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), and a Licensed Professional Counselor (LPC) in South Carolina (License #10969). 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 to clients located in Texas and South Carolina. 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.

I have worked with individuals, families, couples, and groups at non-profit agencies, domestic violence shelters, schools, and private practice. My clinical focus is on trauma survivors, and I have a strong passion for serving diverse populations. In therapy, I incorporate mindfulness and body-oriented techniques to support clients in developing greater self-awareness and emotional regulation skills. I am trained in Eye Movement Desensitization and Reprocessing (EMDR) and find it to be a powerful tool in helping clients process stuck content and move toward healing. My approach is holistic and empowering, drawing from trauma-informed care perspectives, EMDR, trauma-informed yoga, somatic practices, Polyvagal theory, 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 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.

Session Fees and Length of Service

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.

Late Cancellation/No Show Fees:

• Individual Therapy Appointment: $75

• EMDR Intensive: $150

• Group Therapy: $75

FEES FOR PROFESSIONAL SERVICES:

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

• $150.00 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, we may offer a sliding scale fee 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 therapy hour for individual clients. Open Path requires a one-time membership fee of $65, which provides lifetime membership. If you are accepted, you and the therapist will agree on a rate within the Open Path range.

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: $100

· 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 or misunderstandings. 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. 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

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
(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

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
Your rights regarding PHI are explained below. To exercise these rights, please submit a written request to the Practice at the address noted below.

To inspect and copy PHI.
• You can ask for an electronic or paper copy of PHI. The Practice may charge you a reasonable fee.
• 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.

To amend PHI.
• You can ask to correct PHI you believe is 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.

To request confidential communications.
• You can ask the Practice to contact you in a specific way. The Practice will say “yes” to all reasonable requests.

To limit what is used or shared.
• You can ask the Practice not to use or share PHI for treatment, payment, or business operations. The Practice is not required to agree if it would affect your care.
• 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, called an accounting, of the times your health information has been shared. You can receive one accounting every 12 months at no charge, but you may be charged a reasonable fee if you ask for one more frequently.

To receive a copy of this Notice.
• You can ask for a paper copy of this Notice, even if you agreed to receive the Notice electronically.

To choose someone to act for you.
• If you have given someone medical power of attorney or if someone is your legal guardian, that person can exercise your rights.

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 www.hhs.gov/ocr/privacy/hipaa/complaints/.
• The Practice will not retaliate against you for filing a complaint.

To opt out of receiving fundraising communications.
• The Practice may contact you for fundraising efforts, but you can ask not to be contacted again.


OUR USES AND DISCLOSURES
1. Routine Uses and Disclosures of PHI
The Practice is permitted under federal law to use and disclose PHI, without your written authorization, for certain routine uses and disclosures, such as those made for treatment, payment, and the operation of our business. The Practice typically uses or shares your health information in the following ways:

To treat you.
• The Practice can use and share PHI with other professionals who are treating you.
• Example: Your primary care doctor asks about your mental health treatment.

To run the health care operations.
• The Practice can use and share PHI to run the business, improve your care, and contact you.
• Example: The Practice uses PHI to send you appointment reminders if you choose.

To bill for your services.
• The Practice can use and share PHI to bill and get payment from health plans or other entities.
• Example: The Practice gives PHI to your health insurance plan so it will pay for your services.

2. Uses and Disclosures of PHI That May Be Made Without Your Authorization or Opportunity to Object
The Practice may use or disclose PHI without your authorization or an opportunity for you to object, including:

To help with public health and safety issues
• Public health: To prevent the spread of disease, assist in product recalls, and report adverse reactions to medication.
• Required by the Secretary of Health and Human Services: We may be required to disclose your PHI to the Secretary of Health and Human Services to investigate or determine our compliance with the requirements of the final rule on Standards for Privacy of Individually Identifiable Health Information.
• Health oversight: For audits, investigations, and inspections by government agencies that oversee the health care system, government benefit programs, other government regulatory programs, and civil rights laws.
• Serious threat to health or safety: To prevent a serious and imminent threat.
• Abuse or Neglect: To report abuse, neglect, or domestic violence.

To comply with law, law enforcement, or other government requests
• Required by law: If required by federal, state or local law.
• Judicial and administrative proceedings: To respond to a court order, subpoena, or discovery request.
• Law enforcement: For law locate and identify you or disclose information about a victim of a crime.
• Specialized Government Functions: For military or national security concerns, including intelligence, protective services for heads of state, or your security clearance.
• National security and intelligence activities: For intelligence, counterintelligence, protection of the President, other authorized persons or foreign heads of state, for purpose of determining your own security clearance and other national security activities authorized by law.
• Workers' Compensation: To comply with workers' compensation laws or support claims.

To comply with other requests
• Coroners and Funeral Directors: To perform their legally authorized duties.
• Organ Donation: For organ donation or transplantation.
• Research: For research that has been approved by an institutional review board.
• Inmates: The Practice created or received your PHI in the course of providing care.
• Business Associates: To organizations that perform functions, activities or services on our behalf.

3. 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.

4. 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 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 is required to abide by the terms of this Notice currently in effect. Where more stringent state or federal law governs PHI, the Practice will abide by the more stringent law.
• The Practice reserves the right to amend Notice. All changes are applicable to PHI collected and maintained by the Practice. Should the Practice make changes, you may obtain a revised Notice by requesting a copy from the Practice.
• The Practice will inform you if PHI is compromised in a breach.

• The Practice will never market or sell personal information.

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