing you with quality professional service. This includes maintaining your confidentiality and informing you about your condition/diagnosis and treatment options.
Confidentiality
I take very seriously the responsibility to hold in confidence what you discuss with me. Written permission is required to release any information to another agency or to receive any information from another agency. The only exceptions to this policy occur when there are concerns about possible abuse/neglect, threat of serious self-harm or harm to others, medical emergency or in response to a court subpoena. I am required by law to notify appropriate persons/agencies under these circumstances. This office is compliant with the HIPPA Privacy Act and 42 CFR Part 2.
Client Responsibilities
It is important that you arrange for a secure and confidential setting for your teletherapy sessions. It is important that you are on time for your appointments and that you call 24 hours in advance if you are unable to keep your scheduled appointment. You may be billed at the full rate for sessions that are missed without 24 advance notice.
After Hours
Office hours are by appointment only from Monday through Friday. Office hours may vary. In crisis situations you may contact me on my cell phone (701-261-4472). If I am unavailable or your situation requires immediate attention, you are instructed to go to the nearest emergency room for assistance or to call 911 in (ND) or 988 in (NC).
Fee Policy and Insurances
Fees for sessions are as follows:
Initial Intake Assessment $150
Individual Sessions: $100 (see above policy for missed sessions)
At the present time, I am doing only teletherapy sessions in my practice. Instructions for accessing the platform will be provided to you just prior to your session. I am no longer accepting or billing any insurance for my services. If you have a Health Services Account, I may be able to provide you with the needed documentation for you to be reimbursed for your services through this account. Payment for sessions is due at the time of the service through PayPal on my website.
Your Satisfaction is Important to Me
Please feel free to bring up questions or concerns with me regarding your treatment. If you have a complaint about your treatment, please inform me first to discuss the situation. If you do not feel the complaint has been resolved, I would ask that you put your complaint in writing to me and allow me to respond to it. If you still feel that your complaint has not been resolved, you may find it necessary to notify your insurance carrier and file a complaint if you so choose with the state licensing board. You of course have the right to withdraw from services at any time you feel your treatment service needs are not being met. Assistance will be provided to another professional service provider in the community when requested. I abide by the American Counseling Association Code of Ethics.
North Dakota Board of Counseling Examiners 2112 10th Ave SE
Mandan, ND 58554
Phone: 701-667-5969
Email: ndbce@outlook.com
North Carolina Board of Clinical Mental Health Counselors PO Box 77819
Greensboro, NC 27417
Phone: 336-217-6007 or 844-622-3572
Email: LCMHCinfo@ncblcmhc.org
Client Rights
You are entitled to the following rights with regard to your treatment in compliance with ND Article 75-09.1, Chapter 75-09.1-01, Section 23.
- Be treated with respect and dignity
- Be treated without discrimination based on physical or mental disability
- Be treated without regard to race, creed, national origin, sex or sexual preference
- Expect all information to be handled confidentially in accordance with applicable laws, regulations and standards
- Receive notice of federal confidentiality requirements
- Not to be subjected to physical, emotional, or sexual abuse or harassment by this counselor or any other persons who may be present in sessions
- Receive gender and culturally sensitive treatment
- Be treated without discrimination based on religious preferences and practices
The Health Insurance Portability and Accountability Act (HIPPA) entitles you to the following rights with regard to your treatment:
- The right to access your record
- The right to request amendment
- The right to an accounting of disclosures
- The right to file a complaint about privacy practices
- The right to request restrictions on Protected Health Information
- The right to a Notice of Privacy Practices
- The right to request alternative means of communication of Protected Health Information