Sarah Philbeck, PLLC Licensed Professional Counselor 4726-B Park Road Charlotte, NC 28209 Phone: 704-692-0723 E-mail: email@example.com Professional Disclosure Statement Degrees, Credentials, & Certification Degree: M.A., Community Counseling, Appalachian State University, 2006 Credentials: 8 years of counseling experience Individual and couples counseling, Sarah Philbeck PLLC, Private Practice, Sept. 2012-Present Individual, couples and Group Counseling, PsycLinc, Private Practice, March 2008-Present Individual and Group Counseling, Phoenix Counseling Center, Counselor, 2006-2010 Individual Counseling and Clinical Internship, Presbyterian Hospital, 2006 Clinical Internship, Abuse Prevention Council of Shelby, 2006 Certification/Licensure/Training: LPC #6870, Licensed Professional Counselor, 2008 NCC #213453, National Certified Counselor, 2006 Expressive Arts Therapy Certification, Appalachian State University, 2006 Addictions Certification, Appalachian State University, 2006 Level 2 Internal Family Systems Certification Externship â€“ Emotionally Focused Therapy RYT, Registered Yoga Teacher, 2002 Member of:
ACA American Counseling Association
Clientele: I provide consultation and counseling services to adults. The issues addressed include, but are not limited to: depression, anxiety, trauma, relationship difficulties, domestic violence, addiction, spirituality, family of origin issues, death /dying, bereavement, and anger difficulties. Services offered: I provide Individual, Couples, Family, and Group Therapy. Talk therapy is used in individual and group sessions. Some of the counseling models and techniques that I draw from are: Internal Family Systems, Emotionally Focused Therapy, Mindfulness-based Cognitive Therapy, and Dialectical-Behavior Therapy. Expressive Arts Therapy is utilized at times to help the client access and communicate emotion. The art modalities used may include drawing, writing, clay, movement, and/or collage. Philosophy: There are many different life events that may bring one to counseling such as a divorce, illness, stress of daily living, or depression. In counseling sessions, I provide a safe, confidential environment for the client to explore the issues at hand. I have a holistic approach to counseling that considers all aspects of the person: mind, body, and spirit. In exploring these areas one can find healing and growth, and move forward with lifeâ€™s goals. I abide by the Code of Ethics for Licensed Professional Counselors. 1
Records and Confidentiality: All of our communication becomes part of your clinical record, which is available to you upon request. Anything you say to me will be kept strictly confidential. There are limits to confidentiality, which are listed below: - you are a danger to yourself or others - a child, disabled, or elderly person is being abused and/or neglected - I am court ordered to disclose information - during supervisory consultation Fees, Cancellation, and Insurance Reimbursement Initial Intake Evaluation Ongoing Individual Therapy Couples Therapy Telephone calls over 10 min. Late cancellation Fee
1 hour 50min. - 1hour 1hour ea. additional 15 min.
$115.00 $110.00 $125.00 $20.00 $50.00
Payment is collected at the end of each session, unless other arrangements have been made. Cash, personal checks, credit/debit cards are accepted. Please notify me 24 hours in advance if you will be unable to attend a session. More advanced notice is appreciated. If you do not notify me 24 hours prior to your appointment, there is a $50 charge. I will bill your insurance company directly if I am impaneled with that company, and signing this form allows me to receive payment directly from them. Copays must be received at the time your service is rendered. If I am not impaneled with your insurance company, I will be considered out-of-network and I will provide you with a super-bill with pertinent information for claim reimbursement. Although I view individuals through a lens of wellness, I must provide a diagnosis when filing claims for insurance companies, and this will indicate an â€œillnessâ€?. Once it is reported, it will become part of your permanent insurance record. Grievances: Please let me know, if you are ever dissatisfied with my services. If you continue to be dissatisfied, you may report your complaints to the licensing board: North Carolina Board for Professional Counselors at (919) 661-0820. By signing below, you are indicating that you have read and understood this statement and any questions you have had about it have been answered to your satisfaction.
______________________________________ Counselors Signature
______________________________________ Clientâ€™s Signature
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