professional disclosure statement school counseling example

Room 337 Education Building, Laramie, Wyoming, 82071 (307) 766-5329 This disclosure statement contains information about my professional services and information about our program. … I am a graduate student counseling intern working in Durham County Public School System. The professional disclosure statement (PDS) is a document that an LPC, LMFT, or registered intern gives to each client that provides information about the licensee/intern and his/her practice. I employ an eclectic approach with a strong reliance on cognitive-behavioral aspects. Jan Poindexter-Cameron, MS, LPC-- Professional Disclosure Statement As a School Counselor at Mount Holly Middle School, I provide counseling services to all students in grades 6-8, primarily serving students with last names beginning A – M. (The other counselor on staff primarily serves students with last names beginning N – Z). Professional Disclosure Statement Jane Smith, LPC. They have also encouraged me to apply to graduate school in counseling. Philosophy and Approach: I believe that everyone can reach an optimum state of health. Licensed Professional Counselor Supervisor Integral Counseling Services, PLLC 1920 Western Trail Chapel Hill, NC 27516 Phone: 919 304-5754 Fax: 919 304-5346 Website: www.integralcounselingservices.com Email: melieber@mebtel.net PROFESSIONAL DISCLOSURE STATEMENT FOR CLINICAL SUPERVISION Thank you for considering me as your clinical supervisor. Professional Disclosure Statement. Professional Disclosure Statement Meredith, MA, LPC-Intern Providing Services at Open Road Counseling Center 3204 Long Prairie Road Suite A-1 Flower Mound, TX 75022 Qualifications and Experience: I am an LPC-Intern that is qualified to counsel adults, adolescents, and children under the supervision of R. Greg Wells, LPC- S (817-601-5365). I am a North Carolina Licensed Clinical Social Worker (#COO5360) with the … Professional Disclosure Statement. Professional Disclosure Statement Janet Adams MS, LPC, LMFT 11107 McCracken Circle Unit D Cypress, Texas 77429 281-772-4562 This document is designed to provide you with information about your counselor and to ensure that you understand the professional relationship of the counselor and the client. Professional Disclosure Statement- Professional Counselor Bethany A. S. Cramer, M.A., LLPC License #: 6401014390 Educational Background M.A. Professional Disclosure Statement Introduction This document is provided to inform you of your rights and responsibilities as a client and to answer general questions you may have about your therapeutic treatment. Counseling Background . Philosophy and Approach: My role as a counselor is to be a facilitator. I am trained as a Child, Couples and Family Therapist in family systems, and licensed to diagnose and treat mental and emotional disorders within the context of marriage, couples and family systems. If you have any questions, please ask your therapist. The feelings of connection in a professional counseling relationship tempt counselors to self-disclose, sometimes without warning. Client comments often spark the urge for self-disclosure. Keeps information confidential unless disclosure is required to prevent clear and imminent danger to the counselee or others or when legal requirements demand that confidential information be revealed. Licenses/Certifications . These feelings could possibly affect the client’s life outside the counseling office. I promise to do my best in ensuring a safe environment where you can discuss openly your experiences, thoughts, concerns, and feelings. This document is designed to tell you about my background and to help you understand our professional relationship. The parallels between psychother­ apy and supervision are clear and the need for informed consent through the use of disclosure statements in psychotherapy is also clear. For example, ... Can compromise the professional relationship – client views the counsellor more as a “friend ” Can move the focus away from the client; Can create role confusion; Client may feel burdened, and so may “hold back” or censor information. Explanation of Counselor Disclosure Statement Counselors are required by Washington state law to provide written disclosure of the following information to clients before counseling begins, and to obtain signed consent to counseling once the client understands the information to their satisfaction. I believe that all families and individuals have within themselves resources and strengths that can promote healthier lives. Crystal V. Blair, M.S., NCC, LPCA, LCAS-A (336) 770-3288 (o) blairc@uncsa.edu . . Client may feel the counsellor is “too involved”. Professional Disclosure Statement for Clinical Supervision Sarah Lorenz, MA, LPC, NCC, CBSP 29193 Northwestern Highway, Suite 770 Southfield, MI 48034 (248) 470-1131 drsarahlorenz@gmail.com LPC #6401011683 | NCC #350372 Qualifications: I have a Masters of Arts in Counselor Education from Wayne State University, in Detroit, Michigan. 2121 Any Drive . (h) The limits of confidentiality under RCW 18.19.180 . Under the Supervision of Kara Carnes-Holt Ph.D. University of Wyoming Counselor Education Department. I completed a Master of Arts in Marriage and … . professional and business policy is essential in establishing a strong and trusting therapeutic relationship. Jan Poindexter-Cameron, MS, LPC-- Professional Disclosure Statement As a school counselor at Mount Holly Middle School, I provide counseling services to all students in grades 6-8, primarily serving students with last names beginning A – M. (The other counselor on staff primarily serves students with last names beginning N – Z.) Who must have a PDS? Professional Disclosure. in Counselor Education, Clinical Mental Health Counseling, Western Michigan University April, 2014 B.F.A. Please correct the errors described below. My ability to be explicit in this regard, and your willingness to discuss any issues of concern with me, will support the work that we do together. PROFESSIONAL DISCLOSURE STATEMENT. National Certified Counselor # 67140. Professional Disclosure Statement I. LPC PROFESSIONAL DISCLOSURE STATEMENT This document contains important information, and you are asked to review and retain it for future reference. How­ Name and Address: Caren E. Field Phone: (231) 660-1017 The Path to Partnership 812-D S. Garfield Ave. Traverse City, MI 49686 II. Please take the time to read and carefully consider the points made. School Counselor Intern . I am required by law to provide … I appreciate the opportunity to be of help and look forward to us working together. Professional Disclosure Statement . A Counselor-Client Contract Jeremy Elsmore. Approved Clinical Supervisor # 406. I hold a Master in Education in Curriculum and Instruction with Digital Learning and teaching from the American College of Education (2015). I also have a Bachelors of Arts degree in History and Secondary Education from Converse College (2009). Licensed Professional Counselor Supervisor (North Carolina) # 4081S. This statement will inform you of my background, counseling approaches, and your rights. I am a National Certified Counselor, and received an … I … Disclosure Statement. She is a licensed clinical professional counselor who specializes in working with clients to address grief and posttraumatic growth. statements. Please read this Disclosure Statement, sign and date the consent for treatment. The “rules” of self-disclosure are a little muddy. I am a student in Lamar University’s School Counseling program. Every applicant for licensure must submit a PDS as part of his or her application. Licensed Professional Counselor Leslie Williams LLC 2304 East Burnside #105 Portland OR 97214 503.720.8758 Professional Disclosure Statement and Informed Consent Welcome, and thank you for choosing me as your provider for counseling services. This document is designed to inform you about my background and to ensure you understand our professional relationship. p. 1 of 3 PROFESSIONAL SUPERVISION DISCLOSURE STATEMENT Sally Supervisor, M.A., PCC Doctoral Student, Counselor Education, The Ohio State University Phone: (614) 292-5555; email: thebestsupervisor@osu.edu As your Internship instructor, I am responsible for the group supervision you receive this quarter. As a counseling intern, I offer services that are aligned with the standards and practices of the American School Counselor Association (ASCA) National Model. This entails developing a plan for meeting your needs. (i) Disclosure of the certified counselor's or certified adviser's supervisory or consultation agreement as … Sample Forms and Templates. Welcome, and thank you for allowing me to take part in your life's journey. b. Counselor in Training. Professional Disclosure Statement and Informed Consent Qualifications/ Experience Welcome to my practice. Professional Disclosure Statement And Consent for Mental Health Counseling Services Cynthia Dowdy, PhD, NCC, LPC National Certified Counselor since 1993- Certificate #31719 Licensed Professional Counselor in North Carolina– License #3694 I invite you to read this prior to selecting me as your counselor. Karmen Brock. example, some clients will experience uncomfortable feelings, and may, for a time, actually feel worse as they begin to work on sensitive areas of their lives or recall unpleasant memories. Client and Counselor work on identified problems in a collaborative manner. Licensed Marriage & Family Therapist (CO #475) Licensed Professional Counselor (CO #3609) Licensed Marriage & Family Therapist (CA #M12992) Certified Addictions Counselor (CAC III) (CO #7096) AAMFT Clinical Supervisor, (AAMFT … The Counseling Relationship: Counseling is both a helping relationship and a process of change. I encourage you to express any concerns or questions you may have at any time. professional school counselor to help with social-emotional growth, academic needs, ... defined to counselees through a written and shared disclosure statement. Qualifications: I earned a masters of arts in Counselor Education: Marriage and Family Therapy from Western Michigan University and a limited license from the State of Michigan in Marriage and Family Therapy. PROFESSIONAL DISCLOSURE STATEMENT For the Comprehensive Secondary School Counselor Program Public school counselors provide a support service program to help empower each student to fully function in society by assisting all students to reach their potential through a life-long learning process. I am currently holding an associate license as a Mental Health Counselor (LMHCA). Anytown, OR 97111 (503) 222-2424. jane.smith@sample.org . Supervision Disclosure Statement Sally Supervisor, M.A. General Information. Capstone Counseling, LLC. Disclosure Statements and Supervision There have been no studies to date that examine the impact of disclosure statements on supervision. In general, we provide academic, career, crisis and short-term brief counseling. (iii) A statement that clients are not liable for any fees or charges for services rendered prior to receipt of the disclosure statement. I have counseling work experience in residential, acute care, community agency, crisis intervention, college counseling clinic and outpatient private practice settings. Clinical Supervision Professional Disclosure Statement Darnell Johnson, M.S. PROFESSIONAL DISCLOSURE STATEMENT JODY BREHM, MS Licensed Professional Counselor Intern Licensed School Counselor 104 N First Street, Suite 8 Silverton, OR 97381 503.949.2031 Professional Disclosure Statement Thank you for choosing me as your counselor. Consistent with the 2017 Code of Professional Ethics for Rehabilitation Counselors, the use of professional disclosure forms are required.Specifically, Standard A.3.a states, "Rehabilitation counselors review with clients, both orally and in writing, the rights and responsibilities of both the rehabilitation counselor and client.

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