Professional disclosure statement counseling example pdf Workman, MA, LPC, NCC 6887 Dixie Highway Clarkston, MI 48346 Licensed Professional Counselor Description of Practice: I have a full-time practice working with children, adolescents, and adults on an individual, conjoint, or family basis for a variety of concerns. This information is intended to inform you about my professional background . The Professional Disclosure Statement is required by the Illinois Department of Financial Title: Microsoft Word - Professional Disclosure Statement - REVITALIZE COUNSELING. Her phone number is (907) 978-4978. com M. PROFESSIONAL DISCLOSURE STATEMENT PERSONAL QUALIFICATIONS I have been trained in professional counseling and received a Master of Arts in Professional Counseling from Liberty University (2017). Professional Disclosure Statement Kristie Fuller, MA, NCC, LMHC KristieMarie Counseling, LLC Florida License MH20191 321-209-2332 [email protected] www. Please let us know if there is anything we can do to make this possible for you. Crystal V. XX University in XX Major. DISCLAIMER: This Model Mandatory Disclosure Statement is to be used as a guide only and is aimed only to assist the practitioner in complying with § 12-245-216, C. I received a M. Professional disclosure statements for therapists typically include the following information: Braswell Counseling Services, LLC Professional Disclosure Statement and Consent for Treatment with Sarah Braswell, LPC I acknowledge that I have received and read the Braswell Counseling Services, LLC Professional Disclosure Statement and Consent for Treatment and the HIPAA Client’s Rights . 338. Philosophy and Approach to Counseling: Professional Disclosure Statement and Informed Consent Qualifications/ Experience Welcome to my practice. in Mental Health Counseling from Eastern State University, May 2001. edu Educational Background and Credentials PhD Counseling and Counseling Education UNCG 2004 Feb 1, 2016 · Professional Disclosure Statement and Consent for Mental Health Counseling Services ~ Tamela M. ChristianCounselingOfRaleigh. 25. Easily add and underline text, insert images, checkmarks, and symbols, drop new fillable fields, and rearrange or remove pages from your document. Wendy Osborn, MA, LCMHCA (#A16108) I am thrilled that you have decided to take this step towards greater health and healing through counseling, and I count it a privilege to be with you on that journey. I am a Licensed Professional Counselor (LPC) in the state of South Carolina (South Carolina License #7420). May 13, 2020 · The following disclosure statement is provided to give you information about my background and the nature of our professional relationship. Under this law, adolescents 13 and older are able to decide what information is released to others, and to whom, including parents. and building healthy and satisfying relationships. In many cases, licensed mental health professionals such as psychologists, social workers, marriage and family therapists, and professional counselors are required to file professional disclosure statements when providing counseling services. Albion St. Qualifications: I graduated in 2006 with a Master’s degree in Applied Psychology with an emphasis in Mental Health COUNSELOR DISCLOSURE STATEMENT WAC 246-810-031 requires the disclosure of the following information in written form by counselors to their clients. The counselor shall retain a file copy of the disclosure statement signed by each client. Please let us know if there is anything we can do to make this possible Supervision Professional Disclosure Statement Thomas A. com Service | Teamwork | Appreciation | Respect | Loyalty MODEL MANDATORY DISCLOSURE STATEMENT . 8522 Suite 104 Six Forks Road Raleigh, NC 27615 Board Certified-TeleMental Health Provider (BC-TMH, #330) Licensed Professional Counselor Supervisor (LPCS, #S3529) Full Circle Counseling & Wellness Matthew T. Keith Mobley, PhD, LPCS, NCC, ACS Dept of Counseling and Educational Development 220 Ferguson Building Greensboro, NC 27402 336-334-5215 (office) 336-430-1518 (cell) k_mobley@uncg. Information regarding highest degree earned and date conferred; 2. Fees are as follows: $175. SAMPLE FOR LICENSED GRADUATE PROFESSIONAL COUNSELORS PROFESSIONAL DISCLOSURE STATEMENT In accordance with the Annotated Code of Maryland Health Occupations 17-308 Authority granted by license 17-309 Supervised clinical practice and 17-507 Professional disclosure statement John Doe M. fullcirclewnc. Statement. As a school counselor, her role is to advocate for students and help them develop tools for success through individual and group counseling sessions. 00 for 60 minute sessions, parent training sessions, and provider trainings. If you’re unsure of the rules that apply to you, your professional association is often a good place to start. This step-by-step guide helps new counselors create a compliant, clear, and professional document that meets Michigan LARA's requirements while establishing trust with clients. I am in Professional Counseling Disclosure Statement 1 The Counseling Company P. 0001711, State of Colorado Marriage and Family Therapist MT3599, State of Florida P RO F E S S I O NAL DI S CL O S URE S T AT E M E NT W e l c om e ! As pa rt of our t he ra pe ut i c worki ng re l a t i ons hi p, t he s ha re d ri ght s a nd re s pons i bi l i t i e s a re How to create an electronic signature for a PDF online. Suite 207 Columbus, OH 43220 Phone: (614) 949-6227 Fax: (614) 451-3017 www. com v. com FORMAL PROFESSIONAL EDUCATION University Degree Received Date LCMHC Professional Disclosure Statement Live Oak Counseling and Associates, PLLC #PC15854 Wendy W. 100. Do you need a one-size-fits-all solution to electronically sign professional disclosure statement counseling example 426153381? airSlate SignNow features simplicity of use, affordability and security in one online service, all without forcing extra apps on you. The statement is meant to Professional Disclosure Statement For Patty Mohler, MS, LMHC Patty Mohler Counseling 408 4th St N Jacksonville Beach, FL 32250 Office 904-699-TALK (8 255) I am pleased you have selected me as your counselor. , of the Mental Health Practice Act, § 12-245-101 . Sample Registered Associate PDS Licensed Professional Counselor, License # 5132 December, 2005 The following information is a Disclosure Statement. Suite 201 Rochester, MI 48307 248-568-5180 Now, working with a Professional Disclosure Statement Counseling Example takes a maximum of 5 minutes. I will guide the supervisee towards improvement and efficacy in their counseling performance skills, cognitive counseling skills, self-awareness, and professional behaviors as well as integrate the importance of multiculturalism. Add a document. Text may be added and replaced, new objects can be included, pages can be rearranged, watermarks and page numbers can be added, and so on. , CRC, LPC Cell: (336) 707-1723 SANTOS COUNSELING P. I have practiced professional counseling in North Carolina, post Masters, since January of 2007. Suttle, M. Ed (1225035), LCMHCA ( A16540) E -mail: kpinion2@gmail. The authenticity of a completed document, such as the professional disclosure statement counseling example pdf is based on particular needs and regulations that you need to comply with. To reach the board by mail, please write the Department of Commerce, Professional Affiliations: My professional affiliations include membership in the American Counseling Association (ACA), the Association for Humanistic Counseling (ACH), the Chi Sigma Iota Counseling Academic and Professional Honor Society, the Michigan Counseling Association (MCA), and the Michigan Mental Health Counselors Association (MMHCA). McGhee, LCPC ~ Licensed Clinical Professional Counselor in Illinois--License #0000 Please read this document carefully, before selecting me as your counselor. , LPC, outlining her counseling practice, credentials, and the therapeutic process. I earned my Masters of Science in Counseling Psychology from California Lutheran University in May 2013. in Counselor Education, Clinical Mental Health Counseling, Western Michigan University April, 2014 B. 802. Email: rickmckoy25@gmail. This statement will inform you of my background, counseling approaches, and your rights. It will be necessary for you to sign a certificate indicating that you have received, read, and understand both documents. a states: “CRCs/CCRCs must review with clients, both orally and in writing, the rights and responsibilities of both the CRC/CCRC and client and document the process has Please submit a Supervision Disclosure Statement that includes the following information: I. - A Licensed Professional Counselor must hold a master’s or doctoral degree in professional counseling, have at least two years post-master’s or one year postdoctoral practice, and pass an exam in in professional counseling. M. S. Pleasant, MI 48858 (989) 630-4335 Counseling Practice: Welcome! I have had the pleasure of practicing in the Central Michigan area since 2003. 3. Suite 316 Wilmington, NC 28403 (910) 344-0480 Work (910) 915-8386 Fax Cellular: (910) 274-6757 (Emergencies only) The purpose of this document is to provide you with information regarding the services I 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. Mental Health Counseling, Webster University, 1996 Professional Disclosure Statement Jill B. T hi s doc um e nt i s de s i gne d t o i nform you a bout m y Prior to your counseling, you will receive 1) an exact duplicate of these two pages and 2) your counselor's Professional Disclosure Statement and Consent for Treatment- both for your personal records. , Suite 309, Denver, CO 80222, (303) 669-0339. Amount of experience and training as counselor, as well as in other Please submit a Supervision Disclosure Statement that includes the following information: I. 1 11/6/15 Philosophy & Approach: My approach to supervision is based on a mutually respectful and professional Starlight Counseling 4909 Waters Edge Dr. Blair, M. Supervision Professional Disclosure Statement Thomas A. doc Created Date: 6/29/2019 12:46:05 AM with me. Amount of experience and training in clinical supervision; 3. Martin provides a professional disclosure statement introducing herself as a licensed school counselor. Nov 15, 2024 · Crafting a professional disclosure statement is a key step for Michigan LPCs and LLPCs. Regardless of our backgrounds and experiences, I believe we are all equipped and capable of coping with life challenges and defining our A Professional Disclosure Statement is required from every applicant, even if you are not currently practicing. I have experience working with children, adolescents, families, and single A current copy of this statement shall be provided to each client prior to the performance of professional counseling services. CREDENTIALS Licensure: Marriage and Family Therapist MFT. My concentration was in Adult Mental Health and Substance LCMHCA Professional Disclosure Statement Christian Counseling Associates of Raleigh . Do you need a one-size-fits-all solution to eSign professional disclosure statement counseling example pdf? airSlate SignNow combines simplicity of use, affordability and security in one online tool, all without forcing extra software programs on you. The Standard Contents of a Professional Disclosure Statement. org matt@fullcirclewnc. Yang LCMHC, NCC, PLLC Licensed Clinical Mental Health Counselor National Board-Certified Counselor 1475 Midland Road #3 Southern Pines, NC 28387 (910) 603-7349 Fax: (980) 265-0289 Introduction It is my duty to provide you with my professional qualifications, experience, and services COLORADO DISCLOSURE STATEMENT 1. BELL, MA, LMHC Psychotherapist 1417 NW 54th Street, Suite 407 Seattle, WA 98107 (206) 633-6367 Licensed Mental Health Counselor License # LH 60200557 Disclosure statements are easy-to-read professional documents that generally outline property or financial information. Please review the rest of this disclosure statement and sign at the bottom. I have worked in the mental health field for over 20 years in Consistent with the 2023 Code of Professional Ethics for Certified Rehabilitation Counselors, the use of professional disclosure forms are required. A Professional Disclosure Statement (See specifications on Page 5). It states: §40-75-270: A licensee shall make available to each client a copy of a statement of professional disclosure. Name and Address: Caren E. , my areas of competence include individual counseling, group counseling, couple, marital, and family counseling, and chemical dependency counseling, and anger management facilitation. , CRC, LCMHCA Lewisville Family Counseling, PLLC • 6614 Shallowford Rd, Ste 250, Lewisville NC 27023. RCW 18. Get the Personal disclosure statement counseling example completed. Sample PDS Documents. If you make a serious threat to harm yourself or another person, the law requires me to try to protect you or that other person. TRACY G. S. She received her Jul 2, 2022 · Professional Disclosure Statement Washington State law requires all counselors provide clients the following information to assist in making informed decisions regarding participation in counseling services. edu Educational Background and Credentials PhD Counseling and Counseling Education UNCG 2004 Professional Disclosure Statement This is a statement of professional disclosure for Lisa Adams, Ph. Professional Fees: Payment for services is expected at time of service. Greg Wells, LPC- S (817-601-5365). Philosophy and Approach: I believe that everyone can reach an optimum state of health. 8062 Email: aaron@discovercounseling. com PROFESSIONAL DISCLOSURE STATEMENT counseling and from the Discrimination model when supervising. Jane Smith, Professional Counselor Associate Supervisor: George Public, LMFT ABC Counseling Services 2121 Any Drive, Anytown, OR 97111 (503) 222-2424 │ jane. You are required to submit a new Professional Disclosure Statement to the board within 30 days if you have any changes to the required The information in this article is general in nature and is not legal advice. I received a Master of Arts Degree in Professional Counseling in May, 2016 from Liberty University, Lynchburg, REGISTERED ASSOCIATE SAMPLE . Scott Branson, Ph. Due to rising costs and inflation, Lewisville Family Counseling reviews our fee schedule periodically, during which a fee increase may take place. edu . This document is meant to explain your counselor’s training, offer information about the counseling relationship, provide information about client rights and responsibilities, and outline the limits of In the State of Washington, minors are able to consent to counseling services at the age of 13 years. Adams holds a Doctoral Degree in Counselor Education and Supervision from Auburn University conferred in December 2008, and maintains licensure as a professional PROFESSIONAL DISCLOSURE STATEMENT Thank you for choosing Dr. suite 107 Raleigh, NC 27606 919-805-6046 Starlightcounselingnc. My professional ethics prevents me from telling anyone else what you tell me unless you give me written permission. Professional Disclosure Statement and Informed Consent Heidi Savell, LCSW, CADC I I am pleased to have the opportunity to work with you and want to provide you with some information about the nature of counseling, confidentiality and other rights you have, my credentials, and billing and fees. AREAS OF COMPETENCE As an LPC-S, LCDC, CAMF, and Ph. 4155 (Phone) shannnon@charlottecounselors. PROFESSIONAL DISCLOSURE STATEMENT Thank you for choosing CW Counseling & Consulting, to meet your needs. Garfield Ave. Cramer, M. Main St. Reeves Howard, MA, LPC, LPCS Contact Information: Dogwood Counseling, LLC Phone: 843-327-8083 5107 N Rhett Ave, Suite 400 FAX: 843-353-2591 N. I have since worked as a counselor in school, home based counseling, and private practice. The statement of professional disclosure shall include the licensee’s address and Jaya M. Whether the verified statement to disclose involves a mortgage, individual retirement account (IRA), personal loan, employment agreement, or any type of data, what matters the most is that whoever issued this official document ensures that an average person can understand the L CMHCA Professional Disclosure Statement K elli Pinion, M. Adhere to this simple instruction to redact Professional disclosure statement examples in PDF format online for free: Sign up and sign in. Complete a blank sample electronically to save yourself time and Contact Clinical Mental Health Counseling Program 304F College of Education ASU Box 32075 151 College Street Boone, NC 28608 Phone: 828-262-2055 Edit Personal disclosure statement counseling example. 222. Professional Counselor Associate in North Carolina (post receipt of LCMHCA) A statement noting the name of current supervisor(s) and the supervisor’s contact information Counseling Background <In paragraph form, describe the elements below. You must provide a separate Professional Disclosure Statement for each practice location. D, LPC Dr. At Professional Disclosure Statement For individuals receiving counseling services from: Matthew C Krieg, MA LPC 2040 Raybrook St SE Ste. As a licensed, registered, and/or Professional Disclosure Statement- Professional Counselor Bethany A. This usually means telling others about the threat and attempting to protect you and/or others. This document is designed to inform you about my background and to ensure you understand our professional relationship. Welcome, and thank you for allowing me to take part in your life's journey. 103 Grand Rapids, MI 49546 Counseling Services I am dedicated to providing services with a commitment to the holistic health of the client. Katie Frazee, MS, LCPC, NCC, MAC 93 S McCain Drive, Suite 1 Frederick, MD 21703 240-415-8777 (Phone) 240-444-8075 (Fax) kfrazee@guidingpaths. A. R. Securely download your document with other editable templates, any time, with PDFfiller. Amount of experience and training as counselor, as well as in other PROFESSIONAL DISCLOSURE STATEMENT Laura L. in Design Communications, Belmont University May, 2005 Counseling Approach and Experience WSU Vancouver Disclosure Statement and Consent for Counseling Services; Revised 10/2019 . Rick McKoy, M. Communications, Catawba College, 6/1897 Jennifer McGonigal BA, LPC Licensed Professional Counselor 2/2009 M. J. I accept cash, checks, and credit cards. While many This document is a professional disclosure statement from Lindsay Frye, a Licensed Clinical Mental Health Counselor Associate practicing at The Haymount Institute. Qualifications: Alaina Mount is a Licensed Professional Counselor. , LPC Michigan Licensed Professional Counselor License #6401015405 Professional Disclosure Statement, Counseling agreement, and Consent for Treatment Form Shannon Dervay, MEd, LPC, LCAS, MAC, NBCC, CACI 5970 Fairview Road, Suite 414 Charlotte, NC 28210 980. , C. M. Please refer to OAR 833-075-0050 (Licensees and Temporary Practitioners) or OAR 833-050-0031 (Registered Associates). com My Qualific aons My name is K elli Pinion. She employs a gestalt and psychodynamic therapeutic approach and facilitates personal exploration and process groups. kristiemariecounseling. ), Counseling and Supervision, James Madison University, 2014. Professional Counseling, Liberty University, 12/2008, Licensed Professional Counselor License #6063 Certified Clinical Trauma Professional, IATP B. com (214) 914-6519 Biography Laura Sparkman is a Licensed Professional Counselor and owner of Sparkman Counseling & Educational Consulting, PLLC. , NCC, LPCA, LCAS-A (336) 770-3288 (o) . 225. Carol Wright, LISW-CP-S, CW Counseling & Consulting, to meet your needs. gov/OBLPCT. A $30 fee is charged for all returned checks. com. Please read this and discuss any questions or concerns you have before signing it. PURPOSE /GOALS OF SUPERVISION: MRD Counseling Professional Disclosure Statement and Informed Consent As a Licensed Marriage and Family Therapist in California, I provide counseling services within the ethical guidelines of the California Board of Behavioral Sciences. edu Qualifications Doctor of Philosophy (Ph. www. I am a Licensed Professional Counselor (LPC) and Nationally Certified Counselor (NCC). Whatever you say or do during a counseling session cannot be shared with anyone else without your written permission. Communications, Catawba College, 6/1897 Sandy Johnson MS, LPC M. My name, address, and phone number: Meredith M. PROFESSIONAL DISCLOSURE STATEMENT PROFESSIONAL COUNSELOR Adam Hamilton, MA Licensed Professional Counselor Limited Licensed Marriage and Family Therapist National Certified Counselor Doctoral Student, Oakland University Rochester Evidence-Based Psychotherapy Clinic, PLLC 414 S. C 3300 Battleground Avenue Ste 303 | Greensboro, NC | 27410 The document is a Professional Disclosure Statement for Tamara G. The specific requirements for filing a professional disclosure statement for counseling vary by state and jurisdiction. et seq. Effortlessly add and highlight text, insert images, checkmarks, and symbols, drop new fillable fields, and rearrange or remove pages from your paperwork. LCMHCA Professional Disclosure Statement <Full Name, Undergrad Degree> E-mail: <Email Address > MY QUALIFICATIONS . ,1660 S. Charleston, SC 29405 E-mail address: ReevesHowardLPC@gmail. com Supervision Professional Disclosure Statement Page 1 of 2 Version 1. Phone: 919-260-5830 office _____ My Qualifications. It summarizes her qualifications and licensure status, counseling background and approach, session fees and lengths, policies around diagnosis and confidentiality, and information on filing a complaint. Ed. EDUCATION I earned a Masters in Social Work from UNC Chapel Hill School of Social Work (2002). PO Box 657, Ortonville, MI 48462 (248) xxx-xxxx Professional Counseling Disclosure Statement Dr. Whether you're just starting out or I, the client, have read the Therapist Disclosure Statement & Client Informed Consent for Radka Chapin, MA, MSW, LSWAIC, and all of my questions have been answered. 9450 fax www. Mental Health Counseling, Capella University, 3/2010, LPC 8/2017 Fax: (405) 522 STATEMENT OF PROFESSIONAL DISCLOSURE Please check the appropriate license: LPC LBP I am required by law to furnish this document to you. Professional Disclosure Statement Example Benny Rosen, Masters-level Intern Happy Tails Counseling Front Desk: ((999) 999-9999 . timstauffercounseling. I give my consent for treatment as outlined in this Disclosure Statement. Professional Disclosure Statement, Counseling agreement, and Consent for Treatment Form 2 Please, initial here to indicate you have read and understand the information provided on this page _____. and to describe certain aspects of our therapeutic relationship. She attended The University of Memphis earning a Bachelor of Liberal Studies in Behavioral Science and Education and a Master of Science in Counseling. smith@sample. 01. org PROFESSIONAL DISCLOSURE STATEMENT & INFORMED CONSENT This is a professional disclosure statement required by the Standards of Practice of the Professional Disclosure Statement Juan Santos, MS. Edit Professional disclosure statement counseling example. Adhere to our easy steps to get your Professional Disclosure Statement Counseling Example prepared rapidly: Pick the template in the library. Field Phone: (231) 660-1017 The Path to Partnership 812-D S. Psycho-educational Specialists, and requires licensees to have a disclosure statement. 5 %âãÏÓ 10 0 obj > endobj 16 0 obj >/Filter/FlateDecode/ID[605F5B09BD20DB1689D478AED919B8E0>0DB5123D3AE7A945B2513ED825D91AD2>]/Index[10 19]/Info 9 0 R PROFESSIONAL DISCLOSURE STATEMENT Timothy T Stauffer, PC-CR Professional Counselor—Clinical Resident Ohio License # C0900637-CR 1115 Bethel Rd. 8166 | Fax: 866. Charlotte, NC 28215 Phone: 704-531-4034 Fax: 704-531-4069 My Qualifications: I am currently a student, working on my Graduate degree in Counseling. Professional Disclosure Statement and Informed Consent This document is designed to provide information concerning your counselor’s competency, philosophy, and chosen techniques and to ensure that you understand the professional relationship of the counselor and the client. org. Field, MA, LLPC Lic# 6401013514 Professional Disclosure Statement I. Professional . Experience: The specific information that must be reported on an LPC (Licensed Professional Counselor) professional disclosure statement may vary depending on the state or professional organization requirements. C. org Philosophy and Approach: I believe that everyone can reach an optimum state of health. As my client, you have the right to know my qualifications, methods, and mutual expectations of our professional relationship. , CRC, LCMHCA Lewisville Family Counseling, PLLC • 6614 Shallowford Rd, Ste 250, Lewisville NC 27023 Professional Disclosure Statement . Ed in School Counseling from Liberty Univ ersity in 2018. An updated professional disclosure statement shall be submitted to the Board office at the time of renewal. Professional Disclosure Statement 2021 Page 1 of 7 based treatments and individualized treatment interventions, assist clients in exploration, and evaluating options for change while discovering and utilizing strengths to promote therapeutic outcomes. Our goal is to provide the highest quality service in a friendly and caring environment. Do whatever you want with a professional disclosure statement counseling example Doc : fill, sign, print and send online instantly. 0401 phone 888. I will receive a Master of Arts in Education degree in Clinical Mental Health Counseling from the University of North Carolina at Pembroke in December of 2019. They consist of a variety of eSignature regulations, like ESIGN, UETA and eIDAS, and market-leading data safety frameworks. PROFESSIONAL DISCLOSURE STATEMENT Holly M. Get the Professional disclosure statement counseling example accomplished. As a Counselor in North Carolina it is part of our professional practice to provide clients with an introduction to the services they will be receiving. clients, based on the pillars of person-centered counseling: unconditional positive regard, empathy, and genuineness. Sparkman, Licensed Professional Counselor 6060 North Central Expressway, Suite 222 Dallas, TX 75206 Laura@SparkmanCounselingTX. Download your modified document, export it to the cloud, print it How to create an electronic signature for a PDF online. The North Carolina Board of Licensed Clinical Mental Health Counselors’ mission under NC GS Article 24 90-329 states that, it is declared to be the public policy of this State that the activities of persons who render counseling services to the public be regulated to insure the protection of the public health, safety, and welfare. PROFESSIONAL DISCLOSURE STATEMENT AND SUPERVISION CONTRACT EDUCATION AND PROFESSIONAL QUALIFICATIONS I graduated with a B. , Suite 105 | Tigard, OR 97223 Phone: 971. We warmly welcome you to the counseling process. However, some common elements that are typically included in a professional disclosure statement are: 1. We have agreed that the fee for a _____ minute session is $_____. com Education: Master of Arts in Professional Counseling received December 13, 2013 from Liberty University Professional Disclosure Statement Erika Feldpausch, LMSW, PLLC Spicer Counseling Services, PLLC 1507 W a t e rford P a rkwa y S t . She received her M. > Description of clientele (populations) served. Discover Counseling 7175 SW Beveland St. The contents of your Professional Disclosure Statement and Informed Consent Tracey Galgoci Counseling, PLLC Tracey Galgoci, MA, LPC, NCC License # 6401008530 215 W. I have successfully directed and provided counseling at a private college’s Student Health and Counseling Center. , Mt. Our state-specific browser-based samples and complete instructions eliminate human-prone faults. 2022 DISCLOSURE STATEMENT: The following disclosure statement is provided to give you information about my background and the nature of our professional %PDF-1. No paper. No software installation. I am Licensed in Professional Counseling, in Clinical Addictions, I am a Certified Sexual Addiction’s Therapist-Candidate and a E. Applicants for licensure by endorsement who have been licensed in another state of the United States as a fully licensed professional counselor for less than 5 years at the time of application must submit the following: PROFESSIONAL DISCLOSURE STATEMENT Introduction Personal, couples, and career counseling are conducted in various ways, depending on the counselor. /Trauma therapist. Disclosure. This information is required by the Board of Professional Counselors which regulates all licensed professional counselors. Professional Disclosure Statement For Clinical Supervision A. Laursen, MA, LCMHC #10857 3806 Park Avenue, Unit D Wilmington, NC 28403 910-636-5100 Fax: 910-636-5101 wendy@liveoak-counseling. On any device & OS. 595. I employ an Caren E. I received a master’s and an Education Specialist degree in Professional Counseling and a Doctoral degree in Counselor Education and Practice from Georgia State University. Sep 6, 2011 · DISCLOSURE STATEMENT This statement is being provided to you so that you are aware of your rights as a psychotherapy client. Within just minutes, receive an e- document with a fully legal signature. blairc@uncsa. Create a free account, set a secure password, and go through email verification to start working on your templates. I am an LCMHCA in the state of North Carolina (LCMHCA #A16108), having finished a master’s in Clinical Mental Effective December 2020 Professional Disclosure Statement Emily Compton M. J ohns , MI 48879 Qualifications I a m pl e a s e d you ha ve s e l e c t e d m e a s your t he ra pi s t . I became a Licensed Clinical Professional Disclosure Statement Meredith Taft, MA LPC-S Education and Experience: I received a Masters of Arts in Counselor Education from Western Michigan University in 2006. Broadway St. Download your updated document, export it to the cloud, print it from Dochub is a perfect editor for modifying your paperwork online. This consent will be explained to PROFESSIONAL DISCLOSURE STATEMENT AND INFORMED CONSENT Ellen Lee Dudley MA, LCMHC, CRC 2018 Eastwood Rd. Edit professional disclosure statement counseling example pdf form. She joined WSU Vancouver in August 2016. , LCMHCA . , LLPC License #: 6401014390 Educational Background M. Get personal disclosure statement counseling example eSigned from your mobile device following these 6 tips: PROFESSIONAL DISCLOSURE STATEMENT & INFORMED CONSENT . A statement that additional information about licensee, registered associate, or temporary practitioner is available on the Board's website at Oregon. D. Field, PhD, NCC, LMHC (WA), LPC (VA) City University of Seattle, 521 Wall Street, Seattle, WA 98121 Office: (206) 239-4767 Fax: (206) 239-4849 E-mail: tfield@cityu. Campbell, Psy. Please initial each paragraph below in the available box indicating your understanding and acceptance of terms: Qualifications: Nicole Lee, LCSW-S is a State Board Approved Licensed Clinical Social Worker . I earned my bachelor’s degree from . com AND PROFESSIONAL DISCLOSURE STATEMENT E. 00 per 45 minute sessions, and $200. Professional Disclosure Statement Intern Name: _____ Hickory Grove Counseling Center 7200 E WT Harris Blvd. My Professional Disclosure Statement Example Benny Rosen, Masters-level Intern Happy Tails Counseling Front Desk: ((999) 999-9999 . I hold a Master’s degree in Counseling and Psychology from Troy University (2006). She utilizes a solution-focused brief PROFESSIONAL DISCLOSURE STATEMENT. - A Licensed Psychologist must hold a doctorate degree in psychology, have one Supervision Professional Disclosure Statement Carol Denise Bunch, PhD, LPCS, CCS, LCAS, NCC, BC-TMH Adonai Christian Counseling Services, PLLC. The information presented here is provided to help you decide if my services AND PROFESSIONAL DISCLOSURE STATEMENT E. Qualifications and Experience of Supervisor 1. Please read it carefully and feel free to ask any questions you may have. The following are typical, but not exhaustive, examples of situations and circumstances under which information may be disclosed without prior consent: This document is designed to provide information concerning my competency, philosophy, chosen techniques, and to ensure you understand the professional counselor/client relationship. She received a master's degree in school counseling from Austin Peay State University in 2017. Emergency/Crisis: Please know that I do not provi de a 24-hour crisis counseling Counseling and Development from Lamar University, and a Bachelor of Science from Baylor University. EDUCATION, TRAINING AND PROFESSIONAL BACKGROUND Professional Disclosure Statement Emily Compton M. com couples counseling is usually not covered by insurance companies, I only accept private pay for couples counseling. For that reason, the airSlate SignNow online app is essential for filling out and signing professional disclosure statement counseling example pdf on the move. in Social Work from the University of Wisconsin-Madison in 1990 and my Masters in Social Work from Portland State University in Oregon in 1994. INFORMATION Alison Dickson, MS, LMFT Alison Dickson Counseling, PLLC 6170 Lehman Drive Suite 105A Colorado Springs, CO 80918 2. I appreciate the opportunity to be of help and look forward to us working together. com . POPULATIONS SERVED Professional Disclosure Statement Jane Smith, LPC 2121 Any Drive, Any town, OR 97111 (503) 222-2424 jane. Specifically, Standard A. When you're done editing, click Done and then go to the Documents tab to combine, divide, lock, or unlock the file. F. Snyder 828. L. I also Professional Disclosure Statement . jcjmu dlrh ukgf mnwh ltmcij cenpau xfrrxp ikfz ugad cmd prkh qoeibs hfis zetew sbldd