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Terms and Policy

OFFICE POLICIES & GENERAL INFORMATION
YOUR RIGHTS:

To receive quality professional services / To be assured privacy and confidentiality / To review and discuss your fee for services / To refuse service at any time / To see your record upon written request and to insert a written statement into the record about services received or not received

YOUR RESPONSIBILITIES:

To be on time for scheduled appointments / To pay fees for services according to the practice policy / To actively participate in your own treatment / To give a 24 hour notice if canceling an appointment and to pay the full fee of the session upon failure to do so

CONFIDENTIALITY: POLICIES & LIMITATION

Under North Carolina Law, all information disclosed within sessions and the written records pertaining to those sessions are confidential and may not be revealed to anyone without your verbal authorization and/or written consent except where disclosure is required by law. The law most commonly requires disclosure when you or another person identified by you is in eminent danger. Then Glavin Counseling is legally and ethically mandated to communicate with third parties who can protect the endangered person regardless of your preferences. The most common situations for legal disclosure include hospitalizations because of suicidal or dangerously violent behavior; warning potential victims of homicidal intent; and contacting protective services because of neglect, abuse, or molestation of a child or elder person. If there is an emergency during our work together, or in the future after termination, and Glavin Counseling is concerned about your personal safety, the possibility of you injuring someone else, or about you receiving proper psychiatric care, Glavin Counseling will do whatever it can within the limits of the law to prevent you from injuring yourself or others and to ensure that you receive the proper medical care. For this purpose, Glavin Counseling may also contact someone whose name you have provided for me in case of emergency.

Disclosure may also be required pursuant to a legal proceeding. If you place your mental status at issue in litigation initiated by you, the defendant may have the right to obtain the psychotherapy records and/or testimony by Glavin Counseling.

In family, couples and child therapy, confidentiality and privilege do not apply between family members. That being said, in the case of child and adolescent therapy, privacy within the therapy relationship may be essential to treatment. Parents and guardians of minor-aged clients have the right and responsibility to question and understand the nature of the services provided to their children, and clinical discretion will be used to determine what is appropriate disclosure in these circumstances. In instances where the child or adolescent’s judgment is not sound, and the risks they are incurring seem substantial, family members will typically be informed so that they can protect their children.

Disclosure of confidential information may be required by your health insurance carrier or HMO/PPO/MCO/EAP in order to process insurance claims. Whenever possible, only the minimum necessary information will be communicated to the carrier. Glavin Counseling has no control over, nor knowledge about, what insurance companies do with the information they obtain, nor can Glavin Counseling limit who has access to this information once it is provided to them. You should be aware that submitting a mental health invoice for reimbursement carries a certain amount of risk to confidentiality, privacy, or to future capacity to obtain health or life insurance. The risk stems from the fact that mental health information obtained by insurance companies is inherently vulnerable to unauthorized or unwanted access.

It is important to be aware that e-mail and cell phone communication can be relatively easily accessed by unauthorized people and hence can compromise the privacy and confidentiality of such communication. E-mails, in particular, are vulnerable to such unauthorized access due to the fact that servers have unlimited and direct access to all e-mails that go through them. For this reason, Glavin Counseling uses an encrypted email server named Protected Trust to communicate with any external provider.

PROFESSIONAL CREDENTIALS

Rebecca Glavin earned her Masters in Social Work from the Boston University. She is a Licensed Clinical Social Work (#C010179) through the North Carolina Social Work Certification and Licensure Board. Rebecca Glavin, LCSW is qualified by education and experience and is prepared to counsel individuals, groups, parents, families, adolescents and adults. If a client has a complaint, the client is able to contact the North Carolina Social Work Certification and Licensure Board.

WRITTEN RECORDS & REPORTS

Both the law and the standards of our profession require that we keep appropriate treatment records. As a client, you have the right to review or receive a summary of your records at any time, except in limited legal or emergency circumstances, or when we assess that releasing such information might be harmful. In such a case, Glavin Counseling will provide the records to an appropriate and legitimate mental health professional of your choice. Upon your request, Glavin Counseling will release information to any agency/person you specify unless it assesses that releasing such information might be harmful to you. Please remember that legal guardians as well as any parent whose parental rights have not been terminated are legally entitled to the medical records of their child, including psychotherapy records.

TELEPHONE & EMERGENCY PROCEDURES

Clients will be given Rebecca's cell phone number. There is typically no charge for brief telephone calls which are meant to be coaching moments. Scheduled telephone appointments will be charged at the same rate as face-to-face therapy. There is no guarantee that Rebecca will be available during any given crisis, and in a true emergency where you need to talk to someone right away and you cannot reach anyone at Glavin Counseling, you should call Carolinas Behavioral Health's 24 hour call center at 704-444-2400, or proceed to your nearest hospital emergency room.

APPOINTMENTS & CANCELLATION POLICY

Initial intake therapy appointments will take between sixty and ninety minutes. Individual counseling sessions are generally fifty to sixty minutes in length. Because scheduling an appointment involves the reservation of time specifically for you, a minimum of 24 hours notice is required for canceling an appointment without charge. ***If you cancel with less notice in a non-emergency situation, you will be charged the full fee of the session.*** Please be aware that insurance companies rarely reimburse for missed sessions, so you will be responsible for the billed amount even if you have a co-pay or co-insurance that is less than the full fee.

FEES & PAYMENTS

Clients are required to pay the arranged fee at the end of each session. If you agree to pay per session, and miss paying, therapy will be discontinued until your balance is cleared.

The initial intake appointment will be billed at $140 to accommodate the extra time required to organize effective therapy. Subsequent sessions are billed at $120 per individual session. There is then no additional charge for consultation with other professionals involved in your treatment at the beginning of treatment or routine (usually 10 to 15 minutes per week) telephone coaching over the course of therapy. However, school or hospital visits, frequent and extensive consultation with other professionals involved with your family, report writing and reading, longer sessions, travel time, arranging for hospitalization, extensive weekly telephone contact and/or scheduled telephone sessions, etc. are subject to charge at a prorated therapy rate of $25 per fifteen minute increments. Please notify me if any problem arises during the course of therapy regarding your ability to make timely payments.

COUPLES COUNSELING POLICIES

Couples therapy begins with an evaluation of the relationship, past and present. It is important to understand that anything either spouse/partner tells Glavin Counseling individually, whether on the phone or in an individual meeting, may not be held as confidential, and at Glavin Counseling's discretion may be shared with the spouse/partner during a subsequent couple’s session. Please understand that information discussed in therapy is for therapeutic purposes only and is not intended for use in any legal proceedings involving the partners. By entering into therapy, you accept that working toward change may involve experiencing difficult and intense feelings, some of which may be painful, in order to reach therapy goals. You understand that the changes one or both of you makes will have an impact on the relationship and on others around you. You accept that such changes can have both positive and negative effects and agree to clarify and evaluate potential effects of changes before undertaking them. You understand that no promises have been made as to the results of treatment or of any procedures provided by Glavin Counseling. You are aware that you may stop treatment at any time, and you agree to be responsible for paying for the services already received or for those you did not properly cancel. Glavin Counseling's therapeutic focus in couples counseling is on preserving and enhancing the relationship rather than a focus on individual happiness. However, if remaining together is harmful to one or both partners, the focus will be on facilitating an amicable separation.

CONSENT TO TREATMENT

I have read the attached Office Policies and General Information carefully, and I understand the policies outlined, and agree to comply with them. I give my consent to Glavin Counseling to evaluate and/or treat me.
( Type Full Name )
INSURANCE & PAYMENT POLICIES
APPOINTMENTS & CANCELLATION POLICY

Initial intake and assessment therapy appointments are billed at $140, and subsequent sessions are billed at $120 per individual session. Sessions are 45-55 minutes in length. Because scheduling an appointment involves the reservation of time specifically for you, a minimum of 24 hours notice is required for canceling an appointment without charge. ***If you cancel with less notice in a non-emergency situation, you will be charged the full fee of the session.*** Please be aware that insurance companies rarely reimburse for missed sessions, so you will be responsible for the billed amount even if you have a co-pay or co-insurance that is less than the full fee. If you agree to pay per session, and miss paying, therapy will be discontinued until your balance is cleared.

INSURANCE

In order to set realistic treatment goals and priorities, it is important to evaluate what resources you have available to pay for your treatment. If you have Blue Cross Blue Shield of NC insurance or Carolinas Behavioral Health Alliance, your policy will usually provide some coverage for mental health treatment. With your permission, Glavin Counseling and its billing service will assist you to the extent possible in filing claims and ascertaining information about your coverage, but you are responsible for knowing your coverage and for letting Glavin Counseling know if/when your coverage changes.

Glavin Counseling is out-of-network with all other insurance companies. If you are have an out-of-network insurance provider, you can print receipts for each session through CounSol. You can then submit these receipts to your insurance carrier for reimbursement. It is your responsibility to verify the specifics of your insurance coverage and benefits before treatment begins. Please note that not all insurance companies reimburse for out-of-network providers. If you prefer to use a participating provider, Glavin Counseling will refer you to another provider.

Due to the rising costs of health care, insurance benefits have increasingly become more complex. It is sometimes difficult to determine exactly how much mental health coverage is available. Managed Health Care plans such as HMOs and PPOs often require advance authorization, without which they may refuse to provide reimbursement for mental health services. These plans are often limited to short-term treatment approaches designed to work out specific problems that interfere with a person’s usual level of functioning. It may be necessary to seek approval for more therapy after a certain number of sessions. While a lot can be accomplished in short-term therapy, some clients feel that they need more services after insurance benefits end. Some managed-care plans will not allow Glavin Counseling to provide services to you once your benefits end. If this is the case, Glavin Counseling will do its best to find another provider who will help you continue your psychotherapy.

You should also be aware that most insurance companies require you to authorize Glavin Counseling to provide them with a clinical diagnosis. (Diagnoses are technical terms that describe the nature of your problems and whether they are short-term or long-term problems. All diagnoses come from a book entitled the DSM-V. There is a copy in the office, and Glavin Counseling will be glad to let you see it to learn more about your diagnosis, if applicable.). Sometimes Glavin Counseling has to provide additional clinical information such as treatment plans or summaries, or copies of the entire record (in rare cases). This information will become part of the insurance company files and will probably be stored in a computer. Though all insurance companies claim to keep such information confidential, Glavin Counseling has no control over what they do with it once it is in their hands. In some cases, they may share the information with a national medical information databank. Glavin Counseling will provide you with a copy of any report that is submitted, if you request it. By signing this Agreement, you agree that Glavin Counseling can provide requested information to your carrier if you plan to pay with insurance.

In addition, if you plan to use your insurance, authorization from the insurance company may be required before they will cover therapy fees. If you did not obtain authorization and it is required, you may be responsible for full payment of the fee. It is for this reason that Glavin Counseling requests your credit card information. Many policies leave a percentage of the fee (which is called co-insurance) or a flat dollar amount (referred to as a co-payment) to be covered by the client. Either amount is to be paid at the time of the visit. In addition, some insurance companies also have a deductible, which is an out-of-pocket amount that must be paid by the client before the insurance companies are willing to begin paying any amount for services. This will typically mean that you will be responsible to pay for initial sessions with Glavin Counseling until your deductible has been met; the deductible amount may also need to be met at the start of each calendar year. Once we have all of the information about your insurance coverage, we will discuss what we can reasonably expect to accomplish with the benefits that are available and what will happen if coverage ends before you feel ready to end your sessions.

***It is important to remember that you always have the right to pay for services yourself to avoid the problems described above. You are not required to use your insurance even if Glavin Counseling is considered in-network with your provider. If you have decided not to utilize your insurance benefits for services, your signing this document acknowledges your choice and inability to submit claims to your insurance company once treatment has begun.***

ACKNOWLEDGMENT OF RECEIPT OF INSURANCE POLICIES
Your signature below indicates that you have read these policies and agree to their terms.
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