Steven M. Clemens, M.Ed., NCC, LPC
(919) 945-9313
stvnclemens@gmail.com
PROFESSIONAL DISCLOSURE STATEMENT
Qualifications: I was conferred in 2002 with a Master’s of School Administration degree in Educational Leadership from the University of North Carolina at Chapel Hill. In addition, in June 2012, I completed a Master’s in Education in Clinical Mental Health Counseling from North Carolina State University. I have earned the title of National Certified Counselor (NCC #297932) and Licensed Professional Counselor (9615) in the state of North Carolina. In addition, I hold licensure as a Teacher of Exceptional Children (K-12) and Principal (K-12) in the state of North Carolina. My formal education has qualified me to counsel individuals, couples, families, and groups. My services include individual, group, and family counseling for adolescents and adults.
Counseling Experience: Since 2000, through my M.S.A (University of North Carolina at Chapel Hill 2002) and M.Ed. (North Carolina State University 2012) programs and under supervision, I have extensively counseled individuals, couples, families, in agency, community, and private practice settings. In May of 2012, I completed my clinical practicum/internship, which consisted of 700 supervised clock-hours. Since 2006, I have worked full- time as a Qualified Mental Health Professional, Youth Service Coordinator, and case manager. I have extensive experience with Child and Adult Community Support Services and Intensive In Home Services. My areas of interest include mood disorders such as depression and bipolar disorders, anxiety disorders, attention disorders, and behavior disorders. Additionally, I have over ten years of professional experience working with children, adolescents, adults and families as both an educator and mental health professional. I have served these clients as an educator of children with special needs, Learning and Development Coach, Educational Research Specialist (at a National Educational Research Lab), intensive in home professional, and child Case Manager for two different mental health providers. I have experience working with individuals in public schools, homeless shelters, intensive in home services, private office, group homes, and foster care residential placements.
Nature of Counseling: The most successful therapies adapt to the strengths of the individual therapist, but also to each client. All services that are provided emphasize client strengths and abilities. Goals of counseling may include assistance with decision-making, increasing symptom management, working with grief and loss, increasing self-esteem, improving communication and relationships, and developing strategies to improve daily functioning. Our approach will include life skills development; discussion of feelings and/or problems/concerns; and experiments with alternative modes of thinking, feeling, and acting. Common benefits include improvements in self-awareness, self-esteem, self-confidence, hope, relationships with others, and taking an active and responsible role in one’s life. I use a holistic approach to counseling that takes into account your biological, psychological, social, and spiritual dimensions. I strive to establish and maintain a relationship with you, the client, which is characterized by equality and cooperation. Therapy provides the opportunity for growth, self-discovery and insight in the context of a safe, supportive environment. Each client is unique and presents with his or her own counseling needs and concerns. For this reason, there is no one approach that may work best for everyone. With this principle in mind, I utilize integrative models involving insight oriented, cognitive-behavioral, developmental, solution-focused, and mind-body-spirit models. I may occasionally request that you do “homework” by way of providing you with further reinforcement to concepts discussed in session or simply to prompt further insight and self- exploration.
INFORMED CONSENT
Use of Diagnosis: I utilize the Diagnostic and Statistical Manual of the American Psychiatric Association, fifth Edition (DSM-5) to make clinical diagnoses. If a client is using insurance, it is typically necessary for a diagnosis to be given in order for claims to be serviced. In addition to a diagnosis, insurance companies may also request treatment plans or summaries. This information, including the diagnosis would become part of the client’s permanent record. Another scenario whereby diagnoses and other clinical information may be shared (upon client’s consent) is if a client transfers to another therapist or collaboration is necessary with a client’s physician or psychiatrist, for example.
Counseling Relationship: Although our sessions may be very intimate emotionally and psychologically, ours is a professional relationship rather than a social one. As such, maintaining professional boundaries is a vital component in the therapeutic relationship, and I will uphold those boundaries in order to ensure an appropriate therapeutic relationship. It is critical that the professional relationship be based on mutual respect, safety, and trust. Therefore, it is in the client’s best interest that contact with me be limited to individual meetings, group meetings or telephone conversations necessary to his/her therapy. It is not appropriate to extend social invitations or gifts or ask me to relate to you in any other way that is outside of the professional context of your therapy. These limits are designed with the client’s welfare in mind and allow for all efforts to be directed towards the client’s concerns.
Counseling Format: Our initial meetings will be a consultation in order to best understand your concerns, your history, and determine the appropriate course of treatment. This process typically lasts 2-3 sessions, with an initial session of 90 minutes followed by two 50 minute sessions. At the conclusion of these initial sessions, we will collaboratively determine a plan to best address your concerns. This may or may not involve referrals to mental health, medical, or other providers. During the time we work together, we will typically meet once a week for 50 minutes. Occasionally, it is recommended to meet more frequently.
In certain circumstances, I am also available to conduct counseling sessions via telephone. All of the policies and procedures of face-to-face counseling described herein apply, such as scheduling, cancellations, fees, etc.
I do not discriminate on the basis of race, gender, religion, national origin, or sexual orientation. If significant differences, such as in culture or belief system, exist between us, I will work to understand those differences. At your and/or my suggestion, you may bring other family members to a therapy session if you believe it would be helpful.
Effects of Counseling: Clients may be advised that counseling may bring up difficult topics about your history or relationships. The goal is to address these issues respectfully and with sensitivity. At any time, you may initiate a discussion of possible positive or negative effects of entering, not entering, continuing, or discontinuing counseling. Although I expect you to benefit from counseling, I cannot guarantee any specific results. Counseling is a personal exploration and may lead to major changes in your life perspectives and decisions. These changes may affect significant relationships, your job, and/or your understanding of yourself. Although the exact nature of changes resulting from counseling cannot be predicted, I intend to work with you to achieve the best possible results for you.
It is important to understand the risks and benefits of counseling. Since therapy often involves discussing unpleasant aspects of your life, you may experience uncomfortable feelings like sadness, guilt, anger, or frustration. Therapy often leads to better relationships, solutions to specific problems, significant reductions in feelings of distress, and an overall improved well-being. Given the nature of psychotherapy, it is difficult to predict exactly what will happen in terms of therapeutic outcome or to provide a clear estimate of time required in order for a client to reach his or her personal goals. One of the best indicators though for success in therapy often involves the motivation level of the client such as being open to the process of change, being consistent with attending sessions, and working on goals outside of sessions.
Written Consent Required To Release Information: Only records or information, with appropriate written consent by the consumer, may be released to identified parties. The release must specify who may send or release information, as well what specific information may be released. The written release is valid for one year, but may be revoked at any time by the client. If you sign a release of information, you are entitled to receive a copy of the signed release. Also, I may only release information that was generated by me. For example, if you provided a release for me to receive specific records from another agency, I am not permitted to release those records to other parties. You will need to contact that agency if you need those records released.
Client Rights: Some clients need only a few counseling sessions to achieve their goals; others may require months or even years. As a client, you are in complete control and may end our counseling relationship at any time, though I do ask that you participate in a termination session. You also have the right to refuse or negotiate modification of any of my counseling techniques or suggestions that you believe might be harmful.
Group therapy: The right to confidentiality is addressed in the group setting. Triangle Wellness Counseling, PLLC and group therapists are not responsible for any breaches of confidentiality by group members.
Minors and Parents: Children of any age have the right to independently consent to and receive mental health treatment without parental consent and, in that situation, information about that treatment cannot be disclosed to anyone without the child’s agreement. While privacy in psychotherapy is very important, particularly with adolescents, parental involvement is also essential to successful treatment and requires that some private information be shared with parents. For clients 12-17, we request a verbal agreement between our client and his/her parent/guardian allowing us to share general information about the progress of the minor’s treatment.
Appointments, and Cancellations: Clients (or legal guardians) are required to contact me at least one business day in advance if cancelling an appointment. A client who misses an appointment without proper notification will be charged a late fee ½ the hourly rate for the scheduled treatment. Payment will be expected before your next appointment. This will be waived if you have an emergency (i.e., death in the family, hospital emergency). Sessions will be scheduled at mutually agreed upon times. You may make, cancel, or reschedule appointments by contacting me between 9:00 a.m. and 5:00 p.m., Monday through Friday, at the confidential phone number and voice mail listed at the beginning of this form. If you are late for an appointment, I will be happy to see you for the remaining time available, but you will be expected to pay your normal fee. Due to the nature of my work, I may not be always readily available by phone should you need to speak with me outside of our session time. However, I do check my messages periodically and generally try to return phone calls the same day.
Electronic Communications Policy: E-mail and/or text can be immediately broadcast worldwide and be received by unintended recipients. If you are sending e-mail I suggest using SendInc (for more information, contact this website https://www.sendinc.com/). SendInc is a Military-Grade Encryption service that ensures messages are encrypted to and from senders. If you use email, please do not include any information about your mental health. Doing so violates your HIPAA rights and places me at risk. By sending a message through non-encrypted services (Gmail, Hotmail, Yahoo, Outlook, etc.) you are indicating an understanding that communication is not encrypted and the limitations of security and confidentiality of its contents.
Because employees do not have a right of privacy in their employer’s e-mail system, clients should not use their employer’s e-mail system to transmit or receive confidential information.
Triangle Wellness Counseling, PLLC cannot guarantee that electronic communications will be private. Triangle Wellness Counseling, PLLC will take every reasonable step to protect the confidentiality of client e-mail but is not liable for improper disclosure of confidential information not caused by Triangle Wellness Counseling, PLLC.
Client Emergencies: If you experience a mental health emergency, call 911, go to the nearest hospital Emergency Room, or you may call UNC Hospitals Emergency Department: 966-4721 or Holly Hill Respond line at 919-250-7000. If it is urgent, but not life-threatening and you are receiving individual therapy with me you may contact me at (919) 945-9313. If you contact me via phone and it is not an immediate crisis, I will be available for as long as it takes to schedule an appointment. Any conversation beyond that will be considered telephone counseling and will be billed as a minimum of one session according to my fee schedule below.
Additional Crisis numbers:
Local Fire (Chapel Hill Fire Dept.) (919) 968-2781
Local Police Dept. (Chapel Hill Police Dept.) (919) 968-2760
Orange County EMS (919) 245-6100
Orange County Social Services (919)245-2800
Domestic Violence Hotline (919) 828-7740
Mobile Crisis (877)-626-1772
UNC HealthLink Nurse Advice Line: (888) 267-3675 or 966-7890
How do I report a complaint? I render counseling services in a professional manner consistent with accepted ethical standards. If at any point you find that you are dissatisfied with services, please feel free to notify me immediately. I will work diligently to resolve your concerns. This will allow our work together to be more collaborative in nature. However, if you believe you have been mistreated, or treated unethically you can contact the North Carolina Board of Licensed Professional Counselors at Post Office Box P.O. Box 77819, Greensboro , North Carolina 27417 or you may call (844) 622-3572 for clarification of client rights or to lodge a complaint.
Health Insurance: It is important that you understand your insurance benefit coverage. For benefit coverage questions, please call the customer/member services phone number on the back of your insurance card. Although I may be able to assist you, ultimately, it is your responsibility, prior to your first appointment, to verify your plan’s limitations, deductibles and exclusions and obtain updates as required.
In compliance with health insurance contracts, Triangle Wellness Counseling, PLLC requires that all copayments are collected at the time of service. This includes payments toward co-insurance and deductibles. In some cases, the coinsurance /deductible amount collected will be an estimate and adjustments will be made once a response is received from your insurance company regarding the claim. This may result in credit to your account or additional charges. We do not have the option to waive co-payments, deductibles or co-insurance amounts due as that would be a violation of the contract we have with the insurance company.
Please provide your insurance card and driver’s license at your initial appointment so that we may keep a copy in your record in accordance with our contract with the insurance company.
It is your responsibility to provide us with updated information if your insurance company or plan changes or your coverage terminates. It is also your responsibility to notify us of any changes in address or other contact information. If the insurance information you provide to us is later determined to be inaccurate resulting in a denial of your claim, you will be responsible to pay the amount denied by your carrier.
Service/Visit Type Fee
Diagnostic Interview/Testing $225
Psychotherapy, 45 minutes $150
Psychotherapy, 55 minutes $165
Couples $180
Phone call/e-mail/extra documentation $15/15 min
• time spent communicating by phone, e-mail, writing
(past 5 minutes for routine matters).
Missed Appointment $90
Group Psychotherapy $80
Family therapy (with patient present) $180
Payment is due at the time of service. Cash or checks are accepted as forms of payment.
You must pay the session fee in full at each session, unless other arrangements are made. Personal checks should be made payable to Steven Clemens. An additional fee of $50 will apply for any items returned unpaid.
Court Action/Legal Fees, “Clients are discouraged from having their therapist subpoenaed…Even though you are responsible for the testimony fee, it does not mean that my testimony will be solely in your favor. I can only testify to the facts of the case and to my professional opinion.” the following fees are in effect:
1. Preparation time (including submission of records): $220/hr
2. Phone calls: $220/hr
3. Depositions: $250/hour
4. Time required in giving testimony: $250/hour
5. Mileage: $0.40/mile
6. Time away from office due to depositions or testimony: $220/hour
7. All attorney fees and costs incurred by the therapist as a result of the legal action.
8. Filing a document with the court: $100
9. The minimum charge for a court appearance: $1500
A retainer of $1500 is due in advance. If a subpoena or notice to meet attorney(s) is received without a minimum of 48-hour notice there will be an additional $250 “express” charge. Also, if the case is reset with less than 72 business hours notice, then the client will be charged $500 (in addition to the retainer of $1500).
If you are involved in a lawsuit in which I am subpoenaed by any person or party to give deposition or courtroom testimony, you are responsible for reimbursing me at a rate of $225 per hour for time I spend on preparation, legal proceedings, and travel to and from those proceedings. In such a case, I will send you a bill that specifies payment within 30 days.
By signing this Informed Consent you consent for me engage a collection agency in the event that you have not paid your bill within 30 days, in which case I will reveal only your contact information and amount owed. In the event an attorney must be hired to collect any amounts owed, you agree to pay all attorney’s fees.
The condition(s) for which you seek counseling may or may not qualify for reimbursement. If a qualifying diagnosis is appropriate in your case, I will inform you of the diagnosis I plan to render before you submit information to the health insurance provider.
Referrals: Not all conditions presented by clients are appropriate for treatment by me. For this reason, you and/or I may believe that a referral is needed. In that case, I will provide some alternatives including programs and/or people who may be available to assist you. A verbal exploration of alternatives to counseling will also be made available upon request. You will be responsible for contacting and evaluating those referrals and/or alternatives.
Confidentiality: Confidentiality is essential in developing and maintaining a positive counselor/client relationship. I will abide by all rules and regulations regarding confidentiality. Discussions between you and me, and even the fact that you are in counseling with me, are confidential.
Limits of Confidentiality: Generally speaking, information provided by a client during individual or group therapy sessions with a licensed professional counselor is legally confidential and the therapist cannot share or disclose the information without the client’s written consent. However, I must reveal things said by a client if I suspect neglect of a child, elderly or disabled, sexual and/or physical abuse; if I feel the client may harm themselves or others; and/or if I am court ordered by a judge to do so. If I do suspect any of the fore mentioned, I will advise the client of my suspicions and will be required to contact appropriate parties to advise them of your situation and intentions. Additionally, if there is a psychiatric or medical emergency, I may release information to emergency personnel to assist in coordination of emergency services. If you have any questions regarding confidentiality, please feel free to contact me at (919) 945-9313. If I see you in public, I will protect your confidentiality by greeting you only if you greet me first.
Consultation:
I may find it helpful periodically to consult with my supervisor and/or other professional staff about your case. This will be anonymous in nature whereby, specific identifiable information will not be given but rather general information to help facilitate consultation needs. In other words, if I make reference to my counseling with you, I will do so in a way that disguises your identity. If such a disguise is impossible or undesirable, I will ask you to sign a waiver. If you do not agree to sign, I will not make identifiable reference to you. In addition, my sessions from time to time may be audiotaped/videotaped; however, this would ONLY be conducted upon your consent. If you provide consent for sessions to be recorded, your confidentiality will be maintained, and no identifying information will be included in the recording. You need not consent to recording of sessions in order to receive counseling services.
Access to Medical Records: All of our communication becomes part of the clinical record. Consumers, guardians, or legal representatives have a right to have access to medical records. While the actual record is property of the mental health provider, you may request to review all or part of the record. If you choose to review the records, you must sign a written release and you may set an appointment with Mr. Clemens to review your records. Your individual record is accessible to you on request at a separate counseling session specifically for that purpose, unless, in my judgment, the contents may be detrimental to you. Only records generated by me may be released. If you request copies of all or part of the record, a small fee may be charged (not to exceed $15.00 for administrative costs). To protect your confidentiality, I store paper records in a lockable file cabinet and electronic records through a password protection system. I will shred your paper records and delete your electronic records seven years after our last counseling session. If I die while still maintaining your records, my will specifies that your records be transferred to the North Carolina Board of Licensed Professional Counselors at Post Office Box P.O. Box 77819, Greensboro, North Carolina 27417 or you may call (844) 622-3572. If I become incapacitated such that I am unable to maintain your records or provide you with a referral, you consent for my attorney to assign a qualified mental health professional to transfer inactive records to the NCBLPC and to assume active cases by offering to provide continuing mental health services and/or offering referrals for such services.
Conditions of Ongoing Counseling: If you have been in counseling or psychotherapy during the past seven years, I may request you to sign a release so I may communicate with and/or receive copies of records from the professional(s) from whom you received mental health services, if I deem it important to do so. While you are in a professional relationship with me you agree not to maintain or establish a professional relationship with another mental health professional unless you first discuss it with me and sign a release that enables me to communicate with the other mental health professional(s). If you decide to maintain or establish a professional relationship with another mental health professional against my advice, I may consider this your decision to change counselors and I reserve the right to terminate your counseling with me.
I reserve the right to postpone and/or terminate our counseling relationship if you come to your session under the influence of alcohol or illegal drugs. I also reserve the right to terminate our counseling relationship if you do not comply with the medication recommendations of your psychiatrist or physician; if I believe you are not benefiting from counseling; if, in couple counseling, I learn that you are battering your partner/spouse; if I am seeing you in couple counseling and you and your spouse decide to divorce; or if I am impaired in providing competent counseling to you. In the case of group counseling, I reserve the right to deny group entry to anyone I consider inappropriate for the group and to terminate from the group anyone whose behavior I consider detrimental to the therapeutic effectiveness of the group. In all of the aforementioned cases involving termination, I will provide you with referrals. If you choose to decline the referrals, I will terminate our counseling relationship, nevertheless.
Consent to Treatment: If you have any questions, please discuss them with me. To indicate that you have read and understood the information presented to you, please sign and date both copies of this form. A copy of this form will be filed in your confidential records kept in my locked file cabinet and the other will be returned to you for your records. By your signature below, you are indicating 1) that you voluntarily agree to receive mental health assessment and mental health care, treatment, or services, and that you authorize me to provide such assessment and care, treatment, or services as I consider necessary and advisable; 2) that you understand and agree that you will participate in the planning of your care, treatment, or services, and that you may at any time stop such care, treatment, or services that you receive through me; 3) that you have read and understood this statement and have had ample opportunity to ask questions about, and seek clarification of, anything unclear to you; and 4) that I provided you with a copy of this statement. You consent for me to communicate with you by mail, e-mail, and/or phone at the following addresses and phone numbers, and you will IMMEDIATELY advise me in the event of any change. By my signature, I verify the accuracy of this document and acknowledge my commitment to conform to its specifications.
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Client’s Signature Date
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Home Address
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Home Phone Work Phone Mobile Phone Email
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Guardian signature