TEXAS COUNSELING CENTER Steven L. Lackey, Ph.D.., LPC-S, LCDC, CAMF PROFESSIONAL DISCLOSURE STATEMENT The first four pages of this document are yours to keep If you would like a copy of the signature page, I will provide one for you. It is sometimes referred to as a document of informed consent. in Design Communications, Belmont University May, 2005 Counseling Approach and Experience This document is part of the standards of practice of the North Carolina Board of Licensed Professional Counselors. Professional Disclosure Statement I. Number of years of counseling and supervision experience. in Counselor Education, Clinical Mental Health Counseling, Western Michigan University April, 2014 B.F.A. The Board's mission is to protect the people of Texas by ensuring professional counselors are qualified and competent practitioners. Cathy Weeg, LPC Counseling and Therapy Services Informed Consent/Disclosure Statement 1 Thank you for choosing this practice. Professional Disclosure Statement Example Benny Rosen, Masters-level Intern Happy Tails Counseling Front Desk: ((999) 999-9999 . This information is intended to inform you about my professional background . A license applicant should include a statement indicating that he/she is pursuing licensure as a Licensed Professional Counselor Supervisor in North Carolina. I encourage you to A statement documenting training in supervision and experience in providing supervision. This document is intended to inform you of my policies, state and federal laws, and your rights. Professional Disclosure I believe the counseling experience is one in which there is a personal relationship based on trust within a safe and confidential environment. Texas Board of Licensed Professional Counselors . one who may practice independently as specified in R.S. I moved to Texas in 2010 and . in Design Communications, Belmont University May, 2005 Counseling Approach and Experience Please read this statement prior to our first session. Dr. Holly N. Sawyer, PhD, MS, LPC, CAADC, NCC Licensed Psychotherapist 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. I moved to Texas in 2010 and . Staff Assigned to the Board: Cristina De Luna Board Administrator Scope of Practice . Name and Address: Caren E. Field Phone: (231) 660-1017 The Path to Partnership 812-D S. Garfield Ave. Traverse City, MI 49686 . Terri L. Gonzales, Ph.D, LPC 12700 Preston Rd., Suite 150 Dallas TX 75230 214-702-6572 Terri@prestonplacecounseling.com Professional Disclosure Statement Qualifications: I currently hold a Doctoral degree in community counseling from the University of North Texas with a specialization in Play Therapy. Every applicant for licensure must submit a PDS as part of his or her application. Melissa Alvarado, PhD, LPC-S 11467 Huebner Rd, Suite 251 San Antonio, TX 78230 210-660-7122 PROFESSIONAL DISCLOSURE STATEMENT FOR SUPERVISION I. The Counseling Relationship: Counseling is both a helping relationship and a process of change. Client and Counselor work on identified problems in a collaborative manner. Randy Martin, MA, LPC-S Licensed Professional Counselor-Supervisor 3626 North Hall Street, Suite 530 Dallas, TX 75219 Phone: 214-392-8247 PROFESSIONAL DISCLOSURE STATEMENT AND CLIENT CONSENT FORM Welcome to my practice. Apply to the Texas State Board of Examiners of Professional Counselors for your LPC title. You can find the appropriate form here: Continuing Education and License Renewal You must renew your license every two years. LPC Professional Disclosure Statement <Full Name, Credentials> Office: <Number with Cathy Weeg, LPC Counseling and Therapy Services Informed Consent/Disclosure Statement 1 Thank you for choosing this practice. #180.006306) in Illinois. LPC Professional Disclosure Statement Emma Jackson "E.J." Smith, M.S., NCC, LPC-Intern Supervisor: Alison Pourteau, M.A., LPC-S This document is designed to provide you with information concerning your counselor's competency, . 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. The purpose of a professional disclosure statement is to inform clients about your professional background and the limitations of your professional relationship. Licensed Professional Counselor—any fully licensed person (i.e. It and to describe certain aspects of our therapeutic relationship. Tom Kelley, MA, LMFT ~ Licensed Marriage and Family Therapist. Professional School Counselor Professional Disclosure Statement Philosophy and Approach I believe each student possesses their own personal strengths and assets which contribute to a positive school community. Professional Disclosure Statement Example Benny Rosen, Masters-level Intern Happy Tails Counseling Front Desk: ((999) 999-9999 . Name and Address: Caren E. Field Phone: (231) 660-1017 The Path to Partnership 812-D S. Garfield Ave. Traverse City, MI 49686 . The board establishes qualifications for licensure, as well as the ethical standards to practice as a professional counselor in the state of Texas. in Counselor Education, Clinical Mental Health Counseling, Western Michigan University April, 2014 B.F.A. This document is designed to provide information concerning my competency, philosophy, chosen techniques, and to . PROFESSIONAL DISCLOSURE STATEMENT FOR SHANA COLE, MS, LPC-INTERN Qualifications: In May of 2015, I obtained a Master of Science degree in Rehabilitation Counseling with a specialty in brain injury from the University of North Texas in Denton, Texas. Should you have any questions you may contact Mr. Erber at (231) 886-0808. . Qualifications and Experience I hold a PhD in Counselor Education and Supervision from Texas A&M University- Corpus Christi (2009). His areas of expertise include marriage and family therapy, grief and loss, as well as working with adults and adolescents. Professional Disclosure Licensure; Current; PDS; Pursuant to (21 NCAC 53 .0204), Counselors in North Carolina are mandated to provide a Professional Disclosure Statement "to each client prior to the performance of clinical mental health counseling services.This requirement aligns with the American Counseling Association's Code of Ethics (ACA, 2014) which requires counselors to "review in . Professional Disclosure Statement- Professional Counselor Bethany A. S. Cramer, M.A., LLPC License #: 6401014390 Educational Background M.A. The Board's mission is to protect the people of Texas by ensuring professional counselors are qualified and competent practitioners. This document is intended to inform you of my policies, state and federal laws, and your rights. View Template for LPC Professional Disclosure Statement (Document).doc from RHAB 3900 at University of North Texas. The professional disclosure statement (PDS) is a document that an LPC, LMFT, or registered associate gives to each client that provides information about the licensee/registered associate and their practice. Students also deal with many difficult issues while in high school. You will need to provide the Board with a professional disclosure statement at the time of your application for the LPC title. TEXAS COUNSELING CENTER Steven L. Lackey, Ph.D.., LPC-S, LCDC, CAMF PROFESSIONAL DISCLOSURE STATEMENT The first four pages of this document are yours to keep If you would like a copy of the signature page, I will provide one for you. I am currently pursing licensure as a Licensed Professional Counselor- Supervisor (LPC-S) in . Dr. Holly N. Sawyer, PhD, MS, LPC, CAADC, NCC Licensed Psychotherapist 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. LPC PROFESSIONAL DISCLOSURE STATEMENT This document contains important information, and you are asked to review and retain it for future reference. Please This information is intended to inform you about my professional background . As a limited Licensed Professional Counselor I am under the supervision of Nick Erber, MA LPC ACS. Melissa Alvarado, PhD, LPC-S 11467 Huebner Rd, Suite 251 San Antonio, TX 78230 210-660-7122 PROFESSIONAL DISCLOSURE STATEMENT FOR SUPERVISION I. Should you have any questions you may contact Mr. Erber at (231) 886-0808. . Myron D. Jones, PH.D, LPC-S, LCDC 9535 Forest Lane Suite 288, Dallas, TX 75243 PROFESSIONAL DISCLOSURE STATEMENT Qualifications: Myron Jones is a Licensed Professional Counselor, and a Licensed Chemical Dependency Counselor. Staff Assigned to the Board: Cristina De Luna Board Administrator His areas of expertise include marriage and family therapy, grief and loss, as well as working with adults and adolescents. #180.006306) in Illinois. Terri L. Gonzales, Ph.D, LPC 12700 Preston Rd., Suite 150 Dallas TX 75230 214-702-6572 Terri@prestonplacecounseling.com Professional Disclosure Statement Qualifications: I currently hold a Doctoral degree in community counseling from the University of North Texas with a specialization in Play Therapy. I am also a Certified Sexologist through The American College of Sexologists International. Client and Counselor work on identified problems in a collaborative manner. As a limited Licensed Professional Counselor I am under the supervision of Nick Erber, MA LPC ACS. Professional Disclosure Statement - Tom Kelley, LMFT. Please read it carefully and feel free to ask any questions you may have. Texas Board of Licensed Professional Counselors . LPCS Professional Disclosure Statement Jennifer L Fieldman, LPC Office Location: The Healing House Phone: . 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. Please read it carefully and feel free to ask any questions you may have. (Prior to receiving LCMHCS). LPC Professional Disclosure Statement Emma Jackson "E.J." Smith, M.S., NCC, LPC-Intern Supervisor: Alison Pourteau, M.A., LPC-S This document is designed to provide you with information concerning your counselor's competency, . 7825 SW 36th Ave. Suite 202, Portland, OR 97219. I realize that starting counseling is a major decision and you may have many questions. LPC PROFESSIONAL DISCLOSURE STATEMENT This document contains important information, and you are asked to review and retain it for future reference. LPCA Professional Disclosure Statement Kelsey Domann-Scholz, LPCA, NCC (984) 219-3802 kelseydscounselor@gmail.com Hello and welcome! 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). Please read through the following document in order to better understand the services I provide and what you can 37:1107(A)) who holds oneself out to the public for a fee or other personal gain, by any title or description of services incorporating the words "licensed professional counselor" or any similar term, and who offers to render professional mental health . and to describe certain aspects of our therapeutic relationship. I moved to Texas and I am a Licensed Professional Counselor (LPC #67948) in Texas. I earned my The Department of State Health Services maintains this web page, but the 84th Legislature made structural changes to the Health and Human Services system including transitioning the below DSHS functions to the Texas Medical Board (TMB), the Texas Department of Licensing and Regulation (TDLR), the Texas Behavioral Health Executive Council (BHEC), and the Health and Human Services Commission (HHSC). 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). The LPC-I is the starter license which allows you to accumulate the experience needed to become an LPC. Randy Martin, MA, LPC-S Licensed Professional Counselor-Supervisor 3626 North Hall Street, Suite 530 Dallas, TX 75219 Phone: 214-392-8247 PROFESSIONAL DISCLOSURE STATEMENT AND CLIENT CONSENT FORM Welcome to my practice. Professional Disclosure Statement- Professional Counselor Bethany A. S. Cramer, M.A., LLPC License #: 6401014390 Educational Background M.A. Professional Disclosure Statement I. Who must have a PDS? I moved to Texas and I am a Licensed Professional Counselor (LPC #67948) in Texas. It is important to note that the state you practice in may dictate what must be included in your statement of disclosure. Myron D. Jones, PH.D, LPC-S, LCDC 9535 Forest Lane Suite 288, Dallas, TX 75243 PROFESSIONAL DISCLOSURE STATEMENT Qualifications: Myron Jones is a Licensed Professional Counselor, and a Licensed Chemical Dependency Counselor. My purpose in presenting this personal disclosure statement to you is to acquaint you with both my background and theoretical approach to the counseling process. The board establishes qualifications for licensure, as well as the ethical standards to practice as a professional counselor in the state of Texas. This document (the Agreement) contains important information about my professional services and business policies. This document (the Agreement) contains important information about my professional services and business policies. It Please PROFESSIONAL DISCLOSURE STATEMENT FOR SHANA COLE, MS, LPC-INTERN Qualifications: In May of 2015, I obtained a Master of Science degree in Rehabilitation Counseling with a specialty in brain injury from the University of North Texas in Denton, Texas. This document is designed to provide information concerning my competency, philosophy, chosen techniques, and to . I earned my The professional disclosure statement (PDS) is a document that an LPC, LMFT, or registered associate gives to each client that provides information about the licensee/registered associate and their practice. The Counseling Relationship: Counseling is both a helping relationship and a process of change. I realize that starting counseling is a major decision and you may have many questions. Texas has an entry level as well as a full level of licensure for a total of two levels of licensure. Qualifications and Experience I hold a PhD in Counselor Education and Supervision from Texas A&M University- Corpus Christi (2009). Philosophy and Approach: I work with families, individuals and couples to help facilitate change that they agree is going to be most useful. I am a Licensed Professional Counselor and board supervisor in the State of Texas. I encourage you to The two levels are the Licensed Professional Counselor Intern (LPC-I) and the Licensed Professional Counselor (LPC). LPCS Professional Disclosure Statement Jennifer L Fieldman, LPC Office Location: The Healing House Phone: . I am currently pursing licensure as a Licensed Professional Counselor- Supervisor (LPC-S) in .
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