counseling therapy matthews charlotte monroe nc abuse trauma

A Place Called 'There' Counseling

Autumn Austin MA, LPC, BCETS, NCC, CGP, LCAS

1135 Four Lakes Dr. Suite A Matthews, NC 28105

704-651-0668

Specializing in Helping People who have been Hurt.

Evening Appointments Available. Most Insurance Companies Accepted.

Sliding Scales Available

Email Questions or Comments to: aaustin@aplacecalledthere.com

Professional Disclosure Statement

Autumn Austin, MA, LPC, CGP, BCETS, NCC, CSAC

I believe the counseling experience is one of very personal, shared interaction between
two people; the most crucial aspect of this relationship is trust. To help you build this
trust, I want to share with you my professional beliefs, background, and most
importantly, your rights. This document is part of the standards of practice of the North
Carolina Board of Licensed Professional Counselors. Please read this statement prior to
our first session.

Education & Experience:

I have a Masters of Arts in Counseling from UNC Charlotte. My area of special interest
and experience is working with individuals who have been abused or have experienced
other traumatic events, as well as individuals suffering from personality disorders. I
have experience includes working with individuals, families, couples, high risk youth,
chemically dependent individuals and their families, the dually diagnosed, as well as the
geriatric population.

I am a Nationally Certified Counselor (NCC #86968) and I am a Licensed Professional
Counselor (LPC # 4817) with the North Carolina Board of Licensed Professional
Counselors.   I am a Board Certified Expert in Traumatic Stress (BCETS). In addition, I
am a Certified Group Psychotherapist (CGP) with the National Registry of Certified Group
Psychotherapists; and I am a Certified Substance Abuse Counselor (#1926) with the
North Carolina Substance Abuse Professional Certification Board.

I also hold memberships with the American Counseling Association, the Association for
Specialist in Group Work, the North Carolina Counselor Association, the American Group
Psychotherapist Association, the Licensed Professional Counselors Association of NC, as
well as the American Academy of Experts in Trauma Stress.

Counseling Philosophy:
Counseling is a joint effort, which can not be successful without your hard work, energy
and courage. There are many reasons people seek counseling; regardless of the reasons, I
believe an enhanced sense of self understanding and acceptance is essential in all
situations (this includes understanding how past experiences have shaped the way we view
ourselves, as well as how we understand relating to others). Therapy provides a safe
place to explore reactions, thoughts, and feelings about people in your life as well as
yourself. It allows you the opportunity to practice new ways of interacting and, when
ready, to try these in other relationships. I believe that each individual has a unique view
of the world, based on his/her role in it. The understanding; that none of us are totally
individual, but are part of a whole, either as part a small family unit or as a part of the
greater community, is critical to the growth process. Self awareness may be a very short
process for some clients and longer for others. Just as you have the right to decline or
accept any suggestions or therapeutic approach, you also have the right be informed of any
potential risks. Such risk might include, but are not limited to; uncomfortable feelings of
guilt, anxiety, anger or frustration. During the process of changing, current relationships
may become strained because of your growth. With these risks in mind, weigh the
disadvantages of counseling with the benefits; which may include gaining insight into your
self, developing coping skills and equipping yourself to deal more effectively with life.

Together we will decide on the amount of sessions needed to achieve your goals. After
our initial meeting I may ask you to visit a physician to rule out any biological causes for
your distress before continuing forward in the counseling process. In the case of issues
or concerns beyond my scope of competence, I will make every effort to refer you to
more qualified professionals.

I will often recommend that clients join a therapy group, as I believe that groups
maximize growth potential, ground individuals in a better understanding of their own
issue, as well as expanding an individual’s ability to form effective relationships. If you
are referred to a group; all the nuances of that process will be explained in detail before
you are expected to make a choice about entering.

I believe that a great deal of growth can be facilitated by you, outside of the counseling
session. I may make referrals to support groups, 12 step organizations, or stress
management to aid in your understanding and growth. I also believe homework is a vital
part of client growth.

Counseling sessions will be held within the counseling office only. For your best interests
and to protect your personal rights, our relationship must remain professional at all times;
this means that even though our relationship may seem very intimate, you must remember
that I am only sharing with you as a professional and focusing on the goals you have
indicated you desire to reach. This is the primary purpose of our relationship.

Fees and Insurance Reimbursement:

My fee is $130 per 50 minute hour visit, $90 per 2 hour group session, and due at the
time of service, I accept cash or personal checks, Medicaid and Several Insurance plans.
A sliding scale is available for clients meeting the annual financial requirement of
$20,000 per year for individuals and $35,000 for a family of two or more. This will
enable those clients who qualify to pay one fourth of my regular individual fees and one
fifth of my group fee.

Please be aware that any personal information or diagnosis provided to an insurance
company can no longer be held to the same standard of confidentiality, and may well
become part of your permanent insurance record. Appointment cancellation must be made
at least 24 hours in advance to avoid being charged the full fee.

Confidentiality:

All information shared will be kept confidential with the following exceptions;

a) If I believe you are a danger to yourself or someone else

b) If you give me written permission to disclose information

c) In the case of abuse to a child or an elderly person confidentiality will be waived

d) If the information is court ordered

e) If you desire to seek reimbursement from a managed care company, the disclosure of
confidential information may be required for reimbursement

f) In case of a Medical Emergency

g) These rights are waived if accusations of misconduct are brought

Even under these circumstances only essential information will be revealed and as much
as possible you will be informed before confidentiality is broken. In the event the client
is a minor, parents or legal guardians may be included in the counseling process as is
appropriate, however measures will be taken to safeguard confidentiality, always acting in
the best interest of the client.

As a counselor I may be receiving supervision (by an individual who is bound by the same
code of ethics as I am) to continually improve my counseling skills, any information shared
during supervision will be discussed for professional purposes only and every effort will
be made to protect the client’s identity.

Client Rights:

All records are my property; however they are kept for your benefit and are available to
you at your request, if deemed therapeutically valuable. As stated earlier, you have the
right to be informed of your counselor’s qualifications as well as the right to decline or
accept any suggestions or therapeutic strategies. I will remind you of these rights and
choices periodically throughout our therapeutic relationship. Termination of the
counseling relationship will be made by you or by a collaborative decision between us both.

Emergencies:

If you have an urgent situation, which you feel needs immediate support and I am not
available by phone, please contact your local 911 system or go to the nearest emergency
room.

Complaints:

If, at any time, you feel my behavior or my counseling approach is inappropriate or
troubling to you, please let me know. If, however, you do not feel your concerns are being
addressed appropriately, feel free to contact any or all of the following:

North Carolina Board of Licensed Professional Counselors

PO Box 1369

Garner, NC 27529-1369

(919) 661-0820 Fax: (919) 779-5642

or

The North Carolina Substance Abuse Professional Certification Board

PO Box 10126

Raleigh, NC 27605

(919) 832-0975 Fax: (919) 833-5743

Client Responsibilities:

As a client you have the responsibility to set and keep appointments. Let your counselor
know as soon as possible, at least within 24 hours, if you cannot keep an appointment. Pay
your fees in accordance with the schedule you pre-established with the counselor. Help
plan your treatment goals and follow through with agreed upon goals.   The client is
responsible for his/her actions when he/she refuses treatment or does not follow the
practitioner's instructions. The client is responsible for following the facility's rules and
regulations affecting client care and conduct. The client is responsible for being
considerate of the rights of other clients and facility personnel. The client is responsible
for holding in strict confidence other client's mental health/substance abuse information
which may be obtained during group therapy and socialization. It is also your responsibility
to keep your counselor informed of your progress towards meeting your goals and to
terminate your counseling relationship before entering into arrangement with another
counselor.

Please list any questions you have and bring them with you to your first visit. I will be
sure to address all of your questions and concerns.

Consent for Treatment

By signing below, you indicate that you have read this disclosure, that your questions have
been answered and that you understand the above information.   Your signature also
indicates that you are consenting to receive counseling services.

Acknowledgement of Notice of Privacy Practices

My signature indicates that I have received a copy of the HIPAA Notice of Privacy
Practice and had an opportunity to ask any questions I may have.

Grievance Process

I have received a copy of and understand the grievance process.

Client Rights, Responsibility and Confidentiality

My signature attests that I have read, and fully understand my rights as a client, as well
as my responsibilities. Additionally I am aware of the limits of confidentiality.

This is Your Copies

Please Sign and Bring the Next Page to Your Appointment

Consent for Treatment

By signing below, you indicate that you have read this disclosure, that your questions have
been answered and that you understand the above information.   Your signature also
indicates that you are consenting to receive counseling services.

Acknowledgement of Notice of Privacy Practices

My signature indicates that I have received a copy of the HIPAA Notice of Privacy
Practice and had an opportunity to ask any questions I may have.

Grievance Process

I have received a copy of and understand the grievance process.

Client Rights, Responsibility and Confidentiality

My signature attests that I have read, and fully understand my rights as a client, as well
as my responsibilities. Additionally I am aware of the limits of confidentiality.

______________________________________________     ____________

Client Signature                                                                                                Date

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2nd Client Signature Or Parent/Guardian Signature                                          Date

__________________________________________     ____________

Witness Signature                                                                                            Date