No Show & Late Cancellation Policy

CANCELLATION POLICY: Once an appointment is scheduled, that time is reserved exclusively for you. If you are unable to make the appointment, please provide at least 24-hour notice so that you will not be charged the $70.00 cancellation fee and that time can be made available to someone else. We will waive that fee in the case of emergencies (e.g.) death in the family, contagious illness, unsafe driving conditions). Please note that we will not make exceptions for situations such as lack of babysitter, forgotten appointment or a sudden business meeting or time conflict. I have read and understand that missed appointments or appointments not canceled at least 24 hours in advance will be charged the $70.00 fee (excluding Medicaid). 


Below you will find a list of some of our more important practice policies~


Notice of Privacy Practices

Your Rights

You have the right to: 

  • Get a copy of your paper or electronic medical record

  • Correct your paper or electronic medical record

  • Request confidential communication

  • Ask us to limit the information we share

  • Get a list of those with whom we’ve shared your information

  • Get a copy of this privacy notice

  • Choose someone to act for you

  • File a complaint if you believe your privacy rights have been violate                                                                                                                         

Your Choices
You have some choices in the way that we use and share information as we: 

  • Tell family and friends about your condition

  • Provide disaster relief

  • Include you in a hospital directory

  • Provide mental health care

  • Market our services and sell your information

  • Raise funds


Our Uses and Disclosures
We may use and share your information as we: 

  • Treat you

  • Run our organization

  • Bill for your services

  • Help with public health and safety issues

  • Do research

  • Comply with the law

  • Respond to organ and tissue donation requests

  • Work with a medical examiner or funeral director

  • Address workers’ compensation, law enforcement, and other government requests

  • Respond to lawsuits and legal actions


Your Rights
When it comes to your health information, you have certain rights. This section explains your rights and some of our responsibilities to help you.

  • Get an electronic or paper copy of your medical record 

  • You can ask to see or get an electronic or paper copy of your medical record and other health information we have about you. Ask us how to do this. 

  • We will provide a copy or a summary of your health information, usually within 30 days of your request. We may charge a reasonable, cost-based fee.

  • Ask us to correct your medical record

  • You can ask us to correct health information about you that you think is incorrect or incomplete. Ask us how to do this.

  • We may say “no” to your request, but we’ll tell you why in writing within 60 days.

  • Request confidential communications

  • Ask us to limit what we use or shareYou can ask us to contact you in a specific way (for example, home or office phone) or to send mail to a different address. 

  • We will say “yes” to all reasonable requests.

  • You can ask us not to use or share certain health information for treatment, payment, or our operations. We are not required to agree to your request, and we may say “no” if it would affect your care.

  • If you pay for a service or health care item out-of-pocket in full, you can ask us not to share that information for the purpose of payment or our operations with your health insurer. We will say “yes” unless a law requires us to share that information.

Get a list of those with whom we’ve shared information

You can ask for a list (accounting) of the times we’ve shared your health information for six years prior to the date you ask, who we shared it with, and why.
We will include all the disclosures except for those about treatment, payment, and health care operations, and certain other disclosures (such as any you asked us to make). We’ll provide one accounting a year for free but will charge a reasonable, cost-based fee if you ask for another one within 12 months.

There are times when we may be able to disclose information without consent per NC General Statute 122C- 52-6
Get a copy of this privacy notice

You can ask for a paper copy of this notice at any time, even if you have agreed to receive the notice electronically. We will provide you with a paper copy promptly.

Choose someone to act for you

If you have given someone medical power of attorney or if someone is your legal guardian, that person can exercise your rights and make choices about your health information.

We will make sure the person has this authority and can act for you before we take any action.

File a complaint if you feel your rights are violated

You can complain if you feel we have violated your rights by contacting us using the information.

You can file a complaint with the U.S. Department of Health and Human Services Office for Civil Rights by sending a letter to 200 Independence Avenue, S.W., Washington, D.C. 20201, calling 1-877-696-6775, or visiting
We will not retaliate against you for filing a complaint.

Your Choices
For certain health information, you can tell us your choices about what we share. If you have a clear preference for how we share your information in the situations described below, talk to us. Tell us what you want us to do, and we will follow your instructions.

In these cases, you have both the right and choice to tell us to:

  • Share information with your family, close friends, or others involved in your care

  • Share information in a disaster relief situation

  • Include your information in a hospital directory

  • If you are not able to tell us your preference, for example if you are unconscious, we may go ahead and share your information if we believe it is in your best interest. We may also share your information when needed to lessen a serious and imminent threat to health or safety.

In these cases we never share your information unless you give us written permission:

  • Marketing purposes

  • Sale of your information

  • Most sharing of psychotherapy notes

  • In the case of fundraising:

We may contact you for fundraising efforts, but you can tell us not to contact you again.

Our Uses and Disclosures
How do we typically use or share your health information? 
We typically use or share your health information in the following ways.

Treat you

We can use your health information and share it with other professionals who are treating you.

Example: A doctor treating you for an injury asks another doctor about your overall health condition.

Run our organization

We can use and share your health information to run our practice, improve your care, and contact you when necessary.

Example: We use health information about you to manage your treatment and services. 

  • Bill for your services

  • We can use and share your health information to bill and get payment from health plans or other entities. Example: We give information about you to your health insurance plan so it will pay for your services. 

How else can we use or share your health information? 
We are allowed or required to share your information in other ways – usually in ways that contribute to the public good, such as public health and research. We have to meet many conditions in the law before we can share your information for these purposes. For more information see:

Help with public health and safety issues

We can share health information about you for certain situations such as: 

  • Preventing disease

  • Helping with product recalls

  • Reporting adverse reactions to medications

  • Reporting suspected abuse, neglect, or domestic violence

  • Preventing or reducing a serious threat to anyone’s health or safety

Do research

We can use or share your information for health research.

Comply with the law

We will share information about you if state or federal laws require it, including with the Department of Health and Human Services if it wants to see that we’re complying with federal privacy law.

Respond to organ and tissue donation requests

We can share health information about you with organ procurement organizations.

Work with a medical examiner or funeral director

We can share health information with a coroner, medical examiner, or funeral director when an individual dies.

Address workers’ compensation, law enforcement, and other government requests

We can use or share health information about you:

  • For workers’ compensation claims

  • For law enforcement purposes or with a law enforcement official

  • With health oversight agencies for activities authorized by law

  • For special government functions such as military, national security, and presidential protective services

  • Respond to lawsuits and legal actions

We can share health information about you in response to a court or administrative order, or in response to a subpoena.

Our Responsibilities

  • We are required by law to maintain the privacy and security of your protected health information. 

  • We will let you know promptly if a breach occurs that may have compromised the privacy or security of your information.

  • We must follow the duties and privacy practices described in this notice and give you a copy of it. 

  • We will not use or share your information other than as described here unless you tell us we can in writing. If you tell us we can, you may change your mind at any time. Let us know in writing if you change your mind. For more information see:

Changes to the Terms of this Notice
We can change the terms of this notice, and the changes will apply to all information we have about you. The new notice will be available upon request, in our office, and on our web site.

Other important information
Effective Date of this Notice- March 15, 2015
Privacy Official at Peak Professional Group, PLLC- Samantha Mahon, M.S., LCMHCS.  She can be contacted at:  or (919) 412-5685

We never market or sell personal information.

The Privacy Rule requires you to describe any state or other laws that require greater limits on disclosures. For example, “We will never share any substance abuse treatment records without your written permission.” Insert this type of information here. If no laws with greater limits apply to your entity, no information needs to be added.

In accordance with 45 CFR 502 (b), Peak Professional Group, LLC must make reasonable efforts to limit protected health information to the minimum necessary, except in cases when this may not apply.  

Federal privacy law (45 C.F.R. Part 164) protecting health information may not apply to the recipient of the information and therefore, may not prohibit the recipient from disclosing it.  Other laws, however, may prohibit re-disclosure.  When we disclose mental health and developmental disabilities information protected by state law (G.S. 122C) or substance abuse treatment information protected by federal law (42 C.F.R. Part 2), we must inform the recipient of the information that re-disclosure is prohibited except as permitted or required by law.
If records contain information relating to HIV infection, AIDS or AIDS related conditions, alcohol abuse, drug abuse, psychological or psychiatric conditions, or genetic testing this disclosure may include that information.  HIV/AIDS related information, this information will only be released in accordance with G.S. 130A-143. 

Client Rights & Responsibilities

When you receive services through Peak Professional Group, PLLC you have certain rights. This handout will tell you about those rights and what to do if you have problems or questions.

Your rights are guaranteed by law.

Unless you have been declared incompetent by a court, you have the same basic civil rights and remedies as other citizens, including the right to buy or sell property, sign a contract, register and vote, sue others who have wronged you, and marry or get a divorce. You also have other rights guaranteed by North Carolina General Statutes 122C, Article 3, including the right to dignity, privacy, humane care, and freedom from physical punishment, abuse, neglect, and exploitation. It is the responsibility of the person\program that you are receiving services from to provide you or your legally responsible person a written summary of your rights within your first three visits to the agency (or your first 72 hours if you are in a 24‐hour facility).

You have the right to a treatment plan.
A written treatment plan, based on your individual needs, must be implemented within 15 calendar days of admission. You have the right to treatment in the most normal, age‐appropriate and least restrictive environment possible. You have the right to take part in the development and periodic review of this plan. You are entitled to review your treatment plan and to understand how to obtain a copy of it from your therapist or the Medical Records Department. You may obtain a written copy of your treatment plan by asking your therapist for this.

You have the right to refuse treatment.
Before you agree to your plan, you will be informed of the benefits or risk involved in the services you will receive. You have the right to consent to treatment and may withdraw your consent at any time. You have the right to refuse treatment as described in the statute without threat or termination of services except as outlined in the statute. If you have asked to receive services, you always have a right to agree to or refuse any specific treatment. The only time you can be treated without your consent is in an emergency situation, or when it has been court‐ordered, or if you are a minor and your parents have given permission. A minor may seek and receive periodic services from a physician without parental consent for the prevention, diagnosis and treatment of (1) venereal disease and other diseases reportable under G.S. 130A-135, (2) pregnancy, (3) abuse of controlled substances or alcohol, and (4) emotional disturbance.


You have the right to treatment, including access to medical care and habilitation, regardless of age or degree of MH/IDD/SA disability.

You have the right to confidentiality.
The confidentiality of your care and treatment is protected by law. Except as allowed by law and agency regulations, your records and other information about you will not be released without your written permission. Circumstances under which we may be required to share information with another about the services you receive include:

• If you give permission, we may share information with any person that you name.
• Your next of kin may be informed that you are a consumer, if it is in your best interest. With your permission, your next of kin, a family member with a legitimate role in your service, or another person whom you name may be given other information about your care.
• A consumer advocate may review your record when assigned to work on your behalf.
• The court may order us to release your records.
• Our attorney may need to see your file because of legal proceedings.
• Request from the funding source, or an audit
• Additionally: Another facility or HIPAA Covered Entity may need to receive your files when your care is transferred.
• If you become imprisoned we may share your file with prison officials.
• In an emergency another professional who is treating you may receive your records.
• A physician or other professional who referred you to our facility may receive your files.
• If we believe that you are a danger to yourself or to others, or if we believe that you are likely to commit a crime, we may share information with law enforcement.
Special rules may apply if you have a legal guardian appointed, are a minor, or are receiving treatment for substance abuse.

You have the right to see your own records except under certain circumstances, specified by law. You have the right to have those circumstances explained to you.

Review the agency Notice of Privacy Practices for further information.

You have the right to be informed of the rules.
You have the right to be informed of the rules that you are expected to follow in a particular facility or practice and possible penalties for violation of the rules. This information will be provided when you enter the program. You have the right to be free from un‐warranted suspension or expulsion from programs and services. If you are discharged from a facility or practice, you are entitled to a copy of your discharge plan. You may obtain a copy of your discharge plan by contacting your therapist directly.

You have the right to know your treatment costs.
Fees for services should be discussed with you at your first visit. If this does not occur, please let us know. Although it is your responsibility to make arrangements to pay your bill, you will never be denied services because of inability to pay. If you are unable to pay for services rendered, a referral can be made (with your consent) to an agency that has designated funds for clients who are unable to pay for services or who lack insurance benefits.

You have the right to privacy.
You have the right to be free from any unwarranted search of your person or property. At the time of admission to a 24‐hour facility, staff may search you and your belongings to prevent dangerous or illegal substances from being brought into the facility. The facility itself may be searched if dangerous or illegal substances are reasonably believed to be present, and staff may search consumers who are minors.

Should search and seizure apply to a program from which you are receiving treatment, the specific procedures will be explained when you enter the program.

You have the right not to be abused.
At the time of admission to a specific program, you will be informed of the types of interventions that are approved for use by that program. The program cannot administer any potentially painful procedure or stimulus to reduce the frequency or intensity of a behavior, and at no time is corporal punishment allowed. Employees must protect consumers from harm and report any form of abuse, neglect or exploitation.

In an emergency situation, if your behavior is dangerous to yourself or others, or property, or if we determine – based on very strict rules – that it is necessary for your care, an authorized facility may use restrictive interventions such as restraint, seclusion or isolation time‐out. A number of special safeguards must be in place when these interventions are used, and you or your guardian have a right to request that a designated person be notified.


The gravity of some emergencies may require law enforcement assistance or initiation of involuntary commitment procedures. Strict compliance with regulations is also necessary when interventions such as withdrawing or delaying access to possessions, taking away items, halting scheduled activities, or overcorrection are used. Facilities using protective devices to provide support or enhance safety must comply with certain very strict safeguards. These interventions and devices may never be used as retaliation, for the convenience of staff, or in a manner that causes harm or undue discomfort.

You have a special right if you have intellectual disabilities.
If your primary need is related to the fact that you have intellectual disabilities and are placed in a residential facility, you are entitled to assistance in finding another place to live if your original placement can no longer serve you. This right exists unless you have broken the rules you agreed to follow or if we offer another place that can meet your needs and you refuse that offer. The facility must give you, your legal guardian and Alliance Behavioral Healthcare 60 days advance notice if it intends to discharge you. This right does not apply if you live in a privately‐operated ICF‐MR facility.

You have the right to make instructions for your treatment in advance.
In the event that you become incapacitated and unable to make decisions about your treatment, you may prepare a document which outlines your intentions for your treatment, and a person to make decisions based upon your instructions.

You have the right to make a complaint.
If you are dissatisfied with a Mental Health, Intellectual Developmental Disabilities or Substance Abuse service delivered through Peak Professional Group, LLC or a Network Provider through Alliance Behavioral Healthcare, you have the right to state a complaint or file a grievance at any time. Before stating a written complaint, we urge you to first discuss the matter with staff of the program providing the service and allow them an opportunity to help resolve it.

You Have Certain Appeal Rights
If you have Medicaid, you have the right to request an appeal hearing if you are denied a requested service, or if current services are reduced, suspended or terminated.

If you have questions or problems contact:


Peak Professional Group, PLLC
800 W. Williams Street, Suite 280
Apex, NC 27502

Phone #- 919-335-3105 Fax #- 919-355-5694


Disability Rights NC
This statewide agency is designated under federal and state law to protect and advocate for the rights of persons who have disabilities.
Disability Rights NC
3724 National Drive
Suite 100
Raleigh, NC 27612
Toll Free: 877‐235‐4210 Local: 919-856‐2195
TTY: 888-268-5535
Fax: 919‐856‐2244


Standard Notice and Consent Documents Under the No Surprises Act OMB Control Number: 0938-1401 Expiration Date: 03/31/2022

Surprise Billing Protection

The purpose of this document is to let you know about your protections from unexpected medical bills. It also asks whether you would like to give up those protections and pay more for out-of-network care.

IMPORTANT: You aren’t required to sign this form and shouldn’t sign it if you didn’t have a choice of health care provider when you received care. You can choose to get care from a provider or facility in
your health plan’s network, which may cost you less.

If you’d like assistance with this document, ask your provider or a patient advocate. Take a picture and/or keep a copy of this form for your records. 

You’re getting this notice because this provider or facility isn’t in your health plan’s network. This means the provider or facility doesn’t have an agreement with your plan.

Getting care from this provider or facility could cost you more.

If your plan covers the item or service you’re getting, federal law protects you from higher bills:
• When you get emergency care from out-of-network providers and facilities, or
• When an out-of-network provider treats you at an in-network hospital or ambulatory surgical
center without your knowledge or consent.

Ask your health care provider or patient advocate if you need help knowing if these protections apply to

If you sign this form, you may pay more because:
• You are giving up your protections under the law.
• You may owe the full costs billed for items and services received.
• Your health plan might not count any of the amount you pay towards your deductible and ou tof-pocket limit. Contact your health plan for more information.

You shouldn’t sign this form if you didn’t have a choice of providers when receiving care. For example, if a doctor was assigned to you with no opportunity to make a change.

Before deciding whether to sign this form, you can contact your health plan to find an in-network provider or facility. If there isn’t one, your health plan might work out an agreement with this provider or facility, or another one.

To comply with the Good Faith Estimate requirements, all non-insured or self-paying individuals must be provided with a Good Faith Estimate. Non-insured or self-paying individuals are defined as clients who:

Do not have benefits for an item or service under a group health plan, group or individual health insurance coverage offered by a health insurance issuer or a federal or state health care program or the Federal Employee Health Benefits Program;

Do have benefits for an item or service under a group health plan, or individual or group health insurance coverage offered by a health insurance issuer, but do not seek to submit a claim for such item or service; or

Are enrolled in short-term, limited-duration insurance, but are not also enrolled in a group health plan, group or individual health insurance coverage offered by a health insurance issuer, federal or state health care program, or the Federal Employee Health Benefits Program.


You have the right to receive a “Good Faith Estimate”
explaining how much your medical care will cost

Under the law, health care providers need to give patients who don’t have insurance or who are not using insurance an estimate of the bill for medical items and services.
• You have the right to receive a Good Faith Estimate for the total
expected cost of any non-emergency items or services. This includes
related costs like medical tests, prescription drugs, equipment, and
hospital fees.
• Make sure your health care provider gives you a Good Faith Estimate
in writing at least 1 business day before your medical service or item.
You can also ask your health care provider, and any other provider you choose, for a Good Faith Estimate before you schedule an item or service.
• If you receive a bill that is at least $400 more than your Good Faith
Estimate, you can dispute the bill.
• Make sure to save a copy or picture of your Good Faith Estimate.
For questions or more information about your right to a Good Faith Estimate, visit or call 919.412-5685.

No Surprise Act


Good Faith Estimate

At Peak Professional Group, PLLC, we recognize that every client's therapy journey is unique.  How long you need to engage in therapy and how often you attend sessions will depend on many factors including:

  • Your schedule and life circumstances

  • Therapist availability

  • On-going life challenges

  • The nature of your specific challenges and how you address them


You and your therapist will continually assess the appropriate frequency of therapy and will work together to determine when you have met your goals and are ready for discharge.

Peak Professional Group, PLLC provides the following services:

  • Professional Counseling/Psychotherapy Services


Common Diagnostic Codes used at Peak Professional Group, PLLC:

F41.1- Generalized Anxiety Disorder

F43.10- Post Traumatic Stress Disorder

F90.0 (+)- Attention Deficit Hyperactive Disorder

F43.22 (+)- Adjustment Disorders

F32.0 (+)- Major Depressive Disorders

A note about Diagnosis


At Peak Professional Group, PLLC we don't view our clients just from a 'diagnostic' frame of reference and we aim to treat the whole person, not just a "diagnosis".

Where services will be rendered:

We offer our services in our office location, virtually and in school settings.

Below, you will find a cost estimate of based on a year of therapy services if you were to meet with your therapist for 25 sessions in a year (weekly, without skipping any sessions) at the current full rates that we charge at Peak Professional Group, PLLC. 

We understand that there are circumstances where a reduced fee arrangement may be necessary for atime and the fee you pay for services may very well be less that what is reflected below.  Likewise, not all clients will meet with their therapist on a weekly basis.  Each individual provider at Peak Professional Group, PLLC has the ability to determine, along with you the client, whether a reduced fee arrangement is an option, as well as the frequency of sessions.


The current full rates for psychotherapy (counseling) services at Peak Professional Group, PLLC are:  

90791- Initial Diagnostic Assessment $175.00

90837- 60 min psychotherapy session  $167.00

90834- 45 min psychotherapy session  $110.00

90832- 30 min psychotherapy session  $75.00

90847- Family therapy session w/client $165.00

90846- Family therapy sessions w/out client $150.00

*Yearly Cost Estimate $175.00 x 1 + $167 x 51 sessions= $8692.00


Clients who are experiencing a financial hardship and do not have insurance benefits may request an adjusted fee rate as follows:

Initial Intake Appointment- $85.00

Psychotherapy Services

60 minute psychotherapy session-  $75.00
45 minute psychotherapy session-  $60.00
30 minute psychotherapy session-  $45.00
Family therapy session (w/client)-   $70.00
Family therapy session (w/o client)- $65.00

* Yearly Cost Estimate $85.00 x 1 + $75.00 x 51 sessions = $3910.00



The Good Faith Estimate shows the costs of items and services that are reasonable expected for your  health care needs for an item or service.  The estimate is based on information known at the time the estimate was created.  The Good Faith Estimate does not include any unknown or unexpected costs that may arise during treatment.  You could be charged more if complications or special circumstances occur.  If this happens, federal law allows you to dispute (appeal) the bill.  

The Good Faith Estimate is not a contract and therefore does not require you to obtain the items or services provided by Peak Professional Group, PLLC.  At the foundation of a good therapeutic relationship between client and therapist, is the client's right to autonomy and self-determination.  Therefore, you (as the client or guardian of a minor client) have the right to terminate services at any time.

If you are billed for more than this Good Faith Estimate, you have the right to dispute the bill.

You may contact the health care provider or facility listed to let them know that the billed charges are higher than the Good Faith Estimate.  You can ask them to update the bill to match to Good Faith Estimate, ask to negotiate the bill, or ask if there is financial assistance available.

You may also start a dispute resolution process with the U.S. Department of Health and Human Services (DHHS).  If you choose to use the dispute resolution process, you must start the dispute process within 120 calendar days (about 4months) from the date of service on the original bill.  

There may be a fee associated with using the dispute process charged by the reviewing agency.  

To learn more and get a form to start that process, go to or call 1-800-985-3059.