Full Disclosure Statement
Anne Coleman, MSW, LCSW
Professional Disclosure Statement
Welcome! What follows is some essential information about psychotherapy, which serves to help clarify roles, expectations, and agreements that all contribute to a positive experience. Please read and sign at the bottom to indicate that you have reviewed this information.
This document is designed to inform you about my background, disclose my philosophy of therapy, and to inform you of policies, procedures, legal and ethical considerations.
My background: I have been a psychotherapist since 2002 after graduating with a Masters of Social Work (MSW) from the University of North Carolina at Chapel Hill. I have also completed post-graduate school training, including the NC Psychoanalytic Psychotherapy Advanced Coursework. I am a member of the National Association of Social Workers, NC Society for Clinical Social Work, NC Psychoanalytic Society and the American Association for Psychoanalysis in Clinical Social Work. My North Carolina Clinical Social Worker licensure number is C005491.
My approaches to counseling services: I take a psycho-dynamic, solutions-focused, and cognitive behavioral approach to symptom relief, emotional pain, and personality change. How I practice counseling is influenced by how I believe change occurs. I believe people can change if they have enough motivation to understand their feelings and beliefs which influence their interpersonal dynamics.
Counseling includes our collaborative effort to discern appropriate goals and methods to meet these goals. For short-term counseling, symptom relief will most often be our primary goal and sessions will typically be over a period of one to six months. For long-term counseling, understanding the underlying etiology of symptoms will be the primary goal. Long-term psychotherapy not only relieves the symptoms but addresses deeper needs creating the symptom. Sessions will typically be over a period of six months to a year or longer, meeting a minimum of once weekly.
A part of our work will specify the goals, foci, methods, risks, and benefits of treatment. We will discuss the approximate time commitment and financial costs involved, as well as any other aspects of your particular situation that might need consideration. We will agree on a treatment plan and periodically evaluate our progress and, if necessary, redesign our treatment plan, goals, and methods.
As with any intervention, there are both benefits and risks associated with psychotherapy. Risks might include experiencing uncomfortable levels of feelings such as sadness, guilt, anxiety, anger, frustration, depression, or difficulties in relationships. Some changes may lead to what seems to be worsening of circumstances or even losses.
Please note that it is impossible to guarantee any specific results regarding your counseling goals. However, my commitment is to work to achieve the best possible results for you. I will advise you if, for whatever reason, in my professional opinion, I cannot help using the knowledge and techniques I have available.
Confidentiality: I regard the information you share with me with the greatest respect and want to communicate how your information will be handled. The privacy and confidentiality of our work and my records are a privilege of yours and are protected by state law and my profession’s ethical principles. Generally, I will tell no one what you tell me. However, there are four circumstances in which I cannot guarantee confidentiality, legally and/or ethically: (1) when I believe you intend to harm yourself or another person; (2) when I believe a child or an elder person has been or will be abused or neglected; (3) when ordered by a Judge to release information; and (4) when an insurance company requests information. Otherwise, I will not tell anyone anything about your treatment, diagnosis, history, or even that you are a client, without your full knowledge and a signed “Release of Information” form.
Unexpected therapist absence. In the event of my unplanned absence from practice, whether due to injury, illness, death, or any other reason, I maintain a detailed Professional Will with instructions for an Executor to inform you of my status and ensure your continued care in accordance with your needs. Please let me know if you would like the names of my Executor and Secondary Executor. By signing the Acknowledgement of Receipt of Professional Disclosure Statement, you authorize the Executor and Secondary Executor to access your treatment and financial records only in accordance with the terms of my Professional Will, and only in the event that I experience an event that has caused or is likely to cause a significant unplanned absence from practice.
Explanation of Dual Relationships: The client’s concerns and well-being are of utmost importance. The therapeutic relationship is, by its nature, hierarchical in power with the therapist being in the expert position. The client is, in a sense, putting himself/herself in the therapist’s hands. Such a vulnerable position for the client demands added protection against exploitation. It is with these values in mind, that as your therapist, I am legally and ethically required to maintain our relationship in a professional manner and not extend myself beyond that professional relationship into a “dual relationship”. The legal and ethical stance of prohibiting a “dual relationship” means that our relationship may only be a professional relationship, that of therapist and client. As your therapist, I am prohibited from developing any other kind of relationship with you, such as a business relationship, a social relationship, or a sexual relationship.
Length and frequency of treatment: Psychotherapy typically involves regular sessions over time, usually 45 minutes in length. Duration and frequency vary depending on the nature of your specific needs. Although therapy often involves a considerable investment in time and money, the benefits can be substantial in terms of both temporary relief and enduring change.
Fees and Methods of Payment: In return for a fee of one hundred and thirty dollars ($130) per session, I agree to provide counseling services for you. I accept payment for services rendered at each session in the form of cash, personal checks, or credit card. Make checks payable to “Anne Coleman”. I will provide you with a monthly invoice and receipt for all appointments and fees paid.
If you are using insurance, you will be responsible for payment of any appointment according to your policy. Please be advised that most insurance companies will not pay for sessions in which you are partially in attendance or absent. If we encounter this situation, then we will adhere to requirements within the insurance policy. If the policy states you are responsible for partially attended or missed sessions, then you will be responsible for the entire fee determined by the insurance company for that session.
Cancellation policies: If an appointment is missed, or if it is cancelled with less than 72 hours’ notice, individuals will be expected to pay for the missed session. The fee for the session may be waived if an additional makeup session can be scheduled for either the same week of the missed session or the following week. Although I will do my best to make time available for make-up sessions, the times that I have available do tend to be quite limited.
Insurance Policies: Some insurance companies will reimburse for my services and some will not. You are responsible for contacting your insurance company representative to determine: (1) eligibility for reimbursement; (2) need for prior authorization for services rendered; (3) number of sessions allowed; (4) amount of your deductible met so far this year (5) your part of the fee payment (co-pay); and (6) the “provider relations” phone number for me to contact.
Please be advised that in using your insurance for mental health benefits, you and I are agreeing to abide by your insurance company’s protocol. If your insurance company asks for information, we are agreeing to release such information. Insurance companies typically ask for identifying information such as name, address, phone number, date of birth, policy numbers, and employer. They may also request additional information such as diagnosis, symptoms, evaluation, Global Assessment Functioning rating, life stressors, medical information, treatment method and goals, progress notes, and case formulation to assess medical necessity for treatment.
In addition to written information, the insurance company may also require me to discuss your symptoms and treatment with an insurance case manager.
Please be advised that information released to an insurance company is no longer under my control. Such information becomes a part of your permanent record which is subject to the insurance company’s protocol and procedures. Information received by an insurance company may be entered into a database that could possibly be obtained by other entities, such as medical personnel, pharmaceutical personnel, state or federal government personnel, and others allowed to access such databases.
HIPAA: I am compliant with the Health Insurance Portability and Accountability Act, also known as HIPAA.
Phone and emergency contact: If you need to contact me by phone, do not hesitate to leave me a voice mail message and I will return your message promptly. My telephone number is (919) 360-0499. For life threatening emergencies, call 911 or go to any hospital emergency room immediately for assistance.
Complaint Procedures: If you are dissatisfied with any aspect of our work, please inform me immediately. This will make our work together more effective and efficient. If you think that you have been treated unfairly or unethically, by me or any other therapist, and cannot resolve this problem with me, you can contact North Carolina Social Work Certification and Licensure Board at P.O. Box 1043, Asheboro, NC 27204, (336) 625-1679, for clarification of clients’ rights as I have explained them or to lodge a complaint.
Freedom to withdraw: You have the right to withdraw from therapy at any time. If you wish, I will give you the names of other qualified psychotherapists.
Informed consent: I have read and understand the preceding statements. I have had an opportunity to ask questions about them, and I agree to enter a professional psychotherapy relationship with Ms. Anne Coleman, MSW, LCSW.
Please sign and date both copies of this form. A copy for your records will be returned to you. I will retain a copy in my confidential records. (NOTE: I will hand you a physical copy at our appointment time)..