KATHARINE APPLEYARD, M.Ed., LCPCc PSYCHOTHERAPY of Appleyard Counseling, LLC
261 French Street Bangor, Maine 04401 email@example.com (207) 852-3377
DISCLOSURE OF REQUIRED INFORMATION
Welcome to my psychotherapy and counseling practice. I look forward to our work together.
The following information is provided in order to clarify my clinical background and legal responsibilities. Successful therapy is the result of mutual effort and an effective working relationship between us. You have the right to choose a therapist who can best address your specific concerns and the responsibility to choose the provider and treatment modality which best suits your needs. You also have the right to refuse or discontinue treatment at any time. After beginning therapy, if you do not believe our work together is meeting your needs then please feel free to discuss your concerns so we can make appropriate changes. If I am not able to address your concerns then we can arrange for a referral to a different clinician who might. I welcome questions and feedback about our work together at any point throughout our process.
LICENSE AND EDUCATION
I am licensed in the state of MAINE as a clinical professional counselor (LCPC). My credential number is XL4884. I received my Master’s degree in Clinical Counseling from the University of Puget Sound.
THEORETICAL ORIENTATION, PSYCHOTHERAPY, COUNSELING, DURATION OF TREATMENT
I provide a respectful, supportive, and appropriately challenging environment. My training incorporates Family Systems, Cognitive-Behavioral (CBT), Existential, and Solution- Focused techniques. The duration of therapy is based on individual needs of the client. Generally, until we spend time together I am not able to suggest what the duration of treatment will be; this can more accurately be determined once therapy has begun and will be discussed as it becomes apparent.
Information discussed in the therapy setting is held confidential and I will not release any information without your written permission, with the following exceptions as required by law: I may be authorized or required to disclose information you provide to me if I suspect there has been child or elder abuse/neglect or if you are a threat of harm to yourself or others.
At times I will consult with professional colleagues about general aspects of your case. Your name and identifying characteristics will not be disclosed.
The practice of counseling is regulated by the Board of Counseling Professionals Licensure. The board is authorized by law to discipline counselors who violate the board’s law or rules. To learn about the complaint process, or to file a complaint against a counselor, contact:
Office of Professional and Occupational Regulation 35 State House Station
Augusta, ME 04333
COUNSELING FEES: Fee for fifty-minute appointment is $120.00; ninety-minute appointment is $180.00, and 120-minute appointment is $240.
INSURANCE: I am considered an out of network provider; it is your responsibility to contact your provider regarding out of network benefit coverage should you wish to submit for reimbursement.
PAYMENT: I accept cash, personal checks, and most credit/debit cards. In order to preserve time for therapy please have payment ready at the beginning of our session.
APPOINTMENTS: Making and keeping appointments is important to the therapeutic process. Please give 48 hours notice if it is necessary for you to cancel or reschedule an appointment in order to avoid being charged for the appointment; regardless of your reason, the fee for cancellations with less than 48 hour notice or missed appointments is $120.00 and can not be billed to insurance.
COUPLES THERAPY: Please note: many clients assume couples therapy will be reimbursed by their insurance provider when they have insurance benefits which include mental/ behavioral health. Unfortunately this is rarely the case. Most insurance plans require both medical necessity and individual treatment in order for benefits to apply. According to most insurance plans, marital issues typically do not meet either of those criteria. Please consult your individual insurance coverage for more details.
BILLING: Payment is expected at time of our appointment; clients who owe money and fail to make payment arrangements may be referred to a collection agency.
LIMITS OF CONFIDENTIALITY FOR COUPLES AND FAMILIES: When more than one person participates in therapy together then either person, or all persons, may access the entire record of treatment.
ENDING: It is understood an expected goal of treatment is that our relationship will end: should you choose to end therapy prior to achieving goals then I recommend you consider participating in a full or abbreviated closure session. In the absence of an in-person meeting, for documentation purposes, I may call or send an email to confirm treatment has ended.
CONTACT INFORMATION: My priority is to be available to my clients; the best way to contact me is by telephone (207) 852-3377 or email firstname.lastname@example.org. I generally return voicemails and emails within 24 hours. I prefer to utilize email and text messaging for scheduling purposes only. If you would like to communicate with me via email or text then please discuss with me in person first so that we can evaluate the risks and benefits.
CRISIS CONTACT INFORMATION: Your safety and well-being are important. If you are experiencing a crisis and need to speak with someone immediately then please call one of the following:
• Maine Statewide Crisis Line at (888) 568 1112
• SuicidePreventionLifeline.org 1(800) 273-TALK or 1(800) 273-8255
• 911 or go to the nearest emergency room.
RECEIPT OF DISCLOSURE STATEMENT, PRACTICE POLICIES, AND HIPAA NOTIFICATION
I certify that I have read, understand, agree to, and have received copies of Katharine Appleyard’s Disclosure Statement, Practice Policies, and HIPAA Rights Notification. These documents informed me of her counseling orientation and approach, education and training, professional licensure, and my rights as a client. I am now informed of her policies regarding fees, cancellation and rescheduling, and how to contact her. I consent to participating in counseling under the terms described above.
Furthermore, I understand that all information and communication regarding my course of therapy is protected, private, and confidential, except as the limits of confidentiality are described in the Client Rights section above. I understand my health records will not be disclosed to anyone outside of Katharine Appleyard’s office; any exceptions must be jointly agreed upon, and a release of information will be provided.
With regard to privacy and records pertaining to therapy and counseling, my initials represent my understanding that:
____Communication via email or text message may be used to schedule or change appointments only.
____ Records pertaining to couples/family treatment are available to all participants.
With regard to my financial responsibility as outlined above, my initials represent my understanding that:
____All payments are due at the time of service (including cash fees and insurance co-pays). ____If applicable, I am responsible for paying my deductible and any amount not covered by insurance.
____I am responsible to pay appointment fee of $120.00 for missed appointments or cancelations with less than 48 hour notice; this fee cannot be billed to insurance.
Client Signature Date
Client Signature Date