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Sonya Holland, MA
Independent Associate
PEACE OF MIND, INC. 817 West Front Street, Lillington, NC 27546 P.O. Box 2088 Lillington, NC 27546-2088
Office: (910) 814-2197 Fax: (910) 814-2167 Emergency: (910) 977-3494
Web Site: www.peace-of-mind-inc.com E-mail: sonya@peace-of-miind-inc.com
PROFESSIONAL DISCLOSURE STATEMENT This document contains important information, and you are asked to review and retain it for future reference.
THE COUNSELING RELATIONSHIP:
Counseling is both a helping relationship and a process of change. Client and Counselor work on identified problems in a collaborative manner. This entails developing a plan for meeting your needs. In each session, we will review progress towards goals, assess symptoms, and focus on immediate objectives. What you bring to our work is important, including willingness to change certain behaviors, regular and timely attendance at sessions, openness and trust.
ABOUT YOUR COUNSELOR: Sonya Holland, MA:
· Is pursuing licensure by the North Carolina Board of Licensed Professional Counselors (NCBLPC) as a Licensed Professional Counselor. · Holds a Master’s Degree in Counseling, with a concentration in mental health counseling, awarded by Webster University March 10, 2007. · Has passed the National Counselor Exam. · Has 12 total years counseling experience with children, adolescents, and adults. · Has treatment experience working in the field of trauma assessment and treatment, including: childhood sexual abuse; PTSD; ADHD and child therapeutic level foster care. · Is currently serving children, adolescents and adults, in individual, family and group therapy.
TREATMENT, SERVICES AND FEES:
Currently in the process of being approved for several insurance panels contingent upon receiving licensure.
Your session will start on time and will typically last 45 minutes for individual, and 90 minutes for family and group therapy. Your counselor’s framework and theory used is family systems and your counselor will utilize cognitive behavioral strategies and interventions, all of which will be explained to you in an understandable manner at the first session.
Fees for services and responsibility for payment will be discussed with you at Intake. Individual sessions are $100 per session and family and group sessions are $125 per session and can be paid for with cash or money order. In most cases, services are paid for under agreements with NC Medicaid, or third party payer, once licensure and approval for insurance panels are received. If you are personally responsible for any payment or part-payment, you will receive a written explanation of your responsibilities at Intake, prior to receiving services. A sliding scale will not be used for services.
You can expect to learn specific skills intended to enhance relationships, and you will have the opportunity to practice new skills within the safety of the counseling sessions. While the process of learning and change is sometimes uncomfortable, you can expect no harm to come within the counseling relationship. Should you find, in practicing your new skills at home, school, or work that the result has an unintended negative effect in your life; you can also expect to bring that information to your next appointment, where modifications can be considered. Always, your sense of safety is the primary concern and focus.
AFTER HOURS CALLS/EMERGENCIES:
Cancellations and changes to appointments can be made weekdays during or after business hours at (910) 308-3629. If there is an emergency and you are unable to receive a timely response please call 9-1-1 and utilize the emergency department at your local hospital.
MISSED APPOINTMENTS:
In an ongoing effort to reduce insurance costs and manage clinic time, we do ask that you cancel or change an appointment 24 hours before your scheduled time. Frequent cancellations are an issue that affect the counseling relationship and will be addressed as they occur. Please take time to record your appointments on your personal calendar. We will make every attempt to give you a reminder call, but whether or not you receive this call, keeping up with your appointment date and time is your responsibility.
CONFIDENTIALITY:
Your counselor respects your right to privacy and avoids unwarranted disclosures of confidential information. Safeguards are in place, but complete protection of privacy cannot be promised. In rare cases, courts may order disclosure of medical records. Confidentiality may also be breached in emergency situations to protect the safety of the Client or to prevent harm to others. North Carolina law requires report of child abuse or elder abuse and your Counselor does not need a Release to speak to authorities in these cases. If you wish your Counselor to communicate with a third party, or if you request a transfer or release of your medical records, you will be asked to sign a Release form. In addition, you are being provided with a copy of HIPPA regulations, which were put into place primarily to protect vulnerability of client medical data due to increased use of electronic technology.
USE OF DIAGNOSIS:
As is true in all medical billing, your insurance company requires we indicate a code number to represent your diagnosis; they will not reimburse without that code. On occasion, insurance companies may also audit charts, though their sole concern would be to examine for deficits in the method of documentation or billing. Insurance companies usually require treatment plans, when you need authorization for additional services. Since reimbursement for treatment is based on medical necessity, involving symptom-based criteria, your symptoms may be noted in this kind of report.
Please be aware that diagnoses will become part of your medical record, and although this information will be safeguarded to the extent possible, this information may have to be released if the record is subpoenaed into court.
REGISTERING COMPLAINTS:
If issues arise in the course of the counseling relationship, it is hoped that these will first be addressed directly with your counselor. However, if you remain convinced that Professional Ethics have been violated, formal complaint maybe registered in writing. Appropriate Forms are available upon request from the North Carolina Board of Licensed Professional Counselors, by addressing a letter to P.O. Box 1369, Garner, NC 27529; calling (919) 661-0820; or by visiting the web site and downloading a form at http://www.ncblpc.org/complaints.html .
Client Name ___________________ Record #__________________
PROFESSIONAL DISCLOSURE ACKNOWLEDGEMENT:
Please feel free to ask questions at any time.
By signing below, you are agreeing that an opportunity has been provided to discuss any concerns you may have prior to committing to Counseling. The invitation to open discussion will remain in effect throughout the relationship.
__________________________________ _______________________ Client Signature Date
__________________________________ _______________________ Counselor Signature Date
Sonya Holland MA
Rev. 1-08
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Peace of Mind, Inc. |
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817 West Front Street P.O. Box 2088 Lillington, NC 27546-2088 Phone: (910) 814 - 2197 Fax: (910) 814 - 2167 |
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