Peace & Harmony Client Consent Form

Is Client 18 Years of Age or Older?*

Yes, Client is 18 Years of Age or Older

No, Client is Under 18 Years of Age

Name of Therapist*

Name*

First Name Last Name

Date of Birth*

Gender*

SSN*

Age*

Client Name*

First Name Last Name

Client's Date of Birth*

Client's Gender*

Client's Age*

Address*

Street Address City & State ZIP Code

Home/Cell Phone Number*

Work Phone*

Email*

Client's SSN*

Parent/Legal Guardian Name*

First Last

Grade*

Name of School:*

In case of an Emergency, Contact:*

Emergency Contact Phone Number*

Primary Physician*

Primary Physician Phone Number*

Address*

Street Address City & State ZIP Code

Home/Cell Phone Number*

Work Phone

Email*

Occupation*

Employer*

In case of an Emergency, Contact:*

Emergency Contact Phone Number*

Primary Physician*

Primary Physician Phone Number*

Insurance Information

How Do You Plan To Pay For Care?*

Insurance

MedicAid

Self Pay

Opt-Out

By selecting 'Self Pay' you are opting out of paying through insurance and choosing to pay out of pocket

Credit Card Type*

Visa

Mastercard

Discovery

American Express

Name on Card*

First Last

Card Number:*

Expiration Date*

Three Digit Security Code*

American Express Four Digit Security Code*

Billing Address:*

Street Address City & State ZIP Code

Birth Date of Primary Policy Holder*

Name of Primary Insurance Company:*

Name of Primary Policy Holder:*

Employer of Primary Policy Holder*

Relationship to Primary Policy Holder*

Self

Spouse

Child

Other

Primary Policy Holder Address*

Street Address City & State ZIP Code

Primary Insurance ID Number*

Primary Group Number*

Using Secondary Insurance?*

Yes

No

Name of Secondary Insurance Company:*

Name of Secondary Policy Holder:*

Birth Date of Secondary Policy Holder*

Employer of Secondary Policy Holder*

Relationship to Secondary Policy Holder*

Self

Spouse

Child

Other

Secondary Policy Holder Address*

Street Address City & State ZIP Code

Secondary Insurance ID Number*

Secondary Group Number*

Upload Image of Front & Back of Insurance/Medicaid Card*

Drop files here or

Max. file size: 512 MB.

Upload Identification*

Please upload front and back of state issued identification

Drop files here or

Max. file size: 512 MB.

Consent*

I have read the above and accept this policy as outlined.*

I authorize payment of medical benefits to the provider for services rendered, if applicable. I further authorize the release of information to the above-designated insurance carrier. Confidentiality procedures of the managed care and/or insurance company cannot be guaranteed by Peace & Harmony Counseling Services, LLC. Information may be shared with the collection department, outside collection agency, company attorney, credit bureau, law enforcement, or IRS.

Signature*

Signature of Guardian*

Signature of Therapist__________________________ DATE____________

Diagnosis Codes:1.____________ 2.____________ 3.________

Please upload front and back image of insurance or MediAid Card*

Drop files here or

Max. file size: 512 MB, Max. files: 2.

Family Health History:

Please note any family history (in direct bloodline) of depression, anxiety, psychiatric problems, substance abuse, and alcoholism

First Name

Relationship to Client

Nature of Problem

Were/Are You In the Military?*

Yes

No

Military*

Branch

Rank

Beginning Date of Service

End Date of Service

Active?*

Currently Active

Veteran

Type of Discharge*

Medical History*

Please list all of your medical conditions-- Include a brief description of the treatment. To add more use the (+) button.

Condition

Treatment

Medical History*

Please list all of your child's medical conditions-- Include a brief description of the treatment. To add more use the (+) button.

Condition

Treatment

Please list all illegal substances that you have used over your lifetime:*

To add more use the (+) button.

Please list any alcohol or illicit drugs that your child has used in the past 12 months:*

To add more use the (+) button.

Have you been in counseling previously?*

Yes

No

Has your child previously been in counseling?*

Yes

No

Please indicate approximate dates of treatment, reason for treatment, your satisfaction with treatment outcome and therapist’s name (if known):*

Describe any hospitalizations (medical or psychiatric). Give approximate dates and reason for treatment:*

Do you have any physical disabilities and/or limitations?*

Yes

No

Does your child have any physical disabilities and/or limitations?*

Yes

No

Please Specify:*

Years of education completed:

Degrees Earned or Other Specialized Training:*

To add more use the (+) button.

Please note any involvement with the legal system:*

Today's Date*

Signature*

Signature of Guardian*

NOTICE OF PRIVACY PRACTICES AND CLIENT RIGHTS AND RESPONSIBILITIES

THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED, AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW THIS INFORMATION CAREFULLY. {Updated: 5/27/2020}

Protected Health Information

In accordance with all local, state, federal, and ethical standards for privacy and protection (including HIPAA), Peace & Harmony Counseling Services, LLC (hereafter referred to as PHC Services, LLC) acknowledge the critical importance of Protected Health Information (PHI) and strive to ensure the confidentiality of the health information of all of our clients. PHI is any data, including demographic information, that can reasonably be used to identify a person.

In compliance with the current standards, PHC Services, LLC acts with changes made within the fields of mental health, counseling, and social work, and may change or amend this notice at any time for the purpose of remaining in compliance. If changes to this notice are made, reasonable efforts will be taken to ensure that clients receive and sign a copy of the new Notice. Please note that this Notice, as well as any signed revision of this Notice, will apply to all PHI regardless of when it was originally created or received. A copy of our Notice of Privacy Practices can be requested at any time and can be provided in paper or electronic formats.

Use and Disclosure of Protected Health Information

PHC Services, LLC will not sell your PHI or disclose your PHI to any entity that may try to sell you products or services. In most cases, PHC Services, LLC will require written authorization to use, release, or disclose your personal health information. You may request disclosure of your PHI to another party for any purpose at any time with a written authorization. This authorization is available, on request, from your clinician. The following list encompasses the legally and ethically recognized exceptions to our disclosure policy:

For Treatment and Health Care Operations: To assure quality of care, we may utilize health information about you to provide you with treatment, services, or recommendations. (Example: Your PHI could be used to review our treatment and services, evaluate staff performance, or to discuss treatment alternatives or other health-related benefits and services with you as applicable.) In the event that your PHI is utilized for the purposes of professional consultation, reasonable efforts will be made to limit the PHI disclosed during the consultation.

For Purposes of Conducting Business: Some PHI is required for the purposes of conducting business, such as disclosure of information (including demographics and diagnoses) to your insurance company or to our third-party billing service. This also includes collections agencies, when applicable.

When Required by Law: We will use and disclose your PHI if required to do so by law and for the purposes of mandated reporting. For more information regarding Michigan’s rules regarding mandated reporting, please visit https://tinyurl.com/yd6h3jqr . This includes:

For the purposes of reporting child or adult abuse or neglect;
For the purposes of reporting domestic violence;
In the event that a client poses a threat of danger to self or others;
In the event that a client discloses a threat of danger made to self or others;
When served with a court-order or subpoena, specific to the PHI ordered;
When disclosure of specific PHI could save a client’s life (i.e. disclosure of allergies during an allergic reaction, or of known prescription medications if asked by an EMT during an life-or-death emergency situation);
In compliance with workers’ compensation laws;
When required by the Secretary of the Department of Health and Human Services and/or applicable state or federal regulatory agencies.

Individual Rights and Responsibilities

As a PHC Services, LLC client, you have the rights and responsibilities regarding your PHI outlined below. To exercise these rights, a written request must be provided to your clinician and reviewed by PHC Services, LLC management. This request should include how and where (if applicable) you prefer to be contacted. We will honor all reasonable requests made in this manner. You have the right to:

Access, Inspect, and Copy: You have the right to inspect and copy health information that may be used to make decisions about your care. PHC Services, LLC may deny your personal request to inspect portions of your records in limited and reasonable circumstances (i.e. a non-critical request for psychotherapy notes when viewing those notes without appropriate context and understanding could undermine the therapeutic relationship*). Records can be requested for personal use in paper or electronic formats. For an electronic copy of your records, a flash drive must also be included with your request. Please note that electronic copies of your records are more vulnerable to security breaches, and PHC Services, LLC cannot guarantee the safety and confidentiality of your information after transfer. Pursuant to Medical Records Access Act, Public Act 47 of 2004, MCL § 333.26269, Updated for 2018, we reserve the right to charge a fee for the costs of copying, mailing, or other supplies associated with your request for this information.

*Note: If you wish to receive a copy of your records, we strongly encourage you to review them with your clinician so that you can fully understand their contents. If your request for access is denied, your clinician will explain the reason for the decision to deny and discuss with you your options for further review.

Accounting of Disclosures: You have the right to request a list of the disclosures PHC Services, LLC has made of health information about you, such as disclosures made as required by law. This accounting requirement applies to disclosures made on or after April 1, 2018. Records of accounting cannot be made for dates occurring before April 1, 2018 or after the date of the request. Records can be requested in paper or electronic formats. Electronic copies of these records are subject to the same requirements and vulnerabilities as outlined in the Access, Inspect, and Copy section of this Notice. The first request made within a 12-month period will be provided for free. For additional requests in a 12-month period, PHC Services, LLC reserves the right to charge a fee for the cost of responding to these additional requests. A schedule of these fees can be provided on request.

Request Restrictions: You have the right to request a restriction or limitation on the health information we use or disclose about you for treatment, payment, health care operations, and/or to someone who is involved in your care or the payment for your care. Please note that we are not required to comply with your request, particularly if the request is made in regard to uses and disclosures that can be legally and ethically be made without your consent. If an agreement is made to restrict disclosure of your information, PHC Services, LLC will comply with the request until such a time as the disclosure of your information becomes necessary for emergency treatment and/or as required by law (as applicable). You will be notified in any case that a restriction agreement must be terminated.
Amendment: You have the right to request that PHC Services, LLC amends your PHI if you feel it is incorrect or incomplete and may do so for as long as the information is kept. Your request must provide a reason that supports the need for amendment. We may deny your request for amendment if the request is not made in writing or does not include an adequate reason to support the request. Additionally, we may deny your request if the information was not created by us, is not information we keep in your records, is not information that you are normally permitted to inspect and/or copy, or any information that we deem to be accurate and complete. If we deny your request for amendment, you have the right to file a statement of disagreement with us. We may prepare a rebuttal to your statement, and you will be provided with a copy of any such rebuttal. Statements of disagreement and any corresponding rebuttals will be kept with your records and will be included with any future authorized requests for information pertaining to the appropriate portion of your record.

Payment: Payments, including deductibles and co-payment/co-insurance, are due at the time of service and will be collected by your clinician and or office staff. If, for any reason, payment is not collected at the time of service, payment will be due at your next session or within 14 days whichever comes first. Payments can be made in cash, by check, money order or by credit/debit card. A receipt for payment will be made available upon request. Checks should be made payable to Peace & Harmony Counseling Services, LLC. Clients are responsible for contacting their insurance company to obtain authorizations, co-pays, deductibles, and benefit period information. All co- pays and deductibles are due the day of service via the card stored on file. If the card on file is declined services will be suspended until the balance is paid.

We accept the following: Visa, MasterCard, Discover, American Express and Personal Checks.

Individual Therapy Fee: $150 per hour

Couples Therapy Fee: $175 per hour

Family Therapy Fee: $200 per hour

Supervised Parenting Time Fee: $60 per hour

The following services are not billable to your insurance company and must be paid out of pocket before services are rendered.

Legal Services Fee: $600 for the first four hours of court plus $150 each additional hour of court »Legal services are NOT performed unless required by subpoena. Court appearances,depositions, phone calls with attorneys and client records are included in this fee.

Form Completion/ Letter Writing Fee: $150 per hour »This includes recommendation letters, forms for schools, disability forms, and letters to employers.

No Show Fee: $150 per hour »If you are unable to attend your scheduled session and do not cancel within the 24 hours, you will be charged $150 which is NOT billable to your insurance company.

Please note in addition to the changes above, (3) consecutive no-shows/cancellations will result in termination of services. We will offer a 10-minute grace period to allow you time to connect with Telehealth Session.

Peace & Harmony Counseling Services, LLC ONLY accepts the following insurances: Meridian, Molina, McLaren, Blue Cross Complete and United Healthcare Medicaid, Blue Cross Complete, PHP and Aetna insurances. If you DO NOT have one of these insurances or if your Medicaid becomes inactive, you understand you are financially responsible for your therapy services. In addition, if for any reason your health insurance does not cover services, it is your responsibility to pay for the service.

Your initials here agreeing to the “Payment of Fees”:*

Appointments: All appointments will be arranged between the client and applicable clinician. Sessions can be rescheduled or cancelled up to 24 hours before the scheduled start time with no penalty. Sessions cancelled with less than 24 hours’ notice and sessions for which the client does not show will be charged a fee of $50.

Emergencies: In the case of a mental health emergency, please contact 911 or go to the nearest Emergency Room or Community Mental Health Crisis Services office. Your clinician may or may not be available in case of emergency but will make appropriate efforts to establish contact with you or an authorized representative as soon as possible.

Questions, Comments, Concerns

For all questions, comments, and concerns, please contact our owner, Phyllis M. Williams MA, LLPC at (517) 574-5947 or pwilliams@peaceandharmonyllc.com. Please note that it may take up to 2 business days to process and respond to communications. Written communication can also be mailed to the address listed at the top of this Notice.

In the case of a complaint, clients are encouraged to contact the office for resolution. If we are unable to successfully resolve your complaint, you may also submit a written complaint to the Michigan Board of Counseling or the U.S. Department of Health and Human Services. Contact information for these entities will be made available upon request.

Client Name*

Client First & Last Name

Date of Birth*

Today's Date*

Client Signature*

Today's Date*

Parent/Guardian Signature*

Today's Date

Parent/Guardian Signature

As per your signed agreement on the Informed Consent and Authorization for Psychotherapy form, your credit card number will be securely kept on file strictly for purposes of charging a flat $50.00 cancellation fee per missed session. Charging your card for this amount is only necessary should you not give more than 24-hour’s notice that you are unable to keep your appointment. In addition, your co-pay, co-insurance and/or deductible will be charged to this card as well.

Credit Card Type*

Visa

Mastercard

Discovery

American Express

Name on Card*

First Last

Card Number*

Expiration Date*

Three Digit Security Code*

American Express Four Digit Security Code*

Billing Address*

Street Address City & State ZIP Code

How would you like to receive your receipt?*

Email

Text Message

Phone*

Email*

Today's Date*

Signature*

AUTHORIZATION FOR RELEASE OF INFORMATION

Would you want to authorize the release of any information from your sessions?*

Yes

No

With my signature below, I give authorization for:

Therapist Name*

to discuss information relevant to my case with the below-named person:

Name*

Address*

Phone Number*

Information discussed is to be limited to:*

This authorization is valid from the date of authorization until termination of treatment unless otherwise is indicated. I understand this authorization may be revoked in writing at any time, except to the extent that action has been taken in reliance on this authorization. Unless otherwise revoked, this authorization will expire upon termination of psychotherapy services or no more than one year subsequent to the date of this authorization to release information.

Peace & Harmony Counseling Services, LLC, its employees, and officers are hereby released from any legal responsibility or liability for disclosure of the above information to the extent indicated and authorized herein.

Today's Date*

Signature*

This information has been disclosed to you from records whose confidentiality is protected by Federal law. Federal regulations (42 CFR part 2) prohibit you from making further disclosure of it without specific written consent of the person to whom it pertains, or as otherwise permitted by such regulations. A general authorization for the release of medical or other information is NOT enough for this purpose. The Federal rules restrict any use of the information to criminally investigate or prosecute any alcohol or other drug abuse patient.

Telehealth Informed Consent

Telehealth allows the Therapist at Peace & Harmony Counseling Services, LLC to diagnose, consult, treat and educate clients using interactive audio, video or data communication regarding treatment. I herby consent to participate in psychotherapy via the internet (hereinafter referred to as Telehealth) using a platform such as Jitzu and or VSee.

I understand I have the following rights under this agreement: I have a right to confidentiality with Telehealth under the same laws that protect the confidentiality of my medical information for in-person psychotherapy. Any information disclosed by me during my therapy, therefore, is generally confidential. By law, there are exceptions to this rule however; including mandatory reporting of child, elder and or dependent adult abuse and any threat of violence that I make against another person and or animal.

I understand that if I am in such mental or emotional condition to be a danger to myself or others, my therapist and or office staff of Peace & Harmony Counseling Services, LLC has the right to break confidentiality to prevent the threatened danger. Furthermore, I understand that the dissemination of any personality identifiable images or information from the Telehealth interaction to any other entities shall not occur without my written consent.

I also understand that there are several forms of psychotherapy treatment modalities that have been found to be effective in treating a wide range of mental health disorders, personal and relational issues; including Telehealth. However, there is no guarantee that all treatment will be effective. Thus, I understand that while I may benefit from Telehealth, results cannot be guaranteed or assured.

I further understand that there are risks unique and specific to Telehealth, including but not limited to; the possibility that our therapy sessions or other communication by my therapist to others regarding my treatment could be disrupted or distorted by technical failures or could be interrupted or could be accessed by unauthorized persons.

In addition, I understand that Telehealth treatment is different from in-person therapy and that if my therapist believes I would be better served by another form of psychotherapy services; such as in-person treatment. I will be referred to a therapist in my geographic area or Peace & Harmony Counseling Services, LLC that can provide such services.

Finally, I agree that in case of an emergency I will contact 911, visit the nearest emergency room and then contact my therapist to bring him/her up to speed.

I have read and understand the information provided above. I have the right to discuss any of this information with my therapist and to have any questions I may have regarding my treatment answered to my satisfaction. I understand that I can withdraw my consent to Telehealth communication by providing written notification to Peace & Harmony Counseling Services, LLC. My signature below indicates that I have read this agreement and agree to its terms.

Today's Date*

Signature*

LPC Professional Disclosure Statement
Phyllis Marie Williams, M.A., LLPC
Peace & Harmony Counseling Services, LLC
2132 Cedar St.
Holt, MI 48842
Cell: 517-574-5947
Fax: 517-574-5696
pwilliams@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.

Mission: Thriving to help individuals and families achieve and maintain peace and harmony through mental wellness and personal development.

Qualifications: I hold a Bachelor of Arts in Psychology from Michigan State University and a Master of Arts in Counseling from Spring Arbor University. I am a Limited Licensed Professional Counselor (LLPC) through the State of Michigan (6401014303). Previous positions consist of: Program Manager of Housing Services for chronically homeless individuals with mental health disabilities for 10 years, Clinical Supervisor for a nonprofit and a for profit Counseling/Substance Abuse program for 2.5 years and an Independent Mental Health/Substance Therapist for 2.5 years.

Counseling Background: I have extensive experience working with chronically homeless individuals with Mental Health disabilities, Michigan Department of Corrections Paroles with Substance Abuse Disorders, Refugee Women suffering from Post-Traumatic Stress Disorder, Refugee and Domestic foster children, those who have experienced Sexual Abuse, families, couples, children, and adults who are requesting Mental Health and or Substance Abuse services. My theoretical orientation is Cognitive Behavioral Therapy (CBT); which is a form of treatment that focuses on examining the relationships between thoughts, feelings, and behaviors, by exploring patterns of thinking that lead to self-destructive actions. I use various forms of therapeutic interventions such as the empty chair, miracle question, reframing, play therapy, sand tray therapy, Motivational Interviewing, Trauma Focused Cognitive Behavioral Therapy, among others throughout session; based on the clients’ needs. In addition, homework assignments may be assigned to clients to help foster growth outside of therapy.

Fee Schedule: The fee for a 60-minute therapy session is $150.00. Payment in full is expected at the time of service in the form of cash, check, money order or credit card. Checks should be made payable to Peace & Harmony Counseling Services, LLC. 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 a $150.00 fee if a session is cancelled without 24-hour notice or if there is a no show for an appointment. 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 two (2) 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.

Supervision: As a Limited Licensed Professional Counselor (LLPC) in the state of Michigan, I am required to receive supervision from a Licensed Professional Counselor (LPC). During my supervision we will discuss all current clients, treatment approaches and any issues. The LPC under whom I receive my supervision is: Ian D. Shafer, MA, LPC (License #6401012915)

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.

If there is a need to file a grievance against my licensure, please submit all correspondence to:

Michigan Department of Licensing and Regulatory Affairs
Bureau of Professional Licensing
Investigations & Inspections Division
P.O. Box 30670
Lansing, MI 48909
517-335-1980

Today's Date*

Signature*

THERAPIST__________________________ DATE____________

If there is a need to file a grievance against my licensure, please submit all correspondence to: Michigan Department of Licensing and Regulatory Affairs Bureau of Professional Licensing Investigations & Inspections Division P.O. Box 30670 Lansing MI, 48909 517-335-1980

LPC Professional Disclosure Statement
Loretta Brand, MSC/MHC, LLPC, CADC
Peace & Harmony Counseling Services, LLC
2132 Cedar St.
Holt, MI 48842
Office: 517-993-5950
Cell: 517-528-7909
Fax: 517-574-5696
lbrand@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.

Mission: Thriving to help individuals and families achieve and maintain peace and harmony through mental wellness and personal development.

Qualifications:

State of Michigan Limited Licensed Professional Counselor (LLPC)
Master of Science in Counseling from University of Phoenix
Michigan Certification Board of Addiction Professionals (CADC)
Extensive personal experience and participation in Individual/ Group counseling, PTSD, Substance abuse, Anger management, Military Families, Supervised Parenting Time

Fee Schedule: The fee for a 60-minute therapy session is $150.00. Payment in full is expected at the time of service in the form of cash, check, money order or credit card. Checks should be made payable to Peace & Harmony Counseling Services, LLC. 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 a $150.00 fee if a session is cancelled without 24-hour notice or if there is a no show for an appointment. 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 two (2) 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.

Supervision: As a Limited Licensed Professional Counselor (LLPC) in the state of Michigan, I am required to receive supervision from a Licensed Professional Counselor (LPC). During my supervision we will discuss all current clients, treatment approaches and any issues. The LPC under whom I receive my supervision is: John V Farrar Ed.D., LPC.

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.

If there is a need to file a grievance against my licensure, please submit all correspondence to:

Michigan Department of Licensing and Regulatory Affairs
Bureau of Professional Licensing
Investigations & Inspections Division
P.O. Box 30670
Lansing, MI 48909
517-335-1980

Initials*

Code of Conduct: The State of Michigan requires counselors to adhere to a specific Code of Conduct that is determined by the Board of Counseling. Should you wish to file a complaint, you may do so through:

Michigan Department of Licensing and Regulatory Affairs Health Regulatory Division P.O. Box 30670 Lansing, MI 48909 517-373-9196

Emergency Contact: Emergencies arise in people’s lives every day. You can handle most emergencies. You are welcome to call me at (517)528-7909, if you need an emergency appointment. I will do All I can to accommodate you; however, I may refer you to alternative counseling services if I am unable to make an appointment or if your emergency warrants a referral. In case of a dire emergency (suicide attempts, anxiety attacks, etc.) please call your local hospital or 911.

SIGNATURES: I have read, understand and agree to the Declaration of Practices, Procedures, and fee as outlined in the preceding Professional Disclosure of Loretta Brand.

Today's Date*

Signature*

Counselor/Consultant: ______________________________________ Date ______________
Loretta Brand MSC/MHC, LLPC, CADC

MSW Professional Disclosure Statement
Mario J. Wilcox, LMSW
Peace & Harmony Counseling Services, LLC
2132 Cedar St.
Holt, MI 48842
Office: 517-993-5950
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.

Mission: Thriving to help individuals and families achieve and maintain peace and harmony
through mental wellness and personal development.

Education:
Michigan State University, East Lansing, MI, Master of Social Work, 2013,
Wagner College, Staten Island, NY, B.A. in Sociology, 2007.

Certification/Licensure:
• State of Michigan Board of Social Work Licensed Master’s Social Worker (LMSW) ID
No. 6801096491 since May 2018.
• Michigan State University School Social Work Certification since May 2013.
• Certificate in Trauma Focused-Cognitive Behavioral Therapy from Western Michigan University
• Child Welfare Taining Institute Certification

Clinical Background:
Sunny Crest Youth Ranch, Clinical Director (Adolescent Males 10-21)
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)

Experience in treating/focus: (not limited to): Trauma, Career development and transition,
Disability and illness adjustment, Depression, ADHD, Life transitions, Addiction, Gambling,
Stress, and anxiety, utilizing relaxation techniques, eating disorders, post-traumatic stress
disorder, crisis intervention, Grief and Loss, Relationships concerns, ect.

Treatment Modalities: Cognitive Behavioral Therapy, Trauma Focused Cognitive Behavioral
Therapy, Motivational Interviewing, Dialectical Behavior Therapy

Fee Schedule: The fee for a 60-minute therapy session is $150.00. Payment in full is expected at
the time of service in the form of cash, check, money order or credit card. Checks should be made
payable to Peace & Harmony Counseling Services, LLC. 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 a $150.00 fee if a session is cancelled without 24-hour notice or if there is a no show for an appointment. Please note that 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 two (2) 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.

If there is a need to file a grievance against my licensure, please submit all correspondence to:
Michigan Department of Licensing and Regulatory Affairs

Bureau of Professional Licensing
Investigations & Inspections Division
P.O. Box 30670
Lansing, MI 48909
517-335-1980

Today's Date*

Signature*

Counselor/Consultant: ______________________________________ Date ______________
Mario Wilcox, LMSW

PROFESSIONAL DISCLOSURE STATEMENT Patrick Murphy, MS, LLPC

In keeping with the laws and requirements of the State of Michigan set for the counseling profession, I, Patrick Murphy, MS, LLPC declare:

1. That I am a Limited-Licensed Professional Counselor in good standing with the State of Michigan; 2. That my practice is individual and family therapy, delivered via Telehealth or in-person as needed; 3. That I have attained supervision under Jeff Thompson, MA, LPC; 4. That I practice through Peace and Harmony Counseling Services, LLC, located at 2132 Cedar St. Holt, MI 48842; 5. That I attained my Masters in Clinical Mental Health Counseling from Walden University, a CACREP-accredited institution; 6. That all fees charged by my practice are in accordance with, and in fact through, Peace and Harmony Counseling Services, LLC; 7. In the event wherein a Client would like to make a formal complaint, said complaints are to be directed to: Michigan Department of Licensing and Regulatory Affairs Bureau of Professional Licensing Investigations & Inspections Division P.O. Box 30670 Lansing, MI 48909 (517) 241-0205

Today's Date*

Signature

Counselor/Consultant: ______________________________________ Date ______________
Patrick Murphy, MS, LLPC

PROFESSIONAL DISCLOSURE STATEMENT
Carolada Gilbert, LMSW

I practice therapy to provide support, tools, and solutions to assist the population that I serve. My goal is
for my clients to utilize the tools and resources given to them in therapy to achieve their personal goals,
heal, and maintain their progress. I want to provide therapy, research-based practices, and holistic
practices to my clientele.

About me:
I have been working in the field of social work for almost a decade. My experience includes working with
children, adolescents, young adults, and families in clinical and non-clinical settings. As a therapist and
professional I have had the honor of working with individuals and families utilizing my skills and passion
to help them achieve their goals, learn skills and resilience, and equip them with tools to overcome their
day to day challenges. It is my honor and privilege to help others.

I have a bachelor’s degree in Psychology with a minor in Studio Art from Oakland University, and
completed a Master’s in Social Work from Wayne State University with a focus on Cognitive Behavioral
Therapy.

Treatment Approach:

Typs of Therapy

Art Therapy
Christian Counseling
Coaching
Cultually Sensitive
Cognitive Behavioral (CBT)
Dialectal (DBT)
Family/Couple/Marital
Family Systems
Interpersonal
Mindfulness-Based (MBCT)
Motivaltion Inteviewing
Multicultural
Narrative
Person-Centered
Play Therapy
Stength Based

Population

Adults
Adolescents/Teenagers (14 to 19)
Preteens/Tweens (11 to 14)
Children (6 to 10)
Family
Group

Issues

ADHD
Anger Management
Anxiety
Bipoler Disorder
Coping Skills
Depression
Emotion Disturbance
Family Renuification
Parenting
Relationship Issues
Self Esteem
Self-Harming
Stress
Suicidal Ideation
Mood Disorders
Personality Disorders
Thinking Disorders

Today's Date*
MM slash DD slash YYYY

Signature

Counselor/Consultant: ______________________________________ Date ______________
Carolada Gilbert, LMSW

Peace and Harmony Consent Form

Peace & Harmony Client Intake Form

Insurance Information

NOTICE OF PRIVACY PRACTICES AND CLIENT RIGHTS AND RESPONSIBILITIES

AUTHORIZATION FOR RELEASE OF INFORMATION

Telehealth Informed Consent

Typs of Therapy

Population

Issues