Professional Disclosure Statement
Cassandra Phillips, LCMHC, ATRP
Licensed Clinical Mental Health Counselor
Registered Art Therapist, Provisional
cassandra@cassandraphillipslcmhc.com
(919) 636-9192
Please review the following information closely as it will provide you with information about me
as your therapist, as well as various policies and procedures. Please feel free to discuss any questions or concerns you may have prior to signing this document. Your signature at the end of this document serves as an agreement between yourself, as a client, and myself, as the therapist.
QUALIFICATIONS
Education:
45-Hour Approved Clinical Supervisor Training UNCG Greensboro, NC 2026
Master of Arts in Counseling: Art Therapy Adler University Chicago, IL 2019
a dual degree in both Clinical Mental Health Counseling and Art Therapy
BS Photo-Illustration Kent State University Kent, OH 2005
Licensure and Certifications:
I am a Licensed Clinical Mental Health Counselor in North Carolina (LCMHC #16001) and a provisionally Registered Art Therapist (ATR-P 10-401), which is a national certification. For my provisional registration with the Art Therapy Credentials Board, I work under the supervision of Dr. Haley Fox, LMHC, ATR-BCCS, MT-BC, REAT, and she can be reached at drhaleyfox@awe.ninja. I have attended multiple specialized trainings, workshops, and conferences in a variety of both mental health, addiction, and art therapy in an effort to continue my education, increase my clinical skills, and maintain my professional licenses and certifications.
BACKGROUND
I’ve been in the counseling field since 2018. I have primarily worked with adults in a variety of settings, including inpatient, residential, partial-hospitalization, intensive outpatient, outpatient, and community-based programming. I have previously worked as a counselor and art therapist in a residential facility for individuals with developmental disabilities utilizing a person-centered approach. I’ve worked on a variety of treatment teams; as a Co-Occurring Disorders Specialist (substance-use specialist) and Mental Health Clinician on two Assertive Community Treatment Teams (ACTT), and as a Team Lead/Therapist for a Community Support Team (CST). On higher levels of care, I’ve worked with IP/RES/PHP/IOP as a psychotherapist and art therapist providing treatment for individuals with eating disorders and co-occurring disorders. My style as a therapist is collaborative, flexible, and affirming; I value being experiential, clinically-informed, holistic, and I provide support using a compassionate, non-judgmental approach. My theoretical orientation is trauma-informed, rooted in feminist counseling and I utilize a person-centered framework, most often using ACT, CBT, DBT, and ERP. While I am not exclusively an art therapist, I believe the creative process can be an effective means of exploration, communication, a safe outlet, and a coping mechanism. In 2025, I completed a 200-hour Yoga Teacher Training to improve my knowledge of the mind-body connection and somatic influences in therapy.
FEES & INSURANCE
Out-of-Pocket Payment Policy:
The following rates apply to psychotherapy services when paying out-of-pocket.
Clinical assessment (required for ALL psychotherapy services) = $190.00*
55-minute psychotherapy session (individual, couples & family) = $165.00*
Full payment is due at the beginning of services and is non-refundable.
If you have any questions regarding billing policies, please contact me at (919) 636-9192.
Insurance:
I am currently an in-network provider for most Blue Cross Blue Shield plans, Aetna, and Medcost. I can provide a Superbill for all out-of-pocket paid sessions to support session cost reimbursement. Please be aware that you are responsible for paying the difference between the full contracted reimbursement rate minus the amount paid by your insurance plan for services already rendered, up to the full contracted reimbursement rate for your respective insurance plan. Before a session, I will provide clients with information on all benefits and costs, and will keep clients updated if there’s ever a change in coverage. Payment for sessions is payable online through debit or credit card or ACH transfer, unless otherwise established. Payment for sessions is due after each session unless otherwise agreed upon. Receipts may be provided at the time of the charge or monthly. Clients cannot submit bills for cancellations to insurance companies or managed care plans.
Payment is due at the time of service. If unable to pay at the time of service, fees owed will be tracked and will be expected to be paid in full prior to the provision of the next service.
Failure to pay any outstanding balances within 60 days of the date of service may result in your bill being submitted to a collection agency. Please also be aware that there will be a no-show and/or late cancellation fee of $75 for all scheduled missed appointments. I require a 24-hour cancellation notice in advance. I recommend calling, texting and/or emailing as soon as you think you might be unable to keep your appointment. Please note that insurance companies will not reimburse for canceled or missed appointments.
RECORD KEEPING AND CONFIDENTIALITY
Please be aware that I am required to keep records that document your treatment as a person served. You have the right to request all of your records at any time. However, as client records are very thorough and include clinical/technical terminology, I may suggest that a prepared summary might better serve your needs. In the event that you wish to view or have a copy of any or all of your records, it is best that we first meet to discuss your records, or even review them together, so that there are no misunderstandings of any of the content.
Confidentiality will be upheld at all times except under the circumstances listed below. All communication will become part of your clinical record. Your record will be kept in a locked facility. Prior to receiving treatment, we will discuss any other individuals, professionals, or companies that may need to be aware of your treatment, or those entities that need information for payment purposes. Before speaking with any of these individuals or entities, I will ask you to sign a consent for release of information form, which will be valid for one year unless you choose to revoke the release at any point in time. The exceptions to confidentiality are as follows:
1. A release of information is signed by the client or legal guardian of the client.
2. You represent a danger to yourself or someone else.
3. The court system orders a release of information (court order, not a subpoena) or I must comply with the Department of Social Services.
4. You are involved in the abuse, exploitation, or neglect of a child, elderly, or disabled person.
5. A third party who is paying for your services requests information.
COMPLAINTS PROCEDURE
I adhere to the American Counseling Association (ACA) Code of Ethics and Standards of Practice. I also adhere to the codes of ethics stated by the North Carolina Substance Abuse Professional Practice Board, the North Carolina Board of Licensed Clinical Mental Health Counselors, and the Commission on Rehabilitation Counselor Certification. If you have any complaints or concerns regarding my practice, please let me know so we can discuss these concerns and try to resolve them.
Complaints may also be registered with the following:
North Carolina Board of Licensed Clinical Mental Health Counselors P.O. Box 77819 Greensboro,NC 27417
Ph: 844-622-3572 or Ph: 336-217-6007
ACCEPTANCE OF TERMS:
Please sign in the space designated below. Your signature asserts that you have read this document in its entirety, that you understand and agree with the conditions listed in the contents, and any questions you had about the contents of the document have been answered satisfactorily.
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Client Signature Date
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Provider Signature Date