Professional Disclosure Statement
Kristie Fuller, MA, NCC, LMHC
KristieMarie Counseling, LLC
Florida License MH20191
321-209-2332
[email protected]
www.kristiemariecounseling.com
v.01.25.2022
DISCLOSURE STATEMENT:
The following disclosure statement is provided to give you information about my background and the nature of our professional relationship. 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 confidentiality. This document must be signed by the client or by the client’s parent/legal guardian before counseling may begin. Some information contained in this document is clarified further in the additional intake documents you may have already reviewed.
Introduction:
Your counselor is a graduate of the Master of Arts in Mental Health Counseling program at Wake Forest University (WFU). Wake Forest University’s counseling program is accredited by the Council for the Accreditation of Counseling and Related Educational Programs (CACREP) and consists of 60 semester hours of study, including the practicum and internship courses. This program includes training in many areas including the following: counseling theories and practice, human growth and development, diagnosis and treatment of psychopathology, human sexuality, group theories and practice, individual evaluation and assessment, career and lifestyle assessment, research and program evaluation, social and cultural foundations, counseling in community settings, substance abuse, and legal, ethical, and professional standards issues. Your counselor also holds a master’s degree in Psychology from American Public University and a Bachelor’s degree in Liberal Studies from the University of Central Florida.
Your counseling services will be based on a relationship characterized by trust and respect. The counselor and client will work together to both identify goals for counseling and to move toward meeting those goals. The counseling sessions may include an exploration of thoughts, feelings, personal history, communication styles, attitudes and beliefs about self and others, and personal development needs. Some of these experiences may be uncomfortable for some clients. Your counselor is trained primarily to utilize person-centered, mindfulness-based cognitive-behavioral therapy, and wellness approaches in counseling.
Clients have the right to receive counseling in which the individual’s dignity, worth, and uniqueness are respected. Your counselor will provide you with quality informed services that are offered under close supervision. Additionally, however, the success of the counseling relationship depends on your willingness to be open and involved in the process. Individuals who participate in counseling can experience changes in personal views, attitudes, and coping skills. Sometimes those close to you may need time to adjust to the new perspectives and positive behavioral changes that may evolve during your counseling. Finally, clients have the right to receive services that are confidential, with the following exceptions.
Confidentiality:
Confidentiality is a crucial aspect of the professional counselor’s role and is therefore important for the client to understand the limits to this confidentiality.
It is important to clarify the special circumstances where confidentiality cannot be maintained. Confidentiality will conform to state guidelines and the ethical guidelines of the American Counseling Association. All counselors-in-training, their supervisors, and group supervision members will not disclose information except under the following conditions:
Fees & Expectations:
Session fees and length of service shall be determined by the counselor and/or the counseling agency where your counselor is contracted. Your counselor is not contracted with any insurance companies and is self-pay only and does not provide superbills for clients.. The current fees are posted to your counselor's website and can be found online at www.kristiemariecounseling.com/fees–services.html.
Your participation and attendance of each session is very important in order to obtain the greatest benefits of counseling. In addition, your counselor will spend time preparing for your visit to ensure that you have the maximum opportunity for growth in every session. In return, it is expected that if you have a challenge that prevents you from attending an appointment please call the office to reschedule the appointment with a minimum of 24 hours’ notice in order to avoid the cancellation fee.
After the first incident of late cancellation/no show, the client will no longer be able to schedule re-occurring appointments and may lose their “spot” on the calendar. After three incidents, the client may be discharged from the practice. If you have not had contact with your counselor’s office and you fail to show for an appointment, all appointments that may have been scheduled in advance will be removed from the calendar to avoid additional cancellation fees.
Please know that your counselor understands that there may be incidences that arise that make your attendance unavoidable and these will be reviewed on a case-by-case basis.
Payment for services is required the same day as services are rendered. After each session, your counselor will send you an invoice to pay. If a client payment is late more than two times, the client will be required to pay for services at the start of the session.
Intake paperwork and consent forms are required from each client. The client will have until the start of the first session to complete the paperwork on their own and return it to the counselor. If by the start of the first session, the paperwork is incomplete, the session will be coded as an “intake session” and will be spent completing paperwork together, and the client will be charged for the full intake session fee (which is different from the “normal” session fee). If the paperwork cannot be completed, the client will be discharged from the practice.
Boundaries:
Although the session may be very intimate psychologically, it is important for clients to realize that we have a professional relationship. Contact will be limited to the sessions you arrange with me. It is vital for you to know that if the counselor sees you in public, she will protect your confidentiality by greeting you only if you greet her first.
In order to promote a healthy therapeutic relationship certain boundaries and policies have been established to ensure the safety, respect, and independence necessary for growth, nurture and understanding. Once we have entered into the counseling relationship together this will become our priority relationship and all other interactions will become secondary in nature and avoided if they do not directly contribute to the benefits of our therapeutic relationship.
Additionally, it is your counselor's policy to limit the duration of outside contact that is deemed unrelated to counseling such as "running into each other" in public and/or "friending" on Facebook or similar social network sites.
Emergency Contact:
Your counselor may not always be immediately available for contact by phone or email. Please feel free to leave a message and every effort will be made to return your call within 24 hours on weekdays and within 48 hours on weekends. If, for any reason, you feel that you need to speak with someone immediately, please see the emergency resources below:
Termination:
You are free to end, take a break from, or request a referral for treatment at any time. It is encouraged that you discuss your reasons for your decision with your counselor so that sufficient closure can be given to our therapeutic relationship, as well as allow for referrals to be made for treatment options that will best meet your needs. The laws and standards of my profession require that treatment records are kept for a minimum of 7 years. If you wish to see your record
Questions or Concerns:
If you have any questions or concerns, please contact your counselor. Your counselor may be reached directly at (321)-209-2332. You may also choose to email your counselor at [email protected], however, please be aware that your counselor cannot guarantee confidentiality of email communication. If you choose to communicate confidential information with your counselor via email, it will be assumed that you have made an informed decision and your counselor will view it as your agreement to take the risk that email may be intercepted.
Please be aware that email is never an appropriate vehicle of emergency communication. Do not use text, email or voicemail to communicate in a crisis. Please call 911 or Go to the nearest Emergency Room or use the crisis contact numbers listed above.
Although clients are encouraged to discuss any concerns with the counselor, you may file a complaint against the counselor with the organization listed below should you, the client, feel she is in violation of any of these codes of ethics. The Florida Department of Health has the general responsibility of regulating the practice of licensed psychologists, licensed social works, licensed mental health counselors, licensed marriage and family therapists, licensed school psychologists practicing outside the school setting, licensed or certified addiction counselors, and unlicensed interns who practice psychotherapy.
Board of Clinical Social Work, Marriage & Family Therapy, and Mental Health Counseling
Department of Health
4052 Bald Cypress Way, Bin C75
Tallahassee, FL 32399-3290
Phone: 850-245-4339
Email: [email protected]
Website: http://www.floridahealth.gov/licensing-and-regulation/enforcement/index.html
You may obtain a copy of the Code of Ethics from the American Counseling Association at www.counseling.org or by calling 1-800-347-6647
Kristie Fuller, MA, NCC, LMHC
KristieMarie Counseling, LLC
Florida License MH20191
321-209-2332
[email protected]
www.kristiemariecounseling.com
v.01.25.2022
DISCLOSURE STATEMENT:
The following disclosure statement is provided to give you information about my background and the nature of our professional relationship. 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 confidentiality. This document must be signed by the client or by the client’s parent/legal guardian before counseling may begin. Some information contained in this document is clarified further in the additional intake documents you may have already reviewed.
Introduction:
Your counselor is a graduate of the Master of Arts in Mental Health Counseling program at Wake Forest University (WFU). Wake Forest University’s counseling program is accredited by the Council for the Accreditation of Counseling and Related Educational Programs (CACREP) and consists of 60 semester hours of study, including the practicum and internship courses. This program includes training in many areas including the following: counseling theories and practice, human growth and development, diagnosis and treatment of psychopathology, human sexuality, group theories and practice, individual evaluation and assessment, career and lifestyle assessment, research and program evaluation, social and cultural foundations, counseling in community settings, substance abuse, and legal, ethical, and professional standards issues. Your counselor also holds a master’s degree in Psychology from American Public University and a Bachelor’s degree in Liberal Studies from the University of Central Florida.
Your counseling services will be based on a relationship characterized by trust and respect. The counselor and client will work together to both identify goals for counseling and to move toward meeting those goals. The counseling sessions may include an exploration of thoughts, feelings, personal history, communication styles, attitudes and beliefs about self and others, and personal development needs. Some of these experiences may be uncomfortable for some clients. Your counselor is trained primarily to utilize person-centered, mindfulness-based cognitive-behavioral therapy, and wellness approaches in counseling.
Clients have the right to receive counseling in which the individual’s dignity, worth, and uniqueness are respected. Your counselor will provide you with quality informed services that are offered under close supervision. Additionally, however, the success of the counseling relationship depends on your willingness to be open and involved in the process. Individuals who participate in counseling can experience changes in personal views, attitudes, and coping skills. Sometimes those close to you may need time to adjust to the new perspectives and positive behavioral changes that may evolve during your counseling. Finally, clients have the right to receive services that are confidential, with the following exceptions.
Confidentiality:
Confidentiality is a crucial aspect of the professional counselor’s role and is therefore important for the client to understand the limits to this confidentiality.
It is important to clarify the special circumstances where confidentiality cannot be maintained. Confidentiality will conform to state guidelines and the ethical guidelines of the American Counseling Association. All counselors-in-training, their supervisors, and group supervision members will not disclose information except under the following conditions:
- The client or guardian gives written consent to release information to a designated individual or agency;
- The client makes specific violent threats to harm him-or herself or to harm an identifiable victim;
- The counselor and/or their supervisors are named as defendants in a civil, criminal, or disciplinary action arising from the counseling session;
- The counselor receives an authentic subpoena backed by judicial authority that requires the disclosure of information; The counselor has reasonable cause to believe that a child or adult with a disability has suffered abuse or neglect; and
- The counselor may discuss the content of counseling sessions under the direction of a Qualified Supervisor who is held to the same professional standards of confidentiality and its limits.
- The counselor may share your information with other clinicians employed at this site for the purposes of case consultation. This sharing of information will only occur if it presents as beneficial for your development and growth. All clinicians are bound by the governing HIPAA laws and will comply with this confidentiality agreement.
- If you are under eighteen years of age, please be aware that the law may provide your parents the right to examine your treatment records. It is your counselor’s general policy to provide your parents/guardians only with general information about our work together, unless it is felt that there is a high risk that you are being harmed, will seriously harm yourself or will harm someone else. In this case, your parents will be notified of my concern, as well as the appropriate authorities if necessary. Before giving them any information, your counselor will discuss the matter with you, if possible, and do her best to handle any objections you may have with what she is prepared to disclose.
Fees & Expectations:
Session fees and length of service shall be determined by the counselor and/or the counseling agency where your counselor is contracted. Your counselor is not contracted with any insurance companies and is self-pay only and does not provide superbills for clients.. The current fees are posted to your counselor's website and can be found online at www.kristiemariecounseling.com/fees–services.html.
Your participation and attendance of each session is very important in order to obtain the greatest benefits of counseling. In addition, your counselor will spend time preparing for your visit to ensure that you have the maximum opportunity for growth in every session. In return, it is expected that if you have a challenge that prevents you from attending an appointment please call the office to reschedule the appointment with a minimum of 24 hours’ notice in order to avoid the cancellation fee.
After the first incident of late cancellation/no show, the client will no longer be able to schedule re-occurring appointments and may lose their “spot” on the calendar. After three incidents, the client may be discharged from the practice. If you have not had contact with your counselor’s office and you fail to show for an appointment, all appointments that may have been scheduled in advance will be removed from the calendar to avoid additional cancellation fees.
Please know that your counselor understands that there may be incidences that arise that make your attendance unavoidable and these will be reviewed on a case-by-case basis.
Payment for services is required the same day as services are rendered. After each session, your counselor will send you an invoice to pay. If a client payment is late more than two times, the client will be required to pay for services at the start of the session.
Intake paperwork and consent forms are required from each client. The client will have until the start of the first session to complete the paperwork on their own and return it to the counselor. If by the start of the first session, the paperwork is incomplete, the session will be coded as an “intake session” and will be spent completing paperwork together, and the client will be charged for the full intake session fee (which is different from the “normal” session fee). If the paperwork cannot be completed, the client will be discharged from the practice.
Boundaries:
Although the session may be very intimate psychologically, it is important for clients to realize that we have a professional relationship. Contact will be limited to the sessions you arrange with me. It is vital for you to know that if the counselor sees you in public, she will protect your confidentiality by greeting you only if you greet her first.
In order to promote a healthy therapeutic relationship certain boundaries and policies have been established to ensure the safety, respect, and independence necessary for growth, nurture and understanding. Once we have entered into the counseling relationship together this will become our priority relationship and all other interactions will become secondary in nature and avoided if they do not directly contribute to the benefits of our therapeutic relationship.
Additionally, it is your counselor's policy to limit the duration of outside contact that is deemed unrelated to counseling such as "running into each other" in public and/or "friending" on Facebook or similar social network sites.
Emergency Contact:
Your counselor may not always be immediately available for contact by phone or email. Please feel free to leave a message and every effort will be made to return your call within 24 hours on weekdays and within 48 hours on weekends. If, for any reason, you feel that you need to speak with someone immediately, please see the emergency resources below:
- Emergency Service: 911
- Brevard County Crisis Hotline: 211
- National Suicide Prevention Lifeline: 1-800-273-TALK
- National Domestic Violence Hotline: 1-800-799-7233
- Crisis Text Line: text the word “home” to 741741
Termination:
You are free to end, take a break from, or request a referral for treatment at any time. It is encouraged that you discuss your reasons for your decision with your counselor so that sufficient closure can be given to our therapeutic relationship, as well as allow for referrals to be made for treatment options that will best meet your needs. The laws and standards of my profession require that treatment records are kept for a minimum of 7 years. If you wish to see your record
Questions or Concerns:
If you have any questions or concerns, please contact your counselor. Your counselor may be reached directly at (321)-209-2332. You may also choose to email your counselor at [email protected], however, please be aware that your counselor cannot guarantee confidentiality of email communication. If you choose to communicate confidential information with your counselor via email, it will be assumed that you have made an informed decision and your counselor will view it as your agreement to take the risk that email may be intercepted.
Please be aware that email is never an appropriate vehicle of emergency communication. Do not use text, email or voicemail to communicate in a crisis. Please call 911 or Go to the nearest Emergency Room or use the crisis contact numbers listed above.
Although clients are encouraged to discuss any concerns with the counselor, you may file a complaint against the counselor with the organization listed below should you, the client, feel she is in violation of any of these codes of ethics. The Florida Department of Health has the general responsibility of regulating the practice of licensed psychologists, licensed social works, licensed mental health counselors, licensed marriage and family therapists, licensed school psychologists practicing outside the school setting, licensed or certified addiction counselors, and unlicensed interns who practice psychotherapy.
Board of Clinical Social Work, Marriage & Family Therapy, and Mental Health Counseling
Department of Health
4052 Bald Cypress Way, Bin C75
Tallahassee, FL 32399-3290
Phone: 850-245-4339
Email: [email protected]
Website: http://www.floridahealth.gov/licensing-and-regulation/enforcement/index.html
You may obtain a copy of the Code of Ethics from the American Counseling Association at www.counseling.org or by calling 1-800-347-6647
