Updated Pds

Elizabeth Holloway, Wake Forest University
MA Candidate for Clinical Mental Health Counseling

Youth Villages, Family Intervention Specialist
CLIENT DISCLOSURE STATEMENT

(INFORMATION & CONSENT)
The intent of this document is to inform you about my qualifications and to ensure that you
understand our counseling relationship.
I have a B.S in Psychology and a B.A. in Sociology, both from the University of North Carolina
at Charlotte. I am currently in the process of obtaining my Master’s degree from Wake Forest
University in Clinical Mental Health Counseling and expect to graduate in the Fall of 2021.
Following the CACREP guidelines, Wake Forest has based their curriculum on the expectations
needed for accreditation with classes that include: Life Span Development, Research Analysis,
Theories and Models of Counseling, Career Development and Counseling, Cultures and
Counseling, Family Counseling, Group Procedures, Addictions, and more to total over 40 credit
hours earned thus far. Upon graduation, I will be pursuing the requirements necessary to be a
Licensed Professional Counselor in North Carolina.
I have also attended the 2020 North Carolina Association for Play Therapy’s Spring Conference
“Anxiety Disorders and Children of High Conflict Divorce”. The conference included seminars
on Calming Techniques, the Anxiety Cycle, Coping Thoughts, Emotional Vocabulary, Play
Therapy with Anxiety, Tips for Test Taking, Tips for Parents of Anxious Children, Guidelines
for Court Involved Therapy, the Rights of Children, and Custody Issues. In addition, I spent 4
months with Youth Villages as an intern before being hired as a Family Intervention Specialist
with the Intercept program. During my first months with this site, I shadowed programs such as
LifeSet and High Fidelity Wraparound that further cultivated my experience with children and
adolescents in intensive in home therapy settings.
COUNSELING SERVICES AND THEORETICAL APPROACHES

As each counseling relationship is different, I rely on a multisystemic approach to counseling. I
take a holistic approach with each client and account for each individuals culture, biology,
religion, past and present to warrant their progress and create counseling goals that best fit their
needs. I use a collaborative approach that will actively involve you in the decision-making
process of our counseling relationship and create an environment of trust and partnership.
Finally, I also use Person-Centered theory to help guide the sessions and achieve counseling
goals through empathy and unconditional positive regard. Some additional forms of therapy that
I encourage you to practice include bibliotherapy, occasional homework assignments to occur
outside of therapy with reports due the next session, mindfulness, and play therapy for
appropriate ages.
If I am not capable to handle certain situations, such as addiction, a referral or consultation will
be made to ensure you receive the best care. I may also reach out to appropriate supervisors for
further advice on specific situations, if necessary. You will be actively informed of either option
used and your input will be considered before any decisions are made. I will be honest about my
personal limitations in our therapeutic relationship as to prioritize your goals and wellbeing.
Counseling may become uncomfortable at times as you face past trauma or emotions that are
difficult to express every day. I encourage you to think about goals you have in mind before we
begin our counseling relationship, as well as expectations you have for me as a counselor so we
may openly discuss the therapeutic process and what it involves. Honesty about expectations for
all parties involved will foster an environment of trust and open communication and encourage a
beneficial professional relationship for all involved.
CONFIDENTIALITY AND CLIENT RIGHTS

Our sessions will be secured by legal and ethical guidelines that I follow. As a Clinical Mental
Health Counselor, I am obligated to practice confidentiality both morally and legally and
anything you tell me will be protected by those standards. However, in the instance that I believe
you are going to harm yourself or another person or there is abuse or neglect of a child or
geriatric, I may not be able to guarantee such confidentiality. In the rare instance I am
subpoenaed by a court of law, your records may be released. You have access to your records
and are encouraged to take part in the creation of counseling plans throughout our professional
relationship. Your consent and knowledge will be needed before the release of any of your
information, if necessary in another scenario not listed. You also have the right to refuse
diagnoses, services, or modality change. Please know that refusal may lead to consequences
relative to the circumstance. If group, family, or couples counseling were to occur for any
reason, my loyalty for confidentiality would be to the group as a whole without betraying
individual confidentiality.
CONTINUATION OF SERVICES
In the event that I need to take an unforeseen leave of absence, you need me while I am away, or
in the event of my death or incapacitation, your counseling relationship will be transferred to a
colleague best suited to your needs. They will ensure that our counseling plan remains
unbothered and that growth will continue. If you wish to continue counseling with another
counselor of your choice, you may also do so. If I am unreachable for any reason, you will be
given the contact information of another counselor who may temporarily be of service until I am
able to reach out. You may refuse this service but please acknowledge when the situation is
severe enough to contact emergency services and I will contact you as soon as I am able.
TECHNOLOGY
As an intern and graduate student of Wake Forest, I am required to voice record sessions for
credit. This is necessary for my professional growth and to ensure you are receiving the best care
possible. These video recordings may be listened to an onsite supervisor, Kenya Logan , as well
as an academic supervisor from Wake Forest, Holly Kayler Sopko; both supervisor’s contact
information is listed below. There will also be times that I share these recordings with fellow
students who are also counselors-in-training. In these events, no personal information such as
your name or any demographics that are identifiable will be shared. As always, your safety and
confidentiality will be upheld by moral and legal obligations.
Telehealth counseling may take place due to COVID 19 restrictions. At this time this is the safest
option for both counselor and client to maintain social distancing or isolation, if possible. With
this pandemic, and for any unforeseen reasons we may need to utilize telehealth services in the
future, your confidentiality is maintained and permission given by form is required before
sessions. I acknowledge that electronic record keeping may be more vulnerable than paper
records, this may result in authorized or unauthorized access. I will ensure there are security
measures in place, such as encrypted messages, to maintain your protection and privacy. As the
standard in one on one counseling sessions, I will be alone during these telehealth sessions and
far from earshot of others. I encourage you to be situated in a place that you may speak openly
without fear or shame. If you are unable to make such an accommodation, we will further discuss
options so you may feel comfortable and all integrity may be maintained. Prior to telehealth
sessions, a form is required
LENGTH OF SESSIONS
To maintain professional standards, time limits are enforced. An individual session will typically
last 2 hours and I will provide a ten-minute warning before our session ends so there is time to
recall the session. If you feel that your session was stopped at an inappropriate time, please
understand that we will continue at your next session. If you are unable to make your
appointment, please give a notice of 24 hours or more so schedules can appropriately be adjusted
for other clients in need. If you do not show up for session 15 minutes after the allotted time, you
will be counted as a no-show. After 3 no-shows, you will receive a letter that you will no longer
be served by the program.
COMPLAINTS
If you are dissatisfied with your progress, or lack thereof, please let me know as soon as possible.
If you have concerns that you are not comfortable bringing to me, please reach out to my
supervisor Allison Smith at Youth Villages via email Allison.Smith@YouthVillages.org or my
Wake Forest supervisor Dr. Shannon Warden at WardenSP@WFU.edu.
Signing below states that you read, understand, and adhere to the information provided above:
_________________________ _________________________
Elizabeth Holloway, Intern Client’s Signature
_________________________ _________________________
Date Date

Updated Pds

Uploaded by

Copyright:

Available Formats

Updated Pds

Uploaded by

Document Information

Original Title

Copyright

Available Formats

Share this document

Share or Embed Document

Sharing Options

Did you find this document useful?

Is this content inappropriate?

Copyright:

Available Formats

Updated Pds

Uploaded by

Copyright:

Available Formats

Elizabeth Holloway, Wake Forest University

MA Candidate for Clinical Mental Health Counseling

CLIENT DISCLOSURE STATEMENT

COUNSELING SERVICES AND THEORETICAL APPROACHES

CONFIDENTIALITY AND CLIENT RIGHTS

You might also like