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Donya Wallace Counseling & Consulting, LLC
Professional Disclosure Statement,
Consent for Treatment and Payment Contract
 
Thank You for choosing Donya Wallace Counseling & Consulting, LLC to meet your needs, we warmly welcome you to the counseling process.  Our goal is to provide the highest quality service in a friendly and caring environment.  Please let us know if there is anything we can do to make this possible for you.  The majority of this document is mandated by both South Carolina State law and Public Law 104-191; it is provided for your protection.  Donya Wallace Counseling & Consulting, LLC has tried to anticipate any risks you may face as a result of being in therapy. If you have any questions regarding the documents you have received, please feel free to discuss them with your Therapist.
 
Contact Information: Donya Wallace Counseling & Consulting, LLC is located at 128 E Mill Street, Kingstree, SC 29556 and 1505B Heritage Lane, Florence, SC 29505.  This is also our mailing address. Our usual office hours are Monday through Friday 8am- 5pm.  Our website can be found at donyawallacecounseling.com.  Our clients are seen by appointment only and special appointments for evenings, weekends, and other selected times will be considered. Our telephone number is (843) 667-9255 (the voicemail is confidential) and our fax number is (843) 667-1723. Our email address is [email protected], it is checked at least once every working day.  Appointments are also available in Lake City office at 263 Kelley Street, Lake City.
 
Meet our Clinicians:
Donya Wallace, LPC, NCC, LPC/S candidate  is the president and owner of Donya Wallace Counseling & Consulting, LLC.  Please note some of her credentials listed below:
South Carolina Licensed Professional Counselor
National Certified Counselor
South Carolina Licensed Professional Counselor/ Supervisor Candidate
• Member of The International Association of Trauma Professionals
• Member of The American Counseling Association
• Certified TRICARE Mental Health Counselor
• Certified Clinical Trauma Professional
Donya Wallace received her Bachelor’s Degree (BS) from The University of South Carolina in 1993, her Master’s Degree (MA) from Webster University in 2002.  She is trained in a variety of cognitive based therapies and uses an eclectic mix of cognitive modalities.
 
Carrie Privett, LPCI holds a Bachelor of Arts degree in Psychology from Coastal Carolina University (2011) and A Master of Arts degree in Counseling from Webster University (2014).  She is a Licensed Professional Counselor Intern and a member of Psi Chi-Psychology Honors Society and the American Counseling Association.   
 
Services: We provide a number of psychotherapeutic services which include:
􀂾 Comprehensive evaluation, diagnosis and assessment
􀂾Therapy involving adjustment to changes encountered by individual life cycle development
􀂾Therapeutic assessment and treatment of Posttraumatic Stress Disorder (PTSD) in individuals, depression and anxiety
􀂾 Collaboration/ consultation and coordination with primary physicians, schools, human service agencies, employers, attorneys and courts
 
Fees: It is customary to pay for professional services at the time they are rendered. The session fee for individual, couple, and family therapy is $85.00 per unit (defined as 45-55 minutes). Hour long sessions are $105.00 per unit. The initial session fee is $160.00 per unit (defined as 60-90 minutes).  If Donya Wallace Counseling & Consulting, LLC accepts your insurance, you may be required to pay a co-pay for your therapy. If you do not know whether your deductible has been met, you will be charged full fee.  We will refund your fee minus the co-pay if we find your deductible has been met. If you have insurance, you are responsible for any fees - due to Donya Wallace Counseling & Consulting, LLC - that your insurance company does not pay.  Co-pays and deductibles are due the day the service is rendered and prior to the start of your session.  It is unethical to allow our clients to accumulate large balances; therefore all unpaid balances must be brought current before additional sessions will be scheduled.
 
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. Your therapy file can be subpoenaed in South Carolina through a court order (signed only by a judge) but is considered privileged in the federal court system. Donya Wallace Counseling & Consulting, LLC is mandated by standards - through Duties to Warn - to breach confidentiality if it is discovered that:
 1.) you are threatening self-harm or suicide,
 2.) you are threatening to harm another or homicide,
 3.) a child has been or is being abused or neglected, and/or
 4.) a vulnerable adult has been or is being abused or neglected.  
If you have concerns about the protection of your information
Finally, if you wish your protected health information released to another party, you must sign a specific Release of Information.
 
 
Ethics: The practice 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
􀂙The South Carolina Board of Social Work Examiners
􀂙The International Association of Trauma Professionals
􀂙The National Board for Certified Counselors, Inc.
􀂙The American Counselors Association
 
 
Limits of the Therapy Relationship: Psychotherapy is a professional service that is provided to you.  Because of the nature of therapy, our relationship has to be different from most relationships.  It may differ in how long it lasts, in the topics discussed, or in the goals of the relationship.  It must be limited to the relationship of therapist and client only.  Any type of sexual behavior between therapist and client is unethical. It is never appropriate and will not be condoned.  Because of this therapeutic relationship, other relationships such as these are improper:
 
􀂾 Your therapist can not be your teacher, supervisor or evaluator
􀂾 Therapist can not act as therapists to their relatives, friends, friends’ relatives, people they know socially or business contacts
􀂾 Your therapist can not employ you, lend or borrow from you or trade or barter for services
􀂾 Your therapist can not give you legal, medical, financial or any other type of professional advice.
􀂾 Your therapist can not be your friend or socialize with you outside of therapy.
􀂾 Your therapist can not ‘friend’ you on Facebook or communicate with you on any social website.
 
 
Informed Consent: You will be asked to sign the last page of this document. Your signature verifies you have been given this document and the HIPAA document that follows; that you have read and understand these documents, and that you consent to treatment. Further you need to be aware:
o Treatment isn’t always successful and may open unexpected emotionally sensitive areas.
o Your therapist is not a physician and cannot prescribe medications.
o Your therapist may need to consult with your physician, attorney, or other counselor.
o Your therapist is not available 24 hours a day.
o Appointments may be successfully canceled as late as 24 hours prior to the scheduled time. If this is not done, you may be charged $25.00 for a missed appointment.  This missed appointment fee must be paid prior to your next session.  Repeated no-shows or late cancels may result in you being discharged from this practice.
OThis office provides training and supervision opportunities for Masters level students and Licensed Professional Counselor Interns (LPCI).  If you have concerns about an intern being present in your session or about being treated by an LPCI please let your therapist know.
o Donya Wallace 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 at 803-896-4652 (mailing address is P.O. Box 11329, Columbia, SC 29211-1329).
o Carrie Privett 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 at 803-896-4652 (mailing address is P.O. Box 11329, Columbia, SC 29211-1329).
 
o The Executive Administrator for Donya Wallace Counseling & Consulting, LLC is Donya Wallace. She is a confidential administrator under state and federal law. She will be your major contact for appointments, problems, complaints, and commendations.
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Payment Contract
COMPETE TOP PORTION ONLY
 
Client Name:       _______________________________________________________________________________________                   Phone:__________________________________________


Address:___________________________________________________________________________________________________

 
Person responsible for payment of account: ____________________________________________________________________          Phone: __________________________________________
__

Address: __________________________________________________________________________________________________
 


Third party (insurance, EAP) payor: ___________________________________________________________________________           Phone: __________________________________________


Address:__________________________________________________________________________________________________

 
                                Federal Truth in Lending Disclosure Statement for Professional Services
Part 1: Fees for Professional Services I agree to pay Donya Wallace Counseling & Consulting, LLC a rate of 160.00 per clinical unit (defined as 60-90 minutes) for the initial session and $85.00 per clinical unit (defined as 45 minutes) for individual, family and couples counseling.  A $25.00 fee is charged for missed appointments.  It is the client’s responsibility to pay the missed appointment fee.  Payments, co-pays and deductibles are due at the time of service.  Clients are asked to make payments and /or financial arrangements upon arrival/before session.  Clients who do not make responsible progress toward payment of retiring outstanding debt may, at the discretion of the provider be terminated from services.  Clients terminated for services will be given 15 days notice during which their emergence counseling needs will be addressed clients are still financially responsible for paying any services rendered during this time.
Part 2:          Clients with Insurance (Deductible and Co-payment Agreement) Either you or your insurance company (listed above) have informed Donya Wallace Counseling & Consulting, LLC that your policy contains (but is not limited to) the following provisions for mental health services:
Estimated insurance Benefits                     1. $______________ Deductible Amount (Paid by Client)
                                                                2. Co-Payment $_____________ for the first/ last ________ visits.
                                                                3. Co-Payment of $____________ for up to _________ visits.
                                                                4. The policy limit is ________ visits per year.  ____annual      ____ calendar
Please confirm these provisions with your insurance company, as they are not guaranteed.  The person responsible for payment shall make payment for services that are not paid by your insurance policy, all co-payments, any agreed upon services or testing or deductibles.  We will also attempt to verify these amounts with the insurance company.
Your insurance company may not pay for services they consider to not be effective, not medically or therapeutically necessary or ineligible (not covered by your policy or the policy has expired or is not in effect for you or other people receiving services).  If the insurance company does not pay the estimated amount, you are responsible for the balance, the amounts charged for professional services are explained in Part 1 above.  If your insurance policy changes, or is discontinued the client assumes responsibility for full payment of services rendered.
I HEREBY CERTIFY that I have read and agree to the conditions and have received a copy of the Federal Truth in Lending Disclosure Statement for professional services
 
___________________________________________________________________________________________________
Signature of Person Responsible for Payment                                                                                                               Date
Health Insurance Portability and Accountability Act of 1996 (HIPAA)
 
This notice describes how medical information about you may be used and disclosed and how you can get access to this information. Please review it carefully. This document may be updated without notice so please review it each time you visit us. A copy of this statement is always available upon request.
All information revealed by you in a counseling or therapy session and most information placed in your counseling/therapy file (all medical records or other individually identifiable health information held or disclosed in any form [electronic, paper, or oral]) is considered “protected health information” by HIPAA. As such, your protected health information cannot be distributed to anyone else without your express informed and voluntary written consent or
authorization.   The exceptions to this are defined immediately below. Additional information regarding your rights as a client can be found in your therapist’s/counselor’s Professional Disclosure Statement and Consent for Treatment.
 
Use or disclosure of the following protected health information does not require your consent or authorization:
1. Uses and disclosures required by law - like files court-ordered by a Judge
2. Uses and disclosures about victims of abuse, neglect, or domestic violence - like
the Duties to Warn explained in your therapist’s/counselor’s Disclosure Statement
3. Uses and disclosures for health and oversight activities - like correcting records
or correcting records already disclosed
4. Uses and disclosures for judicial and administrative proceedings - like a case
where you are claiming malpractice or breech of ethics
5. Uses and disclosures for law enforcement purposes - like if you intend to harm
someone else (see Duties to Warn in your therapist’s/counselor’s Disclosure
Statement)
6. Uses and disclosures for research purposes - like using client information in
research; always maintaining client confidentiality
7. Uses and disclosures to avert a serious threat to health or safety - like calling
Probate Court for a commitment hearing
8. Uses and disclosures for Workers’ Compensation - like the basic information
obtained in therapy/counseling as a result of your Worker’s Compensation claim
 
Your Rights as a Counseling/Therapy Client under HIPAA
⇒ As a client, you have the right to see your counseling/therapy file. Psychotherapy notes are afforded special privacy protection under the HIPAA regulations and are excluded from this right.
⇒ As a client, you have the right to receive a copy of your counseling/therapy file. This file copy will consist of only documents generated by us. You will be charged copying fees @ $.20/page. Psychotherapy notes are afforded special privacy protection under the HIPAA regulations and are excluded from this right.
⇒ As a client, you have the right to request amendments to your counseling/therapy file.
⇒ As a client, you have the right to receive a history of all disclosures of protected health information. You will be charged copying fees @ $.20/page.
⇒ As a client, you have the right to restrict the use and disclosure of your protected health information for the purposes of treatment, payment, and operations. If you choose to release any protected health information, you will be required to sign a Release of Information form detailing exactly to whom and what information you wish disclosed.
⇒ As a client, you have the right to register a complaint with the Secretary of Health and Human Services if you feel your rights, herein explained, have been violated.
 
Prior to your counseling or therapy, you will receive
1.) an exact duplicate of these two pages and
2.) your therapist’s/counselor’s Professional Disclosure Statement and Consent for Treatment - both for your personal records. It will be necessary for you to sign a certificate indicating that you have received, read, and understand both documents. This certificate will be place in your counseling/therapy file. Please do not sign the certificate if you do not understand any part of the HIPAA Client’s Rights or the Professional Disclosure Statement and Consent for Treatment. Your counselor or therapist will be happy to explain these documents further.
Donya Wallace Counseling & Consulting, LLC
Professional Disclosure Statement,
Consent for Treatment and Payment Contract
 
 
I acknowledge that I have received and read the Donya Wallace Counseling & Consulting, LLC Professional Disclosure Statement, Consent for Treatment and Payment Contract and the HIPAA Client’s Rights.
 
 
 I further acknowledge that I seek and consent to treatment with Donya Wallace. My signature below confirms that I understand and accept all the information contained in the Donya Wallace Counseling & Consulting, LLC Professional Disclosure Statement, Consent for Treatment and Payment Contract and the HIPAA Client’s Rights.
 
 
I (we) authorize Donya Wallace Counseling & Consulting, LLC to disclose initial case records incompliance with the Health Insurance Portability and Accountability Act’s designated record set (Diagnosis, clinical summary and testing results) to the third party payor _____________________________________________________ for the purpose of receiving payment reimbursement directly to Donya Wallace Counseling & Consulting, LLC
 
I understand that I may revoke this consent at any time by providing written notice, and after one year this consent expires.  I understand that if I elect to revoke this authorization, I am assuming liability for any outstanding claims or monies owed to Donya Wallace Counseling & Consulting, LLC for services rendered.  I (we) have been informed what information will be given, its purpose, and who will receive it.  I (we) certify that I (we) have read and agree to the conditions and have received a copy of the Payment Contract and Federal Truth in Lending Disclosure Statement for professional Services.
 
 
__________________________________________________________________________________________
Signature of persons responsible for payment and or parent/guardian                                                 Date
 
__________________________________________________________________________________________
Signature of person receiving services                                                                                                 Date
 
                                                                                                                                                     
If more than one individual (e.g., spouse or family member) is seeking therapy or will be participating in your therapy sessions, please have each of the others sign below. Signatures below confirms that each understands and accepts all the information contained in the Donya Wallace Counseling & Consulting, LLC Professional Disclosure Statement,
Consent for Treatment and Payment Contract and the HIPAA Client’s Rights, and that each seeks and consents to treatment. We will provide additional copies of the Donya Wallace Counseling & Consulting, LLC Professional Disclosure Statement and Consent for Treatment and the HIPAA Client’s Rights upon request.
 
______________________________________                                ______________________________________
Signature of Client #2                                                              Signature of Client #3
 
______________________________________                                ______________________________________
Signature of Client #4                                                              Signature of Client #5
 
    
Helpful Forms

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