Welcome to Wild Goose Counseling!
The following form explains important things about the counseling process, including information about your counselor(s), things to know about our practice, and more. The therapeutic relationship is unique in that it is a highly personal and, at the same time, it is a contractual agreement. Given this, it is important for us to reach a clear understanding about how our relationship will work, and you can expect. This consent provides a clear framework for our work together. If you have any questions, please feel free to discuss any of this with the counselor you want to work with.
The Therapeutic Process
You have taken a very positive step by deciding to seek therapy. The outcome of your treatment depends largely on your willingness to engage in this process, which may, at times, result in considerable discomfort. Remembering unpleasant events and becoming aware of feelings attached to those events can bring on strong feelings of anger, depression, anxiety, etc. In short, there are no miracle cures. Your counselor cannot promise that your behavior or circumstance will change. Your counselor CAN promise to support you through the process of counseling. We will do our very best to understand you, to help you discover any repeating patterns, as well as to help you clarify what it is that you want for yourself.
Confidentiality Limits
We value your privacy! Typically, our client’s session content and all relevant materials to the client’s treatment will be held confidential (unless the client requests in writing to have all or portions of such content released to a specifically named person/persons). However, there are some limitations of the client-held privilege of confidentiality that do exist, as you have read already on the Privacy/Rights page. If you have any questions about privacy and confidentiality at any time during your time with us, or would like another printed copy of the privacy policy, please ask.
As you know, we live in a small town, so it is likely that you may accidentally run into your therapist a time or two (at the grocery store, school, event, medical office, etc). If you happen to see your therapist outside of the therapy office, it is completely fine to smile or say hi, if you prefer to do so.  You are also free to not greet your therapist and your therapist will then respond in kind.  One of the advantages of small town life is that familiar faces are common and, as such, your greeting does not likely compromise your client status. While public greetings are fine if you feel comfortable with them, your therapist will never acknowledge that you are a client, however, or talk about therapy-related topics with you in public settings.  Your therapist will also not be able to “friend” you on Facebook or other social media programs for the duration of your time in therapy and often for some time after.  Your right to privacy and confidentiality is of the utmost importance, and we do not wish to jeopardize your privacy.
Informed Consent for Psychotherapy and Assessment Services
Counselor Disclosure Statement
Molly Davis, LPC, MAC, belongs to the National Association for Addiction Professionals (NAADAC). She is a Licensed Professional Counselor (State of Alaska) and Master Addiction Counselor (NAADAC). She earned a Bachelor of Science in Psychology and a Master of Science in Community Mental Health.
Lydia Davis, LPC, MAC, belongs to the National Association for Addiction Professionals (NAADAC). She is a Licensed Professional Counselor (State of Alaska) and Master Addiction Counselor (NAADAC). Lydia earned a Bachelor of Science in Psychology and a Master of Science in Community Mental Health.
Both Molly and Lydia adhere to the Code of Ethics of the American Counseling Association.
Wild Goose Counseling LLC may also contract with other private counselors on a case-by-case basis.  In those cases, your contracted counselor will provide you with a written documentation detailing his/her disclosure of counseling credentials.  All private counselors who work collaboratively with Wild Goose will also adhere to the ACA Code of Ethics.
Conflict Resolution
We will always work hard to make sure that you have a positive counseling experience. After all, that’s why we do what we do! However, if a conflict occurs despite our efforts, it is agreed that any disputes shall be negotiated directly between the parties. If these negotiations are not satisfactory, then the parties agree to mediate any differences with a mutually acceptable third-party mediator. If these are unsatisfactory, then the parties shall move to arbitration, and then binding arbitration, choosing an arbitrator mutually agreeable to both. Litigation shall be considered only if and after these above- mentioned methods of resolution are all given a good faith effort and are unsatisfactory.
Scheduling, Late Arrival, and Missed Appointments Policy
You will schedule your appointments with your counselor directly, either in person or over the phone. We also provide a text complementary reminder service, if approved by you, in the form of a discreet reminder text sent to your preferred cell number the day before your appointment.  It is always 100% your responsibility to remember your scheduled appointments and to keep them.
24-Hour-Notice for Cancellations: Scheduling an appointment is a commitment that both counselors and clients honor. We have a 24-hour-notice requirement for all cancellations, with the exception of emergency situations only.
Please note that if your counselor becomes suddenly ill or experiences an emergency situation, someone from Wild Goose Counseling will contact you as soon as possible to cancel your appointment and to reschedule you.
Full Charge for Missed Appointments: Once an appointment is scheduled, you will be expected to pay for it unless you provide 24-hour-notice of cancellation in advance of your session (unless we both agree that you are unable to attend due to circumstances beyond your control). Insurance will not pay for missed appointments. We purposely have a very small caseload and your scheduled time is valuable! We are unable to schedule you another appointment until your missed appointment is paid.

Late Arrival Policy: Your scheduled counseling time is valuable. Each session will begin promptly at the appointed time and end at the appointed time. If you arrive a little late, your session will still end at the appointed time. If your counselor begins a session late due to an unavoidable delay, the session will be extended or rescheduled, depending on what is best for you, to provide you with your full session. Please note that neither the client nor therapist is expected to wait longer than 15 minutes past the scheduled time for the start of the session, unless there has been previous notice.

Work Agreement
As you likely know, effective counseling work requires commitment and the counseling process a priority for positive gains to be made.  At Wild Goose, we keep a small client caseload so that we can provide high quality care to all our clients. With a limited amount of counseling spots open, we want to give you our best and we except your best in return. As such, we are unable to continue working with individuals who frequently miss appointments, express regular disinterest, or have an unresolved conflict or impasse with the counselor. Should any of these behavior patterns or problems become an issue, your counselor will discuss this with you and will provide you with a referral to another counselor, agency, or service that can better meet your needs.
Emergency Contacts
Your counselor will establish emergency contacts for you, such as the phone number and location of a trusted family member. Your counselor will also obtain alternative methods for contacting you, such as a mobile phone, or work phone number. These emergency contacts may be used if the counselor perceives an emergency/safety need.
After-Hours Emergency Mental Health Crisis
While your counselor cares about you and your well-being, your counselor will not always be available after sessions and should not be counted on as your primary/only support in the event of a mental health emergency. If you are in a mental health crisis and your counselor is not available, please contact emergency services by calling 911 or go to your nearest emergency room. You may also contact the local Emergency Mental Health Line, which is available 24 hours a day, at 907-283-7511 and staffed by mental health counselors.
It’s very important that you reach out to these resources when you have an emergency or mental health crisis. Your safety and well-being is important to us!
Service Fees and Insurance
You are 100% responsible for payment of services. If you have insurance, we provide insurance billing services to you as a courtesy. You are always responsible for whatever portion that your insurance does not pay. It is important to remember that while may offer courtesy billing as a service to the client, we are not a part of the agreement between you and your insurance provider.
It is very important that you contact your insurance provider to find out about your behavioral health service coverage. We suggest that when you call your insurance company, find out how much is your deductible is, how many sessions are covered, whether prior authorization is needed to begin treatment, and how much is your co-pay (your cash cost per session).
You understand that we are out-of-network providers for some insurance companies. While we like to provide billing services and do so when able, there is a chance that you may have to do your own billing. If this occurs, we will provide you with a receipt after each session (which will include the information required by most insurance companies, including diagnosis, dates of service, and CPT code). You can then submit that to your insurance company for direct reimbursement.
The following are our basic service fees at this time. We reserve the right to change these fees and will provide our existing clients with a minimum of one month’s written and verbal notice when/if fees change.
Initial Assessment (for new counseling clients, 1-2 hours): $220
Individual Psychotherapy Sessions (1 hour): $175
Family Psychotherapy Sessions (1 hour): $200
If you do not have insurance, do not qualify for Medicaid, and are experiencing financial hardship, we may be able to make some financial accommodations based on need.  Please contact the intake counselor to discuss this further.
Your Co-Pay and Monthly Payment Obligations
Your portion of the bill and/or your co-pay must be paid in full by the end of each month. Depending on which payment arrangement works best for your budget, you are welcome to pay your cost at the time of each session, or your can wait until the end of each month to pay the collected total.  We are unable to continue offering services to clients who are unable to pay for them.
If you prefer to bring in a check, bring your checkbook to session or mail your monthly bill to Wild Goose Counseling LLC, 198 W. Marydale Ave., Soldotna, AK 99669.  If you prefer to pay by credit card, simply log in to your Wild Goose Portal and pay your bill there.
That said, “life happens,” as they say, and sometimes that involves a sudden loss of employment or other unexpected financial challenges. If paying your bill with us suddenly become a problem, please don’t wait to let us know! As a small private business, we may be unable to make significant financial accommodations, however know that we will not just abandon you. It is important to us that you continue to get good care! We will be more than happy to provide you with referrals to area agencies that are able to provide sliding scale fees and other assistance to folks in financial crisis.  Just because you are experiencing financial challenges doesn’t mean you need to stop receiving counseling supports.  We can help you make a smooth transition to other counseling services.
Court Appearances and Involvement
It is our preference NOT to appear in court or be involved in legal matters or litigations.
Because of the difficulty (and complexity) of legal involvement, we do NOT accept clients who are seeking counseling services for the primary purpose of having counselor participation in legal proceedings. That said, we understand that these things can happen unexpectedly and, if so, that you may need or desire our services or testimony. If, for any reason, after our treatment relationship is established, we are compelled to become involved, the fee charged to the requesting party or their attorney will be prorated based upon our $175.00 per hour fee. This includes time spent in court testimony, in depositions, waiting in court or other case related meetings, written report or preparation time, etc. If subpoenaed, the parties responsible for the fees shall pay all fees related to the counselor’s time to appear, preparation, and travel time. If the Court subpoenas or calls the therapist to testify, the responsible party identified in this agreement is responsible for all counselor fees.