Professional Disclosure Statement (PDS)
Counseling Disclosure Statement
Jennifer Cook, MA, LCMHC, NCC
5040 New Centre Dr, Suite D, Wilmington, NC, 28403
Office Phone: (910) 613-8661
Qualifications:
I am a Licensed Clinical Mental Health Counselor (LCMHC), [North Carolina Board of Licensed Clinical Mental Health Counselors license # 15242 & National Board for Certified Counselors certificate # 1231780], having received my Master’s Degree in Clinical Mental Health Counseling from Wake Forest University in 2019 and my Bachelor’s Degree from the University of Delaware in 2000. I'm a United States Army veteran, having served in Operation Iraqi Freedom. I love my work with clients, as I truly enjoy walking beside my clients in their journeys to discover themselves and improve their mental health.
Clients Served and Services Offered:
Outpatient therapy services are provided to a range of clients including: children, adolescents, adults, couples, and families. I serve clients with a multitude of mental health symptoms and diagnosis, including anxiety and depressive symptoms, adults and children with a history of trauma, those with thoughts and actions of self-injury, domestic violence, behavioral concerns, abuse and neglect issues. I support LGBTQQIA+ clients, and help with career, parenting, and lifestyle challenges, as well as anger issues, LEO and military needs. These issues are approached on an individual basis and from a person-centered base, using an eclectic integration of cognitive behavioral therapy and other counseling theories, as determined by the needs of my individual clients. I'll gladly meet with you to evaluate the issues you are facing and determine if they are within my scope of practice.
Session length:
Sessions typically run 50-55 minutes, dependent on the needs of the client. Often, for sessions with children and adolescents, I will meet with the parent or guardian for a short time to do a “check in” before or after meeting with the child or adolescent alone. I ask that, even with telehealth sessions, there be a parent or guardian who can be available during this time so that I may speak with them. As with adult clients, children and adolescents who participate via Zoom must be able to do so in a way that they can speak privately.
Session Fees:
I accept cash and credit cards for services and my current fee range for self-pay clients is $125-150 per session. I am currently only taking self-pay clients, and payment for sessions must be made the day of the session. It takes some time to change insurance paneling for clinicians from agency therapy to private therapy, but I expect to be credentialed with United Healthcare, Aetna, Cigna, Oscar Health, and Oxford by early June 2022, and with Blue Cross Blue Shield and MedCost soon after. An active credit card will be kept on file and you will be asked to sign a credit card agreement that allows my practice management
system to bill your card for your session the day of your service. This policy is explained, in writing, to all clients
and client must acknowledge and agree to policy in writing (or digitally), prior to beginning services.
Contact between sessions:
If you have a need to reach me before our next session, (that is not urgent), you may contact me at my office at (910) 613-8661 and leave a voicemail if I am unavailable. Calls to this number will be returned within 2-3 business days, unless otherwise noted on voicemail system, (i.e. during scheduled time off). I do not check voicemails or emails on scheduled days off, after hours, or on weekends. Please do not leave urgent messages on this number. If you are in crisis, please call 911 or one of the local Mobile Crisis Teams, including: Integrated Family Services Mobile Crisis at 1.866.437.1821 / 24 hours a day / 7 days a week, or RHA Health Services Mobile Crisis at 1.844.709.4097 / 24 hours a day / 7 days a week. I am only available during scheduled business hours and do not provide crisis services.
Emergencies:
In case of an emergency, please contact one of the numbers below:
County Emergency Personnel (911)
The National Suicide Prevention Hotline (800) 273-8255
Integrated Family Services Mobile Crisis at 1.866.437.1821 / 24 hours a day / 7 days a week
RHA Health Services Mobile Crisis at 1.844.709.4097 / 24 hours a day / 7 days a week
Text Chat Line – 741-741
Cancellation Policy:
A minimum of 24-hour notice is required for re-scheduling or canceling an appointment, as I need to be able to offer appointments to those who wish to use the time offered. If 24-hour notice is not given of a cancellation or need to reschedule an appointment, $50 will be charged to your credit card on file. Of course, at times, emergencies or other matters come up within 24-hours of a session that cannot be helped. It will be up to my discretion if your card is charged the No Show fee, depending on the circumstances and amount of prior last minute cancellations or reschedules, (within 24-hours of session). If I am unable to make an appointment, I will do my best to give 24-hour notice, as well, and will attempt to contact you as soon as possible. If I am unable to give at least 24-hours notice of a cancellation on my part, I will excuse one last minute (within 24-hours of session), cancellation or need for reschedule, on the client's part, without charging the cancellation fee, if one happens. Repeated no call/no shows for appointments (including cancellations or reschedules within 24 hours of the session), hurt both the work we do in therapy, as well as make it difficult to see the patients who need to be seen. Therefore, three No Call/No Show appointments within a 12 month period will lead to a client being discharged from my practice. To ensure quick communication, please make sure to let me know if your contact information changes.
Confidentiality:
Confidentiality is extremely important in our counseling relationship and I take it very seriously. I must keep records in order to track our work together, however all information disclosed within our session and in electronic records pertaining to those session will remain confidential and may not be revealed to anyone without your written permission, except where the law requires disclosure. On the flip side, I will release information to any agency/person you specify unless I conclude that releasing such information might be harmful in any way. If patient is a minor, they are still owed confidentiality and I will not share information with parents regarding our work together or things clients have said unless they reveal that someone is hurting them, they are going to hurt themself or someone else, or they give me permission to share specific information.
When Disclosure is Required by Law:
Some of the circumstances where disclosure is required by law include: where there is a reasonable suspicion of child, dependent, or elder abuse or neglect; where a client presents a danger to self or to others; in the event that a court of law requires disclosure. This does not include if your records are subpoenaed as a subpoena is not a court order, which would require records to be divulged. If the subpoenaed records are court ordered, disclosure will likely be required by law.
Harm to Self or Others:
Your care and safety are of utmost importance. If I become concerned about your personal safety or the possibility of you injuring someone else, I will do whatever I can within the limits of the law to prevent you from injuring yourself or others and to ensure that you receive the proper medical care. This may mean contacting the authorities, the local hospital, or the emergency contact whose name you provided. If you disclose intent to harm others, it is my legal and ethical duty to attempt to notify that person or people. It is my hope that we can work together to create a safe space to explore issues and establish a plan together. If the patient is a minor who discloses that they are being hurt or abused or they are going to hurt themselves or someone else, I will also take the necessary precautions to make sure client is safe, out of harm's way, and alert the parents or guardians, (under most circumstances), or authorities as required as a Mandatory Reporter.
Other Related Disclosure:
Disclosure may be required pursuant to legal proceeding. If you are involved in a custody dispute or if you place your mental status at issue in litigation initiated by you, the defendant may have the right to obtain therapy records and/or testimony by me. In couple and family therapy, or when different family members are seen individually, confidentiality and privilege do not apply between the couple or among family members. I will use my clinical judgment when revealing such information. I will not release records to any outside party unless I am authorized to do so by all adult family members who were part of the treatment, or required by a court order.
Consultation and Peer Supervision:
I consult regularly with other mental health professionals regarding my cases; however, the
client’s name or other identifying information is never disclosed.
Treatment Planning and Use of Diagnosis:
During the course of assessment and treatment we will likely reference the most recent version of the Diagnostic and Statistical Manual of Mental Disorders (DSM). Not all issues and concerns need a formal medical diagnosis. Some health insurance companies will reimburse clients for counseling services and some will not. In addition, most will require that a diagnosis of a mental-health condition is made and indicate that you must have an “illness” before they will agree to reimburse you. Some conditions for which people seek counseling do not qualify for reimbursement. If you authorize billing of insurance for payment of services, then you agree for your therapist to disclose this diagnosis to the insurance company. Any diagnosis made remains a part of your therapy record and may have ramifications in terms of costs of insurance and long-term insurability. It is my policy that I provide a written diagnosis, if one is applicable, after conducting our Comprehensive Clinical Assessment.
This diagnosis remains confidential under the provisions noted by law. It is important that you understand the diagnosis you have been given. It is my position that the diagnosis is only a tool for your treatment and does not indicate severe pathology. Many people fit criteria for an official medical diagnosis based on symptoms that they experience at some time in their lives. We will use the DSM codes and guidelines only as they are effective for your treatment. You are always able to dispute the diagnosis or discuss at length any concerns you may have.
Paperwork on Your Behalf:
While I will, at times, refer clients for other services that I feel are clinically necessary with the permission of the client, it is not my policy to complete paperwork or write letters on behalf of clients for disability, FMLA, the DMV, the VA, return to school or work determinations, therapy or emotional support pet requests or determinations, custody issues, or any other similar or other legal support letters. If these are desired or needed and are the main reason for coming to therapy, this is likely not the right therapy relationship. If these issues come up during our therapy relationship, you will need to find another source for this
communication on your behalf, as I will not be providing these services.
Termination of Counseling:
During your first few sessions of therapy we will complete a thorough assessment of your therapy needs and your goals for treatment. We will determine together if a therapeutic relationship can be established. I do not work with clients that I feel I cannot help. Given the collaborative nature of therapy, we both have a say if the relationship is working or not. If it is determined that our therapeutic relationship is not effective for any reason, I will be happy to assist in making a referral to other therapists. With your written permission, I can assist the facilitation of transferring records and information about your treatment. You always have the right to end therapy services for any reason.
Dual Relationships:
At times clients and therapists may find themselves in situations where there is a relationship that extends into another area of social life. It is important to remember that confidentiality is maintained even in these unavoidable situations. Not all dual relationships are unavoidable. If a dual relationship presents a problem for you as the client or for me as your therapist, a discussion should be initiated to ensure that all parties are comfortable with the situation. If this cannot be addressed in a way that is comfortable for all parties all efforts will be made to make different arrangements for therapy. Not all dual relationships pose
a problem. It should be very clear that any sexual involvement between a therapist and client is never appropriate.
I also will not accept invitations via social networking sites such as Facebook, Twitter, TikTok, LinkedIn,
Instagram, or other social media platforms.
Complaints Regarding Services:
If you are not satisfied with services or feel that ethical violations have occurred, please note the process in which to address these circumstances. If you are dissatisfied with any aspect of our work, I hope you will discuss your concerns with me personally. This will make our work together more efficient and effective. It is recommended that clients first discuss the situation with the counselor and attempt to resolve the concern. I adhere to the American Counseling Association Ethical Guidelines. These guidelines may be found at www.counseling.org or you may request a copy of these guidelines and a paper copy will be provided to you.
In the event a client wishes to file a formal complaint regarding the behavior of a counselor, all information should be submitted in writing to the North Carolina Board of Licensed Clinical Mental Health Counselors (NCBLCMHC) by obtaining a complaint form at www.ncblpc.org. This should include which American Counseling Association ethical guidelines or laws have been broken.
Completed complaint forms should be sent to:
North Carolina Board of Licensed Clinical Mental Health Counselors
PO Box 77819
Greensboro, NC 27417
844-622-3572 Phone or 336-217-9450 Fax
By signing this disclosure statement, you are agreeing that you have had this information explained to you in a reasonable and appropriate language that you understand, and you have been given opportunity to ask questions regarding the procedure and issues involved in counseling. You will be provided with a copy of your signed statement and one copy will be maintained in the therapist’s records.
_________________________________________Client Signature _____________Date
____________________________________________________________________Date
Parent or Guardian Signature Relationship (other than self)
______________________________________Counselor Signature _____________Date
Jennifer Cook, MA, LCMHC, NCC
Jennifer Cook, MA, LCMHC, NCC
5040 New Centre Dr, Suite D, Wilmington, NC, 28403
Office Phone: (910) 613-8661
Qualifications:
I am a Licensed Clinical Mental Health Counselor (LCMHC), [North Carolina Board of Licensed Clinical Mental Health Counselors license # 15242 & National Board for Certified Counselors certificate # 1231780], having received my Master’s Degree in Clinical Mental Health Counseling from Wake Forest University in 2019 and my Bachelor’s Degree from the University of Delaware in 2000. I'm a United States Army veteran, having served in Operation Iraqi Freedom. I love my work with clients, as I truly enjoy walking beside my clients in their journeys to discover themselves and improve their mental health.
Clients Served and Services Offered:
Outpatient therapy services are provided to a range of clients including: children, adolescents, adults, couples, and families. I serve clients with a multitude of mental health symptoms and diagnosis, including anxiety and depressive symptoms, adults and children with a history of trauma, those with thoughts and actions of self-injury, domestic violence, behavioral concerns, abuse and neglect issues. I support LGBTQQIA+ clients, and help with career, parenting, and lifestyle challenges, as well as anger issues, LEO and military needs. These issues are approached on an individual basis and from a person-centered base, using an eclectic integration of cognitive behavioral therapy and other counseling theories, as determined by the needs of my individual clients. I'll gladly meet with you to evaluate the issues you are facing and determine if they are within my scope of practice.
Session length:
Sessions typically run 50-55 minutes, dependent on the needs of the client. Often, for sessions with children and adolescents, I will meet with the parent or guardian for a short time to do a “check in” before or after meeting with the child or adolescent alone. I ask that, even with telehealth sessions, there be a parent or guardian who can be available during this time so that I may speak with them. As with adult clients, children and adolescents who participate via Zoom must be able to do so in a way that they can speak privately.
Session Fees:
I accept cash and credit cards for services and my current fee range for self-pay clients is $125-150 per session. I am currently only taking self-pay clients, and payment for sessions must be made the day of the session. It takes some time to change insurance paneling for clinicians from agency therapy to private therapy, but I expect to be credentialed with United Healthcare, Aetna, Cigna, Oscar Health, and Oxford by early June 2022, and with Blue Cross Blue Shield and MedCost soon after. An active credit card will be kept on file and you will be asked to sign a credit card agreement that allows my practice management
system to bill your card for your session the day of your service. This policy is explained, in writing, to all clients
and client must acknowledge and agree to policy in writing (or digitally), prior to beginning services.
Contact between sessions:
If you have a need to reach me before our next session, (that is not urgent), you may contact me at my office at (910) 613-8661 and leave a voicemail if I am unavailable. Calls to this number will be returned within 2-3 business days, unless otherwise noted on voicemail system, (i.e. during scheduled time off). I do not check voicemails or emails on scheduled days off, after hours, or on weekends. Please do not leave urgent messages on this number. If you are in crisis, please call 911 or one of the local Mobile Crisis Teams, including: Integrated Family Services Mobile Crisis at 1.866.437.1821 / 24 hours a day / 7 days a week, or RHA Health Services Mobile Crisis at 1.844.709.4097 / 24 hours a day / 7 days a week. I am only available during scheduled business hours and do not provide crisis services.
Emergencies:
In case of an emergency, please contact one of the numbers below:
County Emergency Personnel (911)
The National Suicide Prevention Hotline (800) 273-8255
Integrated Family Services Mobile Crisis at 1.866.437.1821 / 24 hours a day / 7 days a week
RHA Health Services Mobile Crisis at 1.844.709.4097 / 24 hours a day / 7 days a week
Text Chat Line – 741-741
Cancellation Policy:
A minimum of 24-hour notice is required for re-scheduling or canceling an appointment, as I need to be able to offer appointments to those who wish to use the time offered. If 24-hour notice is not given of a cancellation or need to reschedule an appointment, $50 will be charged to your credit card on file. Of course, at times, emergencies or other matters come up within 24-hours of a session that cannot be helped. It will be up to my discretion if your card is charged the No Show fee, depending on the circumstances and amount of prior last minute cancellations or reschedules, (within 24-hours of session). If I am unable to make an appointment, I will do my best to give 24-hour notice, as well, and will attempt to contact you as soon as possible. If I am unable to give at least 24-hours notice of a cancellation on my part, I will excuse one last minute (within 24-hours of session), cancellation or need for reschedule, on the client's part, without charging the cancellation fee, if one happens. Repeated no call/no shows for appointments (including cancellations or reschedules within 24 hours of the session), hurt both the work we do in therapy, as well as make it difficult to see the patients who need to be seen. Therefore, three No Call/No Show appointments within a 12 month period will lead to a client being discharged from my practice. To ensure quick communication, please make sure to let me know if your contact information changes.
Confidentiality:
Confidentiality is extremely important in our counseling relationship and I take it very seriously. I must keep records in order to track our work together, however all information disclosed within our session and in electronic records pertaining to those session will remain confidential and may not be revealed to anyone without your written permission, except where the law requires disclosure. On the flip side, I will release information to any agency/person you specify unless I conclude that releasing such information might be harmful in any way. If patient is a minor, they are still owed confidentiality and I will not share information with parents regarding our work together or things clients have said unless they reveal that someone is hurting them, they are going to hurt themself or someone else, or they give me permission to share specific information.
When Disclosure is Required by Law:
Some of the circumstances where disclosure is required by law include: where there is a reasonable suspicion of child, dependent, or elder abuse or neglect; where a client presents a danger to self or to others; in the event that a court of law requires disclosure. This does not include if your records are subpoenaed as a subpoena is not a court order, which would require records to be divulged. If the subpoenaed records are court ordered, disclosure will likely be required by law.
Harm to Self or Others:
Your care and safety are of utmost importance. If I become concerned about your personal safety or the possibility of you injuring someone else, I will do whatever I can within the limits of the law to prevent you from injuring yourself or others and to ensure that you receive the proper medical care. This may mean contacting the authorities, the local hospital, or the emergency contact whose name you provided. If you disclose intent to harm others, it is my legal and ethical duty to attempt to notify that person or people. It is my hope that we can work together to create a safe space to explore issues and establish a plan together. If the patient is a minor who discloses that they are being hurt or abused or they are going to hurt themselves or someone else, I will also take the necessary precautions to make sure client is safe, out of harm's way, and alert the parents or guardians, (under most circumstances), or authorities as required as a Mandatory Reporter.
Other Related Disclosure:
Disclosure may be required pursuant to legal proceeding. If you are involved in a custody dispute or if you place your mental status at issue in litigation initiated by you, the defendant may have the right to obtain therapy records and/or testimony by me. In couple and family therapy, or when different family members are seen individually, confidentiality and privilege do not apply between the couple or among family members. I will use my clinical judgment when revealing such information. I will not release records to any outside party unless I am authorized to do so by all adult family members who were part of the treatment, or required by a court order.
Consultation and Peer Supervision:
I consult regularly with other mental health professionals regarding my cases; however, the
client’s name or other identifying information is never disclosed.
Treatment Planning and Use of Diagnosis:
During the course of assessment and treatment we will likely reference the most recent version of the Diagnostic and Statistical Manual of Mental Disorders (DSM). Not all issues and concerns need a formal medical diagnosis. Some health insurance companies will reimburse clients for counseling services and some will not. In addition, most will require that a diagnosis of a mental-health condition is made and indicate that you must have an “illness” before they will agree to reimburse you. Some conditions for which people seek counseling do not qualify for reimbursement. If you authorize billing of insurance for payment of services, then you agree for your therapist to disclose this diagnosis to the insurance company. Any diagnosis made remains a part of your therapy record and may have ramifications in terms of costs of insurance and long-term insurability. It is my policy that I provide a written diagnosis, if one is applicable, after conducting our Comprehensive Clinical Assessment.
This diagnosis remains confidential under the provisions noted by law. It is important that you understand the diagnosis you have been given. It is my position that the diagnosis is only a tool for your treatment and does not indicate severe pathology. Many people fit criteria for an official medical diagnosis based on symptoms that they experience at some time in their lives. We will use the DSM codes and guidelines only as they are effective for your treatment. You are always able to dispute the diagnosis or discuss at length any concerns you may have.
Paperwork on Your Behalf:
While I will, at times, refer clients for other services that I feel are clinically necessary with the permission of the client, it is not my policy to complete paperwork or write letters on behalf of clients for disability, FMLA, the DMV, the VA, return to school or work determinations, therapy or emotional support pet requests or determinations, custody issues, or any other similar or other legal support letters. If these are desired or needed and are the main reason for coming to therapy, this is likely not the right therapy relationship. If these issues come up during our therapy relationship, you will need to find another source for this
communication on your behalf, as I will not be providing these services.
Termination of Counseling:
During your first few sessions of therapy we will complete a thorough assessment of your therapy needs and your goals for treatment. We will determine together if a therapeutic relationship can be established. I do not work with clients that I feel I cannot help. Given the collaborative nature of therapy, we both have a say if the relationship is working or not. If it is determined that our therapeutic relationship is not effective for any reason, I will be happy to assist in making a referral to other therapists. With your written permission, I can assist the facilitation of transferring records and information about your treatment. You always have the right to end therapy services for any reason.
Dual Relationships:
At times clients and therapists may find themselves in situations where there is a relationship that extends into another area of social life. It is important to remember that confidentiality is maintained even in these unavoidable situations. Not all dual relationships are unavoidable. If a dual relationship presents a problem for you as the client or for me as your therapist, a discussion should be initiated to ensure that all parties are comfortable with the situation. If this cannot be addressed in a way that is comfortable for all parties all efforts will be made to make different arrangements for therapy. Not all dual relationships pose
a problem. It should be very clear that any sexual involvement between a therapist and client is never appropriate.
I also will not accept invitations via social networking sites such as Facebook, Twitter, TikTok, LinkedIn,
Instagram, or other social media platforms.
Complaints Regarding Services:
If you are not satisfied with services or feel that ethical violations have occurred, please note the process in which to address these circumstances. If you are dissatisfied with any aspect of our work, I hope you will discuss your concerns with me personally. This will make our work together more efficient and effective. It is recommended that clients first discuss the situation with the counselor and attempt to resolve the concern. I adhere to the American Counseling Association Ethical Guidelines. These guidelines may be found at www.counseling.org or you may request a copy of these guidelines and a paper copy will be provided to you.
In the event a client wishes to file a formal complaint regarding the behavior of a counselor, all information should be submitted in writing to the North Carolina Board of Licensed Clinical Mental Health Counselors (NCBLCMHC) by obtaining a complaint form at www.ncblpc.org. This should include which American Counseling Association ethical guidelines or laws have been broken.
Completed complaint forms should be sent to:
North Carolina Board of Licensed Clinical Mental Health Counselors
PO Box 77819
Greensboro, NC 27417
844-622-3572 Phone or 336-217-9450 Fax
By signing this disclosure statement, you are agreeing that you have had this information explained to you in a reasonable and appropriate language that you understand, and you have been given opportunity to ask questions regarding the procedure and issues involved in counseling. You will be provided with a copy of your signed statement and one copy will be maintained in the therapist’s records.
_________________________________________Client Signature _____________Date
____________________________________________________________________Date
Parent or Guardian Signature Relationship (other than self)
______________________________________Counselor Signature _____________Date
Jennifer Cook, MA, LCMHC, NCC