PROFESSIONAL DISCLOSURE STATEMENT FOR SUPERVISION

Tabitha R. Haynes, MA, LPC, LCAS, NCC

Ph.D. Student
NCSU Counseling and Counselor Education Program
Box 7801, 520 Poe Hall
North Carolina State University
Raleigh, NC 27695-7801
As your supervisor, I am responsible for the individual and group supervision you will be
receiving as you work with clients while enrolled in the counseling practicum course.
This statement is designed to inform you of my qualifications and professional
experience, as well as the goals, process, and expectations of supervision. This
document is an overview of the conditions and guidelines under which we both must
operate.
EDUCATION/QUALIFICATIONS
I received a Bachelor of Arts degree in Psychology from the University of North
Carolina at Wilmington in 1998. In 2010, I received a Master of Arts degree from North
Carolina Central University in Agency Counseling. Currently, I am pursuing a doctoral
degree in Counseling and Counselor Education from North Carolina State University.
Both of my graduate programs are accredited by The Council of Accreditation on
Counseling and Related Educational Programs (CACREP).
CLINICAL/COUNSELING EXPERIENCE
I have over 15 years of human service and mental health experience. I have been a
professional counselor since 2011. My training is in mental health counseling with
additional specialization in issues of substance abuse and at-risk populations. My areas
of experience include: mental illness, co-occurring disorders, personal growth, mood
and behavioral concerns, and life transitions. I have provided counseling services to
individuals, youth, adults, and families in the areas of, but not limited to
depression/anxiety, anger management, life transitions, and personal growth.
My counseling theoretical style is a blend of cognitive behavioral therapy, motivational
interviewing, and person-centered practices depending on the needs of the client.
Techniques include individual, couple, and family counseling (talk therapy), screening
and assessment and interpretation of assessments, provision of appropriate information
and facilitation of decision making, and goal setting. In addition, group counseling and
facilitation have been offered and homework exercises given when necessary.
CREDENTIALS AND MEMBERSHIPS
Licensed Professional Counselor #8690
North Carolina Certified Counselor #275116
Licensed Clinical Addictions Specialist #2719
Member, American Counseling Association
Member, Chi-Sigma Iota
SUPERVISON EXPERIENCE AND TRAINING

I have supervised masters level counseling interns in the community mental health,
residential, and inpatient psychiatric settings. I am currently enrolled in ECD 847:
Practicum in Counseling Supervision. While completing this 3 credit course, I will
receive supervision from my university instructor as I assist you in reaching your
counseling goals. Additionally, I also receive on-going clinical supervision as part of my
professional counseling responsibilities in the work place.

SUPERVISON GOALS AND MODALITIES

The supervision process has two goals: the development of counseling skills of the
supervisee or counselor-in training, and the protection of the client being served by the
supervisee or counselor-in-training. During supervision, both of these goals are
addressed. Often times, it may appear as though the primary focus of supervision is on
your developing skills, however, this is occurring because a judgment has been made
that your client is receiving adequate counseling services. When there is a question or
concern about the counseling received by your client, a more active mode of
supervision may be utilized.
My supervision style follows person-centered and cognitive behavioral theoretical
supervision models. Person-centered supervision is a collaborative effort between me
as your supervisor and you as the supervisee. My role is to provide an environment in
which you can be open to your experience and fully engaged with your client.
Supervision process will rely heavily on the supervisor-supervisee relationship to
facilitate effective learning and growth. Additionally, my task as the cognitivebehavioral supervisor is to teach the techniques of the theoretical orientation.
Cognitive-behavioral supervision makes use of observable cognitions and behaviors
particularly of your professional identity and your reaction to the client. Cognitivebehavioral techniques used in supervision will include setting an agenda for supervision
sessions, bridging from previous sessions, assigning homework, and capsule summaries
provided by me as your supervisor.
SUPERVISION POLICIES
Duration and frequency of sessions:
Throughout the semester, we will meet both individually, as well as in a group setting
with other supervisees or counselors-in-training. Individual supervision will occur once
a week for a total of 60 minutes at a mutually agreed upon time and location. Various
forms of observation may be utilized, such as: direct face-to-face observation or video
and/or audio recording. You may be asked to provide self-evaluation and receive verbal
feedback from site supervisors and instructors to supplement the supervision process.
Missed sessions:
When an appointment is made, that time is set aside for you and will not be given to
someone else unless you specifically cancel the appointment within 24 hours.
Therefore, it is very important that appointments be kept. Please be on time to avoid
losing supervision time. Schedules generally will not allow making up time if you are
late.
Supervision fees:

There will be no fee collected for supervision throughout the semester.

AS YOUR SUPERVISOR
My role as a supervisor includes that of a teacher, consultant, and counselor to assist in
your development as a counselor throughout the semester. I will use my various roles to
challenge your thoughts, your feelings, and your behaviors as you conduct your
counseling sessions. I will encourage you to explore cultural issues regarding yourself,
the client, and me as your supervisor. I will support you and your personal goals, and
will help you understand client issues within a theoretical framework. It is important to
note that I will not serve as your personal counselor. While I may from time to time
utilize counseling skills, it should be understood that this is only to help your personal
reactions that may overshadow your positive effects as a counselor. If your personal
reactions are seen as a hindrance in your progress as counselor-in-training, I may find it
necessary to make a referral for individual counseling. It is not unusual for a
supervisee or counselors-in-training to seek individual counseling while working to
complete their counseling degree.
As your supervisor, it is my responsibility to evaluate you and make an assessment of
your skills of professional counseling. Over the course of the semester, written and
verbal evaluation of your skills and progress will be shared with my supervisor and your
course instructor. Any situation requiring mediation would be discussed with you first,
then with my own supervisor.
AS THE SUPERVISEE
You are responsible for upholding ACA code of ethics. Also, as part of the supervision
process, you will be required to submit audio or videotaped counseling sessions. This is
explained further in your syllabus. You may also be required to submit case notes on all
sessions you conduct with your clients. It is your responsibility to turn in all required
tapings and paperwork in a timely manner as outlined by your course requirements.
Your case notes, records, and tapings will be maintained with confidence as outlined in
the confidentially standards presented in this document.
CONFIDENTIALITY
Given that you are a student and counselor-in-training; I cannot guarantee that
information gained in supervision that is relevant to your overall progress in the
program will be kept confidential. Moreover, I cannot guarantee confidentiality of
information received via text message, voicemail, or email. However, I can commit to
honoring the supervision relationship by respecting all information I receive from you
about you and your clients and attempting to keep all such information, whether verbal
or written, as confidential as possible. I will protect the confidentiality of information
received during supervision as specified by federal and state laws, written policies and
ethical standards. For any of the following matters, legally and ethically, I may break
confidentiality and involve others who can help: (ACA Code of Ethics is cited in
parentheses.)
A. If mandated by a court of law (Section B.2.d); note: a subpoena is not a court
order
B. If disclosure is required to prevent clear and imminent danger to yourself
and/or others (Section B.2.a):
C. If I am made aware of the potential or actual occurrence(s) of physical/sexual
abuse of minors, persons

with disabilities or senior citizens (Section B.2.a)

CONTACT INFORMATION
If you have questions and/or concerns and need immediate assistance, feel free to
contact me at 919-816-5274. For non-emergencies, I can be reached via email at
trhaynes@ncsu.edu. If I do not respond in a timely manner, please contact your course
instructor.
CONCERNS
I abide by the NBCC Clinical Supervision Standards of Practice, as well as NBCC, ACA,
and NCBLPC Code of Ethics. You are encouraged to discuss any concerns with me
first, however, if you feel you need immediate assistance, you may contact my course
instructor Dr. Sylvia Nassar-McMillan at Snassar@ncsu.edu.

SUPERVISION ARRANGEMENTS
We agree to meet on the following day and time: __________________________________
ACKNOWLEDGEMENT
I have read the above statement in its entirety. I am informed about the policy
regarding supervision, confidentiality, and the limits of that confidentiality. With full
understanding of these provisions, I give my informed consent to receive supervision
services.
Supervisor Signature _____________________________

Date_______________

Supervisee Signature ______________________________

Date _________________