LMSW Professional Disclosure Statement
Mario Wilcox, LMSW
Peace & Harmony Counseling Services, LLC
2132 Cedar St.
Holt, MI 48842
Office: 517-993-5950 ext. 507
Fax: 517-574-5696
mwilcox@peaceandharmonyllc.com
Dear Client or Parent:
Please review the following information. The State of Michigan requires that I disclose much of this material. I hope it will also help you to be an educated consumer of my Services, or those of any Mental Health Professional.
My job as your therapist is to provide you with quality services. Even if you believe that the situations described here do not apply to you, please read them carefully before signing the document. Please feel free to ask me questions about anything in this agreement.
I feel every individual is a unique and a complex being, therefore, the approach I take with your concerns is based on the information you provide and my assessment of your emotional, mental, physical, social, spiritual, economic, and career characteristics. I believe that everyone is an expert in their own lives, and it takes collaboration to identify what objectives need to be developed in establishing treatment goals.
I believe a trusting working relationship between therapist and client is important and I strive to achieve that collaboration. I am comfortable working with individuals from diverse cultures and lifestyles and feel being accepting, objective, respectful, and genuine are characteristics essential in working with clients. Overall, therapy is a process in which you the individual gain knowledge by raising awareness of unconscious behavior while gaining tools that will facilitate continued growth and development after therapy has ended.
Mission: Thriving to help individuals and families achieve and maintain peace and harmony through mental wellness and personal development.
Qualifications: I attendedMichigan State University, East Lansing, MI to attain my, B.A. in Sociology, 2007. Further educating I attained my Master of Social Work in 2013 from Wagner College, Staten Island, NY. I am a State of Michigan Board of Social Work Licensed Master’s Social Worker (LMSW) ID No. 6801096491 since May 2018. I have had my Michigan State University School Social Work Certification since May 2013. I’m Certified in Trauma Focused-Cognitive Behavioral Therapy from Western Michigan University as well as Child Welfare Training Institute Certification
Counseling Background: I have extensive history with at risk youth and substance abuse for my experience at Sunny Crest Youth Ranch, as Clinical Director (Adolescent Males 10-21) I feel every individual is a unique and a complex being, therefore, the approach I take with your concerns is based on the information you provide and my assessment of your emotional, mental, physical, social, spiritual, economic, and career characteristics. I believe that everyone is an expert in their own lives, and it takes collaboration to identify what objectives need to be developed in establishing treatment goals.
I believe a trusting working relationship between therapist and client is important and I strive to achieve that collaboration. I am comfortable working with individuals from diverse cultures and lifestyles and feel being accepting, objective, respectful, and genuine are characteristics essential in working with clients. Overall, therapy is a process in which you the individual gain knowledge by raising awareness of unconscious behavior while gaining tools that will facilitate continued growth and development after therapy has ended.
Additional Experience:
Turning Leaf, Clinician (Males/Females 18 and up)
Red Cedar Clinic/Lansing Acadia, Substance abuse Therapist (Males/Females 18 and up)
Turning Point Youth Center, Therapist (Adolescent Males 12-18)
Fee Schedule:
$150.00 for a 60-minute individual therapy session
$175.00 for a 60-minute Couples’ therapy sessions
$200.00 for a 60-minute family session
Please note, that payment in full is expected at the time of service in the form of a credit card. If you are covered by insurance for psychological services, you will need to check your policy or check with your insurance company about important details. These will include your deductible, co-pay amount and visit limitation for mental health services. Any issues regarding reimbursement for my services are strictly between you and your insurance company.
Please notify me of any cancellations, as you will be charged the following if a session is cancelled without a 24-hour notice or there is a no show for an appointment.
$150.00 for an individual therapy session
$175.00 for a Couples’ therapy session
$200.00 for a family session
Please note that some insurance companies do not cover late cancellation or no-show charges. Therefore, you will be responsible in full for those fees. In addition, your treatment will be terminated after three (3) no shows occur.
Confidentiality: All communication will become part of your clinical record, which you can access upon your request. Everything between you and I will be kept confidential as part of our counseling relationship, with the following exceptions or a release is signed by you:
- You direct me in writing to disclose information to someone else and sign a release to do so.
- It is determined you are a danger to yourself or others (including child or elder abuse).
- I am ordered by a court to disclose information.
Acceptance of Terms and Conditions: I understand that I am legally responsible for payment for my therapy services. If my payment is returned due to non-sufficient funds, I am responsible for the fees incurred.
The undersigned understood and agreed to work together as therapist and client under the above stated conditions.