Electronic Professional Disclosure Statement —Chadwick Royal, PhD, LCMHCS
This form should be reviewed and completed before your first appointment
Contact Information

Chadwick Royal, PhD, LCMHCS
Licensed Clinical Mental Health Counselor Supervisor
Physical Office Address: 106 S. 4th Street, Suite F, Mebane, NC 27302
Telephone: 336-684-0697
Website: www.chadwickroyal.com
Email: dr@chadwickroyal.com
Qualifications

Education

Doctor of Philosophy (PhD) in Counselor Education from NC State University (CACREP-accredited
program) - 1999
Master of Science (MS) in Counseling from UNC-Greensboro (CACREP-accredited program) – 1996
Bachelor of Arts in Psychology from NC State University – 1993

Licenses, Certificates

Licensed Clinical Mental Health Counselor (NC) - licensed since 8/1999 - #3419
Licensed Clinical Mental Health Counselor Supervisor (NC) - licensed since 4/2011 - #S3419
Reality Therapy Certified - July, 1995, William Glasser Institute
Certified Career Counselor Educator – December 2017, National Career Development Association

I have over 20 years of counseling experience – since completing my master’s degree in 1996.

Counseling Background

I offer counseling to individuals, couples, and families – to all ages of clients (starting at age 5). I offer “talk therapy” through brief, solution-focused, problem-solving services. I use a combination of strengths-based, cognitive-behavioral, behavioral, developmental, cognitive-developmental, strategic, systemic, and person- centered approaches – always dependent upon the needs that are indicated by each individual client. All methods and interventions are tailored to the problems that are presented. For children, I incorporate the use of play, recreation, and art activities – tailored to the age of the child, their needs, and their verbal abilities.

Session Fees and Length of Service

The fee is $45 per session. After your initial assessment session (which should take about an hour-and-a-half), counseling sessions are scheduled in one hour increments -- by appointment only. Meetings are held in my Mebane office. There is no guarantee for how many total sessions may be needed, but I have found that for counseling to be successful - it needs to be regular. A good estimate is to plan on meeting weekly for at least 6 to 8 sessions; it may take more time, it may take less.

All fees should be paid at the time of service. I accept cash, checks, and credit cards. I do not accept any insurance providers. I have done so previously, but my intention is to be able to provide affordable counseling services. I have intentionally set my fees low , so that you pay an amount similar to what you may pay for your normal co-pay - without filing an insurance claim. All clients are responsible for payment of a scheduled appointment, even if they fail to show for our scheduled time together. Cancellation of a scheduled appointment (to avoid this cost) requires a 24-hour notice.

If I am involved in any court proceedings as a result your treatment (for example, issues related to child custody), a separate fee is charged per 1⁄4 hour of time allotted to the court proceedings ($75 per 1⁄4 hour, billed in quarter-hours). This fee applies to any time spent directly related to the proceedings (for example, communication with attorneys, preparation of paperwork, travel time to proceedings, time spent in court).

Use of Diagnosis

Some health insurance companies reimburse clients for counseling services and some will not. In addition, most will require that a diagnosis of a mental-health condition and indicate that you must have an “illness” before they will agree to reimburse you. Some conditions for which people seek counseling do not qualify for reimbursement. Since I do not bill insurance, you are responsible for submitting your own claims and communicating with your insurance provider (if you seek reimbursement). If the reason for your visit is indicative of a mental health diagnosis, this diagnosis will be available to you. Any diagnosis made will become part of your permanent insurance records, if you submit a claim.

Confidentiality

All of our communication becomes part of the clinical record, which is accessible to you upon request. I will keep confidential anything you say as part of our counseling relationship, with the following exceptions: (a) you direct me in writing to disclose information to someone else, (b) it is determined you are a danger to yourself or others (including child or elder abuse), or (c) I am ordered by a court to disclose information.

Communications Policies

Contacting Me

When you need to contact me for any reason, these are the most effective ways to get in touch in a reasonable amount of time:
By phone (336-684-0697), you may leave messages on the voicemail, which is confidential.

If you wish to communicate with me by normal email or normal text message, please read and complete the Request For Non-Secure Communications form provided on my website. Email and text messaging are used ONLY for scheduling and arranging appointments, not the provision of counseling services.

Sending Files or Documents to Me

If you need to send a file or document to me (document, PDF, or image), please use the secure file upload form on the “Client Forms” area of my website: http://www.chadwickroyal.com/index.php/counseling-services/client-forms

Social Media

Please refrain from making contact with me using social media systems such as Facebook, Twitter, Instagram, etc. These systems have very poor security and would break our confidentiality should you attempt to “friend” or “follow” me. I will not “friend” or “follow” you.

Complaints

Although clients are encouraged to discuss any concerns with me, you may file a complaint against me with the organization below should you feel I am in violation of any of these codes of ethics. I abide by the American Counseling Association (ACA) Code of Ethics (http://www.counseling.org/Resources/aca-code-of-ethics.pdf).

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@ncblpc.org

Acceptance of terms

By typing your name below (aka, signing), you are stating that

“I agree to these terms and will abide by these guidelines” (Parent/Guardian signs if client is a minor).

Signature - Please type your full name here
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