Professional Disclosure Statement and Informed Consent

Sean Sandag, Licensed Professional School Counselor, M.A.

Office: ###-###-####
Fax: ###-###-####
E-mail: sean.sandag@gmail.com

Education and Experience

I have a Master of Arts in Counseling with a concentration in school counseling. I earned this
degree from Wake Forest University in Winston-Salem, North Carolina in 2014. This will be my
first year working as an employee in the school system. While earning my degree, I completed a
supervised practicum (5 months) and internship (10 months) in Winston-Salem Forsyth County
Schools.

I am a licensed School Counselor (Standard Professional II, Grades K-12) in North Carolina
(State of North Carolina: State Board of Education/Department of Public Instruction) and
awaiting the results from my National Counselor Examination. After becoming a certified
counselor, I will pursue my license in professional counseling. I have been a member of the Chi
Sigma Iota Counseling Honor Society since 2012.

Counseling Services

As a school counselor, I offer individual counseling, group counseling, and classroom guidance
to students. I collaborate with students, teachers, parents, administrators and community
agencies. I assist parents and teachers regarding academic, social, personal, and career needs of
students.

I accept referrals from students, teachers, parents, and administrators for counseling services.
Sessions are brief, usually lasting 30 minutes or less to limit time out of class. Students in need
of long-term counseling will be referred to outside agencies. Group counseling is composed of
50 minute sessions typically for four to six weeks with six to eight students. Classroom guidance
lessons are 50 minutes.

The foundation of my counseling theoretical orientation is in person-centered counseling. I
believe clients have the strengths to solve their problems, and the relationship between client and
counselor provides a safe place for the client to get unstuck from their problems. I also subscribe
to reality therapy because of its solution-focused nature. I help students evaluate their behavior
and make actions or choices that best satisfy their wants and needs.

There is not a fee associated with any school counseling services provided and therefore
insurance is not required to receive any school counseling services from the school counselor.


Diagnosis

I will not make any clinical diagnosis for a student. It should be known that diagnosis becomes a
part of a clients permanent record. I believe that mental health disorders are the result of a
person behaving in a particular way because it is the best way he or she knows how to deal with
his or her problems. Diagnosis may be helpful in understanding a persons presenting problem.
At times, I may refer to the Diagnosis and Statistical Manual of Mental Disorders 5
th
Edition
(DSM-V) to learn more about the diagnosis of a student.

Confidentiality

All subject matter discussed in counseling sessions and consultations is considered strictly
confidential and will not be shared with anyone else without the clients permission. There are
only three circumstances where confidentiality will be breached. I am legally and ethically
responsible to reports cases in which:
1. Someone is being hurt.
2. Someone is hurting someone else.
3. Someone is hurting himself/herself.
These instances include, but are not limited to, child or elder abuse, neglect, suicidal ideation,
drug abuse, and self-harm. Additionally, information may be shared with a school administrator
if behavior reported is a violation of school policy and must be reported. In group counseling the
expectation of confidentiality is discussed and strongly emphasized as a requirement to
participate. Students are asked to sign a confidentiality agreement. However, there are situations
in which students are tempted to speak about group counseling sessions outside of the group and
breach confidentiality. Confidentiality in group counseling is not guaranteed. Lastly, despite the
subsequent circumstances, I am not legally required to disclose information about a student to his
or her parents, guardians, or the courts. Some information may be helpful for a parent to know,
but I will only disclose this information with a students permission.

Complaint Procedure

I assure you my services will be rendered in a professional manner consistent with accepted
ethical standards and congruent with the American School Counselor Association, American
Counselor Association, and National Board for Certified Counselors. If you are dissatisfied in
any way, please inform me immediately. This will make our working together more efficient
and effective. If you are not satisfied with the results, you may contact the school administrator
(principal). If you think you have been treated unfairly and unethically by me and cannot resolve
the problem with me, you can report the problem to the North Carolina Board for Certified
Counselors. Contact information is provided below.

National Board for Certified Counselors
NBCC
3 Terrace Way
Greensboro, NC 27403
(336) 547-0607





X

Sean Sandag, M.A.



X

Client, I have read and understand the personal disclosure statement and informed consent



X

Parent/Guardian, I have read and understand the personal disclosure statement and informed
consent