Professional Disclosure StatementKelly Jo Hart, MA, LPC, ARPT

Thank you for selecting me as your therapist. This statement is designed to inform you about my background and treatment approach, and to ensure that you understand our professional relationship.

I earned a Master of Arts in Counseling (with an Emphasis in Clinical Mental Health) from Webster University in 2006. I received my Licensed Professional Counselor (LPC #6808 and #13233) status in the state of North Carolina in 2006 and 2017. I am a member of the Association of Registered Play Therapists. I have been in the medical field for over 21 years and in the counseling field for twelve years.

Approach to CounselingOur counseling sessions will require your buy-in and active involvement so that we may mutually address your presenting issues. We will develop a treatment plan and develop goals based off an initial diagnostic evaluation. A treatment plan is ever-changing, as I view it as a “living, breathing document”. Within the treatment plan and during counseling sessions, we will explore your thoughts, feelings, and behaviors in an effort to help you find solutions that will ultimately help you function more efficiently and improve your overall quality of life. I firmly believe that you are the expert in your own life; however, I am here to act as a “sounding board” in order to empower you and to give your inner self a voice.

I am experienced in counseling children, adolescents, and adults with behavioral and emotional health disturbances. My approach to counseling consists of Cognitive Behavioral Therapy (CBT), Rational Emotive Behavior Therapy (REBT), Person Centered Approach, Solution-Focused Therapy, and Existentialism. CBT examines the relationship between thoughts, feelings, and behavior, and helps the client cognitively restructure thinking errors in more positive, effective ways. REBT is a specific type of CBT, mostly utilized with clients who present with symptoms consistent with Cluster B tendencies, such as Borderline Personality Disorder (BPD). CBT is mainly used with a diagnosis of Post-Traumatic Stress Disorder (PTSD) or other traumas; however. it is also highly effective in targeting panic attacks, complicated grief, disturbing memories, phobias, pain disorders, performance anxiety, stress reduction, addictions, sexual and/or physical abuse, and body dysmorphic disorders. Solution-Focused therapy involves focusing on current or future problems and identifying solutions in order to resolve the issue(s). In addition, I have also worked with children utilizing directive and indirective play therapy techniques to assist children with behavioral issues and trauma.

ConfidentialityState law and the ethical principles of my counseling profession protect the privacy of our sessions, conversations, and documentation. Release of information to a third party is strictly prohibited, unless we have obtained your written consent giving us permission to do so. There are five circumstances in which I cannot guarantee confidentiality. They are 1) intention to harm yourself, 2) intention to harm another person, 3) indication that a child has been or is in danger of being abused, 4) indication that an elderly person has been or is in the danger of being abused, or 5) a court order.

PLEASE NOTE:a. I DO NOT PROVIDE CONSULTATION SERVICES FOR CUSTODY CARE OR DIVORCE PROCEEDINGS.

________ (initial)b. SHOULD I BE SUBPOENAED TO TESTIFY IN COURT, I CHARGE A $600 FEE PER DAY.

________ (initial)

Use of DiagnosisA diagnosis or diagnoses are given to a client only if they meet the criteria outlined in the Diagnostic Statistical Manual Fifth Edition (DSM-5). The DSM-5 encompasses all mental health conditions and is utilized for diagnosing clients and to aid in treatment planning. The client’s diagnosis or diagnoses are kept in one’s confidential clinical record and dictate the most appropriate and effective course of treatment. Explanation of Dual Relationships

Updated 5.17.23

It is important for you to realize that we have a professional relationship rather than a social or personal one. In the event that I happen to see you out in the community, I will respect your privacy and not approach you. As regards online social networking, I am not able to be your “friend” on Facebook or any other similar website. Again, this is to respect your privacy and to uphold confidentiality.

Length of SessionsIndividual sessions are typically 30–60 minutes in length; however, they can range anywhere from 16 minutes to 90 minutes (initial intake) in duration. If you are unable to keep a scheduled appointment, please call Thrive Counseling & Consulting at 910.483.5884 or text message me personally to cancel or reschedule at least 24 hours in advance. Please be on time for your appointments! A missed appointment, without prior notification, will be charged a $50 No-Show Fee, which will be due prior to your next scheduled session. Clients who do not call 24 hours prior to their scheduled appointment to cancel (aside from emergencies), or who are not consistent with keeping scheduled appointments, will be subject to discharge from therapy at therapist’s discretion.

Fee PolicyInsurances that I currently accept are Aetna, Blue Cross Blue Shield (BCBS), and NC Tracks. All copays are due prior to session. Self-pay clients will be subject to the following rates:

Initial Intake/Evaluation—$150 60 Minute Therapy Session—$100 45 Minute Therapy Session-—$75 I also offer sliding scale fees, as determined by income and size of household, through Thrive’s nonprofit

partner The S.A.L.T. Project.

Complaint/Grievance ProceduresIf you are dissatisfied with any aspect of treatment, please inform me immediately. If you think you have been treated unfairly or unethically, you may contact the North Carolina Board of Licensed Professional Counselors at P.O. Box 77819, Greensboro, NC, 27417. You may also contact them via phone at (844) 622-3572 or (336) 217-6007. Their fax number is (336) 217-9450. You may also email them at LPCinfo@ncblpc.org.

Acceptance of TermsWe agree to the terms outlined in Kelly Jo Hart’s Professional Disclosure Statement and will abide by these guidelines henceforth:

Client Signature Date

Client or Spouse Signature Date

Parent/Legal Guardian Signature (if minor) Date

Kelly Jo Hart, MA, LPC, ARPT Date

Updated 5.17.23