New Patient Forms

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 dwallacelpc@gmail , 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:

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:

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:

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:

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:

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:

Address:___________________________________________________________________________________________________

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Address: __________________________________________________________________________________________________

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

Address:__________________________________________________________________________________________________

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

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

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Signature of Person Responsible for Payment
Date__________________________________________

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.

Prior to your counseling or therapy, you will receive

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.

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Signature of persons responsible for payment and or parent/guardian Date

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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.