PROFESSIONAL DISCLOSURE STATEMENT
Julia H. Massarelli
Licensed Clinical Mental Health Counselor
919.621.5735
Qualifications:
John Carroll University
20700 North Park Boulevard
Cleveland, Ohio 44118
MA-Department of Counseling and Human Services, 1991
LCMHC License #: 8650
LPCC License #: E2009
30 years counseling experience
Counseling Background: Clientele served: Adult
Description of services:
Diagnosis and treatment of mental and
emotional disorders. Client record confidentiality exceptions
exist, if client is in danger to self or others.
Particular Interest Areas:
Anxiety/Depression/Stress Reduction,
Family/Parenting Dynamic, Separation/Divorce, Life transition
Session Fees and Length of Service:
$250 Intake
$175/50 minute session
$200 couples/family
-Cash and check accepted; paneled with multiple insurance companies
Use of Diagnosis:
Some health insurance companies will reimburse clients for counseling services and some will not. In addition, most will require that a diagnosis of a mental-health condition and indicate that you must have an “illness” before they will agree to reimburse you. Some conditions for which people seek counseling do not qualify for reimbursement. If a qualifying diagnosis is appropriate in your case, I will inform you of the diagnosis before we submit the diagnosis to the health insurance company. Any diagnosis made will become part of your permanent insurance records.
Confidentiality:
All of our communication becomes part of the clinical record, which is accessible to you upon request. I will keep confidential anything you say as part of our counseling relationship, with the following exceptions: (a) you direct me in writing to disclose information to someone else, (b) it
is determined you are a danger to yourself or others (including child or elder abuse), or (c) I am ordered by a court to disclose information.
Complaints:
Although clients are encouraged to discuss any concerns with me, you may file a complaint against me with the organization below should you feel I am in violation of any of these codes of ethics. I abide by the ACA Code of Ethics: https://www.counseling.org/resources/aca-code-of-ethics.pdf.
North Carolina Board of Licensed Clinical Mental Health Counselors
P.O. Box 77819
Greensboro, NC 27417
Phone: 844-622-3572 or 336-217-6007
Fax: 336-217-9450
E-mail: Complaints@ncblcmhc.org
Court Orders:
Absent a Court Order in the form of a Consent Protective Order for the Production of Documents, no records or testimony will be disclosed. Should a subpoena be served to appear and testify before the court, appear and be deposed, or otherwise disclose documents protected by the state or federal level, Julia Massarelli, LCMHC, PLLC reserves the right to terminate any and all services provided with no reimbursement allowed to be sought. In the event a Consent Protective Order for the Production of Documents is entered and served upon Julia Massarelli, LCMHC, PLLC, the fees are as follows:
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To prepare testimony, responsive documents, or otherwise abide by the Court Order: $400/hour;
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To appear and testify: $2,500/day; or otherwise $500/hour;
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Any and all Attorneys’ Fees incurred to object or otherwise represent Julia Massarelli, LCHMC shall be equally divided by the parties. Judge signed Subpoena in compliance with HIPAA: Should there be a subpoena signed by a judge to either appear and testify, be deposed, or otherwise disclose documents, Julia Massarelli LCHMC, PLLC reserves the right to claim any and all privileges as recognized by the State and Federal government. Further, Julia Massarelli, LCHMC, PLLC reserves the right to terminate any and all services provide with no reimbursement allowed to be sought. In the event Julia Massarelli, LCHMC, PLLC, is properly served, the fees are as follows:
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To prepare testimony, responsive documents, or otherwise abide by the Court Order: $400/hour;
-
To appear and testify: $$2,500/day; or otherwise $500/hour;
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Any and all Attorneys’ Fees incurred to object or otherwise represent Julia Massarelli, LCHMC shall be equally divided by the parties.
NC Board of Licensed Clinical Mental Health Counselors POB 77819 Greensboro NC 27417
844-622-3572
Acceptance of Terms:
We agree to these terms and will abide by these guidelines.
Client: ____________________________________________________ Date: _____________
Counselor: ________________________________________________ Date: _____________