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Thank you for
choosing Nadine Rosen, M.A., L.P.C., N.C.C. Todayís appointment will
take approximately 50 minutes. The decision to start counseling is
a major one and you may have many questions. This document is intended
to inform you of my policies, State and Federal Laws and your rights.
If you have other questions or concerns, please ask and I will try my
best to give you all the information you need.
I hold a Masterís Degree from the Adler
School of Professional Psychology, which was received in 1993 and have
been practicing counseling and psychotherapy for over 15 years. I have
a current License as a Professional Counselor in the state of North
Carolina. I am also a Nationally Certified Counselor and a Certified
Clinical Hypnotherapist. I take an eclectic approach to counseling.
That is, I will borrow techniques from various schools of thought, such
as, Alfred Adlerís Individual Psychology, Aaron Beckís and Donald
Michenbaumís Cognitive-Behavioral Therapy, and Acceptance and Commitment
Therapy (ACT) The decision as to which treatment technique to use
will depend on several variables including the success rate of a
process will require that we develop a therapeutic contract or treatment
plan stating goals, methods, and time frame. This plan may need to be
re-evaluated and redesigned after periodically evaluating your progress.
Please note that it is impossible to guarantee any specific results
regarding your counseling goals. However, together we will work to
achieve the best possible results for you.
AND EMERGENCY SITUATIONS:
verbal communication and clinical records are strictly confidential
except for: a) information (diagnosis and dates of service) shared with
your insurance company to process claims, b) information you and/or
you child or children report about physical or sexual abuse; then, by
North Carolina State Law, I am obligated to report this to the
Department of Children and Family Services, c) where you sign a release
of information to have specific information shared, d) if you provide
information that informs me that you are in danger of harming yourself
or others, e) information necessary for case supervision or consultation
and f) or when required by law. If an emergency situation for which the
client or their guardian feels immediate attention is necessary, the
client or guardian understands that they are to contact the emergency
services in the community (911) for those services.
a courtesy I will bill your insurance company, HMO, responsible party or
third party payer for you, if you wish. I ask that at each session you
pay your co-pay or co-insurance. In the event that you have not
met your deductible, the full fee is due at each session until the
deductible is satisfied. If your insurance company denies payment
or does not cover counseling, we request that you pay the balance due at
that time. In the event that an account
is overdue and turned over to my collection agency, the client or
responsible party will be held responsible for any collection fee
charged to my office to collect the debt owed. We ask that every client
authorize payment of medical benefits directly to Nadine Rosen, M.A., L.P.C., N.C.C.
received a copy of my fee schedule_______________ (initial)
I agree to have my insurance company reimburse my provider
Lastly, if you
need to cancel or reschedule an appointment, please give 24 business
hours advance notice, otherwise you will be billed at the hourly rate.
I sincerely appreciate your cooperation and at any time you have any
questions regarding insurance, fees, balances or payments please feel
free to ask. You may have a copy of this form if requested.
OF TREAMENT: It
is important that all health care providers work together. As such, we
would like your permission to communicate with your primary care
physician and/or psychiatrist. Your consent is valid for one year.
Please understand that you
have the right to revoke this authorization, in writing, at any time by
sending notice. However, a revocation is not valid to the extent that we
have acted in reliance on such authorization.
If you prefer to decline consent no inform will be shared.
may inform my physician(s) _______I decline to
inform my physician
NOTICE OF PRIVACY PRACTICES AND
I/We have read and received a copy of
the, Notice of Privacy Practices and Client Rights document.
TREATMENT OF CHILDREN OR ADOLESCENTS:
I/We consent that _____________________________________ maybe treated
as a client by Nadine Rosen, M.A., L.P.C., N.C.C. At times it may be
necessary to schedule appointments during school hours. I ask for your
cooperation to provide the most timely treatment for you and your