PROFESSIONAL DISCLOSURE STATEMENT
The purpose of this document is to inform you about me, the nature of services, our relationship, and our respective rights and responsibilities.
CREDENTIALS AND EXPERIENCE
I have a BS and PhD from Duke University in physics (a very different field!), but I have always had a strong interest in human thought, behavior, and experience. I strongly considered majoring in psychology, rather than physics, as an undergraduate. Thus, I am very excited to be coming to counseling as a second career. After receiving a Master of Arts in Clinical Mental Health Counseling from Wake Forest University in May 2021, I became licensed in the state of North Carolina as a Licensed Clinical Mental Health Counselor Associate (LCMHCA - License number 0000000) and also as a Nationally Certified Counselor (NCC - License number 000000). In addition to formal education and professional credentials, I bring life-experience; I have raised two children, dealt with family illness, overcome loss, undergone trauma, and been a client of counseling myself.
REGARDING MY LICENSURE…
As an LCMHCA, I am supervised for clinical work by Michael Garner, MA, LMFT, DCC. He is available at 919-772-1990 or at [email protected].
MY PERSPECTIVE, MY THEORETICAL APPROACH, AND THE CLIENTS I HELP
I largely work with individuals, both adult and adolescent. I believe each one of us is fundamentally good and capable. Sometimes, however, life can be difficult or traumatic and we become stuck, overwhelmed, despondent, or act in ways we wish we would not. As your counselor, I work as a guide and teammate. I am beside you (nudging you a bit) as we work through trauma or just work holistically toward self-actualization. I will help you discover your strengths, gain new tools, reach understandings, and establish goals so that you can live your best life. Depending on your unique personality, life approach, and specific needs, I will utilize different counseling models and techniques. I largely use person-centered theory and cognitive behavioral theory because, together, these theories provide a path for both exploration and action.
I also enjoy work with couples. Interpersonal relationships are both challenging and rewarding. Whether you are “on the rocks” right now and need help navigating your way off or just want to maximize your connection, I can help you communicate with, understand, and support one another. My couples work is grounded in the Gottman Method, a research-based approach.
OUR SESSIONS – STRUCTURE AND LOCATION
A session is normally an hour long, with the “working” part lasting 50-53 minutes and the “business part” (scheduling next appointment, assigning homework, collecting payment, etc.) lasting the remaining portion of the hour. Sessions occur at Bird In Hand, 104 Canty Court in Cary, NC. The phone number is 919-244-4894.
FEES
I require payment in full at the time services are provided, unless alternate arrangements have been made. Initial sessions are $175.00 and subsequent sessions are $105.00. I accept all major credit cards as well as mobile payments (Venmo, Zelle, etc.). If you are using insurance, your deductible must be met before insurance claims will be filed. Additionally, if you are using insurance, I have a legal and contractual obligation to collect your copayment at the time services are rendered. If my presence is required in court, the fee is $250.00 per hour and includes standby time. Please refer to your financial agreement for a detailed review of all fees, including court fees, medical records request fees, missed appointment charges, etc.
CONFIDENTIALITY
What you say to me stays with me. I will keep confidential anything you say as part of our counseling relationship, with the following exceptions:
1) The right to privacy may be waived by you and/or your legal representative.
You (or your representative) can decide that you want me to share information, and if you direct me to do so, I will.
2) When disclosure is required to prevent clear and imminent danger to yourself or others.
I want to emphasize that the circumstance is “clear and imminent” danger. If you have suicidal ideation (or are considering suicide) and are worried about “being committed” or your confidence violated if you share, please ask me more about this exception to confidentiality. We will walk through scenarios to make sure our lines of communication are open and to make sure that you are both protected and supported.
3) If a court orders to release information without your consent.
If this happens, I will request to the court that disclosure not be required due to potential harm to you or the counseling relationship.
4) If there are reports of abuse against a child or an adult/elderly individual.
I am mandated to report abuse of children and the elderly. If there is a situation that arises and I must report, I will inform you and I will be transparent and open regarding the process.
USE OF DIAGNOSIS
I utilize the Diagnostic and Statistical Manual of the American Psychiatric Association, Fifth Edition (DSM-V) to make clinical diagnoses. It is important for clients to understand that if using insurance, it is typically necessary for a diagnosis to be given in order for claims to be serviced. In addition to a diagnosis, insurance companies may also request treatment plans or summaries. This information, including the diagnosis, will become part of the client’s permanent record. Another scenario whereby diagnoses and other clinical information may be shared (upon client’s consent) is if a client transfers to another therapist or collaboration is necessary with a client’s physician or psychiatrist. Before making any qualifying diagnosis, I will inform you; a diagnosis may not be appropriate or necessary in your case.
EMERGENCY PROCEDURES
In case of a mental health emergency, please call 911 or Holly Hill Hospital Crisis Response at 919-250-1800.
COMPLAINT PROCEDURE
I provide ethical intervention; the ethical code I adhere to is the American Counseling Association Code of Ethics (www.counseling.org/Resources/aca-code-of-ethics.pdf). I encourage you to first discuss any concerns with me (ethical or otherwise), but it is important for you to know that you have other avenues to register complaints. My supervisor is one avenue, available to you at the aforementioned contact. Another avenue is the state board at:
North Carolina Board of Licensed Clinical Mental Health Counselors
P.O. Box 77819
Greensboro, NC 27417
Phone: 844-622-3572
email: [email protected]
ACCEPTANCE OF TERMS
Your and my signatures below indicate that we agree to enter a counseling relationship, that you have read and understand the information provided above, that you have been provided with the opportunity to ask questions and that I have clarified any information that was unclear to you. In other words, we agree to the terms and will abide by the guidelines.
__________________________________________________ _______________________
Client (Guardian) Signature Date
__________________________________________________ _______________________
2nd Client Signature (if couples) Date
________________________________________________ _______________________
Counselor Signature: Genevieve Berry Date
PROFESSIONAL DISCLOSURE STATEMENT
The purpose of this document is to inform you about me, the nature of services, our relationship, and our respective rights and responsibilities.
CREDENTIALS AND EXPERIENCE
I have a BS and PhD from Duke University in physics (a very different field!), but I have always had a strong interest in human thought, behavior, and experience. I strongly considered majoring in psychology, rather than physics, as an undergraduate. Thus, I am very excited to be coming to counseling as a second career. After receiving a Master of Arts in Clinical Mental Health Counseling from Wake Forest University in May 2021, I became licensed in the state of North Carolina as a Licensed Clinical Mental Health Counselor Associate (LCMHCA - License number 0000000) and also as a Nationally Certified Counselor (NCC - License number 000000). In addition to formal education and professional credentials, I bring life-experience; I have raised two children, dealt with family illness, overcome loss, undergone trauma, and been a client of counseling myself.
REGARDING MY LICENSURE…
As an LCMHCA, I am supervised for clinical work by Michael Garner, MA, LMFT, DCC. He is available at 919-772-1990 or at [email protected].
MY PERSPECTIVE, MY THEORETICAL APPROACH, AND THE CLIENTS I HELP
I largely work with individuals, both adult and adolescent. I believe each one of us is fundamentally good and capable. Sometimes, however, life can be difficult or traumatic and we become stuck, overwhelmed, despondent, or act in ways we wish we would not. As your counselor, I work as a guide and teammate. I am beside you (nudging you a bit) as we work through trauma or just work holistically toward self-actualization. I will help you discover your strengths, gain new tools, reach understandings, and establish goals so that you can live your best life. Depending on your unique personality, life approach, and specific needs, I will utilize different counseling models and techniques. I largely use person-centered theory and cognitive behavioral theory because, together, these theories provide a path for both exploration and action.
I also enjoy work with couples. Interpersonal relationships are both challenging and rewarding. Whether you are “on the rocks” right now and need help navigating your way off or just want to maximize your connection, I can help you communicate with, understand, and support one another. My couples work is grounded in the Gottman Method, a research-based approach.
OUR SESSIONS – STRUCTURE AND LOCATION
A session is normally an hour long, with the “working” part lasting 50-53 minutes and the “business part” (scheduling next appointment, assigning homework, collecting payment, etc.) lasting the remaining portion of the hour. Sessions occur at Bird In Hand, 104 Canty Court in Cary, NC. The phone number is 919-244-4894.
FEES
I require payment in full at the time services are provided, unless alternate arrangements have been made. Initial sessions are $175.00 and subsequent sessions are $105.00. I accept all major credit cards as well as mobile payments (Venmo, Zelle, etc.). If you are using insurance, your deductible must be met before insurance claims will be filed. Additionally, if you are using insurance, I have a legal and contractual obligation to collect your copayment at the time services are rendered. If my presence is required in court, the fee is $250.00 per hour and includes standby time. Please refer to your financial agreement for a detailed review of all fees, including court fees, medical records request fees, missed appointment charges, etc.
CONFIDENTIALITY
What you say to me stays with me. I will keep confidential anything you say as part of our counseling relationship, with the following exceptions:
1) The right to privacy may be waived by you and/or your legal representative.
You (or your representative) can decide that you want me to share information, and if you direct me to do so, I will.
2) When disclosure is required to prevent clear and imminent danger to yourself or others.
I want to emphasize that the circumstance is “clear and imminent” danger. If you have suicidal ideation (or are considering suicide) and are worried about “being committed” or your confidence violated if you share, please ask me more about this exception to confidentiality. We will walk through scenarios to make sure our lines of communication are open and to make sure that you are both protected and supported.
3) If a court orders to release information without your consent.
If this happens, I will request to the court that disclosure not be required due to potential harm to you or the counseling relationship.
4) If there are reports of abuse against a child or an adult/elderly individual.
I am mandated to report abuse of children and the elderly. If there is a situation that arises and I must report, I will inform you and I will be transparent and open regarding the process.
USE OF DIAGNOSIS
I utilize the Diagnostic and Statistical Manual of the American Psychiatric Association, Fifth Edition (DSM-V) to make clinical diagnoses. It is important for clients to understand that if using insurance, it is typically necessary for a diagnosis to be given in order for claims to be serviced. In addition to a diagnosis, insurance companies may also request treatment plans or summaries. This information, including the diagnosis, will become part of the client’s permanent record. Another scenario whereby diagnoses and other clinical information may be shared (upon client’s consent) is if a client transfers to another therapist or collaboration is necessary with a client’s physician or psychiatrist. Before making any qualifying diagnosis, I will inform you; a diagnosis may not be appropriate or necessary in your case.
EMERGENCY PROCEDURES
In case of a mental health emergency, please call 911 or Holly Hill Hospital Crisis Response at 919-250-1800.
COMPLAINT PROCEDURE
I provide ethical intervention; the ethical code I adhere to is the American Counseling Association Code of Ethics (www.counseling.org/Resources/aca-code-of-ethics.pdf). I encourage you to first discuss any concerns with me (ethical or otherwise), but it is important for you to know that you have other avenues to register complaints. My supervisor is one avenue, available to you at the aforementioned contact. Another avenue is the state board at:
North Carolina Board of Licensed Clinical Mental Health Counselors
P.O. Box 77819
Greensboro, NC 27417
Phone: 844-622-3572
email: [email protected]
ACCEPTANCE OF TERMS
Your and my signatures below indicate that we agree to enter a counseling relationship, that you have read and understand the information provided above, that you have been provided with the opportunity to ask questions and that I have clarified any information that was unclear to you. In other words, we agree to the terms and will abide by the guidelines.
__________________________________________________ _______________________
Client (Guardian) Signature Date
__________________________________________________ _______________________
2nd Client Signature (if couples) Date
________________________________________________ _______________________
Counselor Signature: Genevieve Berry Date