LCMHCA Professional Disclosure Statement

Emmylou S. Madison, MA, LCMHCA, NCC

Email: madisonemmylou@gmail.com

You have already accomplished the first step in counseling: making the decision to participate. I am honored to walk alongside you as we work together through the counseling process, at your own pace. This document is designed to inform you about my background and to ensure that you understand our professional relationship.

Qualifications:

In December of 2021, I received a Master of Arts Degree (M.A in Clinical Mental Health Counseling from Gardner-Webb University in North Carolina. The graduate program that I completed is accredited by the Council on Accreditation of Counseling and other Related Educational Programs (CACREP This accreditation ensures that I understand my duties as a mental health professional and certifies that I am capable of providing the best care possible according to national standards.

North Carolina requires all professionals who provide mental health services to be licensed. I am certified as a Licensed Clinical Mental Health Counselor Associate to be licensed to practice counseling under the supervision of an experienced and licensed counselor (License #A17297 In addition, I am certified by the National Board of Certified Counselors, a private certifying agency that recognizes counselors who have distinguished themselves by achieving the Board's highest for education, knowledge, and experience (Certification #1622641)

I practiced counseling from August 2020- July 2021 through Gardner-Webb University's Internship Program while under the capable guidance of Dr. Sharon Webb and Professor Kimberly Williams-Thompson. I am competent to provide counseling services but to ensure that I am providing the level of care worthy of our profession; I have practiced counseling from February 2022- present as a Licensed Clinical Mental Health Counselor Associate at Jodi Province Counseling Services, LLC, under the weekly supervision of Jodi Province, MA, LCMHCS, NCC, BC-TMH, Certified Trauma Therapist. This allows the advantage of case consultation by a Licensed Clinical Mental Health Counselor Supervisor.

I have been privileged to serve a varied population, including children, adolescents, and adult clients, dealing with psychological and emotional issues, ranging from relational problems, substance abuse, anger management issues, parent/child issues, behavioral issues, depression, anxiety, post-traumatic stress disorder, adjustment and mood disorders, and numerous other issues. I also hold membership in the American Counseling Association (ACA), which is dedicated to promoting growth and development among the counseling profession.

Counseling Background/Philosophy:

The counseling experience is unique to each individual. One of the most important tools in the counseling process is the relationship between the counselor and the client; it is my goal to build and tailor a genuine relationship with each client SO that we may work together to reach the client's goals. Change is one of the most common experiences among human beings; it is inevitable and whether viewed as positive or negative, it can be disruptive and even frightening. I am eager to help clients navigate through the many different changes in their life. Our genetic makeup, culture, upbringing/childhood, life experiences, etc., help create our personal beliefs and expectations of how people should conduct themselves, especially in relation to one another. I believe that our relationships with one another, (family, romantic, platonic, and professional) are all affected by those, sometimes rigid, expectations. I believe that our relationship with ourselves and our relationships with others are a major source of human joy and pain; helping clients navigate those relationships, and their expectations about them, is paramount to effective counseling. It is my belief that counseling is simply providing uninterrupted time and a safe and culturally considerate space for a client to identify and understand where they are in their life, why, and where they want to go, using their own unique tools, strengths and challenges. My work reflects the value of a Person Centered (Rogerian) lens, as well as Cognitive-Behavioral Therapy, and Strengths based counseling. This means that I use empathy and genuineness to help clients feel safe, allowing them to fully be themselves with focus on working together with clients to figure out how to change unwanted behaviors, while learning about the relationship between our thoughts, feelings and behaviors and how they all work together. I enjoy working with children, adolescents, as well as adults. The professional counseling services I provide are primarily mental health counseling services for children, adolescents, and adults. Specific issues include ADHD, Oppositional Defiant Disorder, Educational, Adjustment Issues, Children of Divorce, Stress Management, Social Skills building, Depression, Grief and Loss, Identity issues, as well as Anxiety. I am capable of providing group and individual counseling. I often use play therapy as a resource for working with children. Together we will determine how many counseling sessions will be needed to accomplish your goals. Even though counseling is a collaborative experience, the client is in control and may end our counseling relationship at any point. Counseling is not used to foster dependence but to help guide the client in times of distress. If counseling is successful, clients should feel that they are able to face life's challenges in the future without my support or assistance. Although our sessions will be very intimate, it is important for you to realize that we have a professional, rather than personal, relationship. You will be best served if our relationship stays strictly professional and if our sessions concentrate exclusively on your concerns. Sessions will last about 50 minutes for adults and between 30 to 45 minutes for children and adolescents. During the first session an intake interview is completed to help me assess your needs. At that time, I gather information from you in order to determine conjointly what goals will be set to structure your therapy sessions. Depending on the nature of the presenting problem, we will most likely meet once a week for our counseling sessions. Additional sessions may be scheduled if necessary. A standard fee of $120.00 will be charged per session while the initial evaluation will be a charge of $150.00. This fee will be due at the completion of each session and is payable through check or cash. Insurance claims will be filed for eligible clients, however clients are still responsible for services provided not reimbursed by insurance companies. Court time is assessed at $200.00 per hour or $600.00 per day for preparation, travel time, and testimony. A standard fee of $80.00 for any letters or documentation needed for court.

Client's Rights:

I strive to ensure that the counseling environment is a safe environment in which you will feel comfortable. In order to do so, I will keep confidential anything you say to me with all of the following exceptions:

If you at any time are a threat to yourself or others. I must inform the proper people that can protect you from following through with a threat of harm. Examples of people that I may notify are: family members, hospital staff, and/or the police.

If there is suspected child/elder neglect or abuse, then I must report that information to the local Department of Social Services.

If you sign a release of information that allows me to disclose information from your record to a third party.

If insurance is filed, certain information must be released to your insurance provider for reimbursement of services.

If I am court ordered to testify then I must disclose the requested information from your record.

The counseling process typically involves a diagnosis according to the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV-TR This information becomes a permanent part of your record and may be provided to your insurance company for coverage policies. All records are my property and are kept for your benefit. However, if deemed therapeutic, they are available upon request. You have the right to decline or accept any and all recommendations about treatment or techniques used.

Emergencies:

My counseling services are limited to the scheduled sessions we have together. In the event you feel your mental health requires emergency attention or if you have an emotional crisis, please contact one of the following: your primary care physician, local law enforcement, or report to the emergency room of a local hospital and request mental health services.

Procedures for Registering Complaints:

As an ethical counselor, I adhere to both national and state Professional Association Code of Ethics. Our professional code includes several standards of behavior appropriate and expected of professional counselors. If a client feels that there has been a violation of any kind committed against them, he/she has the right to register a complaint to the North Carolina Board of Licensed Clinical Mental Health Counselors.

The address and phone number for the Board of Licensed Clinical Mental Health Counselors is as follows:

North Carolina Board of Licensed Clinical Mental Health Counselors P.O. Box 77819

Greensboro, NC 27417 Telephone: 844-622-3572 or 336-217-6007

Fax: 336-217-9450 Consent for Treatment

By signing below you are indicating that you have read this disclosure statement and your questions have been answered. You are also indicating that you understand your rights as a client as well as confidentiality and what may or may not be covered under confidentiality. Lastly, your signature indicates that you would like to proceed with counseling services and you understand the grievance policy if there should be an issue.

Your Signature Client's Signature