Form preview

Get the free professional disclosure statement counseling example form

Get Form
SAMPLE FOR LICENSED GRADUATE PROFESSIONAL COUNSELORS PROFESSIONAL DISCLOSURE STATEMENT In accordance with the Annotated Code of Maryland Health Occupations 17-308 Authority granted by license 17-309 Supervised clinical practice and 17-507 Professional disclosure statement John Doe M.
We are not affiliated with any brand or entity on this form

Get, Create, Make and Sign

Edit
Edit your professional disclosure statement counseling form online
Type text, complete fillable fields, insert images, highlight or blackout data for discretion, add comments, and more.
Add
Add your legally-binding signature
Draw or type your signature, upload a signature image, or capture it with your digital camera.
Share
Share your form instantly
Email, fax, or share your professional disclosure statement counseling form via URL. You can also download, print, or export forms to your preferred cloud storage service.

How to edit professional disclosure statement counseling example online

9.5
Ease of Setup
pdfFiller User Ratings on G2
9.0
Ease of Use
pdfFiller User Ratings on G2
To use the professional PDF editor, follow these steps:
1
Register the account. Begin by clicking Start Free Trial and create a profile if you are a new user.
2
Prepare a file. Use the Add New button to start a new project. Then, using your device, upload your file to the system by importing it from internal mail, the cloud, or adding its URL.
3
Edit counselor professional disclosure statement example form. Rearrange and rotate pages, add and edit text, and use additional tools. To save changes and return to your Dashboard, click Done. The Documents tab allows you to merge, divide, lock, or unlock files.
4
Save your file. Select it from your records list. Then, click the right toolbar and select one of the various exporting options: save in numerous formats, download as PDF, email, or cloud.
pdfFiller makes dealing with documents a breeze. Create an account to find out!

How to fill out professional disclosure statement counseling

Illustration

How to fill out counselor professional disclosure statement:

01
Start by providing your personal information, including your full name, contact information, and professional credentials.
02
Next, include a brief biography or summary of your education, training, and experience as a counselor.
03
List any specialized certifications or areas of expertise that you possess.
04
Include information about your therapeutic approach or the theoretical frameworks that guide your counseling practice.
05
Provide details about your fees and payment policies, including any accepted insurance plans or sliding scale payment options.
06
Include information about your office location and hours of operation.
07
Explain your confidentiality policy and any limitations to confidentiality.
08
Include information about your cancellation and rescheduling policies.
09
Provide contact information for emergencies or after-hours support.
10
Make sure to review and sign the statement before distributing it to clients.

Who needs counselor professional disclosure statement:

01
Counselors who are licensed or registered to practice therapy.
02
Mental health professionals who work independently or in private practice.
03
Counselors who offer their services to clients on a fee-for-service basis.
04
Counselors who work in agency settings may also be required to provide a professional disclosure statement to clients.

Fill form : Try Risk Free

Rate free examples of professional disclosure statements for counseling form

4.0
Satisfied
59 Votes

People Also Ask about professional disclosure statement counseling example

For pdfFiller’s FAQs

Below is a list of the most common customer questions. If you can’t find an answer to your question, please don’t hesitate to reach out to us.

A counselor professional disclosure statement, also referred to as a therapist disclosure statement, is a document provided by mental health professionals to their clients at the beginning of therapy. It outlines important information about the counselor's qualifications, credentials, approach to therapy, ethical considerations, fees, confidentiality, and other relevant policies. The purpose of this statement is to ensure transparency and establish clear boundaries and expectations between the counselor and the client, promoting a safe and trusting therapeutic relationship. It helps clients make informed decisions about their therapy and provides them with information about their counselor's professional background and practices.
Counselors are typically required to file a professional disclosure statement. This requirement may vary depending on the state or country where they practice.
Filling out a counselor professional disclosure statement typically involves providing detailed and accurate information about yourself as a professional counselor. Here are the general steps to follow: 1. Introduction: Begin by clearly stating your name, degree or license, and the title of your profession (e.g., Licensed Professional Counselor, Marriage and Family Therapist). 2. Contact Information: Include your current address, phone number, email address, and professional website (if applicable). 3. Qualifications: Provide a summary of your educational background, including the degrees earned, institutions attended, and any relevant certifications or specializations. Include information about your current professional license or certification and its issuer. 4. Professional Experience: Outline the specific settings and populations you have worked with throughout your career. This may include private practice, counseling centers, agencies, hospitals, educational settings, or any other relevant professional experience. Include the number of years or months you have worked in each setting. 5. Areas of Expertise: Identify the specific areas or issues you specialize in or have extensive experience with. For example, you may have expertise in addiction counseling, trauma therapy, couples counseling, or working with children and adolescents. 6. Treatment Approach and Philosophy: Describe your approach to counseling and the theoretical orientations that guide your practice (e.g., cognitive-behavioral therapy, psychodynamic therapy, humanistic therapy). 7. Confidentiality and Professional Boundaries: Explain your commitment to maintaining client confidentiality and the limits of confidentiality as required by law or ethical guidelines. Clarify your policies on record-keeping, mandated reporting, and any exceptions to confidentiality. 8. Fees and Billing: Specify your fee structure, such as session rates, length of sessions, cancellation policies, and accepted payment methods (e.g., cash, check, credit card, insurance). 9. Licensing and Ethical Guidelines: State that you are a licensed professional counselor and adhere to the ethical guidelines set forth by your licensing board (e.g., American Counseling Association, National Board for Certified Counselors). Provide contact information for relevant licensing boards and professional associations. 10. Contact Availability: Provide your preferred method of contact and specify your availability for appointments. If applicable, indicate whether you offer online counseling or telehealth services. 11. Signature and Date: Conclude the disclosure statement with your signature and the date it was completed. It is important to review and update your professional disclosure statement periodically to keep it accurate and current. Consulting with your licensing board or professional association for any specific formatting or content requirements is also recommended.
The purpose of a counselor professional disclosure statement is to provide clients with important information about the counselor's professional qualifications, experience, and work policies. It serves as a formal document that outlines the counselor's background, credentials, areas of expertise, and approaches to therapy. The disclosure statement also covers topics such as confidentiality, ethical guidelines, fees and payment policies, cancellation policies, session duration, and the process for addressing any concerns or issues that may arise during treatment. By presenting this information upfront, the disclosure statement helps clients make informed decisions about whether to engage in therapy with the counselor and promotes transparency and clarity in the therapeutic relationship.
The specific information required on a counselor professional disclosure statement can vary depending on the jurisdiction and professional organization guidelines. However, the common elements typically included are: 1. Counselor's full name and contact information: This includes the counselor's name, address, phone number, email address, and any other relevant contact details. 2. Professional qualifications and credentials: This includes the counselor's educational background, degrees achieved, and any relevant certifications or licenses held. 3. Areas of specialization: The counselor should specify their areas of specialization or expertise, such as substance abuse, marriage and family therapy, grief counseling, etc. 4. Professional experience: This includes the counselor's work history, including the dates, names of organizations or agencies worked for, and the type of counseling services provided. 5. Fees and payment policies: The disclosure statement should provide transparency regarding the counselor's fees, billing practices, and any accepted forms of payment. It may also mention information about insurance coverage, if applicable. 6. Confidentiality and privacy policies: Counselors typically outline their commitment to maintaining client confidentiality and describe the limits to this confidentiality, such as mandated reporting obligations or circumstances when disclosure may be required. 7. Ethical guidelines and professional standards: Counselors should disclose their adherence to a code of ethics or professional standards, such as those established by a particular counseling organization or the governing regulatory body. 8. Grievance procedure: The counselor may provide details on how to file a complaint or express concerns about their services, including the contact information of relevant regulatory bodies or professional organizations that handle such matters. It is important to note that the specific requirements for a counselor professional disclosure statement may vary depending on state laws, professional licensure boards, and specific counseling organizations. It is advisable for counselors to seek guidance from their respective licensing board or professional association to ensure compliance with specific regulations and guidelines.
The penalty for the late filing of a counselor professional disclosure statement may vary depending on the specific jurisdiction and governing body responsible for regulating counselors. In some cases, there may be a monetary fine imposed for late filing. Additionally, the counselor may have their license or certification temporarily suspended until the disclosure statement is filed. It is important to consult the relevant licensing board or regulatory agency for the specific penalties in a particular jurisdiction.
With pdfFiller, the editing process is straightforward. Open your counselor professional disclosure statement example form in the editor, which is highly intuitive and easy to use. There, you’ll be able to blackout, redact, type, and erase text, add images, draw arrows and lines, place sticky notes and text boxes, and much more.
The best way to make changes to documents on a mobile device is to use pdfFiller's apps for iOS and Android. You may get them from the Apple Store and Google Play. Learn more about the apps here. To start editing professional disclosure statement example, you need to install and log in to the app.
Use the pdfFiller mobile app to fill out and sign examples of professional disclosure statements for counseling form on your phone or tablet. Visit our website to learn more about our mobile apps, how they work, and how to get started.

Fill out your professional disclosure statement counseling online with pdfFiller!

pdfFiller is an end-to-end solution for managing, creating, and editing documents and forms in the cloud. Save time and hassle by preparing your tax forms online.

Get started now
Form preview

Related to professional disclosure statement counseling