Cobblestone Counseling Center, PLLC (For couples /family please complete both columns)
First name: ______________________________________________________ First name _____________________________________________________________
Last name: _______________________________________________________ Last name: _______________________________________________________
DOB: ____________________________________ DOB: ____________________________________
Number(s)where we can call you:
Cell: _____________________________________ Cell: ____________________________________
Home: ___________________________________ Home: ____________________________________
Work: ____________________________________ Work: ____________________________________
Email: _____________________________________________________ Email: _____________________________________________________
Address: ___________________________________________________ Address: ___________________________________________________
EMERGENCY CONTACT(s) NAME/NUMBER:
Who is the Primary insured? ______________________________________________________________ DOB: ___________________________
Circle Insurance Company
BCBS Medicare Cigna MedCost Aetna Magellan TriCare UHC Other: __________________________________
EAP: ________________________________ Authorization #: ______________________________________________________________________
Insurance Member #: ______________________________________________________________________
Group #: ______________________________________________________________________
Co-pay / Co- insurance: $_____________________
Office staff only:
Account # ______________________________ □ Auto-fill
2-Client Agreement and Consent for Treatment
2-Client Agreement and Consent for Treatment
APPOINTMENT REMINDERS will be via email the day before the appointment and will be through [email protected].com. Please add this to your address book. Feel free to call, text or email me.
**NO SHOW POLICY** A No Show appointment will be charged the full amount of the session at $125.00. Cancellations without a 24 hour notice/too many cancellations will result in a $40.00 fee. Please know there are people that are waiting for appointments. Notifying us in advance gives someone else the opportunity to utilize your scheduled time slot. Thank you for understanding.
More information will be explained during your first session.
Your signature at the bottom of this form is authorizing Candace M. Farmer, LCSW/Cobblestone Counseling Center, PLLC to communicate with you via email/text/voicemail and 1-4 below:
1) I hereby give authorization through Cobblestone Counseling Center, PLLC to provide counseling services.
2) I hereby give authorization to Cobblestone Counseling Center, PLLC to release any information necessary to process my insurance claim, if I am using my insurance to cover the cost of this service.
3) I hereby give Cobblestone Counseling Center, PLLC, authorization of payment of services from my insurance company.
4) Client/Parent-Guardian responsible for portion or balance not paid by insurance (when applicable) or other party within 60 days of session date.
Cost of Treatment: $125.00 / Co-pay is due at each session. You have the option of keeping your card number on file.
We accept Cash/Checks/Credit Card/FSA. See below…
□ I give permission to keep this card on file. It will be used for co-pay and will be charged if no show or cancellation
policy is not followed. Please see privacy notice and confidentiality statement.
Card Number: _____________________________________________________________________
Expiration Date: ____________________________________
Card Code on back: __________________
Card zip code: ________________________
□ Visa □ MC □ FSH / HFA / other: __________________________________________
I understand the above statements and policies. My signature below indicates agreement and compliance with the listed policies and consent for treatment. I am aware that this information may be given to me or is available on the Cobblestone website, in addition to the HIPPA policy and emergency contacts in the event my therapist is not available at the time in need. A copy of the therapists Professional Disclosure Statement is available upon request.
√x: __________________________________________________________________________________ ________________________________
Client Signature Date
√x __________________________________________________________________________________ ________________________________
Client Signature Date
HIPPA NOTICE OF PRIVACY PRACTICES
THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATIION. PLEASE REVIEW IT CAREFULLY. Effective date: July 1, 2010
The COBBLESTONE COUNSELING CENTER has been and will always be totally committed to maintaining client’s confidentiality. We will only release healthcare information about you in accordance with federal and state laws and ethics of the counseling profession. This notice describes our policies related to the use and disclosure of your healthcare information.
Uses and disclosures of your health information for the purposes of providing services, providing treatment services, collecting payment and conducting healthcare operations are necessary activities for quality care. State and federal laws allow us to use and disclose your health information for these purposes.
TREATMENT We may need to use or disclose health information about you to provide, manage or coordinate your care or related services; which could include consultants and potential referral sources.
PAYMENT Information needed to verify insurance coverage and/or benefits with your insurance carrier, to process your claims as well as information needed for billing and collection purposes. We may bill the person in your family who pays for your insurance.
HEALTHCARE OPERATIONS We may need to use information about you to review our treatment procedures and business activity. Information maybe used for certification, compliance and licensing activities.
Other uses or disclosures of your information which does not require your consent There are some instances where we may be required to use and disclose information without your consent. For example, but not limited to: Information you and/or your child or children report about physical or sexual abuse: then by North Carolina State Law, we are obligated to report this to the Department of Social Services or if you provide information that informs us that you are in danger of harming yourself or others. Information to remind you of /or to reschedule appointments or treatment alternatives. Information shared with law enforcement if a crime is committed on our premises or against our staff or as required by law such as a subpoena or court order.
4- In Case of an Emergency
4- In Case of an Emergency
- In the Event of a Mental Health Emergency and I cannot be reached, please feel free to use the following resources. In Crisis? Here are Emergency Numbers for you to use:
- Local medical emergency/mental health crisis 911 (local)
- Mecklenburg County - Behavioral Health Center, CMC-Randolph 24-Hour Call Center 704.444.2400
- Mecklenburg Mobile Crisis Team 704.566.3410
- Cabarrus 24-Hour Call Line & Mobile Crisis Services 800.939.5911
- National Suicide Prevention 24-Hour Call Center 1.800.273.8255
- Other Frequently Called Numbers
- Cabarrus County Magistrate's Office (Involuntary Commitment) 704.782.6016
- Mecklenburg County Department of Social Services 704.336.3150
- Mecklenburg County Health Department 704.336.4700
- Mecklenburg County Magistrate's Office (Involuntary Commitment) 704.347.7844
- Mecklenburg Social Security Office 704.532.8583
- Medicaid Questions (Dept. of Social Services) 704.353.1500
- United Way 211 - Community Resource Database 211 (local)
- NON-EMERGENCY NUMBERS
- Cabarrus County - PBH (Piedmont Behavioral Health) http://www.pbhcare.org 1.800.939.5911
- PBH Cabarrus Administrative Office 704.721.7000
- HOSPITALS IN LAKE NORMAN AREA. For Emergencies proceed directly to the ER:
- Presbyterian Hospital HUNTERSVILLE: Phone: 704.316.4000 Address: 10030 Gilead Rd · Huntersville, NC MAIN: Phone: 704..384.4000 Address: 200 Hawthorne Lane · Charlotte, NC Matthews: Phone: 704-384-6500 Address: 1500 Matthews Township Pkwy,Matthews, NC
- Carolinas Medical Centers: CMC Main: Phone:704.355.2000 Address: 1000 Blythe Blvd, Charlotte, NC CMC Mercy: Phone: 704.379.5000 Address: 2001 Vail Ave.,Charlotte, NC CMC Pineville:Phone: 704-667-1000 Address: 10628 Park Road Charlotte,
- Lake Norman Regional Phone: (704) 660-4000 Address: 171 Fairview Road, Mooresville, NC
- Carolinas Psychiatry and Behavioral Wellness-Davidson Phone:(704) 801-9200 Address: 16740 Davidson-Concord Rd, Davidson, NC 28036
5-Insurance Info /FYI
5-Insurance Info /FYI
Cobblestone Counseling Center, PLLC Insurance Panel
ComPsych Coventry HC
EAP (Employee Assistance Programs)
Check with you company for in-network status. For EAP the following information will be needed.....Authorization #, Name of PRIMARY insured, DOB, Employer’s Name, Insurance name, phone and claims address, and # of EAP sessions.
6- Candy M. Farmer, MSW, LCSW
Professional Disclosure Statement
6- Candy M. Farmer, MSW, LCSW
Professional Disclosure Statement
Welcome! I look forward to working with you to achieve the personal goals you set forth and to explore what motivated you to seek counseling. The following information and guidelines have been established to facilitate our work together. Please feel free to comment or ask any questions.
I am a Licensed Clinical Social Worker (LCSW, #C006688) in North Carolina, having earned my Masters in Social Work (MSW) from the University of North Carolina at Chapel Hill with a concentration in family and individual counseling. I graduated from Queens College in Charlotte, NC with a degree in psychology and concentrations in religion and drama. Prior to entering the MSW program, I worked with children, families and couples for 8 years. After graduation I worked with physicians, hospice, individuals and families in a hospital setting/ ICU for 3 years. I then worked with families, couples, and individuals that were affected or had been diagnosed with Multiple Sclerosis since 2002 and ALS since 2003. My past experience has been with children, adolescents, couples, individuals and families in a variety of settings since 1990.
In addition to my private practice, I have worked with CMC Department of Neurology. I also facilitate support groups for people diagnosed with MS, ALS and Muscular Dystrophy and their families. I have jointly facilitated an educational group for individuals, and their families, that have been newly diagnosed with MS and have been involved in presenting workshops for private agencies. I have counseled individuals, adults, children, adolescents, couples, and families regarding marriage, divorce, depression, anxiety, and adjustments to life’s issues for 27 years.
My areas of specialty include marriage, divorce/separation, co-parenting, school issues, relationships, depression, anxiety, adjustments, newly diagnosed individuals, chronically ill, obtaining and adjusting to disability issues, testing for memory and general cognitive issues such as processing information, cognitive flexibility, and executive functioning and accessing community resources.
The counseling relationship is a psychologically intimate, but strictly professional one. It is my absolute commitment, and a requirement of my licensing, that our relationship be limited to our counseling sessions and necessary telephone/email contacts. Therefore, if I see you in public I will not initiate a conversation with you so to ensure privacy and confidentiality for you. You are more than welcome to say hello.
Fees and Billing Practices
Individual counseling sessions are 45-60 minutes in length with a fee of $125.00 per session. Fees/co-pays/co-insurance are to be paid at each session and a receipt and/or invoice provided, if requested. If we agree that I file your insurance directly, then you are responsible for any co-pays due and ultimately responsible for payment in full if your insurance company does not pay within 90 days. It is your responsibility to file with your insurance if we have not made arrangements otherwise. If I am not in-network with your insurance company, I will be glad to file your claim or give you an invoice so that you can file your claim. I will also be glad to write a letter on your behalf and request that your insurance company cover our sessions. Full payment ($125.00) for each session is due until that decision is made by your insurance company.
Additionally, in order to file through insurance, a diagnosis is required. It is important that you know that not all diagnosis’ are covered under a given insurance plan and that when a diagnosis is given, it becomes part of your health records with the insurance company. Likewise, there may be restrictions limiting the number of sessions you are allowed within the insurance company’s calendar year. You should contact a company representative to determine whether your insurance company will cover your fees. However, please remember that you are responsible for paying counseling fees agreed upon. If your insurance company is paying in part or full for your session, they sometimes have the right to gain information regarding your counseling sessions. This varies with different insurance companies. If there is any question about this, it is suggested that you contact the insurer and inquire about the access they are allowed under your policy agreement.
****NO SHOW/CANCELLATION POLICY****
Breaking an appointment without calling/emailing/texting the therapist will result in a fee of $125.00 "No Show" fee. Please note if you do not notify the therapist at least 24 hours prior to that appointment or if cancellations occur too often, you will be billed personally in the amount of $40.00 for each missed/cancelled session. Notifying us in advance gives someone else the opportunity to utilize your scheduled time slot. There are people that ask to be put on a waiting/cancellation list. Thank you for understanding.
Records and Confidentiality
Your counseling sessions and the discussions therein, remain confidential unless I obtain a signed authorization release from you for me to discuss your case with another professional / physician. Case records are confidential and will not be released without written permission from you. However, in certain circumstances it is required that confidential information is disclosed without your consent which include, but are not limited to the following:
1) If you are evaluated to be a danger to yourself or others;
2) If you are a minor, elderly, or disabled and the therapist believes you are the victim of abuse or neglect, or you divulge information about such abuse or neglect;
3) If a court order or other legal proceedings or statute require such disclosure;
4) Your insurance company requires information in order to pay claims; or you can pay out of pocket to avoid this issue.
5) As stated above, at your request. Some health insurance companies will reimburse clients for my counseling services and some will not. Those that do reimburse usually require that a standard amount be paid by you (deductible) before reimbursement is allowed, and then only a percentage of my fee is reimbursable.
Emergency Services In the event of an emergency and to ensure your safety, you are instructed to call 911 or the Center for Mental Health at (704) 358-2800 to receive immediate assistance. I have also given you an emergency contacts sheet in your new client packet. I do not offer emergency services, but I am available for urgent matters. If you have questions about this, please ask and I will be glad to clarify.
Nature of Counseling N.C. Statute 90-343 entitles you to this statement of my professional background to ensure your understanding of the therapeutic relationship and process. I assure you that my services will be rendered in a professional manner consistent with accepted ethical standards as set forth by the National Association of Social Workers (NASW). I look at counseling as a two-way, professional relationship where you are encouraged to set the direction of our sessions as you share your thoughts, concerns, ideas, and feelings about yourself and your situation.
Purpose in Counseling
Your purpose in seeking counseling will help us set goals for your personal growth. These goals are individualized and are likely to change throughout the process of therapy. Homework assignments provide an opportunity to apply theory and practice skills (what we do in the room) once you are at home and are an extension of the therapy hour. Please note that it is impossible to guarantee any specific results regarding your counseling goals. However, I believe that individuals have a natural tendency toward growth and that change is possible, maybe not always easy, but possible. I strive to establish and maintain a therapeutic relationship based on self-determination, respect, trust, acceptance and encouragement. I use an eclectic approach to therapy that can incorporate family of origin, interpersonal, and cognitive-behavioral aspects of counseling, as well as solution focused, systems theory, and when appropriate, brief intervention therapy. There is much to be learned from our experiences in our childhood and then to understand how these patterns can continue to play out in our adult relationships at work and home.
Through our awareness of our personal interactions styles, we can look toward more successful choices in personal relationships. This therapeutic environment is intended to be a safe and honest one; therefore, I am encouraging you to speak openly about any concerns you may have, particularly regarding our progress or the sessions themselves.
Equally, I will be honest and straight forward with you. It is not unusual that as the counseling process progresses and we discuss painful issues that you may feel as though things are getting worse before they get better. While you may end our counseling relationship at any time, I do ask that you participate in a closure session. Should you and/or I believe that a referral is needed, I will provide you with the names of some other therapists as a referral sources. If you have a complaint which you believe needs to be registered with my governing board, you can contact the North Carolina Social Work Certification and Licensing Board.
By having access to and reading this information you acknowledge that you have had the opportunity to ask questions. We will discuss the goals of therapy and understanding that therapy is a joint effort between the therapist and client. Progress depends on many factors including motivation, effort, and other life circumstances. Please let me know if you have any questions or concerns at any time during the course of our professional relationship. My number is 704.433.6644 and my email is [email protected] Thank you for the opportunity to provide this service.