Professional Disclosure Statement Lcmhca

Ashley Hudgens/Wake Forest University
Licensed Clinical Mental Health Counseling Associate

Professional Disclosure Statement
Hello and welcome!
The following document is to help clients better understand the services I provide and
what can be expected from our therapeutic relationship. I want to honor the courage
that it takes to seek counseling services and thank you for coming in today. I look
forward to working together to determine how we can best meet your goals.
Qualifications
I received a B.A. in Psychology, with a minor in Criminal Justice from The University of
North Carolina at Charlotte (2016). I graduated with my Master’s degree in Clinical
Mental Health Counseling at Wake Forest University and have met the requirements to
become a Licensed Clinical Mental Health Counselor Associate in North Carolina as of
April 23rd, 2023. Wake Forest’s Counseling Program upholds The Council for
Accreditation of Counseling and Related Educational Programs (CACREP) guidelines
and standards. I completed my internship at The Center of Creativity and Healing,
under the supervision of Dr. Maria Curran, where I worked with a diverse population
of clients.
Counseling Services Offered/Theoretical Approaches
I view counseling as a collaborative process in which I provide clients with a space to be

open and honest while helping them to identify goals for change. I want to provide the
necessary support that clients need to find the strength and confidence to reach those
desired goals.
I believe that each person is capable of finding personal meaning and purpose in life. I
aim to set up and promote a climate in which you are free and encouraged to explore all
aspects of self in a safe and non-judgmental space. I strongly believe that every
individual is unique, and with that, comes unique concerns. During our interactions,
there may be a variety of theoretical approaches incorporated into treatment and may
include but not be limited to traditional talk therapy, cognitive behavioral therapy,
mindfulness techniques, and more creative approaches such as play therapy or art
supplies. No matter the treatment used, I always uphold the idea of being client-
centered. The client should be in control and feel like they can express anything. My
desire is to facilitate this expression, not to direct it.
Potential Risks
As with many things, there are certain risks with counseling. Counseling has many
benefits but may also pose some emotional risks. It can be challenging to approach
thoughts or feelings that have previously been avoided. Changing thought and
behavioral patterns can be difficult and may not always be welcomed. It is important to
think carefully when considering the risks and benefits of choosing counseling and
accepting the changes in your life. Many people who take these risks find that therapy
is helpful. However, it is your choice whether you deem certain interventions or
changes appropriate for you.
Confidentiality
Trust and privacy are important aspects of a counseling relationship, and I take them
seriously. In general, the privacy of all communications between a patient and a
counselor is protected by law, and I can release information about your work to others
only with your written permission. However, in accordance with ACA and NC ethical
guidelines, there are a few exceptions:
 You give written permission to disclose information to someone else, such as

another health professional, insurance company, or family member
 I determine that you are a danger to yourself or to others.
 You disclose information that leads me to believe a child, disabled person, or
elderly person is being abused or neglected.
 I am ordered by a court to disclose information. (In unusual cases a client’s
involvement in a custody or criminal dispute may lead to me receiving such a
court order.)
Audio Recording Informed Consent
Since I will be a Clinical Mental Health Counseling Associate, I will be required to

record some of my counseling sessions with clients, should permission be granted. I
record sessions to ensure that as the client, you are receiving the best possible care in
our work together, as well as to further my development and growth as a counseling
associate. I understand the idea of recording can sound intimidating; however, the
purpose of the recording is for my supervisor to listen to me to ensure that I am always
providing appropriate service. They are not necessarily listening to you as they will be
listening to how I handle client care.
Restricted Licensure
It is important for me to highlight the limitations of my abilities to practice, and not

exceed these limitations during our time together. If there is ever a situation that goes
beyond my knowledge or capability to safely assist you, I will seek
assistance from my colleagues and supervisor. I will have the opportunity to receive
extensive feedback and supervision so that my actions best serve my clients. My
supervisors and all others that I consult with weekly are trained mental health
professionals held to the same standards of confidentiality. My supervision may include
observations from therapy sessions, co-therapy with my site supervisor, and audio or
video recordings. Before any session is reviewed by a supervisor, I will obtain written
permission from you, and in the case of a minor, also from the legal guardian. If you
have any questions or concerns regarding this, I am happy to discuss it further.
Dual Relationships
Although at times sessions may be intimate and become intense psychologically, ethical
and legal mandates apply and require the relationship to remain professional rather
than operate in a social capacity. Our contact will be limited to our counseling sessions.
Having dual relationships can inhibit the effectiveness of our work together and are
considered unethical. You will be best helped if our sessions and relationship
concentrate exclusively on your concerns and goals.
Length of Service
My services will be completed in a professional manner consistent with accepted ethical

standards in the state of North Carolina. Individual sessions are generally 30 to 60
minutes in duration and will be scheduled at a mutually agreed on time. If for any
reason you are unable to keep an appointment, please call to cancel or reschedule at
least 24 hours in advance. If you fail to cancel at the specified time period, you may
be subjected to a charge for that session. Every effort will be made to start and stop
sessions on time. Both client and counselor share the responsibility for being prompt.
Fees and Methods of Payment
My fees for counseling services are as follows:

20-30 minute session – $50.00
45 minute session – $75.00
60 minute session – $100.00
Intake appointments - $120.00
Payment is due at the time of session and I will provide you with receipts.
Client and Therapist Rights
As a client, you have the right to inquire about my professional credentialing and
experience as a counselor. At any time ,you have the right to discuss concerns or
dissatisfactions about our work together, as well as ask any questions you may have
throughout the counseling process. You may also end counseling at any time if you feel
it is the best option, however, I encourage you to bring any concerns you have during
our sessions and to make a commitment to attend a final session before terminating.
I also hold the right and ethical responsibility to terminate services at any time if I
believe that our sessions are not benefitting you. If for any reason I choose to terminate,
I will provide you with referral resources that best serve your needs.
Complaints
I encourage you to discuss any issues you have in the event you are dissatisfied with
my service. However, if I am not able to resolve your concerns, 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/aca-code-of-ethics.pdf).
North Carolina Board of Licensed Clinical Mental Health Counselors

P.O. Box 77819
Greensboro, NC 27417
Phone: 844-622-3572 or 336-217-6007
Fax: 336-217-9450
E-mail: Complaints@ncblcmhc.org
___________________________________ _____________________
Ashley Hudgens, LCMHCA Date
___________________________________ _____________________
Client Signature Date

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Ashley Hudgens/Wake Forest University

Licensed Clinical Mental Health Counseling Associate

Hello and welcome!

Counseling Services Offered/Theoretical Approaches

I view counseling as a collaborative process in which I provide clients with a space to be

 You give written permission to disclose information to someone else, such as

Audio Recording Informed Consent

Since I will be a Clinical Mental Health Counseling Associate, I will be required to

It is important for me to highlight the limitations of my abilities to practice, and not

My services will be completed in a professional manner consistent with accepted ethical

Fees and Methods of Payment

My fees for counseling services are as follows:

Client and Therapist Rights

North Carolina Board of Licensed Clinical Mental Health Counselors

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