Professional Disclosure Statement

Jaya M. Martin
601 College Street
Clarksville, TN 37044
Office: 931-221-6281
Email: jmartin64@my.apsu.edu
With a warm welcome, I would like to thank you for allowing me the opportunity to be
your childs school counselor. I look forward to working with you and your family during our
time together. The purpose of this document is to provide you with information on my
background, my counseling philosophy, the counseling relationship, confidentiality, and inform
you and your child of your rights as a client. Should you have questions, please do not hesitate to
voice any concerns on completion of reviewing this document.
Professional Education & Experience
In May of 2015, I received my Baccalaureate of Science in English with a minor in Womens and
Gender Studies from Austin Peay State University. I also attended graduate school at Austin
Peay, and received my Masters in Arts in School Counseling in May 2017. I have worked closely
with people of all different ages, cultural backgrounds, and belief systems through advocacy
organizations such as the Clothesline Project, Remember My Name, and the Feminist Leadership
Majority Alliance. I have also served as a counselor through summer camp programs.
Licensure & Professional Memberships
I am a Tennessee Licensed School Counselor certified to work with grades K-12. I am also a
member of the American School Counseling Association (ASCA).
Counseling Services
As a school counselor, my main role is to be an advocate for your child by meeting their
individual needs and understanding their unique developmental levels. I am responsible for a
comprehensive school counseling program that engages students and gives them the tools for
success in their future endeavors. I participate in both individual and group counseling, and
collaborate closely with administrators, teachers, and parents so that your child receives the best
learning experience possible. The areas I focus heavily on are emotional awareness, emotional
intelligence, and college readiness.
Theoretical Orientation
I believe counseling is a natural, healthy part of life. I am an empathetic individual who enjoys
helping others reach their full potential through problem solving. I believe strongly in solution
focused brief therapy, which is a goal-directed collaborative approach to counseling. This form
of psychotherapy provides your child the opportunity to examine his or her personal strengths
and skills to handle lifes demands. Through SFBC your child will learn to identify and analyze

solutions to problems rather than simply focusing on the problem; a skill that will help them
during school and throughout their future endeavors.
Session Fees & Length of Services
As a school counselor, there are no fees accompanying counseling services provided to your
child. Counseling sessions will last 25 minutes. I will collaborate with you and your child to
ensure sessions are opportune for every party involved and will not interfere with academic
responsibilities. I do, however, ask that you keep all scheduled appointments and arrive in a
timely manner. Should your child be late, the session will still end at the scheduled time. In the
case of needing to break an appointment, I ask for a cancelation at least 24 hours in advance so
that we can reschedule. Students attending sessions are still held responsible to complete any
work missed in class due to sessions.
Referrals
If I feel at any time that I cannot help your child through my counseling approach, I will refer
them to another professional or program that I believe will more appropriately meet their needs.
As your childs counselor, it is my duty to ensure they have the best experience possible. If I am
for any reason hindering their therapeutic process, I will ensure that they will be placed with
someone more fit to help them. My primary objective is to guarantee your child receives the best
outcome possible, and as a counselor I will always remain open and honest.
Confidentiality
As a counselor I will maintain the confidentiality of information I receive throughout the
counseling relationship. I am mandated by federal law to abide by the code of ethics presented
by the American School Counselor Association (ASCA). I will keep all parties informed on the
purposes, goals, techniques, and rules of procedure under which they will be receiving
counseling. I will also disclose the limits of confidentiality in a developmentally appropriate
manner to students. Both legal guardians and students will have a full understanding of the limits
of confidentiality. There will be times during your childs treatment when it will be necessary to
share information I have obtained with the childs parents or legal guardians. Should this happen,
I will first collaborate with the student on how to proceed with telling their parents, unless I am
in a situation where contacting parents first seems fit. Throughout counseling, all parties
involved with be an active part of the process and kept up to date with progress and goals. There
will be certain circumstances when I am required by law to break confidentiality and ask others
for help. These instances are:
If a child expresses clear plans to cause immediate harm to themselves or others
If a child expresses potential or actual occurrence of abuse or neglect
If mandated by a court of law
Potential Counseling Risks
Confronting emotionally difficult subjects can be a challenging process, however it can also be a
rewarding one. Students may experience heightened emotional feelings due to a session. Along
with feelings of unease, relationships students have with peers or family members may be

affected. While these are painful developments, they are not uncommon and do not mean
counseling is not working. Discomfort is sometimes apart of our journey to a better outcome. I
will work closely with your child in hopes that they share these occurrences with me so that we
will get through them together. Your child may or may not disclose to you the positive or
negative effects either entering, maintaining, or terminating counseling brings. My primary focus
and overall goal is to aid in the process of students achieving greater happiness and contentment
as they work towards their personal, social, and academic goals.
Complaints
Although clients and guardians are encouraged to discuss openly with me any concerns they
have, you may contact my supervisor through the CMCSS website to file a complaint.
Informed Consent:
Upon your request, a copy of this Professional Disclosure Statement will be given to you to keep
for your personal records. I will also keep a copy for my confidential records.
Indicating by your signature below, you have read, understood, and agreed to the provided
information and have had the opportunities to ask questions. By signing this document you are
stating that you have reviewed the policies above and understand the role I will play in your
childs developmental growth and the limits of confidentiality.

Students Signature ________________________________________ Date _________________

Parent/Guardians Signature _________________________________ Date _________________
Counselors Signature ______________________________________ Date ________________