Client Forms
If you are new, please feel free to fill out these intake forms before our first session. These forms can also be filled out during the first session.
If you feel that you would like to collaborate your session with another provider, simply fill out the following form.
Authorization for Release of Information
TAPROOT INTEGRATIVE COUNSELING, PLLC
PSYCHOTHERAPY PROFESSIONAL DISCLOSURE STATEMENT Updated January, 2024
This is a statement of your rights and responsibilities for our therapeutic relationship. This document is a part of the Standards of Practice of the North Carolina Board of Licensed Clinical Mental Health Counselors (LCMHC).
The Disclosure Statement is designed to inform you of my professional credentials, types of service offered, fee schedule, therapeutic orientation, and counseling style. Please read this carefully and if you have questions that are not covered here or need further clarification, please feel free to ask me when we discuss this statement during our initial therapy session.
Education and Credentials
I received a Master of Science in Clinical Counseling in 2016 from Bellevue University of Nebraska. I have been providing psychotherapy since that time. I am licensed as a Clinical Mental Health Counselor by the states of North Carolina (License # 12786), South Carolina, and Rhode Island. My clinical specialties include trauma, PTSD, anxiety, depression, mood disorders, and adjustment disorders for adults, couples, and families.
Counseling Process and Approach
My theoretical orientation is based on Jungian transpersonal psychotherapy. My counseling approach is holistic and takes into consideration all biological, neurological, psychological, social, spiritual, energetic, and cosmological factors that may affect the body-mind.
I implement Cognitive Behavioral Therapy (CBT), DBT, EMDR (Eye Movement Desensitization Reprogramming), Emotional Freedom Tapping and Thought Field Therapy, Mindfulness-Based Stress Reduction (MBSR), mindfulness meditation, and specific breathing techniques to decrease anxiety. In some cases, certain techniques or modalities may result in some discomfort before relief of symptoms and healing occur.
Services Offered & Length of Individual Session
I specialize in psychotherapy for Highly Sensitive individuals and I also provide therapy for couples, and families. Services are rendered in a professional manner consistent with ethical standards. It is impossible to guarantee any specific results regarding your counseling goals because outcomes depend upon your work as well as mine. Individual sessions are 60 minutes in duration and will be scheduled by mutual agreement.
Insurance Reimbursement & Diagnosis
As of January 1, 2024, I no longer file insurance claims but I can provide a Super Bill for you to mail to your insurance company for possible reimbursement. Please be aware that most insurance companies require a psychiatric diagnosis, clinical assessment intake, and treatment plan in order to reimburse for mental health counseling and any diagnosis based on initial intake will become a part of your permanent insurance records.
All therapy fee services are due on date of session. Regardless of insurance, clients are responsible for payment of all fees for services rendered. Clients will be asked to sign a payment authorization for electronic payment transactions which are processed securely online through Therapy Notes (practice management software) using Visa, MasterCard, American Express, Discover, or HSA Health Savings benefits card.
Private pay rates are as follows:
$150 per 50-minute individual therapy session
$200 for couples therapy (time varies from 60-90 minutes)
$250 for new client intake assessment (2-hour session including diagnosis and treatment plan)
$300 for Ecot-herapy and Forest Therapy (minimum of 2 hours, in-person, weekends only)
$300 for comprehensive clinical assessment (includes individual assessment instruments such as Beck’s Depression Scale)
Cancellation Policy – If you are unable to keep an appointment, please call within 24 hours to cancel and/or reschedule. Unless prior arrangements have been made, you will be charged $100 for missed appointments or failure to cancel your appointment within 24 hours. Please understand that your insurance will not reimburse you for any portion of a missed appointment and you are responsible for the full fee.
Emergencies – I do not provide 24-hour on-call emergency services. You are free to call or text me after office hours at 828-484-1610 and leave a message on my voice mail or email me for urgent/non-emergency needs. Should you have a mental health emergency and are unable to reach me, please go to your nearest hospital emergency room or call 911. Residents of Buncombe County, North Carolina may also call the local Mobile Crisis Management Response Team at 888-573-1006.
For any psychiatric emergency OR suicidal ideation, please call 1-800-SUICIDE
Otherwise, please dial 911 or contact your primary care physician or psychiatric provider.
Confidentiality – All information shared in session is confidential with the following exceptions:
(1) For case consultation purposes, I may consult with other therapists, who are required to keep client information confidential.
(2) The State Law of North Carolina requires that suspected abuse or neglect of a child, elder, dependent adult, or developmentally disabled person be reported.
(3) The State Law of North Carolina requires that others be informed if a client threatens suicide or harm to herself/himself, or others. If the threat constitutes clear and imminent danger, the appropriate agencies and/or law enforcement must be contacted. The person against whom the threat has been made may also be contacted to prevent harm.
(4) Should I be presented with a court order, I may be required to disclose information in the presence of a judge; however, I will first assert legal privilege to protect your confidentiality.
(5) Information which may jeopardize my safety will not be kept confidential.
(6) In the event of a medical emergency on your part, emergency personnel may have to be provided with some confidential health information.
(7) Children and adolescents must have written permission from a parent or legal guardian before receiving therapy services. Confidential information will be shared with a parent or legal guardian only if the child or adolescent is in imminent physical or emotional danger.
(8) If I am made aware that you have a communicable and/or fatal disease to which you have willfully exposed an identified third party.
(9) If you bring a complaint against me with the North Carolina Board of Licensed Clinical Mental Health Counselors, requested information will be released.
Complaint Procedures – I adhere to the highest ethical and professional standards. If you are dissatisfied with any aspect of the counseling process, please inform me so we can determine how our work together can be more effective or if an outside referral is more appropriate.
If you think I have treated you unfairly or unethically, and we cannot resolve the problem without mediation, please contact the North Carolina Board of Licensed Clinical Mental Health Counselors at 336-217-6007 or write to:
North Carolina Board of Licensed Clinical Mental Health Counselors
PO Box 77819
Greensboro, NC 27417.