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Professional Disclosure Statement

Thea E. Vondracek, MA, LPCS

I am glad that you are considering choosing me as your counselor. This document is to inform you about my background and credentials, my methods of therapy, my fee structure, your rights as a counseling client, and other important information. 
I have a master’s degree (MA) in counseling and human services from the University of Colorado at Colorado Springs and a post-master’s certificate (PMC) in marriage and family therapy from the University of North Carolina at Greensboro. I am a North Carolina Licensed Professional Counselor Supervisor (LPCS) license #S6636, and, North Carolina Licensed Marriage and Family Therapist (LMFT) #1326.
 
Counseling Services
I provide in-office counseling services to individuals, couples, and families. A standard counseling session is 55 minutes in length (subject to insurance coverage limitations). Counseling services are provided at Chrysalis Counseling and Consultation Center, 100 NC Highway 150 West, Greensboro, NC 27455. 
Tele-counseling services are available to adults only.  Counseling sessions are offered in 20-minute increments and can be scheduled either as a single "mini-session" or multiple consecutive sessions based on client need and preferences. Tele-counseling services are available from the location of the client's choice through a HIPAA compliant web-based program using audio and video services. Due to licensure regulations, tele-counseling services are provided only to individuals who reside in North Carolina.
Counseling services are offered to anyone without regard to age, color, culture, disability, ethnic group, gender, race, religion, sexual orientation, marital status, or socioeconomic status. I cannot guarantee results, as counseling is experiential in nature. My primary responsibility is to respect your dignity and to promote your welfare.
I follow the American Counseling Association (ACA) Code of Ethics and Standards of Practice which can be found at http://www.counseling.org/Resources/CodeOfEthics/TP/Home/CT2.aspx. I have copies of ACA’s “The Layperson’s Guide to Counselor Ethics: What you should know about the ethical practice of professional counselors” if you would like to have an explanation of the ACA Code of Ethics.
  
Client Rights and Important Information:
  • You are entitled to receive a copy of this Professional Disclosure Statement
  • You can seek a second opinion from another therapist or terminate therapy at any time without penalty
  • In a professional relationship such as ours, sexual intimacy between a therapist and a client is never appropriate. If sexual intimacy occurs, it should be reported to the North Carolina Board of Licensed Professional Counselors.
  • Generally speaking, the information provided by and to a client during therapy sessions is legally confidential. The therapist cannot be forced to disclose the information without the client’s consent except as required by State law. (See Confidentiality and Limits within this document.)
  • A statement regarding all your rights as a counseling client is posted in my lobby. You may request a copy of that statement at any time 
Dual Relationships:  Since counseling sessions involve personal information, it is in the best interest of your counseling needs that we only relate to each other in a professional context. If a dual relationship becomes necessary:
  • It must be appropriate, based on the client's perspective
  • It must not exploit the client
  • It must benefit the client, not the therapist
  • It must not create a harmful situation for the client
If we happen upon one another in a public setting, please note that I will not initiate contact. If you are comfortable acknowledging our professional relationship I will respond appropriately.
 
Spirituality
            In addition to therapeutic treatment, I affirm the importance of your faith perspective for mental health. At some point in therapy you may wish to discuss this with me. Please feel free to do so; if not, there will be no coercion on my part to discuss or disclose any matter of religion or spirituality.
 
Treatment Philosophy
I believe that my role is to listen and reflect what is heard while going with you on your journey toward wholeness. I am a “sounding board” for your thoughts and ideas. We will work together to find resolutions to the challenges you face. In order for counseling to be effective, it is necessary that you take an active role in the process. We will specify goals, plans, and methods as well as other aspects of your particular situation.  Please plan on attending 5-8 sessions in order to maximize your ability to sustain change. 
 
Theoretical Orientation and Techniques Used
I practice therapy from a person-centered philosophy. I believe that you are the expert on your personal situation and have the means to resolve problems within a safe therapeutic relationship. Good emotional health is a congruence of ideal self and real self. Problems occur when there is a discrepancy between what you want to be and what you are experiencing. We will focus on the present moment and on experiencing and expressing your feelings. The past will be discussed as it affects your present feelings and behaviors.  
 
Informed Consent
            Informed consent for treatment includes advising you of the potential risks, alleged benefits, and alternatives to treatment which we will discuss at our initial session.
            Risks:  Be advised that therapy may uncover some uncomfortable feelings as you discover blocks to growth.
            Benefits:  Working through those feelings will be an attempt to create greater self-awareness, greater self-trust, an increased spontaneity and aliveness, and an understanding that growth is an on-going process.
         Alternatives to treatment:  As our relationship develops I may introduce theories or specific techniques to help overcome obstacles to your progress.  These will be discussed with you prior to use, so that you will understand the possible consequences of using those techniques. You have the right to refuse treatment at any time.
 
Confidentiality and Limits:  Professional counselors are bound to the limits of confidentiality as outlined below:
  • The right to privacy may be waived by you or your legally recognized representative
  • Confidentiality does not apply when disclosure is required to prevent clear and imminent danger to self or others, or in the case of child or elder abuse
  • Confidentiality might not apply when I receive information confirming that you have a disease commonly known to be both communicable and fatal. This information may be disclosed to an identifiable third party, who by their relationship with you, is at high risk of contracting the disease.
  • In group or family counseling, or when counseling individuals age 17 or younger, confidentiality cannot be guaranteed
  • If you are seeking payment for services from a third-party payor (such as an insurance company) confidentiality may need to be broken in order for payment of services to be approved
  • Please refer to my Notices of Privacy Practices (HIPAA) for more information regarding how your Protected Health Information (PHI) might be used or disclosed
Diagnostic Information
If applicable, I may need to make a diagnostic classification. This information becomes part of your record and may need to be shared with a third-party payer. Your records will include any diagnoses; all information provided by you, including your medical and personal history; records of our sessions; and my observations and/or recommendations. Records will be kept for a minimum of three years or as required by law. Records that no longer need to be kept will be destroyed in such a way as to safeguard confidentiality.
 
Social Media
            Although I participate in a number of social media activities, I maintain clear boundaries between my personal and professional life. Please do not be offended if I refuse a friend request or connection through a social media site.
 
Electronic Communication
            During the initial gathering of data I will ask you for an e-mail address and ask permission to send you information regarding appointments and other business matters via e-mail. When you make an appointment you will be asked for a phone number for text messaging in order to send appointment reminders to your phone.  You have the right to deny me this information. Confidentiality of information shared through e-mail and text messaging cannot be guaranteed. If you give me permission to contact you through e-mail or text messaging you accept responsibility for any breach of confidentiality.
            I do not do therapy via e-mail, text, or phone.  If you wish to obtain counseling via web-based services, you may sign-up for tele-counseling services that are provided through a HIPAA compliant platform.
 
Outcome Measures
            My goal is for you to overcome the difficulties that brought you to therapy sooner rather than later.  In order to determine your success in treatment, at the beginning of each session I will ask you to complete a rating scale of how you are functioning. This information will be recorded in your chart and compared over time. If we find that you are not making progress towards your goals we will redesign the treatment plan, goals, and methods and consider the possible benefit of a referral to another therapist or treatment program.
            At the end of each session, I will ask you to complete a rating scale regarding our session. My goal is to uncover any blockage to your success that I have inadvertently created during the session. Only through your feedback can I modify my style, approach, and improve my counseling skills.
 
Fees and Payments
In-office 55-minute sessions are $125.00.  If you have insurance coverage for mental health services, and wish to utilize that coverage to pay for counseling services, you will be expected to pay the rate established by the insurance plan. You will be responsible to pay any co-payment or deductible at each session. I will bill the insurance company for the remainder. If your insurance fails to pay, you are responsible for the full payment of your bill.  Payment may be made by cash, check, or credit card.  The reduced rate of $95 for a 55-minute session will apply for self-pay (no insurance billing).
Tele-counseling sessions are billed based on the number of consecutive sessions scheduled.  An individual 20-minute session is $35; a 40-minute session (two consecutive 20-minute sessions) is $70; and a 55-minute session (total of three consecutive sessions) is $95.  Additional 20-minute increments or portions thereof, are $35 each. There is no insurance billing for tele-counseling sessions; therefore, the client is responsible for the full cost of services.  A credit card account will remain on file and services will be billed to the credit card immediately upon end of the session.
 
Cancellations and Missed Appointments
You have the responsibility to be on time for your appointments.  If you arrive more than ten minutes late I reserve the right to ask you to reschedule.  If you are unable to keep your appointment, you must provide notice no less than the day before your scheduled appointment or the credit card on file will be billed $50 for the missed session.
If you are unable to keep your tele-counseling appointment, and do not provide notice to cancel at least the day before your scheduled appointment, your credit card will be charged $15 for each missed 20-minute session scheduled.
If you miss more than two appointments I reserve the right to place you on a walk-in or drop-in only basis. That means a specific appointment time will not be made for you, but you will be seen based on my availability on a first-come, first-served basis. 
 
Ending the Therapeutic Relationship: If for any reason you wish to terminate our therapeutic relationship, you have the right to do so in either of the following ways:
  • You advise me at any time that you wish to terminate therapy (planned discharge)
  • You do not return for services within 60 days of the previous session (drop-out of services)
My goal is that we discuss ending therapy and no one "drops out."  If you wish to discontinue for any reason, just let me know that you will not be making a future appointment.  If you have not discussed ending services with me, and you do not schedule a future appointment within 30 days of your last appointment, I will send you an inquiry to determine if you plan to continue or end services. If you decide that I am not the right fit for you, I will be happy to work with you to find a therapist that better suits your needs.
             Ending therapy can also be based on my belief that sessions are not productive or that the services you need are outside the scope of my practice.  If you are not making progress, a referral to another counselor or service may be appropriate.
 
Contact Information
The best way to contact me is through my cell phone at 336-338-2011. You can leave a confidential message for me through my voice mail. I check my voice mail throughout the day. In a crisis, you can call my cell phone, 911, the National Hopeline Network at 1-800-784-2433 (1-800-SUICIDE), or go to your local emergency room.
You may also contact me through e-mail at [email protected]. My e-mail system is not encrypted; therefore, I cannot guarantee the confidentiality of information sent via e-mail.
The physical address of my practice is: 100 NC Highway 150 W., Greensboro, NC 27455. My website address is www.greensboro-therapy.com
 
Complaint Procedures
The agency that has responsibility specifically for North Carolina Licensed Professional Counselors is the North Carolina Board of Licensed Professional Counselors (NCBLPC). If you believe that you have been treated unfairly or unethically, you may contact the NCBLPC by phone at 844-622-3572, or by mail at P.O. Box  77819, Greensboro, NC 27417.