Client Information & Agreement Form

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SESSION FEES

$160 per Session during office hours

After Hours Fees: Sessions after 5pm weekdays or any time on weekend days - Saturday and Sunday - incur the fee of $190 per session.

PAYMENT POLICY & CANCELLATION

Payment is direct pay by client at time of service (I do not take insurance). You are required to have a current credit card on file for session payment. If you prefer to write a check there will be a $35 fee for all returned checks.

Client will receive a statement client can present to their insurance carrier for reimbursement; Client is responsible for the difference between insurance coverage and session fees.

Cancellation: 24 hours notice is required to keep from being charged for missed session.

DISCLOSURE STATEMENT

Advanced Counseling and Therapy Center Disclosure Statement

• Provider: Joel Lavenson, MA, NCC, LPC, LCPC, BCPC, Board Certified PTSD Clinician, Licensed Therapist, Maine LCPC CC3367, Connecticut LPC001157.

Address: Advanced Counseling and Therapy Counseling Service,

109 Sahagian Road, Belgrade, Maine 04917

Telephone: (207) 689-8004, Business hours: M – F 8 am to 4 PM

• Licensure: Maine Licensed Clinical Professional Counselor, May 2008, renews in May 2025.

• Degrees: Masters of Counseling, 1997, Rollins College, Winter Park, Florida.

• Confidentiality: All limits and scope of confidentiality with the following exceptions:

  1. Threat of serious harm to self or others;

2. Reasonable suspicion of child abuse, neglect of a child, abuse,

and neglect or exploitation of an incapacitated or dependent adult;

3. Court order;

4. Voluntary release signed by client or guardian; and

5. During supervisory consultations.

• Competencies: Joel is trained to work with individuals, couples, and families.

Certfied IMAGO Relationship Therapy,

Certified EMDR Clinician,

ReDirecting Childrens Behavior Trainer and Clinician,

National Certifed Counselor - National Board of Certified

Counselors,

Expert in children's behavior having served over 6,000 families and

children while Director of Maine summer camp.

• Course of Action: Intake, assessment, and goal setting completed during the first 3-4 sessions then shared with client.

  Diagnosis and treatment is gained from interview technique with reference to the DSM V.

  In session 4-5, the client is apprised of the working diagnosis and a treatment plan is crafted subject to regular reviews and adjustments.

• Fee schedule, method of billing and terms of payment:

  Client directly pays the full per session fee of (see pricing above) upon completion of each session and, if applicable, is responsible for submitting statements to insurance company.

  After hours and weekends incur an additional fee (see pricing above).

• Fee modifications: Veterans will receive an adjusted fee schedule and, if covered by Optum, this office will submit claims for the veteran client.

• Insurance – It is the client’s responsibility to confer with their insurance company to obtain reimbursement procedures and follow.