Kim Engel-Hughes, MA, NCC, LPC
Professional Disclosure Statement and Consent For Treatment
The majority of this document is mandated by both South Carolina State law and Public Law 104- 191. It is provided for your protection. Contact Information: Ms. Engel-Hughes’ physical office address is 1700 First Baxter Crossing, Suite 204, Fort Mill, SC, 29708. The office mailing address is 1750 Hwy. 160 W., Suite 101, PMB 200, Fort Mill, SC, 29708. Ms. Engel-Hughes’ office number is 803-547-1106. This voice mail is confidential. Personal Qualifications: Ms. Engel-Hughes received her Bachelor’s Degree in Psychology from Meredith College in Raleigh, NC, and her Master’s Degree in Counseling Psychology and Counselor Education from the University of Colorado at Denver. She practices in South Carolina as a Licensed Professional Counselor (LPC) and National Board Certified Counselor (NBCC). She has also practiced (and been licensed) in North Carolina. Services: Ms. Engel-Hughes’ therapeutic approach combines family systems and cognitive behavioral therapies. She will be glad to discuss her approach and methods with you at any time. If you believe therapy is not being helpful, you may discontinue at any time. Ms. Engel-Hughes will be glad to assist you with a referral to another provider. Please note that Ms. Engel-Hughes does not perform evaluations for disability, insurance, and/or family medical leave act (FMLA). She will be glad to work with your physician to this end. In addition, Ms. Engel-Hughes does not perform custody evaluations, do mediation, or provide written reports to the Department of Social Services (DSS). Fees: The hourly fee for individual, couples, and family therapy ranges from $95 to $105. As it is customary to pay for professional services when they are rendered, this fee is due at the start of each session. Sessions may be successfully cancelled as late as 24 hours prior to the scheduled appointment time. If 24 hours’ notice is not provided, you will be charged a $50.00 “missed appointment fee.” This fee must be paid in full by the next scheduled session. Insurance Coverage/Out-of-Network Behavioral Health: Ms. Engel-Hughes is currently an in-network provider for Blue Cross Blue Shield (effective date 8/31/12). This means that she “accepts” this insurance and will file claims on behalf of the client. Ms. Engel-Hughes is considered an out-of-network provider for all other insurance companies/providers (e.g, Cigna, United, Aetna, etc.). This means that although she does not technically “accept” other insurance plans or file claims directly on behalf of the client, she will still provide detailed receipts so that clients can file claims themselves. Many insurance companies will reimburse clients a portion of the fees they have paid for sessions with out-of-network providers, but this is often dependent upon the client’s individual policy. As such, you may want to contact your insurance company to discuss your out-of-network benefits. Questions that may be helpful to ask include, but are not limited to, the following: Kim Engel-Hughes, MA, NCC, LPC
Professional Disclosure Statement and Consent For Treatment
May I seek services with a therapist who is an out-of-network provider? If so, at what percentage will I be reimbursed? Is there a deductible I must meet before I will be reimbursed? How many visits am I (or is my child/adolescent) allowed per calendar year? Will you reimburse for individual therapy, family therapy, or both? Again, Ms. Engel-Hughes will provide you with a detailed receipt at the end of each session. This receipt will include all the information you will need to submit a claim to insurance for possible reimbursement. Please note while there are a number of benefits to seeking treatment outside the confines of managed care (i.e., only using a therapist “in network” on your insurance plan), perhaps the most important is the right to choose the person who is the best fit for you and your family. Confidentiality: The information you share in psychotherapy is protected health information and is generally considered confidential by both South Carolina statute law and federal regulations. Please note, however, that your therapy file can be subpoenaed in South Carolina through a court order signed only by a judge. It is considered privileged in the federal court system. Ms. Engel-Hughes is mandated by standards through the “Duty to Warn” statute to breach confidentiality if she discovers: You are threatening self-harm (suicide) You are threatening to harm another (homicide) A child has been or is being abused or neglected, and/or A vulnerable adult has been or is being abused or neglected. If you wish for your protected health information to be released to another party, you must sign a specific “Release of Information” intended for this purpose. Ethics: Ms. Engel-Hughes follows the Code of Ethics of the following organizations: The South Carolina Board of Examiners for the Licensure of Professional Counselors, Marriage and Family Therapists, and Psycho-Educational Specialists, and The American Counseling Association. Any type of sexual behavior between therapist and client is unethical. It is never appropriate and will not be condoned. Informed Consent: You will be asked to sign the last page of this document. Your signature verifies that (1) you have been given this document and the HIPAA document that follows, (2) you have read and understand these documents, and (3) you consent to treatment. You also need to be aware of the following: Kim Engel-Hughes, MA, NCC, LPC
Professional Disclosure Statement and Consent For Treatment
Treatment is not always successful and may open unexpected emotionally sensitive areas, Ms. Engel-Hughes is not a physician and cannot prescribe medications, Ms. Engel-Hughes is not available 24 hours a day, and Ms. Engel-Hughes may need to consult with your physician, attorney, or other counselor. She will notify and/or discuss this with you before consultation occurs. Ms. Engel-Hughes is licensed through the SC Board of Examiners for the Licensure of Professional Counselors, Marriage and Family Therapists, and Psycho-Educational Specialists. This Board is located in The Synergy Center (Kingstree Building) in Columbia, South Carolina. The Board’s mailing address is P.O. Box 11329, Columbia, SC, 29211-1329. The phone number is 803-896-4652.