PROFESSIONAL DISCLOSURE STATEMENT

Michelle Rowan, LPC, LCMHC, LMHC, CCTP
Office: (910) 477-8012 / Fax: (910) 569-2196
Email: michellerowan@moontidespllc.com

Qualifications and Background

I am a Licensed Professional Counselor (LPC) in Texas (License #80836), a Licensed Clinical Mental Health Counselor (LCMHC) in North Carolina (License #19503), a Licensed Professional Counselor (LPC) in South Carolina (License #10969), and a Licensed Mental Health Counselor (LMHC) in Washington state (License MHC.LH.70107240). These credentials reflect my status as a fully licensed clinician, which means I practice independently without active supervision, though I regularly consult with colleagues to ensure the highest quality of care. I reside in North Carolina and provide telehealth services. I earned my Master of Arts in Clinical Mental Health Counseling in 2017 from Ashland Theological Seminary and have been practicing in the counseling field since 2016.

My professional experience includes supporting individuals of all ages, families, couples, and groups within various settings, such as non-profit agencies, domestic violence shelters, schools, and group and solo private practice. My clinical focus is on trauma survivors and working with diverse populations. Areas of special training include certification in the Safe and Sound Protocol (SSP), and training in Eye Movement Desensitization and Reprocessing (EMDR). My approach is holistic and empowering, drawing from trauma-informed perspectives. In sessions I draw from an individualized blend of EMDR, SSP, trauma-informed yoga, somatic practices, Polyvagal theory, ACT, expressive arts, and sand tray therapy.

Client Rights

1. You are entitled to receive information about your diagnosis, your provider's methods of therapy, techniques used, expected duration of therapy, and the cost of treatment.

2. You can seek a second opinion from another licensed professional, refuse recommended treatment, withdraw consent for treatment or terminate therapy at any time.

3. You are entitled to an explanation of the risks and benefits of treatment and the potential consequences of any decision you may make to decline or stop treatment.

4. Sexual intimacy is not appropriate in the context of a professional relationship and, if it occurs, must be reported to applicable entities/state regulators.

Appointment Cancellations

Regular attendance at scheduled appointments is essential for effective counseling. If you need to cancel an appointment, you must do so at least 48 hours (2 business days) in advance to avoid a cancellation fee. Please note that Saturdays, Sundays, and national holidays are not considered business days, and cancellations made on these days will be considered received on the next business day. Cancellation fees vary depending on the service type. This policy applies in all circumstances unless prohibited by law, considered an emergency, or unless our agreement with your insurance requires different terms.

Relevant Fees and Policies

Moon Tides PLLC maintains the following fee schedule. If your treatment is covered by insurance, the fee schedule may not reflect the amount you are responsible for, as this is determined by your insurer’s agreement.

• A clinical hour is approximately 50-60 minutes.

• Payment is due at the time of service and will be processed via the payment method on file, which you have authorized in your intake paperwork.

• All payments will be processed electronically using secure payment authorization methods, as part of ongoing health and safety precautions.

• If your intake paperwork is not completed and signed 24 hours prior to your appointment, your appointment may be canceled.

• Please note that I am unable to bill insurance companies for missed appointments or late cancellations, and such fees will be charged to the credit card on file.

Fees for Professional Services:

• $175 for an intake session of 50-60 minutes

• $150 per session, defined as 50-60 minutes, for individual, family, or couples counseling session

• $125 per session, less than 50-60 minutes

• $75 missed appointment/late cancellation fee (48-hour notice required for cancellations); if you have not arrived for your scheduled appointment within 15 minutes past the start time, your therapist will make an attempt to contact you 1 (one) time via a contact method on file.

• EMDR Intensives: approximately $1200 for each 8 hour block, $600 for each 4 hour block, $450 for each 3 hour block, $225 for each 90 minute block

• $150 missed appointment/late cancellation fee for EMDR Intensives (48-hour notice required for cancellations); if you have not arrived for your scheduled appointment within 15 minutes past the start time, your therapist will make an attempt to contact you 1 (one) time via a contact method on file.

For clients without insurance or in financial hardship, sliding scale may be available based on income and eligibility criteria. You may submit a request for sliding scale consideration through Open Path, which offers rates between $40-$70 per session for individual clients. Open Path requires a one-time membership fee of $65, which provides lifetime membership. If you are approved through Open Path, you and the therapist will discuss and agree upon a rate within the Open Path range.

Late Cancellation/No Show Fees:

• Individual Therapy Appointment: $75

• EMDR Intensive: $150

• Group Therapy: $75

Fees for Medical/ Treatment Related Records Requests:

• Medical Records (Electronic Format): $25 for 500 pages or less; $40 for more than 500 pages

• Medical Records (Paper Format): $25 for the first 25 pages; $0.50 per page for additional pages (plus postage of $15)

• Affidavit/Notary Fee: $15

• Treatment Summaries/Letters: $150

• FMLA/Leave/Disability Forms: $150 for forms up to 2 pages; $50 per additional page

Court Related Services and Fees

• Subpoena/Court Appearance Retainer Fee: $1,500 (non-refundable if appearance is canceled or rescheduled within 48 business hours)

• PLEASE NOTE THAT IF COURT APPEARANCES OCCUR OUT OF STATE FOR YOUR PROVIDER, ADDITIONAL FEES WILL APPLY FOR COST OF TRAVEL AND ANY OTHER RELATED EXPENSES

• Late Rescheduling Fees: $250 if the case is rescheduled with less than 48 business hours notice (in addition to the retainer of $1,500)

• Late Notice Fee: $250 if a subpoena or court order for appearance is received without a minimum of 48 business hours notice.

• Daily Fee for appearances after initial retainer: $1,500 per day - Should a case be delayed, the therapist will be paid in full for each day as well as an additional $1,500 fee per day as it hinders the provider’s ability to be available to their other clients.

• Any additional time spent for court related services be billed at the hourly rate for any related services: $150 per hour for preparation time, $150 per hour for consultations of all types, $150 per hour for all related travel time, $150 per hour for all court related time away from the office for testimony or deposition.

All court fee payments must be submitted via cash or cashier’s check and initial retainer fees and invoice balances must be paid 7 days prior to the scheduled court date. Should the court calendar the hearing for another date, the therapist must be re-issued a court order, if applicable, with the new court hearing date. Should the therapist be on vacation, the party initiating the court order must take reasonable steps to avoid imposing undue burden or expense on a person subject to the subpoena. Please be advised that should a therapist be requested to write a Treatment Summary or any other treatment related letter or document, the cost for producing the requested document/letter is at the discretion of the practice and varies depending on document type and complexity: fees range from $100-$250.

OTHER FEES:

• $35 fee for returned/unpaid checks.

*Moon Tides PLLC may update these charges from time to time in its sole discretion

Professional Relationship

To maintain a healthy, professional, and therapeutic relationship, Moon Tides providers do not engage in social or personal interactions with clients outside of the counseling setting. This includes both in-person encounters and virtual interactions, such as those on social media platforms. If your provider sees you in public, they will not initiate contact out of respect for your privacy. You are welcome to approach your provider if you choose, but you are under no obligation to do so. Providers will not add or follow clients on any form of social media. These boundaries are in place to protect your confidentiality and preserve the integrity of the therapeutic relationship.

A mutually respectful and collaborative dynamic is essential to effective therapy. At times, the therapeutic process can bring up discomfort, misunderstandings, and/or possible ruptures. If you ever have concerns about your provider's behavior or approach, we encourage you to discuss them directly with your provider so they can be addressed openly in an attempt to work towards repair and resolution. Likewise, Moon Tides maintains a zero-tolerance policy for behavior that is disrespectful, threatening, or violent. If a client's behavior raises concern, staff will address it and remind them of our behavioral standards. Continued or serious violations may result in the transfer or termination of services, in accordance with legal and ethical guidelines.

Privacy, Confidentiality and Records

Moon Tides PLLC and its providers are committed to protecting your privacy and maintaining the confidentiality of your protected health information (PHI) in accordance with HIPAA and state laws. Your provider may not disclose any information about your PHI/treatment without your written authorization, except in certain situations as required or permitted by law. These exceptions include, but are not limited to:

• You provide written authorization through a Release of Information

• Your provider determines that you present a serious and imminent threat to your own safety or the safety of others

• A court or administrative agency issues a subpoena or order requiring disclosure of records

• There is a reasonable suspicion of abuse, neglect, or exploitation of a child, elder, or dependent adult

• Your involvement in a legal case where the court mandates an assessment or treatment as part of the proceedings

• You are determined to be gravely disabled due to a mental health condition and unable to care for yourself

In some cases, limited information may also be shared with other healthcare providers or agencies involved in your care for treatment coordination purposes, as permitted under HIPAA’s “Treatment, Payment, and Healthcare Operations” provisions.

All records related to your treatment—including session notes, communications, and administrative documentation—are retained securely during and after treatment for the duration required by law. For clients receiving couples counseling, a single joint record will be maintained under the name of the financially responsible party. If that individual is also receiving individual counseling services, separate records will be maintained, and the partner will only have access to information from shared sessions.

Use of Diagnosis

As a licensed professional counselor, I am trained to assess and diagnose mental health conditions using the criteria established in the DSM-5-TR. The use of diagnosis helps guide treatment planning, supports collaboration with other healthcare providers, and may be required by insurance companies for reimbursement. I strive to use diagnostic tools responsibly and respectfully, in partnership with you, and always with the goal of supporting your well-being and personal growth.

Emergency Services

Moon Tides PLLC and its providers do not provide emergency or crisis intervention services. If you or a loved one are in a life threatening situation, call 911 or go to the nearest emergency room. You are responsible for any costs associated with emergency care. For mental health crises that are not life- threatening, the following resources are available:

• National Suicide & Crisis Lifeline: Call or text 988

• National Crisis Text Line: Text HOME to 741741

• North Carolina HopeLine: Call 919-231-4525 or 877-235-4525 / Text 877-235-4525

• Texas Crisis Support: Call or text 2-1-1

• South Carolina Statewide Crisis Response: Call 833-364-2274 or text HOPE4SC to 741741

• Washington Recovery Help Line: Call 1-866-789-1511 or 211, for Teen Link call 1-866-833-6546

Complaints

Clients are encouraged to discuss any concerns with their provider directly. Should you feel your provider is in violation of their code of ethics and you were unable to resolve your concerns together, you may file a complaint with the appropriate licensing boards below. Licensed counselors abide by the ACA Code of Ethics (http://www.counseling.org/Resources/aca-code-of-ethics.pdf).

Texas Behavioral Health Executive Council
1801 Congress Ave., Ste. 7.300 | Austin, Texas 78701
Phone: (512) 305-7700
Investigations/Complaints 24-hour, toll-free system: (800) 821-3205

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

South Carolina Department of Labor, Licensing and Regulation
110 Centerview Dr. | Columbia, South Carolina 29210
SC Board: (803) 896-4658 / SC LLR: (803) 896-4300
File a complaint online: https://llr.sc.gov/fileacomplaint.aspx

Washington State Department of Health
Health Systems Quality Assurance
P.O. 47857 | Olympia, WA 98504-7857

Phone: 1-800-525-0127

E-mail: hsqacomplaintintake@doh.wa.gov

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.

Moon Tides PLLC (the “Practice”) is committed to protecting your privacy. The Practice is required by federal law to maintain the privacy of Protected Health Information (“PHI”), which is information that identifies or could be used to identify you. The Practice is required to provide you with this Notice of Privacy Practices (this “Notice”), which explains the Practice's legal duties and privacy practices and your rights regarding PHI that we collect and maintain.


YOUR RIGHTS
When it comes to your health information, you have certain rights. This section explains your rights and some of our responsibilities to help you. To exercise these rights, please submit a written request to the Practice securely via messaging on your client portal, via email at michellerowan@moontidespllc.com, or fax at (910) 569-2196.

To inspect and copy medical records/PHI.
• You can ask for an electronic or paper copy of your medical records.
• The Practice may deny your request if it believes the disclosure will endanger your life or another person's life. You may have a right to have this decision reviewed.

• We will provide a copy or a summary of your health information, usually within 30 days of your request. We may charge a reasonable, cost-based fee.

To amend your medical records/PHI.
• You can ask to correct your medical records you believe are incorrect or incomplete. The Practice may require you to make your request in writing and provide a reason for the request.
• The Practice may deny your request. The Practice will send a written explanation for the denial and allow you to submit a written statement of disagreement. Our written explanation for denial will be sent within 60 days.

To request confidential communications.
• You can ask the Practice to contact you in a specific way.

• We will say “yes” to all reasonable requests.

To request us to limit what is used or shared.
• You can ask us not to use or share certain health information for treatment, payment, or our operations. We are not required to agree to your request, and we may say “no,” for example, if it could affect your care. If we agree to your request, we may still share this information in the event that you need emergency treatment.
• If you pay for a service or health care item out-of-pocket in full, you can ask the Practice not to share PHI with your health insurer.
• You can ask for the Practice not to share your PHI with family members or friends by stating the specific restriction requested and to whom you want the restriction to apply.

To obtain a list of those with whom your PHI has been shared.
• You can ask for a list (accounting) of the times we’ve shared your health information for six years prior to the date you ask, who we shared it with, and why.

• We will include all the disclosures except for those about treatment, payment, and health care operations, and certain other disclosures (such as any you asked us to make). We’ll provide one accounting a year for free but will charge a reasonable, cost-based fee if you ask for another one within 12 months.

To receive a copy of this privacy notice.
• You can ask for a paper copy of this notice at any time, even if you have agreed to receive the notice electronically. We will provide you with a paper copy promptly.

To choose someone to act for you.
• If someone has authority to act as your personal representative, such as if someone has your medical power of attorney or if someone is your legal guardian, that person can exercise your rights and make choices about your health information.

•We will make sure the person has this authority and can act for you before we take any action.

To file a complaint if you feel your rights are violated:
• You can file a complaint by contacting the Practice using the following information:
Moon Tides PLLC
Michelle Rowan, LPC, LCMHC
(910) 477-8012

michellerowan@moontidespllc.com

• You can file a complaint with the U.S. Department of Health and Human Services Office for Civil Rights by sending a letter to 200 Independence Avenue, S.W., Washington, D.C. 20201, calling 1-877-696-6775, or visiting https://www.hhs.gov/hipaa/filing-a-complaint/index.html.

• The Practice will not retaliate against you for filing a complaint.

YOUR CHOICES

You have some choices in the way that we use and share information as we:

• Tell family and friends about your condition

• Provide disaster relief

• Include you in a hospital directory

• Provide mental health care

• Market our services and sell your information

• Raise funds

For certain health information, you can tell us your choices about what we share.

If you have a clear preference for how we share your information in the situations described below, talk to us. Tell us what you want us to do, and we will follow your instructions.

In these cases, you have both the right and choice to tell us to:

• Share information with your family, close friends, or others involved in your care or payment for your care

• Share information in a disaster relief situation

• Include your information in a hospital directory

If you are not able to tell us your preference, for example if you are unconscious, we may share your information if we believe it is in your best interest. We may also share your information when needed to lessen a serious and imminent threat to health or safety.

In these cases we never share your information unless you give us written permission:

• Marketing purposes

• Sale of your information

• Most sharing of psychotherapy notes

In the case of fundraising:

• We may contact you for fundraising efforts, but you can tell us not to contact you again.

If we have your substance use disorder patient records, subject to 42 CFR part 2, we will give you clear and obvious notice in advance and a choice about whether to receive fundraising communications that use your Part 2 information.

OUR USES AND DISCLOSURES

We may use and share your information as we:

• Treat you

• Run our organization

• Bill for your services

• Help with public health and safety issues

• Do research

• Comply with the law

• Respond to organ and tissue donation requests

• Work with a medical examiner or funeral director

• Address workers’ compensation, law enforcement, and other government requests

• Respond to lawsuits and legal actions

To the extent that we have your substance use disorder patient records, subject to 42 CFR part 2, we will not share that information for investigations or legal proceedings against you without (1) your written consent or (2) a court order and a subpoena.

Records Subject to Additional Federal Protections

We may receive records from other providers that are protected by a federal law called 42 CFR Part 2, which applies to certain substance use disorder treatment records. When we receive such records, their use and disclosure may be subject to stricter federal requirements than those that apply to other health information under HIPAA.

Limits on Use and Disclosure

Unlike other protected health information, records subject to 42 CFR Part 2 generally may not be used or disclosed for treatment, payment, or health care operations without the individual’s written consent, except as permitted by law.

Restrictions on Legal Use

Records protected by 42 CFR Part 2, and any testimony relaying the content of such records, may not be used or disclosed in civil, criminal, administrative, or legislative proceedings against the individual without written consent or a court order that meets federal requirements.

Redisclosure

Information disclosed to us that is subject to 42 CFR Part 2 may carry restrictions on further use or disclosure. We will comply with those restrictions as required by law.

How do we typically use or share your health information?

We typically use or share your health information in the following ways.

Treat you

• We can use your health information and share it with other professionals who are treating you.

• Example: A doctor treating you for an injury asks another doctor about your overall health condition.

Run our organization

• We can use and share your health information to run our practice, improve your care, and contact you when necessary.

• Example: We use health information about you to manage your treatment and services.

Bill for your services

• We can use and share your health information to bill and get payment from health plans or other entities.

• Example: We give information about you to your health insurance plan so it will pay for your services.

How else can we use or share your health information?

We are allowed or required to share your information in other ways – usually in ways that contribute to the public good, such as public health and research. We have to meet many conditions in the law before we can share your information for these purposes.

In all cases, including those listed below, if we have substance use disorder patient records about you, subject to 42 CFR part 2, we cannot use or share information in those records in civil, criminal, administrative, or legislative investigations or proceedings against you without (1) your consent or (2) a court order and a subpoena.

Help with public health and safety issues

We can share health information about you for certain situations such as:

• Preventing disease

• Helping with product recalls

• Reporting adverse reactions to medications

• Reporting suspected abuse, neglect, or domestic violence

• Preventing or reducing a serious threat to anyone’s health or safety

Do research

We can use or share your information for health research.

Comply with the law

We will share information about you if state or federal laws require it, including with the Department of Health and Human Services if it wants to see that we’re complying with federal privacy law.

Respond to organ and tissue donation requests

We can share health information about you with organ procurement organizations.

Work with a medical examiner or funeral director

We can share health information with a coroner, medical examiner, or funeral director when an individual dies.

Address workers’ compensation, law enforcement, and other government requests

We can use or share health information about you:

• For workers’ compensation claims

• For law enforcement purposes or with a law enforcement official

• With health oversight agencies for activities authorized by law

• For special government functions such as military, national security, and presidential protective services

Respond to lawsuits and legal actions

We can share health information about you in response to a court or administrative order, or in response to a subpoena.

Uses and Disclosures of PHI That May Be Made With Your Authorization or Opportunity to Object
Unless you object, the Practice may disclose PHI
• To your family, friends, or others if PHI directly relates to that person's involvement in your care.
• If it is in your best interest because you are unable to state your preference.

Uses and Disclosures of PHI Based Upon Your Written Authorization
The Practice must obtain your written authorization to use and/or disclose PHI for the following purposes:
• Marketing, sale of PHI, and psychotherapy notes.

You may revoke your authorization, at any time, by contacting the Practice in writing, using the information above. The Practice will not use or share PHI other than as described in this privacy notice unless you give your permission in writing.

OUR RESPONSIBILITIES
• The Practice is required by law to maintain the privacy and security of PHI.

• The Practice will inform you promptly if a breach occurs that may have compromised the privacy or security of your information.
• The Practice must follow the duties and privacy practices described in this notice and give you a copy of it. Where more stringent state or federal law governs PHI, the Practice will abide by the more stringent law.

• The Practice will not use or share your information other than as described in this notice unless you tell us we can in writing. If you tell us we can, you may change your mind at any time. Let us know in writing if you change your mind.

• The Practice will never market or sell personal information.

• The Practice will never share any substance abuse treatment records without your written permission

For more information see: www.hhs.gov/ocr/privacy/hipaa/understanding/consumers/noticepp.html.

Changes to the Terms of this Notice

We can change the terms of this notice, and the changes will apply to all information we have about you. The new notice will be available upon request, in our office, and on our website.

Other Instructions

Because Moon Tides PLLC utilizes an online client portal, you can request access and obtain access to records via the portal. If you have any questions on how to obtain access to records please reach out via email at michellerowan@moontidespllc.com or via secure messaging in your client portal.

The original copy of this notice was effective on 4/01/24. Updated notice is effective on 2/24/26.

TELEHEALTH SERVICES

***PLEASE NOTE THAT MOON TIDES PLLC IS LOCATED IN NC AND CAN ONLY OFFER TELEHEALTH TO OUT OF STATE CLIENTS***

To use telehealth, you need an internet connection and a device with a camera for video. Your Provider can explain how to log in and use any features on the telehealth platform. If telehealth is not a good fit for you, your Provider will recommend a different option or refer out when necessary. There are some risks and benefits to using telehealth:

Risks of Telehealth
• Privacy and Confidentiality. You may be asked to share personal information with the telehealth platform to create an account, such as your name, date of birth, location, and contact information. Your Provider carefully vets any telehealth platform to ensure your information is secured to the appropriate standards.
• Technology. At times, you could have problems with your internet, video, or sound. If you have issues during a session, your Provider will follow the backup plan that you agree to prior to sessions.
• Crisis Management. It may be difficult for your Provider to provide immediate support during an emergency or crisis. You and your Provider will develop a plan for emergencies or crises, such as choosing a local emergency contact, creating a communication plan, and making a list of local support, emergency, and crisis services.

Benefits of Telehealth
• Flexibility. You can attend therapy wherever is convenient for you.
• Ease of Access. You can attend telehealth sessions without worrying about traveling, meaning you can schedule less time per session and can attend therapy during inclement weather or illness.
• Recommendations
• Make sure that other people cannot hear your conversation or see your screen during sessions.
• Do not use video or audio to record your session unless you ask your Provider for their permission in advance.
• Make sure to let your Provider know if you are not in your usual location before starting any telehealth session.

Acknowledgements and Rights for Clients

• Telehealth-based services and care may not be as complete as face-to-face services for certain needs and circumstances.

• There are potential risks to this technology, including interruptions, unauthorized access and technical difficulties and that I may not hold Moon Tides or my provider liable for technology failures.

• The provider or the client may unilaterally choose to discontinue the telehealth encounter if it is determined the technology is not appropriate under the circumstances.

• Clients have the right to withhold or withdraw consent to the use of telehealth and/or telehealth services in the course of their care at any time, without affecting their right to be referred for future care or treatment from a qualified provider who provides in-person care.

• A variety of alternative methods of health care may be available to clients from other healthcare providers, such as an in-person encounter in lieu of a telehealth encounter, and that clients may choose one or more of those options at any time from a provider who may, or may not, be affiliated with Moon Tides.

• Telehealth may involve electronic communication of my personal healthcare information to other healthcare practitioners who may be located in other areas, including out-of-state or internationally, when appropriate, for providing me with care that is requested.

• All existing confidentiality protections apply to telehealth encounters, and clients have the right to access all healthcare information related to telehealth encounters and to receive copies of such information at cost upon request.

• Clients have the right to any healthcare records created as a result of a telehealth encounter and all records will be maintained in a manner that is in compliance with state and federal patient privacy laws.

• Telehealth encounters will not be recorded without express written consent.

• When using technology to facilitate healthcare delivery, there may be cultural or language differences that may affect the delivery of services and there may be time zone differences.

• There is the possibility of the denial of insurance benefits for telehealth encounters.

• Clients will be provided with information regarding provider(s)' training credentials, license number(s), physical location and contact information.

• It is the client’s responsibility to notify the healthcare provider if others are present at my location during the time of the appointment and the client Is responsible for their own privacy at their own location. The provider may ask questions to ensure the privacy of appointments to protect clients and their PHI.

• It is the client’s duty to inform the healthcare provider of electronic or in-person interactions regarding their care that they may have with other healthcare providers.

• Clients may expect the anticipated benefits from the use of telehealth services in their care, but no results can be guaranteed or assured.

• Clients will have the opportunity to ask the healthcare provider any questions they may have regarding this consent before proceeding with a telehealth encounter.

Eye Movement Desensitization and Reprocessing (EMDR) is a treatment technique that facilitates the reprocessing of impactful/traumatic memories through the use of bilateral stimulation (BLS) ─ tapping, auditory tones or eye movements. Scientific research has established EMDR as effective for the treatment of post-traumatic stress, phobias, panic attacks, anxiety disorders, stress, sexual and physical abuse, disturbing memories, complicated grief, and addictions.

However, you should be aware of these considerations:
• EMDR is not appropriate for those who are actively experiencing suicidal ideation or homicidal ideation
• Distressing, unresolved memories may surface during the phases of EMDR, including the possibility of repressed memories coming up
• Some clients can experience reactions during EMDR that neither they nor the clinician may have anticipated, including a high level of emotional or physical sensations
• Subsequent to the EMDR session, the processing of incidents or material may continue. Other dreams, memories, flashbacks or feelings can also surface between sessions.
• If you are involved in any legal action, the “relief” obtained through the EMDR procedures may reduce your ability to recall the details of your trauma, which may be necessary to
testify clearly or convincingly
• EMDR intensives can be beneficial, but some people may experience increased side effects listed above. It is best to stay in contact with your EMDR therapist about any of these
side effects that become too distressing for you to handle on your own.

Your acknowledgment and understanding:
• Your clinician will explain to you the reasons why the use of EMDR
therapy is recommended for you or for your child.
• There are other options available to you or your child should you decide not to use EMDR therapy.
• Your therapist will provide you with an explanation of the nature of EMDR
and your questions about EMDR will be answered to your satisfaction.
• You may discontinue EMDR at any time.
• EMDR/EMDR Intensives are completely optional

**Just because EMDR is discussed or recommended does not mean you will start the processing phase right away. EMDR is an 8 phase process and each person will need to be assessed for appropriateness and readiness. EMDR is not a guarantee just because it is offered as a modality by this practice

Records Requests

If you would like to access your health records, please reach out to the practice either by email at michellerowan@moontidespllc.com, by phone at (910) 477-8012, or by fax (910) 569-2196.

Fees for records requests are as follows:

-Medical Records (Electronic Format): $25 for 500 pages or less; $40 for more than 500 pages

-Medical Records (Paper Format): $25 for the first 25 pages; $0.50 per page for additional pages (plus postage of $15)

*Please be advised that a release of information may be required. You will be notified if this applies in your particular situation.

Complaints and Concerns

Clients are encouraged to discuss any concerns with their provider directly. Should you feel your provider is in violation of their code of ethics and you were unable to resolve your concerns together, you may file a complaint with the appropriate licensing boards below. Licensed counselors abide by the ACA Code of Ethics (http://www.counseling.org/Resources/aca-code-of-ethics.pdf).

Texas Behavioral Health Executive Council
1801 Congress Ave., Ste. 7.300 | Austin, Texas 78701
(512) 305-7700 or (800) 821-3205
Website for more information on filing complaints: https://bhec.texas.gov/complaints-enforcement-faqs/
To file a consumer complaint via the Attorney General website: https://www.texasattorneygeneral.gov/consumer-protection/file-consumer-complaint

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

South Carolina Department of Labor, Licensing and Regulation 110 Centerview Dr. | Columbia, South Carolina 29210
SC Board: (803) 896-4658 / SC LLR: (803) 896-4300
File a complaint online: https://llr.sc.gov/fileacomplaint.aspx

Washington State Department of Health
Health Systems Quality Assurance
P.O. 47857 | Olympia, WA 98504-7857

Phone: 1-800-525-0127

E-mail: hsqacomplaintintake@doh.wa.gov

Under the No Surprises Act (H.R. 133 – effective January 1, 2022), health care providers need to give clients or patients who do not have insurance or who are not using insurance an estimate of the bill for medical items and services.

• A Good Faith Estimate (GFE) shows the costs of items and services you can reasonably expect for your health care needs.

• You have the right to receive a GFE for the total expected cost of any non-emergency items or services.

• The GFE does not include any unknown or unexpected costs that may arise during treatment. You may experience additional charges if complications or exceptional circumstances occur.

• If you receive a bill at least $400 more than your GFE, you may dispute or appeal the bill.

• You may contact us to let us know that billed charges are higher than the GFE. We will work with you to update the bill to match the GFE, negotiate the bill, or discuss how financial assistance may be available. 

• You may also start a dispute resolution process with the U.S. Department of Health and Human Services (HHS). If you choose to use the dispute resolution process, you must start the dispute process within 120 calendar days (about four months) of the date on the original bill. There is a $25 fee to use the dispute process. If the agency reviewing your dispute agrees with you, you will have to pay the price on this GFE. If the agency disagrees with you and agrees with the health care provider or facility, you will have to pay the higher amount.

Note: A Good Faith Estimate is for your awareness only and does not require immediate financial commitment or payment.

To learn more, go to www.cms.gov/nosurprises or call 800-985-3059. For questions or more information about your right to a Good Faith Estimate or the dispute process, visit www.cms.gov/nosurprises or call 800-985-3059. Keep a copy of this Good Faith Estimate in a safe place or take pictures of it. You may need it if you receive a bill in a higher amount.