Professional Disclosure Statement and Consent for Treatment
Much of this document is mandated by both South Carolina State law and Public Law 104-191; it is provided for your protection. Watermark Counseling LLC has tried to anticipate any risks you may face as a result of being in therapy. If you have any questions regarding the documents you have received, please feel free to discuss them with Dr. Fredric Mau.
Contact Information: Watermark Counseling LLC is located at 1705 Richland Street, Columbia, SC 29201. This is also our mailing address. Our usual office hours are 9:00 a.m. to 8:00 p.m. Monday through Thursday, and 9:00 a.m. to 5:00 p.m. on Friday. Our clients are seen by appointment only and special appointments for evenings, weekends, and other selected times may be considered. Our telephone number is (803) 750-2000 (the voicemail is confidential). Our email address is email@example.com it is checked at least once every working day. Our webpage is watermarkcolumbia.com and contains more information regarding Watermark Counseling LLC. In the event of an emergency call 911.
Personal Qualifications: Dr. Mau is the sole practitioner at Watermark Counseling LLC. Please note some of his credentials: SC Licensed Professional Counselor Supervisor, license number 6785, National Certified Counselor, Distance Credentialed Counselor, and Board Certified Hypnotherapist.
Dr. Mau received his Doctor of Ministry from Reformed Theological Seminary in Jackson, MS, his Master of Arts in Professional Counseling as a graduate with high distinction from Liberty University in Lynchburg, VA, his Master of Divinity from Westminster Theological Seminary in Escondido, CA, and his Bachelor of Arts from Covenant College, Lookout Mountain, GA.
Services: Dr. Mau provides a number of psychotherapeutic services which include therapeutic assessment and treatment of anxiety, mood, stress, affective, compulsive, and other disorders, as well as dependence, relationship, sexual, and other difficulties. These services are ordinarily provided in individual therapy, but may be addressed in therapeutic group settings.
Dr. Mau utilizes a brief therapy model, which generally involves a set number of sessions. A recommendation for treatment will be provided based on an initial assessment of the client. Dr. Mau is qualified to provide a diagnosis under the standard and current Diagnostic and Statistical Manual of Mental Disorders, however the brief therapy model does not provide diagnosis as a matter of course. A diagnosis will be given at Dr. Mau’s discretion when this is needed for insurance purposes or for specific therapeutic reasons. Generally a diagnosis should be understood as a shorthand for a particular group of behaviors, rather than as a condition of the person.
Fees: Dr. Mau provides brief therapy and typically sees clients from three to nine sessions; this is an effective approach which also limits costs. Typically services are recommended in three, six, or nine session increments, and a 10% discount is given if three sessions are paid in a block. In order to provide continuity of care and the best therapeutic outcome, single sessions are typically not provided, but may be provided at Dr. Mau’s discretion at a rate of $217 per hour. Sessions are typically once a week and last approximately one hour. Three sessions are $651, $587 if paid in a block. Cash, checks and certain cards are accepted. If payment in blocks is not made payments can be made each visit. A payment plan at no interest is also available through an automatic debit from a checking account (this does not have to be paid within time of service). Smoking cessation is provided in a single session, at $320 (typically an hour and a half session); this is discounted to $100 plus the normal session charge for those who are otherwise clients ($307). The Highlands Ability Battery including a two hour feedback session is $487). A single session assessment is $150. Discounts may be offered based on multiple programs or ability to pay. Watermark Counseling LLC typically does not employ a debt collection service, but reserves the right to do so. Payment is for therapy services; human behavior cannot be guaranteed. Refunds typically are not provided, however if a refund is given and accepted the client agrees that this will end any dispute or legal action. By signing and accepting this Professional Disclosure Statement and Consent for Treatment, the client agrees to mediation as the means to resolve any dispute, and to pay any legal or related fees incurred by Dr. Mau or Watermark Counseling LLC. At the discretion of Watermark Counseling LLC the next step, if necessary, may be arbitration.
Group therapy typically is not typically offered through Watermark Counseling LLC. If it is offered a fee schedule will be provided. Business consultation or group fees are not normal therapy fees; these will be bid in response to requests for proposals. Fees for training sessions or workshops are published separately.
Insurance: Watermark Counseling LLC does not directly file insurance. At the client’s request a detailed invoice including a diagnosis and treatment statement will be provided to clients who wish to self file insurance claims. No representation is made as to whether a particular insurance company or policy will reimburse for these therapy services in whole or in part. Distance services are consultative not therapeutic, so no diagnosis will be provided. Watermark Counseling LLC does not provide Medicare or Medicaid services. Detailed invoices may not be submitted to Medicare or Medicaid for reimbursement. By signing this agreement the client agrees to pay any fines levied against or legal fees owed by Watermark Counseling LLC or Dr. Fredric Mau as a result of the client filing a claim with Medicare or Medicaid.
Confidentiality: The information you share in psychotherapy is protected health information and is generally considered confidential by both South Carolina statute law and federal regulations. Your therapy file can be subpoenaed in South Carolina through a court order (signed only by a judge) but is considered privileged in the federal court system. Dr. Fredric Mau is mandated by standards – through Duties to Warn – to breach confidentiality if he discovers: 1) you are threatening self-harm or suicide, 2) you are threatening to harm another or homicide, 3) a child has been or is being abused or neglected, or 4) a vulnerable adult has been or is being abused or neglected. If you want a copy of your therapy file or a letter from Dr. Mau for use in a legal action, Dr. Mau requires a subpoena for release of this information. By signing and accepting this Professional Disclosure Statement and Consent for Treatment, the client agrees that Dr. Mau may use information in an anonymous fashion for instructional or research purposes, and may consult with professional colleagues for therapeutic, ethical, educational or related purposes regarding treatment (again while keeping the client’s identity anonymous). If you are seeing a physician or qualified mental health professional regarding matters related to your request for counseling with Dr. Mau, please inform Dr. Mau. By signing this agreement you hereby authorize a release of records to and professional consultation with these providers. Because of confidentiality concerns, the client agrees not to post reviews of services by Dr. Mau on social media (such as Facebook or Twitter) or review sites (such as Yelp). Confidentiality is desirable in a group therapy setting, but cannot be guaranteed. Reasonable efforts will be made by Watermark Counseling LLC to maintain confidentiality when using electronic communications such as email, web conference, text, instant messaging, mobile devices and telephone, but complete confidentiality cannot be guaranteed or expected when these media are used. Some services such as Google (gmail) and Skype claim ownership of materials transmitted through their media. By signing this agreement the client specifically releases confidential information to be transmitted through electronic media services, even when these services may not be HIPAA compliant. Clients agree to allow an appointment reminder to be left on voicemail. Finally, if you wish your protected health information released to another party, you must sign a specific release of information.
Recording of sessions: Sessions involving guided imagery, functional relaxation, hypnosis or similar processes are regularly recorded and the recordings are given to the client for therapeutic purposes. At the client’s request a counseling session may be recorded. Highlands Ability Battery feedback sessions are regularly recorded. Recordings are given to the client; recordings are not ordinarily part of the therapy file, psychotherapy notes, or client records and Watermark Counseling LLC does not necessarily retain a copy. By signing this statement the client agrees to these recordings. Watermark Counseling LLC is not responsible for equipment failures which may prevent a recording from being made. Hypnotic recordings are not to be used while driving or operating machinery.
Ethics: Dr. Fredric Mau follows the Code of Ethics of the following organizations: American Mental Health Counselors Association, South Carolina Association of Licensed Professional Counselors, South Carolina Counseling Association, National Guild of Hypnotists, International Association of Counselors & Therapists. Any type of sexual behavior between therapist and client is unethical. It is never appropriate and will not be condoned. By signing this document the client agrees that therapeutic processes designed to address sexual problems do not constitute inappropriate, unethical, or harassment behavior. The client further agrees that non-sexual contact, such as hypnotic anchoring, is approved as part of a therapeutic process.
Informed Consent: You will be asked to sign the last page of this document. Your signature verifies you have been given this document including the HIPAA document that follows; that you have read and understand these documents, that you consent to treatment, and that you agree to stipulations herein. Further you need to be aware:
- Treatment isn’t always successful and may open unexpected emotionally sensitive areas.
- Dr. Fredric Mau is not a physician and cannot prescribe medications.
- Dr. Fredric Mau may need to consult with your physician, attorney, or other mental health professional.
- Dr. Fredric Mau is not available 24 hours a day. In case of an emergency dial 911.
- Appointments may be successfully canceled as late as 24 hours prior to the scheduled time. If this is not
done, you may be charged $50.00 for a missed appointment.
Dr. Fredric Mau is licensed through the SC Board of Examiners for The Licensure of Professional Counselors, Marriage and Family Therapists, and Psycho-educational Specialists; this Board is located in The Synergy Center (Kingstree Building) in Columbia, South Carolina at (803) 896-4652 (mailing address is P.O. Box 11329, Columbia, SC 29211-1329). The Executive Administrator for Watermark Counseling LLC is Dr. Mau. He is a confidential administrator under state and federal law. He will be your major contact for appointments, problems, complaints, and commendations.
Health Insurance Portability and Accountability Act of 1996 (HIPAA)
This notice describes how medical information about you may be used and disclosed and how you can get access to this information. Please review it carefully. This document may be updated without notice so please review it each time you visit us. A copy of this statement is always available upon request.
All information revealed by you in a counseling or therapy session and most information placed in your counseling/therapy file (all medical records or other individually identifiable health information held or disclosed in any form [electronic, paper, or oral]) is considered “protected health information” by HIPAA. As such, your protected health information cannot be distributed to anyone else without your express informed and voluntary written consent or authorization. The exceptions to this are defined immediately below. Additional information regarding your rights as a client can be found in your therapist’s/counselor’s Professional Disclosure Statement and Consent for Treatment (above).
Use or disclosure of the following protected health information does not require your consent or authorization:
- Uses and disclosures required by law – like files court-ordered by a Judge
- Uses and disclosures about victims of abuse, neglect, or domestic violence – like the Duties to
Warn explained in your therapist’s/counselor’s Disclosure Statement
- Uses and disclosures for health and oversight activities – like correcting records or correcting
records already disclosed
- Uses and disclosures for judicial and administrative proceedings – like a case where you are
claiming malpractice or breech of ethics
- Uses and disclosures for law enforcement purposes – like if you intend to harm someone else
(see Duties to Warn in your therapist’s/counselor’s Disclosure Statement)
- Uses and disclosures for research purposes – like using client information in research; always
maintaining client confidentiality
- Uses and disclosures to avert a serious threat to health or safety – like calling Probate Court for a
- Uses and disclosures for Workers’ Compensation – like the basic information obtained in
therapy/counseling as a result of your Worker’s Compensation claim
Your Rights as a Counseling/Therapy Client under HIPAA:
- As a client, you have the right to see your counseling/therapy file. Psychotherapy notes are
afforded special privacy protection under the HIPAA regulations and are excluded from this
- As a client, you have the right to receive a copy of your counseling/therapy file. This file copy
will consist of only documents generated by us. You will be charged copying fees at 20¢per
page. Psychotherapy notes are afforded special privacy protection under the HIPAA regulations
and are excluded from this right.
- As a client, you have the right to request amendments to your counseling/therapy file.
- As a client, you have the right to receive a history of all disclosures of protected health
information. You will be charged copying fees at 20¢per page.
- As a client, you have the right to restrict the use and disclosure of your protected health
information for the purposes of treatment, payment, and operations. If you choose to release
any protected health information, you will be required to sign a Release of Information form
detailing exactly to whom and what information you wish disclosed.
- As a client, you have the right to register a complaint with the Secretary of Health and Human
Services if you feel your rights, herein explained, have been violated.
Prior to your counseling or therapy, you will receive 1) an exact duplicate of these two pages and 2) your therapist’s/counselor’s Professional Disclosure Statement and Consent for Treatment – both for your personal records. It will be necessary for you to sign a certificate indicating that you have received, read, understand, and agree to both documents. This certificate will be placed in your counseling/therapy file. Please do not sign the certificate if you do not understand any part of the HIPAA Client’s Rights or the Professional Disclosure Statement and Consent for Treatment. Your counselor or therapist will be happy to explain these documents further.
Thank you – it is a pleasure to be of service to you.
Signature Certificate for Consent and Disclosure Form
I acknowledge that I have received and read the Watermark Counseling LLC Professional Disclosure Statement and Consent for Treatment and the HIPAA Client’s Rights. I further acknowledge that I seek and consent to treatment with Dr. Fredric Mau. My signature below confirms that I understand, accept, and agree to all the information and stipulations contained in the Watermark Counseling LLC Professional Disclosure Statement and Consent for Treatment and the HIPAA Client’s Rights.