Professional Disclosure Statement

Jonora K. Jones
jonorakjones@gmail.com
office: (###) ###-####
fax: (###) ###-####
I am looking forward to working with you as a counselor and thank you for allowing me this opportunity.
The purpose of this document is to provide you with information about my background, describe the
nature of the counseling relationship, and to inform you of your rights as the client. Please do not
hesitate to follow up with any questions or concerns after reviewing the complete document.
My Qualifications
I received a Master of Arts in Counseling with a Clinical Mental Health focus from Wake Forest
University (2016). My undergraduate degree in History is from the Massachusetts Institute of
Technology (1996). I am a member of the American Counseling Association (ACA) and Chi Sigma Iota,
the Counseling Academic and Professional Honor Society.
Restricted Licensure
I am pursuing licensure as a Professional Counselor Associate in the state of North Carolina. I am
currently under the supervision of XXX. If you need to contact my supervisor, he/she may be reached at
(###) ###-####.
Counseling Background and Professional Approach
My approach to counseling is based upon Person-Centered and Cognitive-Behavioral theoretical
approaches. I focus on the whole person, his/her feelings, behaviors, thoughts, and beliefs, believing
that each individual is capable of self-direction and growth. During sessions, I work to maintain an
environment emphasizing unconditional positive regard, empathy, and genuineness.
The populations I serve include young and older adults. I provide counseling services in both the
individual and group settings. During my masters program, I provided individual and group counseling
services to adults with chronic mental illness and developmental disabilities for approximately a year
and a half. I have had additional training in Wellness Recovery Action Plan (WRAP). My special interests
include comorbid mental illnesses and developmental disabilities as well as mood disorders.
Session Fees and Length of Sessions
Sessions will last approximately 45-50 minutes. We will work together to schedule sessions that are
convenient for all parties involved. I do ask that you keep all appointments made and arrive on time. In
the event that you are late, I will end the session at the originally scheduled time. If you miss your
session, it will be rescheduled at my convenience. If you are unable to keep an appointment, please
notify me to cancel or reschedule at least 24 hours in advance. You are subject to payment for any
missed appointments except in the case of personal emergency.
Fees are $XX per session. [accepted payments insurance language]
Referrals
If I feel at any time that I cannot help you with my skills and approach, I will refer you to another
professional or program that I believe may be more appropriate for your needs. While it is impossible

for any therapist to guarantee that treatment goals will be achieved or to predict the outcome of
therapy, we will work as a team toward the best outcome possible. As therapist, I will always be
straightforward and honest with you about your progress.
Use of Diagnosis
Some health insurance companies will reimburse clients for counseling services and some will not. In
addition, most will require a diagnosis of a mental health condition and indicate you have an illness
before they will agree to reimburse you. Some conditions for which people seek counseling do not
qualify for reimbursement. If a qualifying diagnosis is appropriate in your case, I will inform you of the
diagnosis before we submit the diagnosis to the health insurance company. Any diagnosis made will
become part of your permanent insurance records.
Confidentiality
As your counselor, I respect your privacy. Anything discussed during counseling sessions is confidential,
with the following exceptions:
1. You direct me, in writing, to tell someone else;
2. You are determined to be a danger to yourself or someone else;
3. There are indications of child or elder abuse that I am legally obligated to report;
4. I am ordered by a court to disclose information; or
5. Your insurance company requests information regarding reimbursement of fees.
Complaints
I encourage you to discuss any concerns or questions that you may have regarding my services with me.
This will allow our work together to be more collaborative in nature. If I am unable to resolve your
concerns, please feel free to contact my supervisor, XX. You may also report any complaints to the North
Carolina Board of Licensed Professional Counselors by phone at (844) 622-3572 or you may write to:
NCBLPC, P.O. Box 77819, Greensboro, NC 27417.
Acceptance of Terms
We agree to these terms and will abide by these guidelines.

Client: ___________________________________________________ Date: ___________

Counselor: ________________________________________________ Date: ___________