Professional Disclosures & Informed Consent
Provider: Nicole Thompson MSW, LCSW
License: Licensed Clinical Social Worker
State of Licensure: North Carolina
License Number: C018233
Practice Name: Flourish & Grace Therapy PLLC
Practice Address: Telehealth only
Email: n.thompson@flourishandgracetherapy.com
Phone: 910-492-3077
Effective Date: 12/12/25
1. Provider Qualifications and Scope of Practice
I am a Licensed Clinical Social Worker (LCSW) licensed in the State of North Carolina. I provide mental health assessment, diagnosis, and psychotherapy services within the scope of my education, training, and licensure.
I do not provide medical services, prescribe medication, or offer emergency or crisis care through this website or via telehealth.
2. Nature of Psychotherapy
Psychotherapy is a collaborative process that may involve discussing difficult or emotional topics. While therapy can be beneficial, outcomes cannot be guaranteed, and emotional discomfort may occur.
Participation in therapy is voluntary. You may ask questions, request clarification, or discontinue services at any time.
3. Telehealth Services
Psychotherapy services may be provided via telehealth using HIPAA-compliant platforms (including Headway). Telehealth services are provided in accordance with:
- North Carolina law
- HIPAA
- NASW Code of Ethics
Telehealth may not be clinically appropriate for all individuals or concerns.
Client Location Requirement
Telehealth services are provided only when you are physically located in North Carolina at the time of the session, unless otherwise permitted by law. Your physical location will be verified at each session for legal and emergency purposes.
Risks and Benefits of Telehealth
Benefits may include increased access, convenience, and flexibility.
Risks may include technology failures, reduced nonverbal cues, and privacy risks if sessions are conducted in non-private or unsecured environments.
By participating in telehealth services, you acknowledge and accept these risks.
4. Confidentiality and Its Limits
Confidentiality is a fundamental ethical obligation under the NASW Code of Ethics and is protected by HIPAA and North Carolina law.
Information shared in therapy will not be disclosed without your written authorization except as required or permitted by law, including:
- Serious, foreseeable, and imminent risk of harm to yourself or others
- Suspected abuse, neglect, or exploitation of a minor, disabled adult, or elder
- Court orders, subpoenas, or other lawful legal requirements
A separate Notice of Privacy Practices describes your HIPAA rights in detail and applies fully to all services, including telehealth.
5. Electronic Communications
Email, text messaging, and secure portal messaging may be used for scheduling and administrative purposes only. These methods:
- Are not appropriate for clinical emergencies
- May carry some privacy risk despite reasonable safeguards
6. Fees, Insurance, and Billing
Fees, insurance participation, and billing practices will be discussed prior to the start of services. Insurance billing and payment processing may be facilitated through Headway.
Clients are responsible for understanding their insurance benefits, copayments, deductibles, and any non-covered services.
Good Faith Estimate (No Surprises Act)
Under the No Surprises Act, you have the right to receive a Good Faith Estimate explaining the expected cost of psychotherapy services if you are not using insurance or choose to self-pay.
What the Good Faith Estimate Includes
The Good Faith Estimate will include:
- A description of the services to be provided
- The expected cost per session
- An estimate of the total cost of services over a specified period
- Any known additional fees
Because therapy is individualized, actual costs may vary.
When You Will Receive a Good Faith Estimate
A Good Faith Estimate will be provided:
- Upon request, or
- Automatically if you are a self-pay client
Timing requirements:
- Within 1 business day if services are scheduled at least 3 business days away
- Within 3 business days if services are scheduled at least 10 business days away
Disputing Charges
If you receive a bill that is at least $400 more than your Good Faith Estimate, you may dispute the bill through the U.S. Department of Health and Human Services (HHS) within 120 days of receiving the bill.
Insurance Clients
Clients using insurance are generally not eligible for a Good Faith Estimate under the No Surprises Act. However, expected copayments, deductibles, and non-covered services will be discussed in advance.
7. No-Show and Cancellation Policy
To ensure fairness and availability of services, the following policy applies to all scheduled appointments.
Cancellation Notice Requirement
Clients must provide at least 24 hours’ notice to cancel or reschedule an appointment. Notice may be given by email, phone, or through the client portal.
Late Cancellations
Appointments canceled with less than 24 hours’ notice may be charged a late cancellation fee of $50.
No-Show Appointments
A no-show is defined as missing a scheduled appointment without prior notice, or for telehealth sessions, failing to log in within 15 minutes of the scheduled start time.
No-show appointments may be charged a fee of $75.
Insurance Considerations
Insurance companies do not reimburse for missed or late-canceled appointments. Late cancellation and no-show fees are the client’s responsibility and will not be billed to insurance, even when billing is otherwise handled through Headway.
Emergencies and Exceptions
Fees may be waived at the therapist’s discretion in cases of:
- Medical emergencies
- Severe illness
- Unforeseeable circumstances beyond the client’s control
Repeated Missed Appointments
Repeated late cancellations or no-shows may result in:
- Limited scheduling availability
- Review of treatment appropriateness
- Termination of services with referrals provided, if necessary
8. Emergencies and Crisis Situations
I do not provide 24/7 crisis or emergency services. If you are experiencing an emergency or are in immediate danger, contact:
- 911
- 988 Suicide & Crisis Lifeline (call or text 988)
- Your nearest emergency room
9. Client Rights
You have the right to:
- Receive respectful, ethical, and non-discriminatory care
- Be informed about the nature, risks, and benefits of therapy and telehealth
- Participate actively in treatment planning
- Have your information kept confidential within legal limits
- Access your records in accordance with HIPAA and North Carolina law
- Receive clear information regarding fees and billing
- Withdraw consent for therapy or telehealth services at any time
- Expect professional boundaries consistent with the NASW Code of Ethics
- File a grievance or complaint without fear of retaliation
10. Client Responsibilities
You agree to:
- Provide accurate and complete information for treatment, billing, and emergency purposes
- Participate honestly and responsibly in therapy
- Attend scheduled sessions or cancel according to the cancellation policy
- Participate in telehealth sessions from a private, secure location
- Use electronic communications only for administrative purposes
- Understand and meet financial obligations
- Seek emergency assistance when needed
- Maintain respectful and appropriate behavior during sessions
Services may be paused or terminated if behavior becomes unsafe, abusive, or outside the scope of therapy.
11. Formal Grievance Procedure
If concerns arise, you are encouraged to discuss them directly with me whenever possible.
If unresolved, you may file a complaint with:
North Carolina Social Work Certification and Licensure Board (NCSWCLB)
Website: https://www.ncswboard.gov
Phone: (919) 828-4620
You may also file a privacy-related complaint with the U.S. Department of Health and Human Services (HHS). No retaliation will occur for filing a complaint.
12. Website and Relationship Disclaimer
Information on this website is for general informational purposes only and does not establish a therapist-client relationship. A therapeutic relationship is formed only after completion of intake procedures and mutual agreement to begin services.
13. Acknowledgment and Consent
By engaging in services, you acknowledge that you have reviewed this Professional Disclosures & Informed Consent document, understand its contents, and agree to the terms described above.
You may request clarification or withdraw consent at any time.