SOUTH MOUNTAIN COUNSELING SERVICES PRACTICE DISCLOSURE STATEMENT
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We are pleased that you have chosen South Mountain Counseling Services for your clinical services. This agreement will give you information about our practice operation and procedures and our professional relationship with you.

South Mountain Counseling Services (SMCS] is staffed by professionals who are licensed and/or certified in the appropriate therapeutic methods and domains. Our practice offers both diagnostic and therapy services to children, adolescents, adults, groups and families and couples. Many of our Clients come to us for help dealing with issues of loss, trauma, anxiety, depression, difficulties and adjusting to life events.

In our practice we provide help for individuals and families who are experiencing emotional problems that interfere with their educational, occupational, community or personal lives. SMCS offers individual, group, and family therapy to children, adolescents, and adults in Frederick County. Our Licensed Clinical Professional Counselors deliver effective treatment that focuses on symptom reduction, education, and skill enhancement.

We believe that all individuals have the capacity and desire to resolve their own problems and at times need guidance and assistance. As people move through the therapy process they gain the tools they need to be purposeful and successful. In time they grow in self awareness and self acceptance and become more capable of finding fulfillment and meaning in their lives. We offer solution oriented therapy services that are directed towards assisting clients to resolve the issues that caused them to seek our services. We find that our clients often require only a few sessions to resolve their presenting issues. We do not enable our clients to continue to engage in self destructive behaviors and we will actively attempt to intervene to assist our clients to resolve their issues. If counseling is successful, clients should feel that they are able to face life's challenges without further assistance and intervention.

Our clients have the right to:

•  To terminate our professional services without any moral, legal, or financial obligation to continue to receive services;

•  To ask for and receive referral to another qualified clinician whenever the choice is made to terminate our professional services;

•  To receive information regarding the procedures that will be used in your evaluation and therapy process;

•  To be informed of your diagnosis and treatment plan goals and objectives, the clinical plan to meet those goals and objectives and the financial costs of our treatment services to you;

•  To review your clinical records with your clinician at any time;

•  To have your case information maintained in a confidential manner as outlined in this Professional Disclosure Statement;

•  To have your records released to others at your written request or as oLJtlined below in this statement;

•  To be treated with respect and dignity according to the Codes of Ethics that govern our professional conduct at all times.

Although our sessions are very intimate and personal, it is important for you to understand that we have a professional relationship. Our professional Code of Ethics does not allow us to attend social gatherings with you, to accept gifts from you, or to accept goods or services in lieu of payment for services rendered. We have numerous rules and regulations that govern our professional conduct with you during the time that we will be providing professional services to you. We will be happy to discuss our professional Code of Ethics with you upon your request.

We will keep everything that you say to us confidential with the following exceptions: Your requests for us to tell someone else information that you desire to have released; you reveal to us that you have knowledge of unreported child abuse/neglect that must be reported according to state law; information that you have revealed to us suggests that you are a danger to yourself or to others; when we are ordered by a Court to disclose

your information; or your insurance company requests clinical information that they are entitled to receive for diagnosis or payment purposes.

In return for your treatment fee, we agree to provide professional services to you. Your treatment fees will vary depending upon your contracted fee schedule with your fee payor. Our normal session length is 45 minutes. While it is impossible to guarantee specific results regarding your treatment and goals, we assure you that our services will be rendered in a professional manner that is consistent with accepted ethical standards of professional practice. We will bill third party payors for the remainder of your fees if you request that we bill your third party insurance company.

Our initial session with you will consist of issue identification, history taking of the presenting issue, a review of your previous efforts to resolve the . problem, your expectations for a solution to the problem, and the development of a treatment plan,. Subsequent sessions will focus on the resolution of your identified problems. With your approval we will utilize individual, couples, family, education, and referrals to specialists when needed for evaluation and counseling services. Of course, we cannot solve your concerns and issues for you, but it is our goal to increase your own problem solving which will lead to issue resolution and self satisfaction and improvement.

Foreseeable Risks of treatment include:

•  Increased awareness of unpleasant experiences from the past.

•  Possible difficulty with present relationships, including family, job and social situations.

•  The expected benefits of treatment include:

•  Improved understanding of my psychological makeup and its effect on others.

•  Improvement with identified symptoms.

•  Better relationships with significant people in my life.

•  Better ability to cope with adversity in my life.

Fees

Your fee for each session is due at each session unless other financial arrangements have been made. We are providers for many major insurance companies and we will accept co-payments for services rendered in accordance with their established fee schedules and financial policies. For third party billing we will require accurate insurance billing information at the time of your first session. If we do not have accurate insurance billing information at the time of your first session, please be prepared to pay for your first session yourself as this session will likely not be covered by your insurance plan. We will be happy to contact your insurance company or managed care company to determine what benefits you have for payment for our services at the time that services are delivered. We will file for insurance reimbursement for you. If payment is not received, it will become your responsibility to pay for the services that are rendered by our staff. Please also note that we will charge you the session fee if the third party does not pay for your session due to your not completing paperwork or documentation that they have requested of you which has prevented us from being paid for that session. If requested by you, we will provide you with a receipt when you pay your session fee.

Reimbursement

If you want to seek reimbursement for our services from your insurance company, we will be happy to furnish you with any necessary information required by your insurer to submit to them for payment. Most insurance companies will reimburse clients for our services, but some will not. Insurance plans that do reimburse for our services typically require that clients meet certain annual deductibles and usually only a percentage of our fee is reimbursable by insurance. If payment is not received as a result of filing for payment with your insurance carrier, it will be your responsibility to pay the charges.

Reimbursable Conditions

Health Insurance company payers require that we diagnose your symptoms to determine that you have a reimbursable condition for insurance payment purposes. We will discuss with you the diagnosis that we plan to submit to your insurance company prior to the end of your initial session. Any diagnosis that is rendered will become part of your permanent record and will be handled with complete confidentiality by our staff. Please note that your insurance company has the right to request your records if payment is being requested from them.

Appointments

If you are unable to keep a scheduled appointment, kindly notify us 24 hours in advance to your scheduled session. If we do not receive notice of your appointment cancellation within this time period, you will be responsible for paying the fee for the session that you missed. If you are experiencing an emergency situation, please leave a message at any time on our voice mail system. We will return your call as soon as possible.

Mental Health Emergencies

Should you encounter a mental health emergency situation, please call 911 or go to the nearest emergency room for immediate emergency assistance. You may also contact us via 301-305­ 2585. Emergency instructions are also available on our voice mail when you contact the main telephone numbers at our office locations.

Additional Information

You can visit our web sites on the internet at: www.southmountaincounseling.com

We offer information about our services, maps to our locations, email messaging to our counselors, appointment scheduling request services and additional information regarding our practice.

CLIENT SERVICE AGREEMENT

I agree to contract with my counselor to provide me with the clinical services I require, which may include all or part of the following:

•  Initial Evaluation

•  Treatment Plan Development

•  " Standardized Counseling Assessment

• Direct Counseling and Psychotherapy Services for myself and/ or other designated family members.

•  Specialized Assessment of Specific Problem Area such as depression, AD/HD, etc.

•  Referral to approved and qualified Medical Personnel if required and with my approval or to any other appropriate treatment specialist; and

•  Maintenance of appropriate case and billing records required to provide these clinical services.

•  These services are to be provided to the individual named in the Client Information Form.

•  I further agree to have my counselor provide mutually agreed upon sessions consisting of the above referenced services to the designated individual listed in the disclosure statement. I agree to pay the negotiated and agreed upon fee charged by my counselor for those professional services listed above that he/she renders.

•  I understand that I can terminate the services that I am receiving from my counselor at any time. I further agree that I am contracting only to pay for those professional services that are actually provided by my counselor.

•  The payer source for services that are to be provided by my counselor will be listed in the Client Service Agreement form.

I agree to pay the payment/co-payment amount due each session to my counselor. I do understand that I will be responsible for the unpaid portion of the fee for services rendered that are not paid for by the payer source listed in the Client Referral Form.

The contents of our counseling, intake, or assessment forms and sessions are considered to be confidential. Both verbal information and written records about a client cannot be shared with another party without the written consent of the client or the client's legal guardian. It is the policy of this practice not to release any information about a client without a signed release of information. Noted exceptions are as follows:

Duty to warn

When a client discloses intentions or a plan to harm another person, the health care professional is required to warn the intended victim and report this information to legal authorities. In cases in which the client discloses or implies a plan for suicide, the health care professional is required to notify legal authorities and make reasonable attempts to notify the family of the client:

Abuse of Children and Vulnerable Adults

If a client states or suggests that he or she is abusing a child (or vulnerable adult] or has recently abused a child (or vulnerable adult), or a child (or vulnerable adult) is in danger of abuse, the health care professional is required to report this information to the appropriate social service and/or legal authorities.

Prenatal Exposure to Controlled Substances

Health care professionals may be required to report admitted prenatal exposure to controlled substances that are potentially harmful if the life of the unborn child is placed at risk. In the Event of a Client's Death, the spouse or parents of a deceased client have a right to access their child's or spouse's records.

Professional Misconduct

Professional misconduct by a health care professional must be reported by other health care professionals. In cases in which a professional or legal disciplinary meeting is being held regarding the health care professional's actions, related records may be released in order to substantiate disciplinary concerns.

Court Orders

Health care professionals are required to release records of clients when a court order has been placed. It is our policy to inform you of the Court

Order or Subpoena and or our intent to release your records prior to releasing them to any party.

Minors/Guardianship

Parents or legal guardians of minor clients have the right to access the client's records through the age of 14 in the State Of Maryland.

In Case of Provider's Death or Incapacitation

In the event of an unexpected death or incapacitation of your counselor your case will be reviewed by another professional of South Mountain Counseling Services and she will make arrangements to discuss treatment or referral options with you.

Other Provisions

When fees for services are not paid in a timely manner, various methods may be utilized in collecting unpaid debts. The specific content of the services [e.g., diagnosis, treatment plan, case notes, testing] is not disclosed. If a debt remains unpaid it may be reported to credit agencies, and the client's credit report may state the amount owed, time frame, and the name of the clinic.

Insurance companies and other third-party payers are given information that they request regarding services to clients. Information which may be requested includes type of services, dates/times of services. diagnosis, treatment plan, description of impairment, progress of therapy, case notes, and summaries. This information is only given upon written request and to supply them with information needed to process claims and to approve further or additional treatment services. Please note that certain demographic and diagnosis information is released to permit your insurance company to pay for the services that your counselor has rendered. Information about clients may be disclosed in consultations with other professionals in order to provide the best possible treatment. In such cases the name of the client, or any identifying information, is not disclosed. Clinical information about the client is discussed when you are referred or when you

request that information be sent to another provider. When couples, groups, or families are receiving services, a joint file is kept for individuals for information disclosed that is of a confidential nature. The information includes [a] testing results. [b] information given to the mental health professional not in the presence of other person[s] utilizing services, [c] information received from

other sources about the client, [d] diagnosis, Ie] treatment plan, [f) individual reports/summaries, and [h) information that has been requested to be separate. The material disclosed in conjoint family or couples sessions, in which each party discloses such information in each other's presence, is kept in the client of records file in the form of case notes and clinical data. In the event in which the clinic or mental health professional must telephone the client for purposes such as appointment cancellations or reminders, or to give/ receive other information, efforts are made to preserve confidentiality. Please tell us where we may reach you by phone and how you would like us to identify ourselves. For example, you might request that when we phone you at home or work. we do not say the name of the clinic or the nature of the call, but rather the mental health professional's first name only. If this information is not provided to us during the intake process, we will adhere to the following procedure when making phone calls: First we will ask to speak to the client [or guardian) without identifying the name of the clinic. If ttie person answering the phone asks for more identifying information we will say that it is a personal call. We will not identify the clinic [to protect confidentiality). If we reach an answering machine or voice mail we will follow the same guidelines.

If we should happen to encounter you in a public place we will not acknowledge you unless you do so first. We believe it is important to protect your confidentiality and respect your decision of acknowledging a association with us.