Carmen Hinds, LCMHC 1914 JN Pease Place Charlotte, NC ...

Carmen Hinds, LCMHC 1914 JN Pease Place Charlotte, NC 28262 704-728-5955

Professional Disclosure Statement

Carmen Hinds, MS, LCMHC License #7151

(Phone) 704-728-5955 (Email) hindscounseling@

Thank you for your interest in counseling services. I believe that the counseling experience is a very personal experience shared between two people. Because of this I would like to share with you my professional beliefs, my background and experience, and most importantly your rights. This document is part of the standards of practice of the North Carolina Board of Licensed Professional Counselors. Please take a moment to read this document prior to our first session.

Education and Experience I am a Licensed Clinical Mental Health Counselor in the state of North Carolina. My license number is (7151). I received a Masters of Science degree in Mental Health Counseling from Nova Southeastern University in 1999. I have 26 years of counseling experience. My experience includes providing home based counseling, outpatient counseling to individuals and groups, and crisis intervention services.

My area of special interest is working with adults and couples. However, my experience includes working with a variety of populations including high-risk youth, adults, families, couples, chemically dependent individuals, individuals with severe mental illness, and dually diagnosed persons. I have worked with individuals from various ethnic backgrounds, cultures, religions, and sexual orientations in the attempt to provide the best possible treatment based on the specific needs of each client.

Therapeutic Orientation and Session Information Counseling sessions will be 60 minutes in duration. However, there may be exceptions due to insurance requirements. This information will be discussed during your initial assessment session. The therapeutic orientations I use are Cognitive Behavioral and Solution Focused techniques. I recognize it is essential to focus on building a trusting relationship with you, while at the same time creating a comfortable environment where you feel safe enough to openly express yourself and your feelings. It is important to keep in mind that there may be moments during the counseling process when you may feel a variety of different emotions due to painful past or present experiences. I recognize that it can be very difficult to change past behaviors and to deal with past or present issues. With this in mind, I will make sure to work with you at your pace to overcome these issues.

Carmen Hinds, LCMHC 1914 JN Pease Place Charlotte, NC 28262 704-728-5955

There are many reasons why people seek counseling. Regardless of the reasons, I believe it is important for you to gain an enhanced sense of self and acceptance during counseling. During our sessions, we will explore how ones past experiences can shape the way we view ourselves.

Together we will create your goals and decide on the frequency of sessions needed to achieve those goals. I believe a great deal of growth can occur outside of the counseling session. Therefore, I may ask you to complete homework assignments, to begin participating in group counseling, or attend other meetings such as Alcoholics Anonymous or Narcotics Anonymous. Overall, my goal in the counseling process is to assist individuals increase self-awareness, develop satisfying personal relationships, make healthy decisions and gain a greater sense of control over their lives. Although this may be the goal, I cannot guarantee a positive counseling outcome. With this in mind, I am hopeful that our work together will be of help to you.

Therapist/Client Relationship During this therapeutic process it is important that you understand that this is a professional relationship. Sessions will take place in an office setting. However, there may be times were counseling sessions may take place by telephone or by internet via online or distance counseling. In these cases the confidentiality rules still apply but may have limitations. These limitations will be discussed on an individual basis as needed. Due to the nature of the client/counselor relationship, I am unable to attend any of your personal functions or meet you anywhere besides the counseling office. I am also unable to accept any gifts of any kind.

Confidentiality: I protect the confidentiality of the communications, clinical records, and contacts with all of my clients. I will only release information about our work to others with your written permission. There are instances in which confidentiality may be waived they include the following:

? If I believe you are in danger to yourself or someone else ? In the case of abuse to a child or elderly person ? If information is court ordered ? If you desire to seek reimbursement from a managed care company, confidential

information may be required for reimbursement ? In case of a medical emergency ? Confidentiality rights are waived if accusations of misconduct are brought

Fees and Cancellations: I currently accept the following insurance for reimbursement of sessions, Blue Cross Blue Shield, Aetna, Cigna, and United Healthcare. If you choose not to use insurance my fee is $100 for each 60-minute individual session and $75 per 1-hour group session. Most

Carmen Hinds, LCMHC 1914 JN Pease Place Charlotte, NC 28262 704-728-5955

sessions are weekly, although scheduling will be ascertained when counseling goals are established. Full payment and/or copayments are due at the conclusion of each therapy session. Payments are accepted in the form of cash, personal check, and most major credit cards. Appointments must be cancelled 24 hours in advance. Otherwise a full standard fee charge will be made directly to the client.

In the case of health insurance, I will assist in filling out all relevant forms for insurance reimbursement. Thereafter, it is your responsibility to make sure that the required steps are taken to ensure that financial obligations are satisfied by all parties involved.

Client Rights All clinical diagnoses and treatment goals are maintained in client records. The records are kept for your benefit. You have the right to request a copy of your records at any time. You have the right to terminate counseling at any time. You have the right to refuse any suggestions made by me. I also reserve the right to terminate services if I feel the therapeutic process is no longer assisting you, thereby I will give an appropriate notice and refer you to another qualified counselor.

Emergencies In case of emergency please contact 911 or go to the nearest emergency room. If you have an urgent situation and are in need of immediate support you may call me after hours at 704-728-5955

Complaints If at any time you feel my behavior or counseling approach is inappropriate or troubling please make me aware. If you do not feel your concerns are being addressed appropriately feel free to contact the following:

North Carolina Board of Licensed Professional Counselors P.O. Box 77819 Greensboro, NC 27417 (844) 622-3572 Fax (336) 217-9450

By signing below you are stating that you have read this disclosure, your questions have been answered and that you understand the above information including your client rights and the limits of confidentiality. You signature also indicates that you are consenting to counseling services.

Client(s) signature

Date

_______________________________ Parent or Guardian signature

Therapist's signature

Carmen Hinds, LCMHC 1914 JN Pease Place Charlotte, NC 28262 704-728-5955

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