LPCA Professional Disclosure Statement

Robert Green
Telephone: 336-553-7039

Qualifications/Experience: I have one and one half (1.5) years of counseling experience
through my practicum and internship. My clinical experiences consist of a 600-hour supervised
internship and 200-hours supervised practicum experience at Essential Life Connections in
Winston-Salem, NC.
Restricted Licensure: I am currently pursuing licensure as a Professional Counselor Associate
in North Carolina. Once this license is obtained, I will be under supervision as a Licensed
Professional Counselor Associate (LPCA) in NC. Upon becoming an LPCA, I will practice
under supervision from a Qualified Professional approved by the North Carolina Board of
Licensed Professional Counselors. A contract indicating this supervisory relationship will be on
file with the Board, and I will update this Professional Disclosure statement to reflect this
change.
Counseling Background: My counseling treatment philosophy is based in cognitive behavioral
therapy, and solution-focused therapy. I work with adolescents and adults on a range of
developmental, mental health, and addictions-related concerns. I am qualified to conduct
individual and group counseling. Specific areas of clinical experience include depressive
disorders, bipolar and related disorders, anxiety disorders, trauma, substance-related and
addictive disorders, concerns of adult children of dysfunctional families, gender and adjustment
concerns.

Guiding Philosophy: I believe that clients have within themselves a capacity to learn and grow
from their experiences as they develop more meaningful, healthier, and happier lives. Seeking
counseling can be an initial step towards finding clarity and affirmation of ones self. My role as
a counselor is to help facilitate a non-judgmental professional partnership with clients as we
work together towards that clarity. Counseling may include healing emotional wounds,
addressing coping skills, or simply working towards improving oneself.

Early in the therapeutic work, we will co-create goals based on the concerns brought to
counseling. My therapeutic style is relationally-based, and most of the work will happen in
conversation. When it seems helpful, I may use strengths or values card-sort activities; decisional
balances; anxiety, trauma, depression; a wellness wheel; or other hands-on tools to help clarify
client strengths, goals, and ideas about the world. With any techniques, as with any aspect of
counseling, I will do my best to explain the process and invite your consent and feedback. I am
competent in motivational interviewing, cognitive behavioral therapy, person-centered
counseling, and solution focused counseling.

Session Length & Frequency: Individual sessions are 50 minutes in length, typically at a
frequency of one session per week. If the client requires more or less frequent sessions, client
and counselor will discuss this and come to an arrangement that suits the clients needs and
schedule. Group sessions are typically 90 minutes in length at a rate of one session per week.

Fees & Payment: The fee for a 50-minute individual counseling session is $100. The fee for a
90-minute group counseling session is $70. Payment should be made at the time of services
rendered unless another arrangement is agreed upon by counselor and client prior to beginning
treatment. Cancellations must be made at least 24 hours in advance, otherwise you will be
charged the regular rate per session. Methods of payment accepted include cash or check. At this
time, I do not accept insurance or Medicaid.


Diagnosis: Counseling services begin with a screening and assessment to determine
appropriateness for therapy. A comprehensive clinical assessment is used along with other
factors to establish a mental health or substance abuse diagnosis, and becomes a permanent part
of the client record. Assessment and diagnosis are vital to the accuracy of treatment planning,
and are required for the treatment process to continue. Some health insurance companies will
reimburse clients for counseling services and some will not. In addition, most will require that a
diagnosis of a mental-health condition and indicate that you must have an illness before they will agree
to reimburse you. Some conditions for which people seek counseling do not qualify for reimbursement.
If a qualifying diagnosis is appropriate in your case, I will inform you of the diagnosis before we submit
the diagnosis to the health insurance company.

Disclosures: All information shared during counseling sessions is confidential, with the
following exceptions:
(a) You direct me in writing to disclose information to someone else
(b) It is determined you are a danger to yourself or others (including child or elder abuse)
(c) I am ordered by a court to disclose information.

Complaints: Although clients are encouraged to discuss any concerns with me, you may file a
complaint against me with the organization below should you feel I am in violation of any of
these codes of ethics. I abide by the ACA Code of Ethics
(http://www.counseling.org/Resources/CodeOfEthics/TP/Home/CT2.aspx).


North Carolina Board of Licensed Professional Counselors
PO Box 1369
Garner, NC 27529
Phone: 919.661.0820
Fax: 919.779.5642
E-mail: ncblpc@mgmt4u.com

Acceptance of Terms:


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


Client: ___________________________________________________ Date: ___________

Counselor: ________________________________________________ Date: ___________