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Michael Reynolds, M.Div., Ph.D. Dayspring Counseling, PLLC Eden Office
209 South Edgewood Drive
Eden, NC 27288
336-635-1899 Informed Consent All sessions are confidential to persons outside of the therapy with some exceptions. I am required by law to report: * threats of harm to another or oneself * domestic violence * child or elder abuse * by court order * per your signed release You really do the work of therapy - I accompany you on that journey. I will ask you for goals for your therapy, and we will talk about the therapeutic process and approximate length of time needed. Sometimes, if not often, symptoms may get worse before they get better as change requires feelings of discomfort and other intense feelings. While therapy should end through mutual agreement once goals have been reached, you have the right to end therapy at any time. Please feel free to ask questions of me at any time. Therapy only works if you have trust and confidence in me and feel my respect and care for you. In counseling children or adolescents, I prefer to keep confidentiality as much as possible in order for the therapeutic process to work. While you as parent or guardian may have a legal right to information, know that if you insist on knowing what is being said, your child may well lose confidence in the process and in me, and the benefits of therapy may be lost. Cancellation Policy I agree to cancel appointments only in the event of extreme necessity. I understand I will be charged full fee unless I provide 24 hours advance notice. In the case of insurance, last minute cancellations will need to be paid in full by you as I cannot bill for a “no show.” Professional Information Dr. Michael Reynolds received a Master of Divinity degree from Vanderbilt University in 1990 and a Ph.D. in Psychological Counseling from The Union Institute and University 2002. Dr. Reynolds has been licensed as a Licensed Professional Counselor in the State of North Carolina (License 4211) since 2002. He is also an ordained minister with the Disciples of Christ in the North Carolina Region. Services Offered Dr. Reynolds offers counseling services to children, adolescents, and adults. His therapeutic approach will vary depending upon which approach produces the most favorable results for the client. His major therapeutic techniques include cognitive therapy, person centered therapy, behavior therapy, reality therapy, REBT, narrative therapy and play therapy. Hypnosis is also offered for behavioral change. In order for a therapeutic treatment plan and to meet insurance and Medicaid requirements, a diagnosis will be made of your mental health status based on criteria from the most recent edition of the Diagnostic and Statistical Manual, and this diagnosis does become a part of your client record. Fees Sessions are generally scheduled for 45-50 minutes or for 75 minutes depending upon the nature of the presenting problem and depending upon the authorization of your insurance provider. All initial diagnostic sessions are $135.00 for a 45-50 minutes session. Follow up sessions are $115.00 for a 45-50 minute session and $135.00 for a 75 minute session. All fees are due at the time of the session. Insurance will be billed for you after your co-payment and any deductible is met. If your insurance does not pay within a reasonable time period (60 days), or if your insurance refuses payment for any reason, you will be billed for the full amount due. If you are a Medicaid patient and Medicaid refuses payment for any reason, you will be billed and you are responsible for the rate normally paid by Medicaid. Court Fees It is not unusual for a mental health professional to be asked to appear in court for testimony and presentation of records especially in cases involving the custody of children or other legal matters. As I cannot book clients on these days, the fee for appearing in court is $250.00 per hour with a minimum retainer fee for two hours of $500.00. The minimum fee of $500.00 is not returned if the court case is continued or dismissed within 7 days of the scheduled court date as I have left this day open just to appear in court with you and could not schedule appointments. Also, if I am placed “on call” for court testimony, I cannot schedule appointments for that day, and the fee for being “on call” is $500.00. When placed “on call,” the $500 fee will cover up to two hours in actual court time, but you will be billed at $250.00 per hour beyond two hours. Please be certain to ask your attorney to notify me of any upcoming court dates as I will need sufficient time to prepare testimony and records for your case. Letters for Client There is no fee charged for forwarding your records to another medical or mental health professional provided you give your written consent. Fees for letters written to an employee, attorney, parole or probation officer, court system or other person or agency on your behalf are charged at $135.00 per hour which is payable prior to the letter being released. Complaints The United Nations Declaration of Human Rights states that you, and people all over the world, have the right to be treated with respect and dignity. While in professional counseling, you will be treated with respect and dignity. It is important to note that in counseling, the counselor may question or challenge your past or present behaviors which may be contributing to emotional pain and suffering for you and for others. Yet, your respect and dignity will never be intentionally compromised. Therapy is very hard work for both the client and the counselor. If you feel, at any time, that you have a concern or complaint in counseling, please share this concern or complaint with the counselor. In the majority of cases, this brings about resolution which is acceptable to all. If the complaint cannot be resolved with the counselor, you have the right to register an official complaint against the counselor by writing to the North Carolina Board of Licensed Professional Counselors, Post Office Box 1369, Garner, NC 27529-1369. _______________________________________________ Signature of Client Date _______________________________________________ Dr. Michael Reynolds Date cc: patient file
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