LCMHCA Professional Disclosure Statement

Leslie R. Smith, MA LCMHC-A Jodi Province Counseling Services, PLLC Office: 336-818-0733

E-mail: smithleslie2107@gmail.com

My Qualifications

I am a graduate student at Wake Forest University, completing my master's degree in clinical Mental Health Counseling and graduated in August 2023. I received a Bachelor of Arts degree in psychology from Penn State University in December 2019. I have completed over 600 internship hours. I volunteered for a little over year at the ARK, emergency, and temporary housing for women, working closely with the women in a supportive capacity and dispensed medication. I also am a mentor through the Surry County, Surry Friends of Youth.

Restricted Licensure

I have earned a Licensed Clinical Mental Health Counselor Association (LCHMCA) in North Carolina. I am also a National Board-Certified Counselor. I am working on my supervision hours towards full licensure. I am under the supervision of Jodi Province. Jodi Province, MA, LCMHCS, NCC. Her contact information is 336-818-0733, email jodi.province@gmail.com. From time to time, recordings of the counseling sessions will be used only for the purpose of providing clinical supervision. Her office is located at Jodi Provinces, Counseling Services, PLLC 1260 College Avenue, Suite 1, Wilkesboro, NC 28697. She is available Monday-Friday, 8am 5:00pm.

Counseling Background

I work primarily with children and adolescents, with the occasional adult client. My counseling treatment philosophy is based on person-centered approach and uses motivational interviewing techniques. During my internship, I have become familiar with Trauma Focused Cognitive Behavioral Therapy and Theraplay®. I have completed course work in Life Span Development, Theories and Models of Counseling, Family Counseling, Cultures and Counseling, and Advance Skill and Crisis Management.

Session Fees and Length of Service

Appointments are generally 45 to 50 minutes in length. The duration of counseling varies widely among clients depending on their needs and preferences. You may choose to terminate therapy at any time, but I strongly suggest that we have a final session together once you decide to terminate SO that I am best able to help you prepare for and process the conclusion of our work together. Session Fees for Private Pay the Initial Intake $175.00 Counseling Sessions $150.00 Letters $45.00 FMLA Paperwork $25.00. Jodi Province Counseling Services, PLLC is networked with several major insurance carriers including Blue Cross and Blue Shield, Medcost, Medicaid, Medicare, Cigna, Aetna, Tricare, Magellan, and NC Healthchoice. Co-pays are accepted in the form of cash, check, or credit. We are also credentialed with many local industry's Employee Assistance Programs (EAP Please check with your human resource department to determine eligibility.

Use of Diagnosis

Some health insurance companies require you to authorize us to provide them with confidential information such as a clinical diagnosis, treatment plans/summaries, or copies of records. 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. All insurance companies claim to keep such information confidential, however we have no control over this information once received by the insurance companies. To avoid the potential problem described above, you may always pay for services yourself.

Confidentiality

Your verbal communication and clinical records are strictly confidential except for: a) information (diagnosis and dates of service) shared with your insurance company to process your claims, b) information you and/or your child or children report about physical or sexual abuse; then by North Carolina State Law, I am obligated to report this the Department of Social Services, as well as any report that c) you the client have an infectious disease that you will intentionally spread to others d) where you sign a release of information to have specific information shared and e) if you provide information that informs me that you are in danger of harming yourself or others f) information necessary for case supervision or consultation and g) or when required by law.

Complaints

Although clients are encouraged to discuss any concerns with me, you may file a complaint against me with the organization below should you feel I am in violation of any of these codes of ethics. I abide by the ACA Code of Ethics (http://www.counseling.org/Resources/aca-code-of-ethics.pdf

North Carolina Board of Licensed Clinical Mental Health Counselors P.O. Box 77819 Greensboro, NC 27417 Phone: 844-622-3572 or 336-217-6007 Fax: 336-217-9450

E-mail: Complaints@ncblcmhc.org

We agree to these terms and will abide by these guidelines.