PROFESSIONAL DISCLOSURE STATEMENT



PROFESSIONAL DISCLOSURE STATEMENT

& OFFICE POLICIES

JEANETTE M. DIEKMAN, MA, LPC

NC LICENSE #3447

I graduated from Vermont College with a Master’s of Counseling Psychology and have 16 years of counseling experience. I am a Licensed Professional Counselor (LPC) in North Carolina. I work with children, adults, couples, and families. I approach therapy using methods and techniques from Cognitive-Behavioral Therapy, Family Systems Theory, Play Therapy, and other integrative and eclectic therapies. I stay informed of effective, evidenced-based practices that will best meet the needs of individuals and families.

Appointments

My office is located inside Back 2 Back Chiropractic at 206 Joe V. Knox, Avenue, Suite, C, Mooresville, NC 28117. Appointments may be scheduled by calling 704-500-1208. If you are unable to reach me directly, please leave a message and I will return your call or email as soon as I am able. My office hours vary, but will be held at least four days each week.

Fees

My fee for the initial therapy session is $140. Subsequent sessions are billed at $100 each. All sessions are 53-60 minutes long. Phone, Internet, or Skype counseling is not provided. Excessive time spent on phone calls with you or other professionals relating to your care in addition to excessive time spent replying to email messages may also be billed at the rate of $100/hour. Records or other paperwork provided to insurance companies on your behalf for disability claims or other reasons will require a $50 payment. Payment (Co-pay or Deductible) is due at the time services are rendered. I accept cash, personal checks, VISA, Mastercard, and Discover. A $50 fee will be charged for any checks returned for insufficient funds. Please let me know if you need a receipt and I will be happy to complete one for you after each session. In the event that I am subpoenaed or asked to appear in a legal proceeding you are expected to pay $200.00 per hour including my time for travel, waiting in court, and preparation time required prior to my clearing of my calendar for that date.

Late fees of $20/month will be assessed against any balance outstanding over 45 days. If your account has not been paid for more than 60 days, and arrangements for payment have not been agreed upon, I have the option of using legal means to secure payment. This may involve hiring a collections agency which will require me to disclose otherwise confidential information. If legal action is necessary, its costs will be included in the claim.

Cancellations and Missed Appointments

Because appointment times are often in demand, please notify me as soon as possible if you are unable to keep an appointment time. If the appointment is missed or cancelled without 24 hours notice, you will be charged $50 for the appointment. This charge is not covered by insurance and will be your responsibility.

Confidentiality

Any information you share with me is confidential and highly protected. No information is released without your verbal or written consent. In order to provide you with the best care possible, I may ask you to sign a release of information form allowing me to consult with other therapists, doctors, school personnel or family members. Exceptions to confidentiality occur when there is a clear intent on your part to harm yourself or others, if I suspect abuse or neglect of a child, elderly, or disabled adult, or for insurance reimbursement requirements. In rare cases, a court subpoena may require that information be disclosed. Please read and sign the HIPPA notice.

Insurance Billing

I am in network with many of the major insurance agencies. I am not in network for Medicare regardless of whether it is the primary or secondary insurance. If you have insurance coverage, I will file the insurance claim for you with the companies for which I am a contracted provider. You are responsible for the copay or deductible at each session. I request that fees/copays be paid in full and that reimbursement is signed over to me. Please note that I file insurance as a courtesy to you and that you, not your insurance company, are ultimately responsible for your bill.

Health insurance companies often require that I diagnose your mental health condition and indicate your diagnosis before they will reimburse. Any diagnosis made will become part of your permanent insurance record.

I, ________________________, hereby agree to and understand the practice policies as stated above. I authorize the release of any medical or other information necessary to process health insurance claims.

As a Licensed Professional Counselor, I am mandated to provide the following information to my clients:

Clients have the right to address complaints and grievances to the Board at the following address and telephone number:

North Carolina Board of Licenses Professional Counselors

P.O. Box 77819

Greensboro, North Carolina 27417

844-622-3572

You can also obtain information on their website:

Emergency/After hours

In the event that you feel you are unsafe due to suicidal or homicidal intentions, I ask you that immediately call 911 and ask for help or go to the nearest emergency room.

Your signature acknowledges you have read the information in this document and agree to abide by its terms during our professional relationship, and that you understand and/or have requested to read the Notice of Privacy Practices. I look forward to working with you.

____________________________ ____________________________

Patient (or Responsible Party) Date

___________________________ ____________________________

Jeanette M. Diekman, MA, LPC Date

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