DECLARATION OF PRACTICES AND PROCEDURES

Angela Pitre Pellegrin, LPC-S

License # 4144

985-688-7730

106 Birch St., Thibodaux, LA 70301/ 5540 Hwy 1, Lockport, LA 70374

Qualifications: I earned a Master of Arts in Psychological Counseling from Nicholls State University in 2001. I am licensed as a LPC # 4144 with the

LICENSED PROFESSIONAL COUNSELORS BOARD OF EXAMINERS

8631 SUMMA AVENUE

BATON ROUGE, LOUISIANA 70809

TELEPHONE: (225)765-2515

Counseling Relationship: I see counseling as a process in which you, the client, and I, the counselor, having come to understand and trust one another, work as a team to explore and define present problem situations, develop future goals for an improved life and work in a systematic fashion toward realizing those goals.

Areas of Focus: I have a general practice and see clients with various emotional, mental health, career, and developmental issues.

Fees and Office Procedures: Counseling fees are $130 an hour. Clients are seen by appointment only. Insurance is filed. Client is responsible for any fees not covered by insurance.There is a sliding scale fee schedule for uninsured clients.

Services Offered and Clients Served: I approach counseling from a cognitive-behavioral perspective in that patterns of thoughts and actions are explored in order to better understand the clients' problems and to develop solutions. I work with a variety of formats, including individually, as couples and as families. I also conduct group therapy.

Code of Conduct: As a Counselor, I am required by state law to adhere to the Code of Conduct for practice that has been adopted by my licensing Board. A copy of this Code of Conduct is available upon request.

Privileged Communications: Materials revealed in counseling will remain strictly confidential except for:

1.) The client signs a written release of information indicating informed consent of such release.

2.) The client expresses intent to harm him/herself of someone else.

3.) There is a reasonable suspicion of abuse/neglect against a minor child, elderly person (60 or older), or a dependant adult.

4.) A court order is received directing the disclosure of information.

It is my policy to assert privileged communication on behalf of the client and the right to consult with the client if at all possible, except during an emergency, before mandated disclosure. I will endeavor to apprise clients of all mandated disclosures as conceivable. In the event of marriage or family counseling, material obtained from an adult client individually may be shared with the client's spouse or other family members only with the client's permission. Any material obtained from a minor client may be shared with that client's parents or guardian.

Emergency Situations: If an emergency situation should arise, you may seek help through hospital emergency room facilities or by calling 911.

Client Responsibilities: You, the client, are a full partner in counseling. Your honesty and effort is essential to success. If as we work together you have suggestions or concerns about your counseling, I expect you to share these with me so that we can make the necessary adjustments. If it develops that you would be better served by another mental health provider, I will help you with the referral process. If you are currently receiving services from another mental health professional, I expect you to inform me of this and grant me permission to share information with this professional so that we may coordinate our services to you.

Physical Health: Physical health can be an important factor in the emotional well-being of an individual. If you have not had a physical examination in the last year, it is recommended that you do so. Also, please provide me with a list of the medicines you are currently taking.

Potential Counseling Risk: The client should be aware that counseling poses potential risks. In the course of working together additional problems may surface of which the client was not initially aware.

If this occurs, the client should feel free to share these new concerns with me.

THIS NOTICE DESCRIBES HOW MEDICAL/MENTAL HEALTH INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY.

Effective January 31, 2011, Information will only be released in accordance with state and federal laws and the ethics of the counseling profession.

This notice describes policies related to the use and disclosure of your, the client's, healthcare information. Use and disclosure of protected 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.

The use and disclosure of health information may be needed for TREATMENT to provide, manage or coordinate care, consult with other healthcare professionals and to communicate with referral sources. For example, information may be shared with providers to create a treatment plan specifically to meet your needs.

The use and disclosure of health information may be needed for PAYMENT to verify insurance/ coverage and to process claims and collect fees. For example, information may be shared with Blue Cross/ Blue Shield to cover services rendered.

The use and disclosure of health information may be needed for HEALTHCARE OPERATIONS to review treatment procedures and business activities, certification, training, and compliance and licensing activities. For example, staffing with another LPC may occur to explore treatment options.

The use and disclosure of health information may be needed for OTHER USES AND DISCLOSURES WITHOUT YOUR CONSENT such as mandated reporting, emergencies, criminal damage, appointment scheduling, treatment alternatives and as required by law. For example, if a child is being physically abused, as a mandated reporter, the authorities must be contacted.

CLIENT RIGHTS

The following is to inform you, the client, as to your rights under state and federal law.

1. You have the right to request where I contact you (ex: home, work, cell phone or any other means you prefer). This information was identified in your initial intake. You maintain the right to change this at any time.

2. You have the right to request the release of your medical records.

a. In order for you records to be released, you will need to provide written authorization to release the records (ex: changing to a new counselor for therapeutic services).

b. You have the right to revoke this release by submitting a written request

c. Revocation is not valid to the extent that you have acted in reliance on such previous authorization. In other words, information disclosed with the release cannot be undone with revocation. For example, your counselor may want to consult with your physician in regards to medication management.

3. You maintain the right to inspect and copy your medical billing records. In most cases, you maintain the right to review or request copies of you records. You may be charged for the costs associated such as copying and/ or mailing.

4. You have the right to add information or amend you medical records. You may request to amend your record in writing, and provide a reason for your request. While the counselor may deny this request, you have the right to file a disagreement statement. Your disagreement statement and response will be filed in the record. Any amendment request must be in writing.

5. You have the right to accounting of disclosures for a 6 year period beginning with the date January 2012.

Exceptions include:

a. Disclosure for treatment, payment or healthcare operations

b. Disclosures pursuant to a signed release

c. Disclosure made to client

d. Disclosures for national security or law enforcement

6. You maintain the right to request restrictions on uses and disclosures of your healthcare information. In other words, you have the right to request to limit how your information is used or disclosed. This request must be in writing and you must identify what information you want to limit and to whom you want the limits to apply. You can request in writing for the limit to be terminated. The counselor is not obligated to agree.

7. You maintain the right to complain. Please contact your counselor, Angela Pellegrin, first to discuss; however, if you are not satisfied, you have the right to complain to the U.S. Dept. of Health and Human Services. If you file a complaint, you maintain the right for no retaliation by your counselor.

8. You maintain the right to receive a notice of changes of policy that affect you on or after the effective date of change

Acknowledgment of Financial Responsibility