I am pleased that you have chosen me for your counselor. This document is designed to inform you about my background, ensure that you understand our professional relationship, and document your understanding of and consent to treatment.

I received a master's degree in Christian counseling from Gordon Conwell Theological Seminary in January, 2010. I am a Licensed Clinical Mental Health Counselor (LCMHC) in North Carolina, License #8021 and a  Nationally Certified Counselor (NCC #630543). I am a member of the EMDR International Association (EMDRIA) I have sixteen years of counseling experience working with individuals 18 years of age and older,  couples struggling with a variety of emotional, psychological, spiritual and behavioral concerns. These include, but are not limited to, depression, anxiety, abuse, sexual identity issues, co-dependency, self-injury, PTSD, marital difficulty, job stress, grief, fertility, adoption issues and significant life changes, among other mental health conditions.

Counseling Services Offered and theoretical Approaches

You can get the most out of our time together if you understand how counseling works and something about how I practice. This is an introduction only, and you may feel free to ask me questions at any time during our work together.

Counseling includes both the development of a trusting relationship between us and the development of goals for your situation and plans to accomplish them. Thus, counseling will include your active involvement and efforts to understand and change your thoughts, feelings and behaviors. You will have to work both in and out of the counseling sessions. Some steps may include homework assignments, exercises, writing in a journal, observing yourself and practicing new behaviors.

Early on in our sessions, we will be focusing our efforts on understanding your situation and developing specific goals that will make a positive difference for you. These goals will be your goals, and will need to be realistic ones towards which you yourself can work. Before going any further, I expect us to agree upon the planned goals to which we will both adhere. I will encourage you, support you, and help you develop appropriate steps that will help you move closer to your goals.

In respect to my theoretical basis for counseling, I am committed to an approach that includes an integration of my Christian faith with compatible psychological perspectives. I am an evangelical Christian, and believe that we are whole persons, with physical, social and spiritual aspects. Whether we include discussion of the spiritual dimension of life in our time together will be up to you, but I want you to understand that this informs you who I am and how I understand others and the nature of and solutions for problems in living. This spiritual perspective is integrated with the perspective of family systems, internal family systems (IFS), narrative, and cognitive-behavioral understandings of how people work. With adolescences and families, I work primarily from the theoretical approach of Trust-Based Relational Intervention (TBRI), an approach based on the theory of attachment. With individuals I work from a Cognitive-Behavioral and Internal Family Systems and am certified in Eye Movement Desensitization and Reprocessing (EMDR) therapy. With Couples, I use tools and techniques from Marriage Strong; a practical, highly effective couples therapy. The Cognitive-behavioral model is based on the idea that our thoughts impact our feelings and behaviors, not external things, like people, situations, and events.  By exploring the thoughts the client has about any given situation, we can work to change the way the client thinks, and this can impact how they act and then ultimately how they feel even if the situation does not change. Internal Family Systems is a powerfully transformative, evidence-based model of psychotherapy that believes the mind is made up of many parts that is a good thing.  Each inner part contains valuable qualities and our core Self knows how to heal, allowing us to become integrated and whole. We will work to create goals for our time together and we will revisit these often to make sure we are making gains toward the goals or whether the goals needs to be shifted. EMDR seeks to address maladaptively stored memories that continue to impair the present by desensitizing the memories and enabling cognitive restructuring of self-statements within the client. These are well-established and researched methods of therapy that are widely respected as being effective.

I will enter our relationship with hope and expectation for positive change. It is important, however, that you understand there are possible risks as well as benefits of counseling. Risks might include uncomfortable levels of feelings like sadness, guilt, anxiety, anger or frustration, or having difficulties in relationships with other people. Sometimes relationships with others can take unaccustomed directions that feel quite awkward at first. That initial awkwardness can occur no matter how you evaluate the balance between the long-term cost and benefits compared to the old ways of relating. Decisions you make regarding these areas of your life will remain your responsibility.

I work with adults, and couples. Clients with whom I work seek counseling for difficulties due to common life events or overcoming past traumatic events and are not currently in ongoing crisis. This includes people experiencing depression, anxiety, grief and loss, PTSD, adjustment difficulties, confusion about identity, or life goals, as well as, issues involving relationships. I work with adolescence from "hard places" and those adults who seek to help them heal. I also work with women who have survived physical, emotional and/or sexual abuse. I do not work with people whom, in my professional opinion I cannot help using the resources and skills I have available, and will in such cases to another therapist who may be better equip to help.

Confidentiality

I regard the information you share with me with the greatest respect, so I want us to be as clear as possible about how it will be handled. As a counselor, I adhere to the ethical standards, laws, and practices of the following governing entities: the National Board of Certified Counselors (NBCC), and the American Mental Health Counselors Association (AMHCA), and the State of North Carolina statutes. For more information on ethics in the counseling field, please feel free to visit any of the following websites:

1) NBCC - www.nbcc.org 2) AMHCA - www.amhca.org 3) NCBLPC - www.ncblpc.org

Based on the professional code of ethics I practice by, it is my responsibility to protect your right to privacy. Therefore, all identifying information regarding a client is kept confidential unless I have your expressed written permission to inform or consult someone else. I may consult with colleagues for supervision with the understanding that I will not disclose your name or any other identifiable personal information. There are a few exceptions to this that are presented below:

1. I must disclose information regarding an impending suicide risk. I have a duty to protect your life.

2. I must disclose information to a third party if I learn that you pose a threat of danger to yourself or another person. I have a duty to protect you and others from harm.

3. I must disclose information if I learn of any potential or past abuse or neglect of a child, mentally challenged person or elderly person (from client or someone outside of counseling session). I have a duty to protect those who may not be able to protect themselves.

4. I must disclose information if there is a court order and/or records are subpoenaed by a court of law.

5. I can disclose information if you desire this with a signed Release of Information form

6. I cannot guarantee confidentiality regarding the information obtained from your electronic device. It is your responsibility to manage location services and microphone usage in your phone settings while you are at an office location and/or with you during in person or Telehealth sessions. 

Explanation of Dual Relationships

Although our sessions may be very intimate psychologically, it is important for you to realize that we have a professional relationship rather than a social one, including any form of social media. Our contact will be limited to the sessions that you arrange with me. You will be best served while I am seeing you for counseling if our relationship stays strictly professional and if our sessions concentrate exclusively on your concerns. You may learn more about me as we work together, but it is important for you to remember that you are experiencing me as a professional therapist. 

Fees, Insurance Reimbursement

The fee for counseling is $175 for the initial diagnostic evaluation and $155 per 53-minute session. I am able to file insurance for Blue Cross Blue Shield, Samaritan's Purse UMR plan and Aetna. You may choose to pay out of pocket, or I can help you with filing insurance. I do have a set number of scholarship slots at $85 or $100 per 53 min session that can be applied for. If interested, please ask if any slots are available. It is your responsibility for payment at time of service (scholarship rate, copay and/or amount applied toward deductible). Therefore, come prepared with payment, ID number and Group number. I accept cash, check or credit card through the IVY platform. Administrative duties (sending files, writing letters etc.) is billed at the rate of $60 per 6o minutes and will be rounded up at each 15 minute interval after the first hour.  If you must cancel, please notify me by phone or email within 24 hours of the appointment to allow others on the wait list to take advantage of the open appointment. There is a $85 late cancelation fee for appointments canceled less than 24 hours in advance.

Complaint Procedures

If you are dissatisfied with any aspect of our work, this is most effectively and productively dealt with in our sessions together. Please feel free to ask any questions, or clarify any confusion about our work. If you think that you may have been treated unfairly or unethically by me or any other counselor, and cannot resolve this problem with me, you may file a complaint against me with the organization below should you feel I am in violation of any of these codes of ethics.

North Carolina Board of Licensed Clinical Mental Health Counselors

PO Box 77819 Greensboro, NC 27417
Phone: 844-622-3572 or 336-217-6007
Fax: 336-217-9450
E-mail: LCMHCinfo@ncblcmhc.org

Consent for Treatment

In signing this form:

I voluntarily give my consent for evaluation and counseling service to be provided by Jennifer Greene MA, LCMHC, NCC. If I have further questions, I can ask her and she will assist with finding the answers.

I understand the policy on confidentiality and the exceptions to the confidentiality.

I understand that my role as client is:

To be honest during counseling sessions and demonstrate a cooperative attitude and willingness to change

To be punctual and committed to my attendance

To be free to withdraw myself (or the client if a minor) at any time from treatment and refuse any treatment offered.

I am required by law to maintain the privacy and security of your protected health information ("PHI") and to provide you with this Notice of Privacy Practices ("Notice"). I must abide by the terms of this Notice, and I must notify you if a breach of your unsecured PHI occurs. I can change the terms of this Notice, and such changes will apply to all information I have about you. The new Notice will be available upon request, in my office, and on my website.

Except for the specific purposes set forth below, I will use and disclose your PHI only with your written authorization ("Authorization"). It is your right to revoke such Authorization at any time by giving me written notice of your revocation.

Uses (Inside Practice) and Disclosures (Outside Practice) Relating to Treatment, Payment, or Health Care Operations Do Not Require Your Written Consent. I can use and disclose your PHI without your Authorization for the following reasons:

1. For your treatment. I can use and disclose your PHI to treat you, which may include disclosing your PHI to another health care professional. For example, if you are being treated by a physician or a psychiatrist, I can disclose your PHI to him or her to help coordinate your care, although my preference is for you to give me an Authorization to do so.

2. To obtain payment for your treatment. I can use and disclose your PHI to bill and collect payment for the treatment and services provided by me to you. For example, I might send your PHI to your insurance company to get paid for the health care services that I have provided to you, although my preference is for you to give me an Authorization to do so.

3. For health care operations. I can use and disclose your PHI for purposes of conducting health care operations pertaining to my practice, including contacting you when necessary. For example, I may need to disclose your PHI to my attorney to obtain advice about complying with applicable laws.

Certain Uses and Disclosures Require Your Authorization.

1. Psychotherapy Notes. I do not keep "psychotherapy notes" as that term is defined in 45 CFR 164.501; rather, I keep a record of your treatment and you may request a copy of such record at any time, or you may request that I prepare a summary of your treatment. There may be reasonable, cost-based fees involved with copying the record or preparing the summary.

2. Marketing Purposes.As a psychotherapist, I will not use or disclose your PHI for marketing purposes.

3. Sale of PHI. As a psychotherapist, I will not sell your PHI in the regular course of my business.

Certain Uses and Disclosures Do Not Require Your Authorization. Subject to certain limitations mandated by law, I can use and disclose your PHI without your Authorization for the following reasons:

1. When disclosure is required by state or federal law, and the use or disclosure complies with and is limited to the relevant requirements of such law.

2. For public health activities, including reporting suspected child, elder, or dependent adult abuse, or preventing or reducing a serious threat to anyone's health or safety.

3. For health oversight activities, includingaudits and investigations.

4. For judicial and administrative proceedings, including responding to a court or administrative order, although my preference is to obtain an Authorization from you before doing so.

5. For law enforcement purposes, including reporting crimesoccurring on my premises.

6. To coroners or medical examiners, whensuch individuals are performing duties authorized by law.

7. For research purposes, includingstudying and comparing the mental health of patients who received one form of therapy versus those who received another form of therapy for the same condition.

8. Specialized government functions, including, ensuring the proper execution of military missions; protecting the President of the United States; conducting intelligence or counter-intelligence operations; or, helping to ensure the safety of those working within or housed in correctional institutions.

9. For workers' compensation purposes. Although my preference is to obtain an Authorization from you, I may provide your PHI in order to comply with workers' compensation laws.

10. Appointment reminders and health related benefits or services. I may use and disclose your PHI to contact you to remind you that you have an appointment with me. I may also use and disclose your PHI to tell you about treatment alternatives, or other health care services or benefits that I offer.

Certain Uses and Disclosures Require You to Have the Opportunity to Object.

1. Disclosures to family, friends, or others. I may provide your PHI to a family member, friend, or other person that you indicate is involved in your care or the payment for your health care, unless you object in whole or in part. The opportunity to consent may be obtained retroactively in emergency situations.

YOUR RIGHTS YOUR REGARDING YOUR PHI
You have the following rights with respect to your PHI:

1. The Right to Request Limits on Uses and Disclosures of Your PHI. You have the right to ask me not to use or disclose certain PHI for treatment, payment, or health care operations purposes. I am not required to agree to your request, and I may say "no" if I believe it would affect your health care.

2. The Right to Request Restrictions for Out-of-Pocket Expenses Paid for In Full. You have the right to request restrictions on disclosures of your PHI to health plans for payment or health care operations purposes if the PHI pertains solely to a health care item or a health care service that you have paid for out-of-pocket in full.

3. The Right to Choose How I Send PHI to You. You have the right to ask me to contact you in a specific way (for example, home or office phone) or to send mail to a different address, and I will agree to all reasonable requests.

4. The Right to See and Get Copies of Your PHI. Other than "psychotherapy notes," you have the right to get an electronic or paper copy of your medical record and other information that I have about you.
I will provide you with a copy of your record, or a summary of it, if you agree to receive a summary, within 30 days of receiving your written request, and I may charge a reasonable, cost-based fee for doing so.

5. The Right to Get a List of the Disclosures I Have Made.
You have the right to request a list of instances in which I have disclosed your PHI for purposes other than treatment, payment, or health care operations, or for which you provided me with an Authorization. I will respond to your request for an accounting of disclosures within 60 days of receiving your request. The list I will give you will include disclosures made in the last six years unless you request a shorter time. I will provide the list to you at no charge, but if you make more than one request in the same year, I will charge you a reasonable cost-based fee for each additional request.

6. The Right to Correct or Update Your PHI. If you believe that there is a mistake in your PHI, or that a piece of important information is missing from your PHI, you have the right to request that I correct the existing information or add the missing information. I may say "no" to your request, but I will tell you why in writing within 60 days of receiving your request.

7. The Right to Get a Paper or Electronic Copy of this Notice. You have the right get a paper copy of this Notice, and you have the right to get a copy of this notice by e-mail. And, even if you have agreed to receive this Notice via e-mail, you also have the right to request a paper copy of it.

HOW TO COMPLAIN ABOUT MY PRIVACY PRACTICES
If you think I may have violated your privacy rights, you may file a complaint with me, as the Privacy Officer for my practice, and my address and telephone number are: Jennifer Greene (828) 367-7963 1723 Deerfield Rd Boone, NC 28607.

You can also file a complaint with the U.S. Department of Health and Human Services Office for Civil Rights by:

1. Sending a letter to 200 Independence Avenue, S.W., Washington, D.C. 20201;

2. Calling 1-877-696-6775; or,

3. Visiting www.hhs.gov/ocr/privacy/hipaa/complaints.

I will not retaliate against you if you file a complaint about my privacy practices.

EFFECTIVE DATE OF THIS NOTICE
This notice went into effect on 3/1/2022.