Hello,

My name is J. Matthew Smith. I am a Therapist at Woodridge Psychiatric Hospital (part of the Mountain
States Health Alliance), and a Graduate Student in Wake Forest Universitys Counseling Department.
I am currently being supervised by a licensed supervisor (David Sapp, LPC, ) while I am on-site at
Woodridge Hospital.
Site Supervisor:
David Sapp, LPC
Woodridge Hospital
Johnson City, Tennessee
(423) 431-7111

I hold a Bachelors of Science Degree in Clinical Psychology from Radford University, and I am currently
working to complete my Masters Degree in Clinical Counseling from Wake Forest University. I am in my
final year of study at Wake Forest, and by the time of my anticipated graduation in August of 2016, I will
have completed 60 relevant credit hours in the field of clinical counseling.
My coursework has included foundation courses pertaining to the profession, core course learning in the
field, as well as specific counseling styles and techniques.
I will be pursuing the professional licensure of: Licensed Professional Counselor- Mental Health Service
Provider (LPC-MHSP) in the state of Tennessee. Once a licensed practitioner, I will continue to participate
in educational opportunities and trainings that will both broaden and enhance my effectiveness as a
Mental Health Counselor.
My current main focus and approach to counseling is built upon the tenets of Person-Centered
Counseling and Cognitive Behavioral Therapy. I also incorporate elements of Gestalt and Existential
Therapies into my personal approach.
I have been trained to work with individuals, couples, families, and groups.
During the duration of your stay at Woodridge, you will be offered the opportunity to participate in
individual therapy sessions, group therapy sessions, community group trainings, and intensive outpatient
support groups. All services provided to you during your stay will be provided and reflected in overall
service fee for your hospitalization.
Confidentiality
All of our communication becomes part of a clinical record, which is accessible to you upon request. I will
keep confidential anything you say as part of our counseling relationship, with the following exceptions: (1)
You direct me, in writing, to disclose information to a third party. (2) It is determined you are a danger to
yourself and others (please note: that this includes both child and elder abuse). Or (3) I am ordered by the
court to disclose information.
For case consultation and educational/training purposes, I may be required to consult with my site and/or
university supervisor(s), who are required to keep client information confidential.

If at any time you may have questions, concerns, and/or complaints about my performance or
professional conduct as your counselor, please feel free to contact and discuss this with my supervisor,
David Sapp, LPC (contact information at the top).

If you Agree with the terms and will abide by its guidelines, it would be might great honor to assist you in
your journey toward wellness.
In order to show your agreement, please sign and date the following:

_____________________________________________
Client Signature

______________
Date

_____________________________________________
Counselor Signature

_______________
Date