THIS NOTICE DESCRIBES HOW INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW THIS DOCUMENT CAREFULLY.

The purpose of this notice is to explain to you how your protected health information (PHI) may be used and disclosed for the purposes of treatment and healthcare operations. It also provides you with information about how you may access your PHI and ask to have restrictions placed on the information about you that could be released without your authorization to another person or organization under the Health Insurance Portability and Accountability Act (HIPAA) of 1996. If you have any questions, please feel free to ask.

All information given to your provider during the evaluation and treatment process is considered confidential. The disclosure of protected health information will be governed by NCGS 12C, federal law regarding substance abuse records 42CFR Part 2, and the HIPAA (1996), as well as any other applicable federal or state laws. When there is a discrepancy between HIPAA mandates and mandates of North Carolina laws governing the practice of psychology or my ethical code of conduct, I will do my best to uphold the strictest form of confidentiality and provide you with the maximum amount of protection for your private health information.

Disclosure of protected health information outside the counseling relationship with Ann Marie Sochia, MS, LCMHC, MS, CHT, NLP is permitted when you or your legal representative signs a written authorization, or gives verbal authorization in an emergency situation. Any authorization for disclosure may be revoked at any time, except to the extent that action has been taken in reliance on it.

You have a right to request restriction of disclosure of your health information. Under the following specific conditions, however, disclosure of information outside of the counseling relationship with Ann Marie Sochia, MS, LCMHC, CHT, NLP, is permitted and/or required by law and professional ethics without your specific authorization.

- When there is a medical or psychiatric/psychological emergency involving your health and safety or the safety of others
- When Ann Marie Sochia, MS, MS, LCMHC, CHT, NLP, is required by law to report instances of neglect or abuse of a child, elderly person, or disabled adult
- When Ann Marie Sochia, MS, LCMHC, CHT, NLP, is responding to a court order or participating in a commitment proceeding
- When Ann Marie Sochia, MS, LCMHC, CHT, NLP, is required by North Carolina Administrative code to disclose information due to an incident that would cause a health risk to other persons

If in the event that a disclosure or release of information is deemed necessary, I will make every effort to discuss it with you before taking any action and will limit my disclosure only to what is necessary.


You also have other rights related to the use and disclosure of health information in your medical record. These can be exercised by contacting Ann Marie Sochia, MS, LCMHC, CHT, NLP, and would include:

- The right to request limitations on your PHI that I may disclose. (I may decline your request if the information is needed to provide you with emergency treatment.)
- The right to inspect and request a copy of your medical record. (Under limited circumstances, your request may be denied.)
- The right to request an amendment of any section of your medical record. (I have the right to deny your request.)
- Each disclosure of protected health information will be documented in your medical record. (You have the right to request an accounting of these disclosures.)

Ann Marie Sochia, MS, LCMHC, CHT, NLP, duties regarding your privacy:
- Ann Marie Sochia, MS, LCMHC, CHT, NLP, is required by law to maintain the privacy of protected health information and to provide you with a notice of our legal duties and privacy practices with respect to protected health information.
- Ann Marie Sochia, MS, LCMHC, CHT, NLP, reserves the right to change the privacy policies and practices described in this notice. Unless I notify you of such changes, I am required to abide by the terms currently in effect.
- Retain records for 7 years following your last therapy contact. After that time, records will be destroyed to protect your privacy.

Ann Marie Sochia, MS, LCMHC, CHT, NLP, may leave voice messages on telephones or mail information to you regarding appointment reminders, billing information, or other information about treatment alternatives or services that may be of interest to you. If you do not wish to receive voicemails or mailings from Ann Marie Sochia, MS, LCMHC, CHT, NLP, please notify me.

If you are concerned that I have violated your privacy rights, or you disagree with a decision made about access to your records, please bring it to my attention so we can address the matter. If there are concerns that we are not able to resolve to your satisfaction, the North Carolina Board of Licensed Professional Counselors (NCBLCMHC) can be contacted at (919) 661.0820 to review and evaluate any concerns that you may have.

You are required to read this information prior to your initial appointment with Ann Marie Sochia, MS, LCMHC, CHT, NLP. You may request a paper copy of this notice at any time.

The purpose of this document is to aid in the establishment of our counseling relationship. Please read it over carefully and thoroughly and let me know if you have any questions.

Background and Experience:

My name is Ann Marie Sochia. I hold a Master's degree in Mental Health Counseling (2012) from Capella University and a Bachelor's degree in Sociology from Christopher Newport University (1996). I am also a Certified Hypnotherapist (2002) with specializations in Neuro-Linguistics Programming, Elmanian Hypnosis, Pain Management, Weight Management, Stress Management and meditation and mindfulness. I began my hypnosis experience with a company called Positive Changes, where I worked as a Hypnotist. My Counseling experience was obtained through my Graduate Mental Health Counseling Program as an Intern throughout the Practicum and Internship phases of the program. During those phases I worked at Heartfelt Alternatives, Inc. and Community Link Counseling Services, both of which are located in North Carolina. My focus at these agencies was on helping children and young adults with mental health issues ranging from schizophrenia to depression using cognitive behavior therapy and motivational interviewing in individual and group sessions. Currently I am owner and counselor in a private counseling and hypnotherapy practice, seeing clients with a variety of mental health needs. I am a Licensed Clinical Mental Health Counselor (LCMHC) in the state of North Carolina License #9822.

Counseling Services Offered and Theoretical Approaches:

As your counselor, I will assist you in determining and then making the desired changes to help you successfully achieve your goals in a safe, non-judgmental, respectful, and supportive environment. This is done using a combination of humanistic, cognitive behavior, and holistic gestalt theoretical approaches.

As your counselor, I believe in following the basic principles of the humanistic therapy practices of genuineness, positive regard, congruence, and empathy while helping you work toward and achieve success. This is done integratively with a cognitive behavior approach which follows the basic tenet those emotions and behaviors are directly linked to cognitive processing; thus, a person's view of him or herself along with their worldview defines how they feel and act. Combined with the gestalt belief that the whole is greater than the sum of individual parts, my approach is always to treat the whole person and not just the individual parts.


Confidentiality:

Keeping confidentiality is a cornerstone of the counseling relationship between the counselor and client. Thus, it is important to state exactly what you can expect from me and what my policies are regarding confidentially.

I will not share your confidential information without your permission, except as required by law, that is, in an emergency situation, when I believe there is potential you are going to harm yourself or others, or when there is reason to believe there is any form of abuse occurring in your life or someone else's. In very rare circumstances, as an LCMHC, I can be ordered by a judge to release normally confidential information, and in this situation, relevant records would need to be released to the court. If you wish me to release confidential information to others (e.g. family members), you will need to complete an Authorization for Release and Exchange of Information Form.

HIPAA:

The Health Insurance Portability and Accountability Act (HIPAA) is a federal law that provides privacy protections and patient rights with regard to the use and disclosure of your Protected Health Information (PHI) used for the purpose of treatment, payment and healthcare operations. HIPAA requires that I, as your counselor, provide you with a Notice of Privacy Practices (found on the Waves of Change website under "New Client Forms") for use and disclosure of your PHI for treatment, payment and healthcare operations. The Notice of Privacy Practices explains HIPAA and its application to your personal health information in detail; it is important that you read this document carefully and let me know if you have any questions. By signing this disclosure statement, you are also indicating that you understand HIPAA and agree to how your PHI will be used by me in terms of your treatment, contact with your health insurance provider, and process of claims for payment. Again, please let me know if you have any questions.

Emergency Procedures:

If, as a client, you feel you are in an emergency situation (mental health emergency) please call 911 or go to your local emergency department for more immediate assistance. Otherwise, I will return all calls and emails within 24 hours except major holidays or when I am on vacation. Please note that I will always let you know when I am not going to be available and will leave a contact for referral.

Canceling Sessions:

Counseling sessions are offered in a professional manner, holding to the strict ethical standards and codes of the American Counseling Association and the National Guild of Hypnotists, both of which I am a member in good standing. All individual therapy sessions are 50 minutes in length except the first session which is 60-90 minutes in length. Sessions with families or couples may be 60-90 minutes in length. All sessions are by appointment only. Once an appointment is scheduled, your time is blocked out and is no longer available for other clients. Thus, I respect your time and ask that you respect mine. If you need to reschedule or cancel any appointment, I kindly ask for at least 24 hours' notice. Any appointment missed, canceled, or rescheduled with less than 24 hours' notice will incur the full fee except in emergency situations. All payments are expected at time of service unless you are purchasing a discounted multi-session package which is to be prepaid. All clients will receive a receipt of payment via email or in person as requested. If you need something specific for your medical reimbursement program, please let me know. I am not able to guarantee that reimbursement is possible in all situations. Your signature at the bottom of this form indicates your understanding of these policies and procedures. If for any reason you would like to be referred to another counselor, contact me as soon as possible so we can talk, and I can make the appropriate referral. If for any reason I feel my expertise is not an appropriate fit for you, I will discuss the matter with you and make an appropriate referral. In all cases your best interest will always be served and held with the utmost priority.

Late Arrivals:

Each client is seen by appointment only. If you arrive late, the appointment must end as scheduled, and you will be charged for the full amount of the scheduled time. This will allow me to see each client as scheduled, showing respect for your time and that of the client scheduled after you.
Billing and Payments:

You are expected to pay for each session at the time it is held and prior to the session commencing unless a multi-session package was purchased in advance. Payments can be made by cash, check, PayPal, or credit card.
Insurance Reimbursement

At this time I do not accept insurance. However, if you would like to have a receipt to submit to your insurance company, I will be happy to provide one. Once providing you a receipt for your insurance company, I can no longer accept responsibility for any confidential information shared by you with your insurance company.

Termination:

Clients are under no obligation to continue counseling with me or anyone and can decide to terminate at any time. However, I ask you to contact me in person so that we can openly and honestly discuss this. If you feel I am not the appropriate therapist for you, I am happy to provide referrals. Similarly, if at any time I feel I am not the most appropriate counselor for you, I will personally talk with you and then refer you, and we can terminate our counseling relationship.

Complaint Procedures:

Although clients are encouraged to discuss any concerns with me, you may file a complaint against me with the organization below should you feel I am in violation of any of these codes of ethics. I abide by the ACA Code of Ethics (http://www.counseling.org/Resources/aca-code-of-ethics.pdf).

North Carolina Board of Licensed Clinical Mental Health Counselors P.O. Box 77819

Greensboro, NC 27417 Phone: 844-622-3572 or 336-217-6007 Fax: 336-217-9450 E-mail: Complaints@ncblcmhc.org

Contacting Me:

You may call me on my cell phone at (919) 272-6220; my voice mail is private and confidential, so you may leave a message. I will make every effort to return calls within 24 hours, with the exception of weekends and holidays. You can also email me. However, I cannot guarantee complete confidentiality with emails as they are internet based and can be viewed in some rare circumstances by others. You will need to provide me with a phone number where you will be comfortable having me return your calls and identifying myself and/or leaving a voicemail or an email. Again, if this is an emergency situation and immediate assistance is needed, please call 911 or go to the nearest emergency room and ask for the psychiatrist on call.

You may also reach me via email (annmarie@wavesofchangenc.com) for general inquiry and/or to request an appointment. If you need to reschedule an appointment please do so via telephone, if less than 24 hours' notice. I will make all attempts to respond to emails in a timely manner. Please be aware that email is not a completely secure form of communication. I cannot protect against the possibility that the information sent over e-mail might be intercepted by unwanted parties. As a general rule, I ask that you refrain from disclosing any sensitive or personal information over email.

I look forward to working with you, and please do not hesitate to let me know if you have any questions regarding this document or the counseling process. Thank you.


Sincerely,


Ann Marie Sochia MS, LCMHC, CHT, NLP

Signature: _______________________ Date: ________

Client Name: ________________

Signature: ___________________ Date: _______________