Green Pak Psychiatric Services

Professional Disclosure Statement

Mind and Spirit Counseling and Education Services LLC 3045 Rodenbeck Drive Beavercreek, Ohio 45432 Phone: 937-520-8437 FAX: 937-320-9630

Name: Mark R. Stobie,

Title: Professional Clinical Counselor, (E0501350) National Certified Counselor NCC (235123)

University Degree Received Date Received Bowling Green State A.A. S Human Services May 20, 2001 University Firelands College

Empire State College B.S. Human Services February 15, 2004 State University of New York

Wright State University M.S. Mental Health March 17, 2007 Counseling

Areas of Competence: Career counseling, child and adolescent counseling, personal and social counseling, marriage counseling, family counseling, mental health counseling, consultation, administration, diagnosis and treatment of mental and emotional disorders.

If you have complaints about professional services from a counselor social worker and/or marriage and family therapist contact the:

Ohio Counselor, Social Worker, and Marriage and Family Therapist Board 77 South High Street, 24th Floor Columbus, OH 43215 Phone (614) 466-0912 -Website: www.cswmft.ohio.gov

1 Professional Disclosure Statement

Counseling Philosophy I approach counseling from an evidence-based as well as an experiential/spiritual perspective. This philosophy is demonstrated by my use of Cognitive Behavioral Therapy interventions, along with strengths-based and Christian intervention strategies.

Specialty Areas Depression Anxiety Disorders PTSD Anger Management ADHD Asperger’s Syndrome Marriage Counseling Family Counseling and Education

Client Rights and Responsibilities

Client Rights

1) As a client you have a right to professional and ethical counseling services conducted with the goal of treating you with respect, dignity, and honesty. You also have the right to be an active partner in your therapy process, remember, it’s your therapy experience, and my role is to help guide you through your options in a safe and non-judgmental environment.

2) Confidentiality: As a client participating in counseling services, you are entitled to confidentiality during session, as well as any written notes or records related to your therapy sessions. Records or other documents cannot be released to anyone without written permission from the client, and may be revoked by the client at any time. However, there are exceptions to confidentiality the counselor must abide by as a matter of state law, these exceptions are listed below:

a) Suicidal Behavior: If a client expresses thoughts of suicide and/or leads the counselor to believe he or she has a plan and the means to carry out the plan, it is the counselor’s duty to report these items and assist the client in obtaining appropriate emergency treatment.

b) Homicidal Behavior: If a client expresses homicidal thoughts directed toward an individual or other people or entities, it is the counselor’s duty to warn those who may be at risk of harm from the client. If a client expresses that he or she has a plan and/or the means to carry out a homicidal act, it is the counselor’s duty to notify the proper authorities, and assist the client in obtaining appropriate treatment.

c) Abuse and Neglect: If a client expresses to the counselor that he or she is being abused or is the perpetrator of any type of abuse or neglect of a child or adult, it is the counselors duty to report the abuse or neglect to the appropriate agency 2 Professional Disclosure Statement

d) Court Actions: A Magistrate or Judge may order via subpoena that a counselor discuss specific facts and details of session content if he or she feels it is relevant to the outcome of a legal proceeding which may directly or indirectly involve the client. In addition, officers of the court may request and obtain documents related to the client’s therapy sessions for the purpose of conducting evaluations and reports.

e) The state may impose other limits to confidentiality in cases where public safety is at risk, and criminal actions may cause harm to self and others.

3) Informed Consent: As a client receiving counseling services, you are entitled to inquire into the nature of any documents you may be asked to sign and to inquire about options or available alternatives to treatment strategies.

Client Responsibilities

1). Appointments: It is the client’s responsibility to arrange appointments with the counselor, and to inform the counselor within 24 HOURS prior to the appointment if an appointment cannot be kept. The counselor is unable to bill the insurance company for client no-shows. THEREFORE THE CLIENT WILL BE BILLED FOR ANY NO-SHOW CHARGES, unless prior discussion with counselor has taken place due to medical, transportation, or other complications.

2) Attendance Policies : In order for counseling therapy to be helpful, it is important to stay engaged in the process on a regular and consistent basis. It is for this reason that the agency has adopted the following attendance policies:  Three (3) consecutive no-shows within a thirty (30) day period can result in termination of services under the agency’s definitions of non-compliance  Five (5) re-schedules of appointments within thirty (30) days can result in termination of services under the agency’s definitions of non-compliance  Two (2) missed scheduled Intake Assessment appointments will resulting client need to seek services elsewhere  Ninety (90) days without any form of communication with the agency will result in the client’s case being closed.

3) Enrollment of Children and Adolescents for Counseling Services: For parents seeking counseling services for minor children, a signed consent form is required before any counseling can begin. In the case of divorce, please provide any court generated custody agreement which clearly states which parent has custodial or residential rights to approve and sign documentation for counseling services. In the case of shared parenting, both parties must be in agreement in order to enroll the child in counseling.

4) Financial Responsibility:  To become informed about their insurance plan including benefits available.  To become knowledgeable of the system to access care/service.  To cooperate in providing insurance information and any required client insurance pre- authorizations numbers/codes.  Providing Authorization numbers/codes, (where applicable).  To pay co-pay or deductibles at the time of the visit.  To pay for Self-Pay charges at the time of service, unless other payment arrangements have been agreed to by Mind and Spirit Counseling and Education services.  To be solely responsible for payment of any “no-show” fees which are not covered by insurance? FEES

Self-Pay Rate Counselor Assessment $ 120.00 Self-Pay Rate Individual Session (45 minutes.) $ 82.00 Self-Pay Rate Individual Session (60 minutes) $ 100.00 Self-Pay Rate Couples and Family Session $ 75.00 Processing Fee late co-pay $ 10.00 No-show $ 20.00 Letters $ 20.00 Government and Private Agency Paperwork Per Case Basis Court Appearances $ 200.00 per hour Records Purchase by Client  First ten (10) pages $ 2.74 per page  Pages 11-50 $ 0 .57 per page  Pages 50 and above $ 0.23 per page

5). Personal Conduct: As a client participating in counseling services, the goal of counseling is to improve your ability to manage stress, and interact appropriately with others. Therefore, it is my policy to expect my clients to practice the new skills and healthy thinking patterns being learned in therapy as often as possible in order to bring about positive change. With this in mind, anyone behaving in an aggressive or violent manner with myself, any other staff members, or other clients is at risk for IMMEDIATE TERMINATION from counseling services.

6). Changes in Personal Information: It is the client’s responsibility to inform the agency personnel of any changes of name, address, phone number, and insurance benefits or coverage.

7). Client Termination Policy: As a private practice agency, it is the right of Mind and Spirit Counseling and Education Services LLC to terminate counseling services when certain conditions exist, these conditions are as follows:

 Three (3) consecutive no-shows within a thirty (30) day period can result in termination of services under the agency’s definitions of non-compliance

 Five (5) re-schedules of appointments within thirty (30) days can result in termination of services under the agency’s definitions of non-compliance

 Two (2) missed scheduled Intake Assessment appointments will resulting client need to seek services elsewhere

 Ninety (90) days without any form of communication with the agency will result in the client’s case being closed.

 Inappropriate behavior such as verbal or aggression or physical aggression while interacting with Therapist and/or agency staff

 Suspected or proven allegations of abuse of a child by parent(s) while child is a client of this agency. This also applies to clients who are otherwise impaired adult who is a ward of and/or in the custody of the Court or family members due to Counselor’s duty to report such allegations to proper authorities for investigation.

Counselor Responsibilities: The Ohio Counselor Social Worker marriage and Family Therapy Board issues licenses to counselors with the expectation that counselors will practice in an ethical and professional manner to prevent harm of clients. As part of this expectation, there are duties that are mandated by the sate which are not optional for licensed counselors, they include:

 Duty to report: Any allegations of child abuse or neglect to Children’s’ Services when such allegations are brought to the counselor’s attention, or the counselor suspects neglect or abuse

 Duty to Warn: A person or persons who may be harmed by a client after client has made specific violent or homicidal threats involving person or persons. This may include informing police of client’s threats and/or intent to harm others

 Duty to act to Prevent Client from Causing Harm to Self: Counselor is mandated to act in the client’s best interest when client has expressed suicidal feelings, along with a plan to do harm to self, along with the means the client names as the way he or she is going to harm him or herself. This may involve referral for voluntary hospitalization, or need to call Police to facilitate involuntary hospitalization evaluation and execution of involuntary hospitalization.

I have read the above disclosure statement, and have been given the opportunity to obtain clarification on any part of its content as part of my right to informed consent before any evaluation and treatment services begin. By signing this and other applicable forms as part of the intake process, I agree to the terms and conditions therein.

______Signature of Client or Legal Guardian Date

______Signature of Witness Date