Joseph Hyland M



Professional Disclosure Statement

Veritatis Splendor Counseling

Justin D. McColl MA. LPC License # 957

1735 Sheridan Ave, Suite #237

Cody, WY 82414

307-213-4341

Thank you for choosing Veritatis Splendor Counseling. This document is intended to inform you of my policies, your rights, and state and federal laws. If you have any questions or concerns please ask, and I will try my best to give you all the information you need.

I am a licensed Professional Counselor. I use an eclectic approach based on Catholic philosophical and moral principles. I offer individual, group, family and couples’ counseling. I offer comprehensive mental health services.

As a licensed Professional Counselor, Wyoming law requires that I provide you with the following information:

• You are entitled to know my qualifications. If you have any questions about my abilities and qualifications please feel free to ask. As your counselor, I will inform you of purposes, goals, techniques, rules and procedures under which you may receive counseling. You may accept or reject any suggestions offered in therapy. As a unique and valuable individual, you will be treated with respect and dignity.

• You have the right to confidentiality. No personal information will be released without your written consent, unless substantial or immediate danger of physical harm exists to you or others. State and federal law require me to report any suspected cases of child abuse or neglect, and the abuse or neglect of the elderly or mentally incompetent. Clients involved in groups will be asked to maintain the confidentiality of others in the group. Violations of confidentiality may be grounds for discharge from treatment.

• I strive to offer the highest quality of service. The relationship I have with a client is professional in nature. I refrain from all other kinds of close relationships that occur between persons, including friendships and sexual relationships. I follow ethical guidelines set by the American Counseling Association of which I am a member.

In case of an emergency and I am unavailable, I advise you to call 911 or seek assistance at the nearest emergency room.

Financial Agreement:

Name of client: _________________________________ Date: ___________________

Name of Parent /Guardian (if client is a minor) _______________________________

I _____________________________ (please print name) understand that I am responsible for payment of all sessions. I understand I will receive an invoice detailing the amount owed at the end of each month. I understand the full amount of my invoice is promptly due unless other firm arrangements have been made in advance.

Payment for services can either be made via personal check, cash or Credit/Debit Card.

(Please note that there will be a 4.5% charge for all Credit and Debit cards transactions for the Credit Card/Bank companies processing and charging fees.)

Insurance Reimbursement:

• If you intend to seek reimbursement through your insurance company, you are responsible for pursuing this avenue.

• You are responsible for the full amount due and for paying the invoice each month.

• You can then submit your invoice to your insurance company and seek reimbursement.

• The invoices will be properly coded with all necessary information to seek insurance reimbursement.

Pricing:

a. The initial interview (in person or on the phone) will determine suitability for counseling and this is free.

b. Therapy sessions will be $125.00 per hour (in person or on the phone).

i. $125.00 is the minimum fee you will be charged.

ii. After the first hour, the rate will be $125.00 for the following hour. The session hours are not prorated.

c. There will be a $125.00 charge for failure to give a 24-hour notice of canceling our next scheduled appointment.

d. Emergency calls, counseling, hospital visits etc. that occur outside of scheduled session times or on weekends will be charged double the hourly rate: $250.00 per hour.

e. 3 un-notified cancelations will result in termination of counseling services.

f. Failure to pay the agreed bill may result in termination of counseling services or your account turned over for collections.

g. Preparation of progress notes, official letters written, therapeutic email responses (this does not include logistical emails), phone calls/ consultation with other professionals/law enforcement/department of family services/child protective services etc as well as insurance companies, and any other tasks associated with your therapy outside of the therapy session will be billed at the rate of $125.00 per hour prorated to the every 15 minutes.

h. Meetings with parents, guardians and any other family members and/or others associated to client regarding client’s treatment will be billed at the hourly rate of $125.00. This fee is the minimum fee that will be charged. After the first hour, the rate will be prorated to the next 30 minutes.

i. I understand that email, cell phones, which includes texting, land line phones, faxes and other electronic mediums may not be secure and therefore Veritatis Splendor Counseling cannot ensure confidentiality if any of these mediums are compromised.

E-mails, phone calls, voicemail and any other form of electronic communication to and from your Therapist:

E-mails, including attachments, phone calls, voicemail, texts etc.. to and from your therapist are covered by the Electronic Communications Privacy Act, 18 U.S.C. §§ 2510-2521, they are confidential and may be legally privileged or otherwise protected from disclosure. If you are not the intended recipient of any e-mail, voice message, text, etc… sent from Veritatis Splendor Counseling, you are hereby notified that any retention, dissemination, distribution, or copying of this communication is strictly prohibited. Please reply to the sender that you have received the message in error, and delete it.

j. In-depth Therapy Sessions:

i. In-depth sessions are defined as sessions occurring 3 or more times per week.

1. $300.00 flat rate per in-depth session.

2. Only if necessary: Tac/AudioScan: Approximately $135.00 plus shipping and handling (approximately $11.00) “The Tac/AudioScan comes complete with headphones, tactile pulsers, carrying case and 9v battery”.

Veritatis Splendor Counseling reserves the right to refuse counseling services to anyone.

Please Initial _______

EMDR Consent Advisor

I have been advised and understand that Eye Movement Desensitization and Reprocessing (EMDR) is a treatment approach that has been widely validated by research for PTSD. Research on other applications of EMDR is now in progress.

I have also been specifically advised of the following:

Distressing, unresolved memories may surface through the use of the EMDR procedure. Some clients have experienced reactions during the treatment sessions that neither they nor the administering clinician may have anticipated, including a high level of emotion or physical sensations. Subsequent to the treatment session, the processing of incidents/material may continue, and other dreams, memories, flashbacks, feelings, etc., may surface.

Before commencing EMDR treatment, I have thoroughly considered all of the above. I have obtained whatever additional input and/or professional advice I deemed necessary or appropriate to having EMDR treatment. By my signature below I hereby consent to receiving EMDR treatment. My signature on this Acknowledgement and Consent is free from pressure or influence from any person or entity.

Please Initial _______

Justin McColl, M.A. LPC

BA, Philosophy, Holy Apostles College, Cromwell CT

MA, Professional Counseling, Franciscan University, Steubenville OH.

The above-mentioned information is required by the Wyoming Mental Health Professions Act and the Wyoming Mental Health Professions Licensing Board, 2001 Capitol Ave Emerson Building,  Room 104 Cheyenne, WY 82002 (307-777-7788)

I have read, understand and consent to the information in this document.

I acknowledge that I am financially responsible for the balance of my account and agree to the financial statement noted above in this document.

______________________________ _________

Client’s Signature Date

______________________________ _________

Client’s Signature Date

______________________________ _________

Signature of Parent or Guardian Date

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