Kimberly L Herz LCSW

Licensed Clinical Social Worker

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Disclosure Statement

Kimberly L. Herz LCSW
Professional License # LC 15767
88 Hammond St Suite 301
Bangor Maine 04401

The purpose of this Disclosure Statement is to provide you with important information regarding my work with you. As my client, you have the right to know my qualifications, methods, and mutual expectations of our professional relationship. This information is for your benefit so that you can enter a therapeutic relationship in an informed manner. It’s for you decide if my services are suitable to your needs at this time. If you have any questions, I would be pleased to discuss them with you. Please read this statement in its entirety and sign on the space provided

Qualifications, Credentials and Supervision: I hold a Bachelor of Science degree in Mental Health and Human Services awarded from University of Maine –Augusta as well as a Masters of Social Work degree awarded from the University of Maine- Orono. I am credentialed as a Licensed Clinical Social Worker . I am qualified to provide therapy and provide services to adolescents and adults. I am licensed through the State Board of Social Work Licensure, 35 State House Station, Augusta Maine 04333-0035. Phone: (207) 624-8674, fax: (207) 624-8637.

Experience: I have internship experience as a school-based clinical provider working with children from age 5 through 17. Additionally, I have worked as an outpatient clinical provider and in a residential facility providing therapy services in the residential, educational setting with children, adolescents and families.

Nature of Therapy: Persons entering therapy for the first time are often unsure of what to expect. Initially, I will conduct an intake and screening. Through this process, we will complete documentation which will include releases of information, payment agreement, and insurance information as well as personal details including information regarding mental, physical, social, spiritual, financial and career choices. Therapy provides the opportunity for understanding and growth in a safe, supportive, therapeutic environment. The therapeutic approaches I utilize are Cognitive Behavioral Therapy and Solutions Focused Therapy. These approaches allow my clients to make the association between how our thoughts, behaviors, and feelings are connected. ecognizing patterns of maladaptive behaviors, emotional dysregulation and irrational thoughts are essential in making positive changes. When small changes occur in any one area, changes in all facets of a person’s being follow suit.

Availability: I am available for appointments Monday and Tuesday from 8 am until 6 pm. Other appointments times may be made by appointment. If I am going to be out of the office I will notify you. If I suddenly become ill you will be notified. Our appointments are strictly confidential unless a release of information is signed by you allowing my communication with another entity or individual. Exceptions to this are if I believe you are in danger of harming yourself, another, if you reveal information regarding the child or elder abuse or if I am ordered to release your records by a court of law. If you experience a mental health crisis dial 911 or go to your nearest emergency department.

During the time we work together initially I will schedule weekly appointments lasting 60 minutes. As therapy progresses sessions may be changed to every other week or increased to more frequent sessions as the need arises. Our relationship will be professional and I will be governed by the ethics of my profession. I am not available for any court appearances as legal testimony is not my area of expertise.

Benefits and Risks: Therapy offers potential benefits as well as possible risks. The risks may include but are not limited to discomforting feelings of guilt, sadness, frustration, anger and anxiety. The benefits may include positive changes in yourself allowing increased participation in enjoyable daily activities, development of skills and strategies to utilize when coping with difficult people or situations and obtaining the ability to live a more fulfilling life.

Professional Regulation: The practice of Clinical Social Work is regulated by the State Board of Social Work Licensure. The board is authorized to discipline those who violate board laws or rules. .To learn about the complaint process or file a complaint, contact: State Board of Social Work Licensure, 35 State House Station Augusta, ME 04333-0035. Ph. 207-973-0505, Fax 207-992-2175

Fee Schedule, Cancellation Policy, No Show, Fee Modifications
Fee Schedule.
Fees for services are charged on a “per hour” basis.” My current fee is $130 per therapeutic hour (53-60 minutes). MaineCare is accepted, as well as other various insurances.
Self –pay fees and co pays are payable at the beginning of each session by check or cash. Make checks payable to Kimberly L. Herz, LCSW.

Cancellation Policy. Due to the time commitment that I make to you, I require a 24-Hour Notice of Cancellation. Individuals who fail to cancel properly will be charged a $130 fee, with the exception of true emergencies. Additional appointments will not be scheduled until any such fees are paid in full.
No- Show.
If you do not cancel and also do not show up for an appointment then you are still responsible for the payment unless collection is prohibited by Maine Laws and Rules.
Fee Modifications.
Please feel free to discuss payment plans & special circumstances regarding payment.
As a licensed professional I am accountable for my work with you. If you are dissatisfied with any aspect of the counseling process, please inform me so we can determine if our work together could be more effective or efficient in any way or if a referral might be appropriate.

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