Welcome to Waking Wellness! We are honored you are considering inviting us to join you on your present life’s path. We understand the uncertainty that often accompanies such a decision and want to do all that we can to equip you with important information regarding our policies, the state and federal laws and your rights, so that you can feel confident you are making informed choices. Please know that we welcome any questions, comments and/or answers at any point in our relationship and value your feedback in its development. Engaging in the therapeutic relationship is completely voluntary and you have the right to end such a relationship at any time.
Identifying information:
Rachelle Bevilacqua, MS, LPC is a Licensed Professional Counselor in the state of PA. Pursuant to good practice standards, she does engage in ongoing professional collaboration with various mental health colleagues. She has a Bachelor’s Degree in Criminal Justice from Kutztown University and a Master’s in Counseling and Educational Psychology from West Chester University. After five years in the juvenile justice field, Rachelle transitioned to the Counseling profession, working with adolescents, adults, geriatric and young adult populations. She is also a Yoga/Meditation Teacher. Rachelle has also taught courses in both psychology and yoga at Penn State Berks Campus. She is the founder of Waking Wellness, currently seeing clients at:
Sadar Psychological
1288 Valley Forge Road
Suite 72
Phoenixville, PA 19460
“My philosophy of counseling and the therapeutic relationship embraces collaboration and integration. It embraces the value of awareness, mindfulness and commitment; moving ever closer toward total wellness. It is a journey I believe we are all inherently equipped to take. I honor the opportunity I'm given by each client who invites me to be a part of his/her journey, sharing his/her unique spirit with me. Together we rediscover your 'authentic nature' and work towards aligning your way of being to your inner truths. We practice waking up to our lives without judgment, and embracing each moment as an opportunity for growth. Through the process we awaken to our greatest potential and reconnect to a feeling of wholeness and well-being.”
Our relationship is a key factor in this process. It is important that you feel a sense of comfort and/or connection with your counselor and feel safe at all times. If, during this process, you find times when you’re feeling as if you are deteriorating or are unhappy with any aspect of the counseling relationship or its course, it is essential that you share this experience with the counselor. This allows us to better serve your needs and provide appropriate, optimum care.
Confidentiality: It is important to us that we provide a safe environment for the context of our relationship. To that end, trust is essential. For this reason and based on the ethics of the counseling profession: All information you choose to share with a counselor is confidential, except in the following circumstances:
- To protect you or identified others from serious and foreseeable harm
- Mandated reporting of physical or sexual abuse of children or elderly
- Case where you knowingly and willingly sign a release of information
- Those required by law (subpoenaed for court)
- In cases where insurance is billed: Diagnosis and dates of service shared with your insurance company to collect payments
- Information necessary for mentorship or consultation
Counselors may engage in mentoring/supervision/consultation groups and/or relationships to maintain ethical practice. Therefore, some information regarding the content, course or characteristics of our relationship may be discussed with these qualified individuals. Please be assured that all identifying information will remain confidential according to the above guidelines.
If you have read and understand our confidentiality policy, please sign: ______
Session Fees and Policies:
Individual sessions50-60 min$150.00
Group sessions90 minutes$50.00
Workshopsvariesvaries
At this time, Waking Wellness accepts “out of pocket” payments and Aetna health insurance. We are also in network with ComPsych and Carebridge. If you would like to submit for ‘out of network’ reimbursement, we will provide you a ‘superbill.’ Payment or copay is due in full prior to session. Please note, payments via Visa, Mastercard or American Express will be charged an additional 3% processing fee.
If you find yourself hesitating or feelingprohibited by these fees or procedures, please let us know so we may find a way to support you within your present life circumstances. This may involve referral, or an adjustment of fees based on an assessment of resources and current life circumstances.
Late Cancellations and Missed Appointments: If you need to cancel and/or reschedule an appointment, you are required to give at least 24 hours notice so that I may offer the time to other clients. Failure to give at least 24 hours notice will result in a $50 fee for the time reserved. Please note that it is possible to leave a message via voicemail 24 hours a day and that, late cancellations and missed appointments are not covered by insurance.
Emergency Situations: If you find yourself in a situation in which you need immediate assistance to feel safe and are unable to contact this (through above phone number and/or email) or any other counselor, please call 911 or take yourself to the nearest emergency room.
If you have read and understand our fee schedule and emergency procedures, please sign: ______
NOTICE OF PRIVACY PRACTICES
Health Insurance Portability and Accountability Act of 1996 (HIPAA)
I acknowledge receipt of the HIPAA procedures from Rachelle Bevilacqua, MS, LPC
______
SignedDate
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Signed (Witness)Date
___Self
___Guardian
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Your information:
Name: ______D.O.B.:______Address: ______
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Contact Info:
Number:This is my: May we contact you here?May we leave a message?
______wk___hm___cell____yes ____no____yes ____no
______wk___hm___cell____yes ____no____yes ____no
Email Address: ______yes ____no____yes ____no
Insurance Information:
ID#______Are you the primary member: ____yes ____no
Please provide primary members name DOB and address (if different than your own) ______
Are you currently taking or using any medications or substances? ____yes ____no
If ‘yes,’ please list medication and dosage. ______
Have you ever had thoughts of suicide? ____yes ____no
If ‘yes,’ have you had thoughts of suicide within the last week? ____yes ____no
Have you ever attempted suicide? ____yes ____no
If ‘yes’, when?______
Have you received prior mental health support? ____yes ____no
If ‘yes,’ would you provide further information (what type and when)? ______
Did you find this experience supportive and/or helpful? ____yes ____no
Why or why not?
______
Anything you would like us to know? (intentions, fears, information, concerns, hopes, fun facts)
______
Emergency contact person: Name:______Number:______Relationship:______