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Professional Disclosure Statement Essay

My Qualifications

I received a BA degree in Psychology from Lehman College University at NY in May 2003. I then received a Master of Science degree in Counseling Psychology from Capella University in May 2012. I currently am applying for the License Professional Counselor Associate.

The Counseling Process

People come to counseling because they want something to be different in their lives. They may want to change their personal or family situation, solve a particular problem, or simply bring a healthier balance to their lives. The counseling process can be fun and exciting. It can also, at times, be very challenging, difficult and even painful. However, the goal will always be to bring about some positive change.

Your Rights and Responsibilities

You have the right to ask me to explain my reasons for making certain recommendations or for using certain procedures. You also have the right to refuse to follow these recommendations, and/or to terminate the counseling process at any time and for any reason. I have the right and ethical responsibility to terminate counseling and offer a referral to another counselor if you choose not to follow my recommendations. Either of us may request a final session to discuss the reasons for termination, and to decide on an appropriate referral if desired. Please inform me if you are seeing another counselor or mental health professional during the course of our work together, so that we may provide consistent treatment for you. You have the right to confidentiality in the counseling relationship as described in the next section.


The counseling process is a confidential one. Even when the client is under the age of 18, the details of what happens in therapy cannot leave the session. I will encourage open communication when deemed necessary and will provide parents with guidance and support; however it is counterintuitive to treatment for details of a child/adolescent session, spouse session, etc., to be revealed to other family members. It is also counterintuitive to treatment for a family member to ask a client about the details of a session. There are some circumstances in which confidentiality cannot be maintained. Those situations include when the client is at risk of harm to self or others, when there has been disclosure of abuse and/or neglect, when a court asks for records, or when information disclosed in a session involves criminal activity that must be reported to law enforcement. In all other circumstances, the client or legal guardian must sign consent for release of information to authorize communication with outside parties.

Attendance/Cancellation Policy

Our work can only be effective with commitment and continuity. If you must cancel a scheduled appointment, please inform me no later than 24 hours before the appointment. You will be responsible for payment for any missed appointments, except in the case of personal emergency. Please be on time for your scheduled sessions, as other clients may have appointments with me immediately following yours. Note that if you are late, the session will still end on time, and you will still be responsible for full payment.


I currently accept Medicaid and a small number of private insurances that will be disclosed upon request. In the event that you do not have a form of insurance that is accepted by me, I charge $125 for the intake session and $100/hr for each subsequent 50 minute session (individual, family, and couples). If attending a group, the fee for the entire group will be disclosed prior to intake and payment will be required in full before the second group meeting. In the event that a check is returned unpaid, cash payments will be required. I am unable to accept credit card payments at this time.


If you are not satisfied with my services, I encourage you to express those concerns to me. If you are not satisfied with the response, follow the instructions for filing a complaint with the North Carolina Board for Licensed Professional Counselors at http://www.ncblpc.org/complaints.html.

North Carolina Board of Licensed Professional Counselors
PO Box 1369
Garner, NC 27529
Phone: 919.661.0820
Fax: 919.779.5642
E-mail: [email protected]

Acceptance of Terms

We agree to these terms and will abide by these guidelines.

Client: ___________________________________________________ Date: ___________

Counselor: ________________________________________________ Date: ___________

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