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Printable version of Disclosure
Professional Disclosure Statement and Consent for Services
Michael Sullivan, MA, LPC , CAAC
INTRODUCTION
Welcome to the office of Michael Sullivan, MA, LPC, CAAC at Sullivan Counseling Services. Sullivan Counseling Services is located in Petoskey at 820 Arlington Ave., in the same building as the Free Clinic. This disclosure statement is meant to provide you with some important information about your counselor and the counseling process. Please read the entire document and sign the last page. If you have any questions please ask Michael.
COUNSELOR APPROACH AND CREDENTIALS
I began my career as a Professional Counselor in 2004 at Ferris State University. While at Ferris I was trained extensively in the process of helping clients to define their career goals and succeed in their education as well cope with the stress and strain of college life. I also helped develop the crisis intervention team at FSU to meet the growth of suicidal ideation among American college students. I opened my private practice in February of 2006 and have worked with Harbor Hall outpatient in Petoskey as well.
I treat adults, adolescents, couples, and families using a Person-Centered, Strength Based approach to counseling. I do my best to create a safe, positive, and supportive environment for your growth. At times, I use Cognitive/Behavioral therapy to help you understand thought processes and behaviors that are causing difficulty in your life. I will never tell you what you should do, but will provide feedback with many options to try. My experience includes working with survivors of incest, substance abuse, men’s issues, anger, defiant youth, stress, loss, grief, Anxiety disorders, relationship issues, and depression. I am respectful of diversity, differences of lifestyles and all spiritual practices.
My father, Dr. Paul Sullivan has been serving the community for over thirty years as a clinical psychologist and my mother, Elizabeth Sullivan MSW, worked for Woodland Counseling Center in Petoskey. My introduction to mental health started at age four when my father opened a residential treatment facility for mentally impaired adults in Brimley Michigan.
My license (lic. #6401009216) allows me to practice professional counseling in the state of Michigan.
COUNSELING PROCESS
Most individuals who participate in Counseling find their experience to be rewarding and beneficial. Those who participate in Career and Educational Counseling usually demonstrate an improved ability to define their education and career goals as well as showing enhanced learning capabilities that serve them throughout life. For counseling to be the most effective, however, client participation is necessary.
We will explore your current situation in the initial session(s) to define your counseling goals. Then, I will present you with a plan to work towards those goals as we determine the strengths you already have, what obstacles you might encounter along the way, and how we will know when we have reached your goals. Sometimes these goals will be best facilitated by assessments that I may suggest as part of that process. I am confident that you will reach your desired healing and growth if you are willing to work for it. As a result, change can occur which may present new challenges. After reaching a goal we may decide to set more goals or we may choose to terminate.
TERMINATION
I have an open door policy and you are always free to leave counseling whenever you wish. However, a termination session is a very important part of the process. My hope is that when you have completed your goals you will have a strong feeling of accomplishment. If you wish to end counseling, please discuss this with me so we can maximize the time we have spent together and I can suggest alternative ways for you to continue your growth such as books, workshops, support groups, or referrals to other professionals. If you decide that you would like to see another counselor, I would be happy to make a referral.
COUNSELING APPOINTMENTS
Please come to 820 Arlington (suite #2) for your session unless otherwise advised. A session typically lasts fifty minutes. The fee for the initial session is $100.00 and following sessions are $85.00. Full payment is due upon completion of the session unless other arrangements have been made. If this fee is unaffordable other arrangements are sometimes available, please consult with Michael prior to setting up your first appointment. Please pay Michael directly and a receipt will be provided.
Assessments are not included in session fees. Prices for assessments vary, please ask Michael for current prices.
If you cannot make a scheduled appointment, please call as soon as you can. If an appointment is not canceled/rescheduled prior to 24 hours before the agreed meeting time, a $25 rescheduling fee will be charged. If an appointment is missed without notifying Sullivan Counseling services via the telephone, full charge for the missed session will be charges. Sullivan Counseling Services may choose to waive these charges in case of dire and legitimate emergencies.
LIMITS OF CONFIDENTIALITY
As a professional counselor, I am ethically bound to provide you with confidentiality. That means that I will keep what you say between us, except when the law requires me to do otherwise (see below) or if you wish me to share your information with another. If you would like me to share your information with a third party, I must first obtain your written permission.
The limits to confidentiality are as follows:
1) Child or Dependent adult Abuse- If I have reasonable cause to suspect child or dependent adult abuse or neglect, I must report this suspicion to the appropriate authorities as required by law.
2) Danger to self or other- If I have reasonable cause to suspect that you are in imminent danger of causing serious harm to yourself or another person, I am obligated by law to take action to protect you and/or inform the other person(s) and relevant authorities.
3) Court order- If I am ordered by a court subpoena I am required by law to release your records
4) Adult and Domestic Abuse- If I have reasonable cause to suspect you have been criminally abused, I must report this suspicion to the appropriate authorities as required by law.
5) Your information may be revealed if I have to pursuit payment through legal means.
6) In an emergency, if I need to act upon your behalf I will need to contact the emergency contact person you designate below
Emergency contact person:
Name: ____________________________________________
Phone number: _____________________________________
Relationship: _______________________________________
INFORMED CONSENT
If you have any questions about this disclosure statement and Consent for services please ask Michael Sullivan, MA, LPC before signing. If you would like a copy for yourself, one can be provided for you.
I, _________________________________________, have read and understand the information outlined above. I understand that I will have an opportunity to discuss any questions I may have regarding these services during my sessions. I have been informed of HIPPA regulations regarding my health care, the limits of confidentiality, Sullivan Counseling Services’ fees and terms and I consent to receive counseling services from Michael Sullivan, MA, LPC and agree to pay all fees incurred.
________________________________________________________________
Signature Date
Parent signature _________________________________________________
(Required only if client is 17 years of age or younger)
COMPLAINTS
If you wish to register a complaint regarding this counselor, you may contact the Department of Community health, Complaint and Allegation Division, PO Box 30670, Lansing, MI 48909. Phone number (517) 373-9196.