Education, training, and experience

My highest degree is an M.A. in Clinical Psychology from Roosevelt University in Chicago, Illinois. I completed my B.A. in Psychology at Mundelein College in Chicago, Illinois. I have been licensed as a Mental Health Counselor by the state of Florida in 1997.

I have been working with adults, children and families in various capacities since 1993. I have worked as a therapist for non-profit agencies and in private practice. I have worked in residential and school settings with children and adolescents. I have also supervised other therapists in school settings. I believe that my diversity of experiences has provided me with a range of skills and an ability to flexibly approach each client's unique circumstances.

Methods of counseling

My counseling approach is based on the belief that we have the right answers for ourselves but at times cannot see all our options without assistance. I attempt to provide a supportive, non-judgmental environment in which my clients feel comfortable sharing and exploring their feelings and choices. My goal is to help my clients develop long term skills for coping and thriving.

Confidentiality

Confidentiality and privileged communications is regulated by Florida Statue 491.0147.  Per this statute, “any communication between any person licensed as a mental health counselor and her or his patient or client shall be confidential. This secrecy may be waived under the following conditions:

1. When the person licensed or certified under this chapter is a party defendant to a civil, criminal, or disciplinary action arising from a complaint filed by the patient or client, in which case the waiver shall be limited to that action.

2. When the patient or client agrees to the waiver, in writing, or, when more than one person in a family is receiving therapy, when each family member (my emphasis) agrees to the waiver, in writing.

3. When there is a clear and immediate probability of physical harm to the patient or client, to other individuals, or to society and the person licensed or certified under this chapter communicates the information only to the potential victim, appropriate family member, or law enforcement or other appropriate authorities. ”

In addition, information such as your diagnosis and dates of services are shared with your managed care company to collect payment.

I have read and understand the terms of confidentiality.

____________________________________________   ____________________

Signature                                                                   Date

Contacting you

Maintaining your privacy is of utmost importance to me. Please list the telephone numbers where you can be reached and whether it is acceptable to leave a message for you if you are unavailable.

Number: __________________________ Leave a message (Yes/No)____________
 

Number: __________________________ Leave a message (Yes/No)____________
 

Number: __________________________ Leave a message (Yes/No)____________

Emergency situations

If you need to contact me outside our appointment time, I may be reached at (386) 503-9674, which is my cell phone number. If I am unavailable when you call, please leave a message on my voice mail.

In the event of an emergency, please take one of the following courses of action:

• Call 911

• Go immediately to the nearest emergency room (Florida Hospital, 60 Memorial Medical Parkway, Palm Coast)

• Contact Act Corporation Pinegrove Crisis Center 1150 Red John Road, Daytona Beach (1-800 -539-4228)

I have read and understand the emergency policy.

____________________________________________   ____________________

Signature                                                              Date

Financial policy

Please understand that payment of your bill is considered a part of your treatment. The following is a statement of my Financial Policy which I require you read and sign prior to any treatment.

1. Full payment is expected at the time of service. I accept cash, checks, Visa, MasterCard, and debit cards. If you are on a managed care plan co-payments (if any) are due at the time of service.

2. All accounts over 90 days are charged interest at the legal rate of 1.5% per month on the unpaid balance with a minimum charge of $.50 regardless of whether insurance is pending or not.

3. All returned checks are subject to a fee of $20.00.

4. You will be billed for 50% of the session fee for all missed sessions not canceled 24 hours in advance of your appointment

Regarding insurance

I am able to provide you with a receipt appropriate for submission to your insurance carrier for each visit/service. The balance is your responsibility whether your insurance company pays or not. Your insurance policy is a contract between you and your insurance company. I am not a party to that contract. I do not guarantee payment from your insurance company. If your insurance company has not paid your account in full within 90 days, the balance will be automatically due and payable by you. Please be aware that some, and perhaps all of the services provided may be non-covered services or may not be considered to be reasonable and/or necessary under your medical insurance program. I do not bill third parties.

Regarding missed sessions

I believe that it is important for clients to attend all sessions scheduled for them, except, of course, in an emergency. Missed or canceled sessions are counterproductive and increase the time it takes to bring about the changes which you entered counseling to make. My policy, therefore, is to bill you 50% of the session fee for all missed sessions not canceled 24 hours in advance of your appointment. I will try to reschedule these sessions for you during the same week. If you miss a session without notice, I will bill you directly.

Insurance and managed care companies rarely, if ever, pay for sessions that you miss and it would be fraudulent for me to submit a claim for these.

Please sign the following statement to indicate that you have read and understood this financial policy:

I have read and understood your policy concerning missed sessions. I understand that I will be billed for all avoidable missed sessions and late cancellations for which I have not given 24 hours notice. I agree to pay for these sessions.

_________________________________    _________________

Signature                                             Date

If you should have questions or concerns, please do not hesitate to bring them up. My goal is to have counseling be a positive, productive part of my clients' lives. I will give my utmost effort to help accomplish this goal.

I have read this disclosure statement and understand its content. I also acknowledge receiving a copy of this statement. I have been provided with a fee agreement stating the agreed cost of counseling sessions and policies regarding payments.

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Signature                                                   Date

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Client name (Please print)

Mailing address:

____________________________________________________________________

____________________________________________________________________

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Counselor's signature                                  Date

Consent for treatment of minors

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I/We consent that _________________________________________ be treated as a client by Pamela E. Derr, LMHC.

___________________________________    __________________

Parent/Guardian signature                           Date

___________________________________    __________________

Parent/Guardian signature                            Date

____________________________________   ____________________________________    Parent/Guardian name (printed)                     Parent/Guardian name (printed)