Professional Disclosure Statement

Professional Disclosure Statement
Alexander C. Conway, QMHP-A, RMA
Qualifications
I graduated in 2020 from Randolph College with a BA in Psychology and am

currently enrolled in a Clinical Mental Health Counseling program (MEd) at the
University of Lynchburg. I have been licensed in the state of Virginia as a
Qualified Mental Health Professional (QMHP-A) since 2021 (license
#0732009093), permitting me to render behavioral health and adjunct counseling
services to adult clients. I also have been licensed as a Registered Medication Aide
since 2022 (license #0031013868), permitting me to administer medications to
residents of Assisted Living Facilities in Virginia.
Counseling Background
I have five years’ experience in the mental health field, beginning in 2017. I have
worked with adolescents and adults in outpatient, residential, and community
agency settings. My professional and educational background has focused on
providing holistic care for those experiencing addiction and severe mental illness. I
am prepared to provide psychoeducation and skill-development, crisis
stabilization, recreational therapy, and behavioral counseling to individuals and
groups, to provide education to their loved ones, and to communicate progress to
stakeholders.
I believe in a counseling approach that highlights client wellness, not illness.

People seek counseling services for issues that include, but are not limited to:
• Stress and burnout • Grief and loss

• Relationship or family troubles • Significant life changes
• Communication and boundaries • Anxiety, depression, substance use
To help clients resolve such issues, I employ counseling principles and techniques
from multiple theoretical bases, including existential, cognitive-behavioral, reality,
and narrative therapy. Additionally, I believe counseling is most effective when
systems are provided with services (e.g., partners, families, communities), rather
than only individuals. People are social beings, and it is crucial to incorporate
social supports to optimize physical, mental, emotional, spiritual, and occupational
wellness for the individual. Many clients believe, with an unfair perspective, that
they alone are responsible for life’s circumstances. Yet, society needs healing and
wellness in many ways. Developing or healing our inner circles, in conjunction
with healing ourselves, can do much to relieve the psychological pain we
experience as human beings.
If you choose to pursue a counseling relationship with me, we will establish

counseling goals together, and you will set the pace at which you work towards
these goals. We will assess progress toward these goals periodically, and adjust as
needed, to ensure that you are getting the most out of the counseling sessions.
Session Fees and Length of Service
I will render counseling services to you in a manner consistent with professional

expectations. Sessions will last 60 minutes and the price per session is $100,
payable by cash, check, or credit card at the beginning of each session. If you are
eligible for insurance coverage, I will submit this information on your behalf and
you will only be responsible for the co-pay amount determined by your provider.
Use of Diagnosis
I believe that counseling is a wellness-based service, but most insurance companies

only reimburse clients if the counselor determines that the client has an “illness”
requiring treatment. Not all issues for which people seek counseling qualify as
diagnosable “illnesses.” If an eligible diagnosis is appropriate for you, I will
inform you before submitting this information to your insurance company. All
diagnoses will become a part of your permanent medical record.
Confidentiality
All client-counselor communications are a part of your clinical record, accessible

to you upon request. I will maintain confidentiality of this record with the
following exceptions: a) you request, in writing, that I disclose your record, b) it is
determined that you are an immediate danger to yourself or others, c) you disclose
ongoing child or elder abuse, or d) I am ordered by a court to disclose information
(in which case I will work with you, your attorney, and the requesting party to
reach an agreement about the information that must be disclosed). All other
communications between us will remain entirely confidential.
Complaints
I encourage all clients to first discuss complaints with me, the counselor, in the
belief that we can communicate effectively. If this is not possible, if you feel
otherwise, or if you believe that I am in violation of my professional code of ethics,
you may file a complaint with me at the organization below:
Virginia Department of Health Professions, Enforcement Division

Perimeter Center
9960 Maryland Drive, Suite 300
Henrico, VA 23233-1463
Phone: 1-800-533-1560 or (804) 367-4691

Fax: (804) 212-2174
Web: http://www.dhp.virginia.gov/PractitionerResources/Enforcement
Acceptance of Terms
We agree to the above terms and will abide by them.
Client: _______________________________________ Date: __________
Counselor: ____________________________________ Date: __________

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Professional Disclosure Statement

Alexander C. Conway, QMHP-A, RMA

I graduated in 2020 from Randolph College with a BA in Psychology and am

I believe in a counseling approach that highlights client wellness, not illness.

• Stress and burnout • Grief and loss

If you choose to pursue a counseling relationship with me, we will establish

Session Fees and Length of Service

I will render counseling services to you in a manner consistent with professional

I believe that counseling is a wellness-based service, but most insurance companies

All client-counselor communications are a part of your clinical record, accessible

Virginia Department of Health Professions, Enforcement Division

Phone: 1-800-533-1560 or (804) 367-4691

We agree to the above terms and will abide by them.

Client: _____________________________ Date:

Counselor: __________________________ Date:

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