The following information is provided to my clients to assist you in understanding policies and procedures at my office. We strive to provide you with care which is both comfortable and of the highest quality. Please do not hesitate to ask questions of me at any time about these matters.

Attached to this Client Agreement Form is the newly required Notification of Client Rights document now required with the passage of the federal "medical records privacy law" known as HIPAA (Health Insurance Portability and Accountability Act). I am required by law to give you a copy of this document and to secure your signature indicating you have received a copy of it. Laws such as these are important, but also complex, and in my Notification of Client Rights document I have tried to inform you about your rights in plain, simple language. Please read the contract and do not hesitate to ask me about any questions you might have about these matters.

Pastoral Counseling for Growth is founded to provide ministries of Pastoral Counseling, Growth, and Consultation within the context of a theological perspective. I seek to nurture persons as they grow toward wholeness and well-being. I offer supportive care and counseling for persons experiencing life’s problems and pain, and for those desiring to grow emotionally or spiritually. As a pastoral counselor, I rely upon the insights and caring perspectives of faith and the psychological sciences. Pastoral Counseling for Growth will provide: counseling, consultation for churches, businesses, and other groups; and educational/growth events for a variety of church and community groups.

I received my Doctor of Ministry degree in Pastoral Counseling and Psychotherapy from Garrett-Evangelical Theological Seminary, Evanston, IL, in 1996. I also earned a Masters of Divinity from Southeastern Baptist Theological Seminary, Wake Forest, NC, in 1980. I am a Member Certified in the American Association of Pastoral Counselors (# 4945). I am licensed in Tennessee as a Clinical Pastoral Therapist (# 0011). I am licensed in Tennessee also as a Licensed Professional Counselor (# 1195). I am endorsed for the specialized ministry of pastoral counseling by the Assembly of Episcopal Healthcare Chaplains.

I have been in full-time ministry since 1980, including five years as pastor; reserve chaplain in the US Air Force; counselor/case manager for adolescents in group treatment facilities, and director of a church-sponsored group home for adolescent boys. I completed one year of Clinical Pastoral Education at Baptist Hospital, Knoxville, TN. I was a pastoral counseling resident and fellow for a period of three years at the Pastoral Institute, Columbus, GA. I have been in private practice since 1995, serving in Asheville, NC, Bristol, TN, and now Knoxville, TN.

I use a variety of approaches in my work, depending upon my assessment of what will best help you meet your goals for counseling. The approaches I draw upon most often are: object relations, self psychology, family systems, cognitive-behavioral, and solution-focused therapies. I am trained to provide individual, couple, family, and group therapy for adolescents (ages 13-18), adults (ages 19-64) and geriatric adults (ages 65+). While Tennessee law permits minors sixteen years and older to consent to mental health care without parental consent, I do not treat minors without parental permission/authorization.

I believe strongly that pastoral counseling can help you respond creatively and courageously to the difficulties you are facing. Our task together is to establish a safe, confidential, criticism-free atmosphere where these difficulties and your present ways of managing them can be explored. The counseling relationship is a commitment of energy, money, and time. At first, it is usually best for us to meet weekly. This allows you to assess the safety and trustworthiness of the counseling relationship, and it allows the counseling process to develop some momentum. The counseling process may provide you relief for anxiety or pain; it may also increase your experience of anxiety or pain. The outcome of counseling cannot be guaranteed, but honesty will allow the process to move most rapidly and will increase the likelihood of your having a successful experience.

Safety, confidentiality, and trust are essential to the chances of success in counseling. Part of what this means is that we will have a professional relationship rather than a social one. Our contact will be limited, as far as possible, to the sessions you arrange with me. Should we see one another outside this office, I will wait for you to decide whether you speak to me, introduce me to a companion, etc. It is not my intent to avoid you or ignore you, but to respect your privacy. Our sessions may be very personal in nature, and you may learn a great deal about me as we work together. However, the focus of our sessions is you and your concerns.

As a pastoral counselor, I am respectful of the beliefs and traditions of others. I will work with you to achieve mutually agreed upon counseling goals. After assessing your personal concerns, we will decide together if I am the best resource for you. Referrals to other professionals or agencies will be made when appropriate.

Appointment times are decided upon in mutual consultation. Individual, couple, and family sessions are 45-50 minutes in length. Longer or shorter sessions may be negotiated according to need and available time. Please give at least twenty-four (24) hours notice if you must cancel your reserved time. Sometimes illnesses and emergencies happen which prevent you from keeping your reserved time, and I do not charge a fee for these infrequent occurrences. In the absence of such circumstances, you will be charged your usual fee for missed appointments. Please understand that insurance companies cannot be charged for missed appointments and you are fully responsible for any charge due to a missed appointment.

Should there ever be an EMERGENCY need for assistance, your first resource is the emergency room of your closest hospital, or the 911 service. I maintain a voice mail service to take after-hours calls. However, the messages are normally retrieved at the first of the following business day during the week. Messages from a weekend or holiday are retrieved daily. The urgency of the need will be assessed and I may return the call that day. I do carry a pager for urgent calls and I will try to return those calls at my earliest opportunity. The pager is not activated between the hours of 11 p.m. and 8 a.m.

My fee is $100.00 for a 45-minute appointment. It is my intent to run this practice only as fee-for-service, not using medical insurance. If you must use insurance because of the cost savings under your policy, I will file third party insurance forms for you. Generally speaking, copayments and deductibles are due at the time services are rendered. The fee will be collected in cash or personal check. A flexible fee schedule is available for those who will not be using medical insurance. If you use the flexible fee schedule, I will not be able to interact with your insurance company on your behalf.

Many clients elect to file third party insurance coverage, including Medicare, for services rendered. I will file insurance for you, provided you authorize me to do so and provide me with the necessary information for filing such claims. Otherwise, you will be responsible for filing the forms with your insurance company. As you know, the world of health care has experienced a tremendous change in the manner in which insurance companies reimburse for third party payment. Many plans require an initial pre-certification of care before you can use your insurance benefits. It is your responsibility to make sure such pre-certification requirements are met by you if you elect to use your insurance benefits. (i.e., referral from your primary care medical doctor, employee assistance program, or other "gatekeeping" mechanisms such as calling an 800 number for approval.)

In filing your insurance claim for you, it is understood that you are granting me permission to reveal confidential information, such as the dates you are seen, the length of the appointment, and your diagnosis. This type of information is required by your carrier if you want insurance to pay your claim. Additionally, nearly all companies now require further utilization review and participation with outcome and quality measures. Unless your care is very, very brief, it is highly likely I will be forced to submit a more extensive report documenting the clinical and medical necessity for your care, as well as revealing some of the details of your care to date, if further sessions are going to be authorized by your carrier. Many carriers will require auditing/review of your records for every visit here. Nearly all companies require participation in outcome and quality care studies such as client satisfactions surveys. If your carrier requires such activities in order for you to use your insurance, I will comply with those requirements if you want me to.

My responsibility is to inform you about the compromising of your confidentiality and privacy when complying with such requirements. The compromising of your confidentiality is standard in today’s marketplace whenever one elects to use third party insurance coverage for services rendered. Fortunately, the newly enacted HIPAA regulations do provide you an increased degree of privacy and confidentiality regarding your protected health information. Payors of care can no longer make full release of all of your entire mental health record a condition for payment of your claims. Instead, I will be able to limit release of your mental health record to only your designated mental health record set and not my psychotherapy notes of our sessions together. As explained in my Notification of Client Rights Document given to you, the designated mental health record is limited to the following information: billing information, paperwork you completed today, a summary of your initial visit today, your mental status examination, your comprehensive treatment plan, progress notes, any reports or clinical summaries, any correspondence with outside parties you authorized me to release, and any utilization review reports which have occurred regarding your care.

Tennessee has a strong privileged communication law which carries the same legal status as that of attorney-client. What you talk about in your established relationship with me is protected by privileged communication laws and confidentiality principles, with the exceptions of certain specific actions (i.e., clear and imminent danger to self and/or others, suspected child abuse, elder abuse, information about fatal, communicable disease that is not being revealed to an at-risk partner, worker’s compensation related cases, if your psychiatric or psychological health becomes an issue in a lawsuit, whatever information is shared in utilization review reports for authorization of care, or compliance with chart audits by your insurance carrier). With these exceptions, unless you specifically sign a release of information authorizing me to talk to someone, all communications here are kept private, confidential, and privileged (i.e., if someone calls here asking for you, I will not acknowledge even knowing you unless you tell me otherwise). I will strive to maintain the sacredness and privacy of your confidential communications with me.

Each state requires persons licensed as Licensed Professional Counselor to have regular supervision and consultation with colleagues. This is to ensure that you receive the best possible treatment. Any information shared in supervision will be presented in a manner to keep your identity protected.

One of the best ways for me to get supervision and consultation is through the use of recorded sessions. By this method, my colleagues hear or see me in action, rather than just by my report. I will record sessions only with your agreement and signed permission. All recordings of sessions will be erased immediately after consultation. Sometimes clients find it helpful to make their own recordings of sessions to review later. You are welcome to do that.

If at any time you feel you have been treated unfairly or unethically, please let me know. If talking with me does not bring a satisfactory resolution to the problem, you have the right to contact the TN Department of Health, Health Related Boards, Board of Professional Counselors, Marital and Family Therapists, and Clinical Pastoral Therapists, First Floor, Cordell Hull Building, 425 Fifth Avenue North, Nashville, TN 37247-1010, telephone (888) 310-4650, or the American Association of Pastoral Counselors, 9504 A Lee Highway, Fairfax, VA 22031-2303, telephone (703) 385-6967, to voice your complaint. If the problem is a HIPAA concern, please contact the Department of Health and Human Services, Office of Civil Rights, 200 Independence Avenue, S. W., Washington, D.C. 20201.

I have provided this information to you in the hope of fully informing you about the policies of my office and some of the parameters of care you will receive here, such as the importance of confidentiality. Mental health care, like other things in life, offer no absolute guarantee of success and there are limitations to any form of care offered a client. Since such limitations are always a function of the particular problem in question, I invite you to discuss your treatment plan with me. After we have met to discuss your concerns, I will construct an individualized treatment plan and share it with you so that you and I have our plan for what problems we are going to try to solve and how.

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Signature of adult client or parent/legal guardian of client less than 18 years of age Date

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