Welcome to Willow Tree Counseling Associates (WTCA). We look forward to being of service to you. If you ever have questions or concerns, simply speak with your counselor, Charlie Berman 201-602-7523 or Sue Nobleman 201-602-7783. We want to meet your treatment needs.

The following Orientation Material is yours to read and keep for your reference, and in some cases, to complete, sign and return to Willow Tree. Please retain items 1 – 8 and then complete and return items 9 – 11 to us, last page. 

1.     WTCA Treatment Philosophy

2.     WTCA Objectives

3.     Hours of Operation

4.     Behavior Expectations (including drug use expectations during treatment)

5.     Client Bill of Rights

6.     Client Privacy Rights

7.     WTCA’s Payment & Billing Information

8.     Emergency Services

9.     Consent for Addiction Counseling

10.  Statement of Understanding re: the use of mood altering substances while in counseling.

11.  Consent for Release of Confidential Alcohol & Drug Treatment Information and Client Orientation Verification Form

Thank you for deciding to work with Willow Tree Counseling Associates. We hope you will be happy with the services provided.

Willow Tree's Treatment Philosophy

Mission Statement:  Through a personalized approach, Willow Tree Counseling Associates LLC empowers, counsels & educates individuals, couples, families, schools and community groups to build mentally well, alcohol and drug-safe, caring individuals and communities.

Values: At Willow Tree Counseling Associates, we value and are committed to being on T.R.A.C.K. — meaning that we are:  Trustworthy, Resilient, Authentic, Creative and Kind.

Location, Hours and Days of Operation

Willow Tree Counseling Associates located at 213 Village Road in Green Village, NJ 07935. Hours are arranged through appointments made specifically with the assigned counselor. We will do our best to accommodate your schedule.

Holiday Closures

We will be closed on the following holidays:

1.         New Year's Day (January 1)

2.         President’s Day (Third Monday in February)

3.         Memorial Day (Last Monday in May)

4.         Independence Day (July 4)

5.         Labor Day (First Monday in September)

6.         Columbus Day (Second Monday in October)

7.         Thanksgiving (Fourth Thursday & Friday in November)

8.         Christmas Eve & Christmas Day (December 24^th and 25^th)

WTCA Behavior Expectations

• Cancellations:  We request 24 hours notification for cancellations. “No Shows” will be billed.
• Tardiness: Please be on time for appointments. One-hour sessions will begin and end on time.
• Relationships:  Clients may not have an outside social relationship with WT counselors. Two years must pass after official discharge for a sponsorship relationship to be possible. Romantic relationships and cohabitating with WT staff is never permitted.                                                                                     
• Respect:  You will be treated with respect and are expected to treat others at WT the same.
• Upon acceptance into the WT, clients agree to no use of any mood altering drugs including alcohol. When in doubt, check it out.  There are no exceptions.

WTCA Client Bill of Rights  Each client receiving services through Willow Tree Counseling Associates will have the following rights:

• To be informed of these rights, as evidenced by the client ’s written acknowledgement;
• To be advised of Willow Tree Counseling Associates’ rules that apply to his/her conduct as a client;
• To be informed of services available through WT;
• To be treated with courtesy, consideration, respect and recognition, protecting the client’s dignity, individuality and right to privacy;
• To privacy and confidentiality of all records pertaining to the client’s treatment, except as otherwise provided by law. The facility may release data about the client for studies containing aggregated statistics when the client’s identity is masked;
• To be free from mental and physical abuse and free from exploitation;
• To expect reasonable continuity of care;
• To develop a client centered Treatment Plan with your counselor, one that reflects your goals & aspirations;
• To receive from the counselor information necessary to give informed consent prior to the start of any treatment;
• To participate in the planning of his/her own care and treatment;
• To refuse treatment and to be informed of the medical and legal consequences of such action, should any apply. Such refusal will be documented in the client’s record.
• To be provided with an appropriate discharge plan, including follow-up care and resources;
• To be advised if Willow Tree Counseling Associates proposes to engage in or perform experimental research, to be included in only when the client gives informed and written consent to such participation;
• To exercise civil and religious liberties, including the right to independent personal decisions. No religious beliefs or practices, or any attendance at religious services will be imposed on any client;
• To treatment without discrimination because of age, race, religion, gender, sexual orientation, nationality, or disability.

Client Privacy Rights

Confidentiality of Drug and Alcohol Client Information

This notice describes how information about you may be used and disclosed and how you can gain access to this information. PLEASE REVIEW THIS NOTICE CAREFULLY & SIGN on the last page, noting that you’ve been advised of your privacy rights.

The Rule:

• Willow Tree Counseling Associates’ personnel are required by law to maintain the privacy of protected health information and may not disclose any information about any client (under 42 CFR Part 2 and “covered entity” under HIPAA Privacy Rule) for any reason.
• Patient information is maintained for treatment and payment purposes only.
• Patient participation is voluntary and confidential and all identifying information will be withheld. 

The Exception:

• If a person under age 18 is currently in a seriously neglectful or abusive situation at home or has ever been sexually abused, there is a duty to report such incidents to the NJ Division of Child Protection and Permanency (NJDCPP) 1-800-792-8610.
• If someone of any age states that he or she intends to inflict bodily harm on another and has a plan to do so, there is a duty to call the police and to inform the person being threatened.
• If a person under age 18 seems or reports being suicidal, there is a duty to bring this to the attention the parents or legal guardians. Parents should be encouraged to have their child immediately evaluated by a psychiatrist for level of risk.
• If a person 18 or over seems to be or reports being suicidal, clinician is to:

     —Ask if client has:

1.  A Suicide Plan;

2. A means to carry out that plan;

3. The ability and willingness to delay putting the plan into action.

— Ask client to rate self (1 being low and 5 being high) for suicidal risk.

—If at a 4 or 5, ensure client is taken to an emergency room for an immediate evaluation by a psychiatrist;

—Document client's stated or perceived intentions, and record the action taken by the counselor.

Conditions permitting disclosure without proper written consent from client:

— Internal communications & supervision.

— Research and data collection for county and state reports. Client-identifying information will be concealed.

— Medical Emergency.

— Crime on premises or against Willow Tree Personnel. 

Reporting:

— Suspected child abuse or neglect (report made to appropriate state or local authorities);

— Client indicates intent to harm self and/or another person(s);

— Person under age 18, who is the victim of present or past sexual abuse.

Note:     All other uses and disclosures will be made only with the client’s written authorization, which can be revoked by the client if placed in writing at any time.

42 CFR Part 2:  Federal law & regulations protecting confidentiality of alcohol & drug abuse client records: 

• Client records are protected under the federal regulations governing Confidentiality of Alcohol and Drug Abuse Patient Records, 42 CFR Part 2, and the Health Insurance Portability and Accountability Act (HIPAA) and cannot be disclosed without written consent of the client. If asked, Willow Tree Center staff may not disclose whether or not a client is or is not a client at the agency. The language to be used is as follows: “I may neither confirm nor deny the presence or involvement of the person in question.”

• The exceptions listed describe limited circumstances under which Willow Tree may acknowledge that the individual client is present at the facility or disclose outside the program information identifying the client as an alcohol or drug abuser.

• The client’s commission of a crime on the premises or against program personnel, or a report of child abuse or neglect made to appropriate state or local authorities, is not protected.

Individual Rights of Clients:

The individual has the right to:

• Request restrictions on certain uses and disclosures of protected health information. However, Willow Tree (under 42 CFR) is not required to agree to a requested restriction.
• Receive confidential communications of protected health information.
• Inspect, copy, and amend protected health information.
• Receive an accounting of disclosures of protected health information.
• Obtain a paper copy of the notice from the covered entity upon request.
• Complain to the Secretary of the Department of Health and Human Services if the individual believes his/her privacy rights have been violated.

 Client Informed Consent

 Clients of Willow Tree Counseling Associates are eligible to receive a range of services. The type and extent of services offered will be determined following an initial assessment and thorough discussion with the client. The goal of the assessment process is to determine the best course of treatment. Typically, treatment is provided over the course of several weeks to several months and up to two years.

All information shared between Sue Nobleman and Charlie Berman, employees of Willow Tree Counseling Associates, is confidential and no information will be released without consent. During the course of treatment at Willow Tree Counseling Associates, it may be necessary for a counselor to communicate with outside agencies or services. Written authorization will be requested, prior to any discussion with any outside agency or service.  

There are specific and limited exceptions to this confidentiality which include the following:

• When there is risk of imminent danger to myself or to another person, the clinician is ethically bound to take necessary steps to prevent such danger.
• When there is suspicion that a child or elder is being sexually or physically abused or is at risk of such abuse, the clinician is legally required to take steps to protect the child or elder, and to inform the proper authorities.
• When a valid court order is issued for client records, the clinician and the agency are bound by law to comply with such requests.

If you have any questions regarding this consent form or about the services offered through Willow Tree Counseling Associates, you are encouraged to discuss them with your counselor. Your signature and initials on the Client Orientation VERIFICATION Form (last page) will be taken to mean that you have read and understand the above. It will also indicate your consent to participate in the evaluation and treatment offered by Willow Tree Counseling Associates. You may stop treatment at any time.

Willow Tree Rates, Payment & Billing Information

Clients are financially responsible for the cost of services provided and are expected to fulfill these financial responsibilities in a timely manner. Please note that payment is expected at the time of service. 

Clients are responsible for payment of missed sessions when cancellations are made with no notice. You must leave a credit card on file so that we may ensure payments for services rendered are covered.

Willow Tree Counseling Associates Fee Schedule: 

$250           Addiction Evaluations to determine whether or not further treatment is needed, and at what level. The assessment will take approximately two hours of face-to-face time followed by up to two hours of time executing a specialized report that will include treatment recommendations.

 $35 per     Flourishing Skills Group (FSG): Participants will gain skills to thrive, not just survive. The FSG includes 10 group sessions that are 2 hours in length and you must commit to attend all 10 sessions. If you pay for all ten sessions upfront, you will receive a $100 discount on the total.

$20 per     Willow Women (WW) is a Flourishing Skills Group for women in long-term sobriety, helping you to live the willow way, which means practicing self-care and developing healthy relationships. This is a weekly, on-going group, where participants must agree to attend the first 10 sessions at a minimum.  

$150           Individual 1-hour in-person, telephone or Skype sessions

$175           Couple Counseling Sessions:  1.5 hours with two counselors

$200           Family Counseling Sessions:  1.5 Hours with two counselors

$3,500      Family Interventions. Successful Family Interventions usually take 33 hours of intensive planning and practice over the course of 3 weekends plus two hours for the intervention itself. The initial cost to learn about the process is $150. If you decide to go ahead with the process, this will be absorbed into the total fee of $3,500 and a fee structure will be established where $1,250 is paid at the beginning of the first 2 weekends and $1,000 at the beginning of the last. 

NOTE:         A Sliding scale and payment plans are available in hardship cases. Discuss with counselor.

Policy on Sliding Scale

Discount eligibility is based on household income, and clients must bring TWO of the following to Willow Tree to determine if eligible:

• Most current year's tax filing form (1040 form)
plus
• 2 current pay stubs
or
• 1 unemployment stub
or
• Letter from employer on letterhead that states your salary or wages
• If none of the above are available, you must provide a letter of reference from any non-profit organization on their letterhead (for example, your church)

Sliding Scale Fees Discount levels for qualifying clients are based upon incomes as follows.

Emergency Services  

·      In the event that the Governor of New Jersey declares a state of emergency, Willow Tree Counseling Associates will be closed to keep our clients safe and off the road.

·      In case of a psychological emergency, you may call the home of Willow Tree’s Directors, Sue Nobleman and Charlie Berman (973-301-1784) or go to your nearest hospital emergency room to receive a psychological evaluation and support.

·      In the case of a medical emergency while at Willow Tree, we will call 911 and your emergency contact to advise him/her of the situation.

Consent for Addiction Counseling

Office Copy – Place in Client’s File

• I (print name of client if over age 18), ___________________________________ do hereby consent and authorize _______________________________________ of Willow Tree Counseling Associates to provide personal individual, group, couple or family counseling.

·  If the client is a minor (age 18 or under): I (legal guardian’s name), __________________________________, authorize The Willow Tree Counseling Associates to provide counseling for (client’s name) ___________________________________.

• I sign this consent form freely and voluntarily.

________________________________                                                                             ________________________________

Client’s Signature                                                                                                                           Date of Signatures

________________________________                                                                             ________________________________

Witness/Counselor                                                                                                        Signature of guardian, when required

Client Orientation Verification (updated 4/22/18)

I, ___________________________, do hereby attest that I have received, read, understand and agree to the material contained in the Willow Tree Client Orientation Packet. Where consent is requested, my signature and initials below indicate my agreement.

Willow Tree Orientation Material: (Please Initial that you have received, read and understand the following:)

_____      WTCA Treatment Philosophy     

_____      WTCA Objectives

_____      Hours of Operation

_____      Behavior Expectations (including non-use of all mood altering substances throughout treatment)

_____      Client Bill of Rights

_____      Client Privacy Rights

_____      WTCA’s Payment & Billing Information (I agree to pay for sessions canceled with no notice or less than 24 hours. Credit Card on File to Assure Payment for services rendered: (circle) Visa, Discover, Master Card, American Express 

                  Card Number: ________________________________________  Exp. Date: ___________  Sec. Code: __________ Card Holder Name: ____________________________________ Address: ________________________________   ____________________________________________________________________________________________

_____      Emergency Services

_____      Client Orientation Verification Form/file

_____      Consent for Addiction Counseling/This form placed in client file

_____      Consent Forms for Release of Confidential Alcohol & Drug Treatment Information/placed in client file

Alcohol & Drug Use:    By signing below, I understand that upon acceptance into WTCA, I am expected to refrain from the use of any and all mood altering drugs including alcohol. When in doubt, check it out.  There are no exceptions.

Client’s or Guardian’s Signature                                                                                                                         Date

Counselor’s Signature                                                                                                                                                                                                       Date