FLYING SOLO COUNSELING LLC

DISCLOSURE STATEMENT

Identification: Cheryl L. Klein, M. Div., Licensed Pastoral Counselor; PO Box 204, South Windham, Maine 04082 Phone (207) 892-7656 Email: WeFlySolo@hotmail.com

Credentials: Bachelor of Arts, California State University, Northridge (1980), Master of Divinity, Harvard University (1984). Maine License # LP1091. First licensed 10/26/94; renewal every two years; current license expires 10/31/08.

Area of Competence: I am a licensed pastoral counselor trained to work with individuals, couples, adolescents and children, in individual or group sessions.

Treatment is offered to clients focusing on their expressed needs and concerns. At the first interview session, a treatment plan will be co-created with each client, stating issues to be discussed and a proposed time frame for resolution.

All information shared in counseling sessions is confidential. However, this counselor may release confidential information if the client presents a clear and present danger to himself or herself, or to some other identifiable victim and refuses explicitly, or by his or her behavior, to accept further treatment, or for the following reasons:

• Reasonable suspicion of child abuse, abuse of an elder or incapacitated person;
• Court order;
• Voluntary release signed by client or guardian;
• In defense against legal action or formal complaint which client makes before a court or regulatory board;
• During supervision consultation.

This counselor receives ongoing supervision and may review client's case with other counselors involved in the supervision arrangement.

Fees are in accordance with insurance company's co-payment/deductible schedule; third-party payments are accepted to the extent that the proposed course of treatment is reimbursable under the client's insurance plan. If insurance is not used, a sliding-scale fee basis is available starting at $75 per session; the maximum fee to be charged is $95 per session.

CANCELLATION FEE: Clients who cancel a scheduled office visit with less than 24 hours notice are required to pay a $35 cancellation fee.

CHECK POLICY: Checks are accepted for fee payment; fees are required at each session. Fee for returned checks: $25.

HOURS: Office hours are as follows:

Mondays:     `9:15AM to 4:00 PM

Tuesdays:      1:45 to 4:00 PM

Wednesdays: 9:15AM to 4:00 PM

Thursdays:     9:15AM to 4:00 PM

This practice of counseling is regulated by the Board of Counseling Professionals Licensure, Department of Professional and Financial Regulation, at the State of Maine office of Licensing and Registration, 35 State House Station, August ME 04333.