Cindi's LGCC Counseling Professional Disclosure Statement and Counseling Agreement

Cindi's LGCC Counseling Professional Disclosure Statement and Counseling Agreement
Cynthia R. Dodd, M.A., LCMHC

We are pleased that you have selected Level Ground Christian Counseling and me, Cindi Dodd, M.A., LCMHC as your counselor. The decision to seek counseling is a bold step. It is my commitment to do whatever I can to bring healing and help for your specific situation.

Before earning a Master’s in Counseling (May 2005) from Trevecca Nazarene University, my life was dedicated to full time church ministry, for more than thirteen years. During those years of service, I often found myself assisting families/individuals with a variety of situations such as family conflict, grief, divorce, marital strife, parenting concerns, job and life transitions, etc. Later in my adult life I began to realize the need to pursue advanced studies in counseling and my ministry only confirmed the need.

My work at LGCC deals with a wide range of mental health issue, to which I use an eclectic approach, in an effort to provide the best help/care possible. In addition, I have experience in providing treatment to both adolescents and women. My training also includes DBT (Dialectical Behavioral Therapy).

*By typing in my name and or initials below, I acknowledge that it is taking the place of my handwritten signature.

NATURE OF COUNSELING

We understand that counseling is unique and individual. Therefore, we are committed to use the different modalities for your specific treatment need. Counseling is successful through the involvement of the client being willing to work hard, during the therapeutic process. It will possibly be recommended that you take the Personality Assessment Inventory. This provides an additional resource for your treatment and helps to better serve you as the client. If needed, the assessment will be administered in our office, at a cost of $100.00. The results of the test are known only by this therapist.

NATURE OF COUNSELING (cont.)

The goal at LGCC is to help the client identify possible childhood wounds, faulty thinking, and unhealthy behavioral/relational patterns. To walk beside the client in the healing process, is our strong desire. There are no “quick fixes” in counseling, only hard work in the form of sessions, possible homework assignments, writing, and reading, learning new tools and techniques, and attending workshops when necessary/appropriate. While eclectic, a behavioral-cognitive theoretical approach is emphasized. It should be noted that in the assessment process, a diagnosis of the mental health issue demonstrated, is quite possible. This diagnosis will become a part of the client’s permanent record.

PRIVACY AND CONFIDENTIALITY. We may use or disclose your mental health information…

• To your physician or other healthcare provider, who is treating you, with your written authorization. • To a family member, a person responsible for your care or your personal representative, in the event of an emergency. This will not be done if you object. However, if you are incapable of responding, we may use our professional judgment in light of the nature of the emergency, to go ahead, if it is in your best interest. We commit to keep confidential what you say in the counseling process. The following are the only exceptions: • Case Consultation: A part of our commitment to providing quality care, is to regularly consult with other professionals. Your identity is kept confidential during these consultations. • Requirements by law: The records from you counseling are confidential except in the following conditions, as provided by law. (1) When we believe you are a threat to yourself or someone else, (2) when we believe there is actual or suspected physical, emotional, sexual abuse or neglect of children or disabled adults, (3) when court ordered.

COUNSELING RELATIONSHIP

Ours is a professional relationship and must be respected by both sides. There may be times in which we see each other in another context. To protect you, I will avoid initiating contact with you. However, you always have the freedom to initiate contact with me.

BENEFITS AND RISKS OF COUNSELING

Research shows that counseling and the counselor/client relationship can provide great healing. People report lessened anxiety, depression, better self-esteem, more healthy relationships with others…themselves, and so much more. But there could be risks such as looking at painful past experiences and feeling sadness, discomfort, anger, frustration and guilt. Most of these feelings are normal and to be expected. I will walk beside you through this time. If you are experiencing any of this, please share we me, as your counselor.

EMERGENCIES

We are not set up to handle emergency situations. We will do everything we can to respond to you in case of an emergency, but we do not provide 24-hour coverage. If you experience a mental health emergency or a life-threatening emergency, please call 911 or go to your nearest emergency room.

EMAILS OR TEXT MESSAGES

If you correspond with this therapist by email or test message, CONFIDENTIALITY CANNOT BE GUARANTEED. At any point, someone can access the email and even store the message. In addition, therapy cannot be done via email or texting, and only used to conduct business or information sharing. Any therapeutic issues will be handled during the face to face meetings, or as appropriate, by telephone in emergencies. We will do our best to read and respond to your messages, but this therapist cannot guarantee that they will be read and responded to within any particular period of time, especially during business hours.

MINORS

In case of a minor, who may have individual sessions, parents may legally access the child’s file. However, discretion is advised in order to encourage your child’s open sharing with us. Consent from all custodial parents is required before treatment.

FEES/METHODS OF PAYMENT…PLEASE SEE FINANCIAL POLICY AND AGREEMENT FORM

INSURANCE REIMBURSEMENT

If you wish to file a claim with your insurance company, I will provide you a receipt with the necessary insurance codes, dates, etc. The insurance company (according to your policy) will provide any reimbursement to you directly.

YOUR SATISFACTION

If you are dissatisfied with any aspect of my work, please discuss it with me. This will make our work together more efficient and effective. If necessary, we can refer you to another counseling practice or to the most appropriate community referral to meet your needs. If a problem arises requiring a legal remedy, the client agrees to solve all problems through the means above or independent mediation and not pursue formal litigation. Complaints should also be registered with the North Carolina Board of Licensed Clinical Mental Health Counselors, P.O. Box 77819, Greensboro, NC, 27417.

DURATION OF COUNSELING

The length of time someone spends in therapy depends on one’s issues, circumstances and rapport with the therapist. It can vary in many ways. If you desire to stop counseling, it is important to discuss this with this counselor before you make this decision.

If you have any questions, please feel free to ask me. Once you have read and understood this statement, please sign and date. Thank you for choosing this practice to meet your needs. I have read, initialed, and understand counseling with these conditions.

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Cindi's LGCC Counseling Professional Disclosure Statement and Counseling AgreementCynthia R. Dodd, M.A., LCMHC

Cindi's LGCC Counseling Professional Disclosure Statement and Counseling Agreement
Cynthia R. Dodd, M.A., LCMHC