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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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William R. Powell LPC, MS Ed, LPC, NCC, LMHC Independent Associate Outpatient Therapist
PEACE OF MIND, INC. 817 West Front Street P.O. Box 2088 Lillington, NC 27546-2088
Office: (910) 814-2197 Fax: (910) 814-2167 Cell: (919)-812-4529
Web Site: www.peace-of-mind-inc.com E-mail: william@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:
William R. Powell, MS Ed, LPC, NCC, LMHC:
· Is licensed by the North Carolina Board of Licensed Professional Counselors (LPC # 6861, January 5, 2008) · Is licensed by the New York State Education Department: Office of the Professions a Licensed Mental Health Counselor (LMHC # 000242, January 3, 2006), and since July, 2001, has been credentialed by the National Board of Certified Counselors (NBCC) as a National Certified Counselor (NCC # 56621). · Holds a Master of Divinity Degree from Asbury Theological Seminar, Wilmore, KY. · Holds a Master’s Degree in Education, with a concentration in mental health counseling, awarded by Alfred University, in New York State, in May of 1999. · Has 8 years post-master’s counseling experience with children, adolescents, and adults. · Has had 20 years experience with counseling parishioners, with experience with people in recovery from drugs and alcohol. · Has 7 years experience working in the field of domestic violence and has provided the education for men who batter in Steuben County, NY. · Is currently serving children, adolescents and adults, in individual and family group therapy specializing in marital difficulties, in family therapy; stepfamily dynamics, violence prevention and trauma issues.
TREATMENT, SERVICES AND FEES:
Your counselor is a self-employed independent outpatient therapist contracting with Peace of Mind, Inc., at 817 West Front Street, Lillington, North Carolina.
Current insurance panels include Medicaid. There is no sliding fee scale. Fees charged for client sessions are as follows: Initial Assessment $120 Individual Session 75 Family Session 90
Cash or checks are acceptable methods of payment.
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.
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) 814-2197. While Peace of Mine, Inc. does not provide emergency answering service for evenings and weekends I do frequently check messages on the office answering machine, and messages will also reach me by calling the emergency cell phone number at: (919) 812-4529. 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 HIPAA 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 .
NAME ________________________ MR # __________________
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
William R. Powell LPC, MSEd, NCC, LMHC
Rev. 1-08 |
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