Professional Disclosure Statement; Donaiel A. Allen, MA, LCMHC, NCC, (License # 16572 This information is intended to inform you about my professional background. Please read this information and sign and date to acknowledge receiving this information and feel free to call if you have any questions: Jodi Province Counseling Services, PLLC. (336) 818-0733.

My Qualifications:

In October 2020, I graduated with a Master of Arts in Clinical Mental Health Counseling from Montreat College, Montreat, North Carolina. I currently practice as a Mental Health Therapist; I am employed by Jodi Province Counseling Services, PLLC, (JPCS) in Wilkesboro, NC. I am recognized by the National Board of Certified Counseling (NBCC) as a National Certificated Counselor (NCC

Background

I have worked in Mental Health Services serving adolescents, adults, and families for over 15+ years as a Qualified Professional. I have been employed with JCPS, since July, 2021. I possess Advanced Certification in Corrections for the NC Criminal Justice in complying with North Carolina Department of Adult Corrections, NCDAC (formerly; NCDPS); I've been trained as a certified trainer in Cognitive Behavioral Interventions (CBI), and Certified Crisis Intervention Training (CIT) through NCDAC since 2013. Prior to my current job, I've worked in various capacities with community mental health by way of; Local Non-Profits, State and Local law enforcement, NC Vocational Rehabilitation, and NC public schools. I am an Ordained Minister and Associate Pastor since 2011; where I offer faith-based counseling.

Use of Diagnosis

I view diagnosis as an important tool used by clinical staff that help individuals find the answers to situations that are causing distress in their lives, and assisting them with finding tailored treatment options, and treatment planning. My role is to help individuals understand their diagnosis and the prognosis, and how it may impact their lives; also teaching interventions that can assist them with managing symptoms, making sure that they are well informed concerning therapies, treatments, and/or medication provided by their prescribers, linking them with the proper resources to provide positive solutions SO that individuals can live their best quality of life.

My theoretical approach to counseling is centered around Cognitive Behavioral Therapy (CBT), Existential Counseling with Grief Recovery and Spiritual counseling components, Solution Focused Brief Therapy; and other evidence-based interventions including Mindfulness Based Interventions, Expressive Arts, and Trauma Informed Care.

I have served individuals diagnosed with Depression and other Mood disorders, Anxiety, Eating Disorders, ODD, ADHD, Personality Disorders, Substance Use disorders, Trauma related disorders, and Chronic SPMI. I've facilitated Group Therapy for Addictions counseling for support with sobriety and relapse recovery, in both institutional and community settings; other specialty groups for Women's Empowerment, Youth, Faith and Spirituality, Crisis/Safety groups in connection with my faith-based ordination.

My mission is to serve ALL people in their pursuit of fulfillment/wellness/hope. My vision is to assist, support, and connect with individuals on life's journey. My motto: Seek Justice, Love Mercy, and Walk Humbly before God and the People I meet along the way.

Appointments and Fees: (Set by JPCS)

Appointments are generally 45 to 60 minutes. Initial intakes are $175.00, Counseling sessions are $150.00 Other services including report writing, telephone conversations longer than 10 minutes, attendance and meetings with other professionals, court appearances/involvement, etc. can be charged at hourly rates. A $100 up-front fee is charged for any court appearances. Letter/report fees $45. As a courtesy we will bill your insurance company, HMO, responsible party, or third-party payer for you if you wish. We ask that at each session you pay your co-pay. In the event you have not met your deductible, the full fee I due at each session until the deductible is satisfied. If your insurance company denies payment or does not cover counseling, we request you pay the balance due at the time. If your account has not been paid in 60 days and arrangements for payment have not been agreed upon, we have the option of using legal means to secure payment. This may involve but not be limited to hiring a collection agency or going through small claims court. If that were necessary, you will be responsible for all cost of litigation including attorney's fees. If this happens, the client's name and address, nature of services provided, and the amount due will be released to the above-named parties. Your cooperation is sincerely appreciated, if you have any questions regarding insurance, fees, balances, or payment feel free to ask. Most insurance companies will require your authorization to provide them with confidential information such as clinical diagnoses, treatment plans/summaries, or copies of records; SO that the information can become part of your insurance company's files.

Confidentiality

As the standard set by the NCBLMHC, all our communication becomes part of the 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 that are in accordance with the state law: 1) you express intention to hurt yourself or someone else, 2) there is indication of child or elder abuse/neglect, 3) a court order is received which requires disclosure of information, 4) you are a minor for whom confidentiality is limited to the extent exercised by your parent or legal guardian, 5) I am working with other professionals where disclosure of information is required in order to provide you with optimal care. Complaints Although clients are encouraged to discuss any concerns with me, you may file a complaint.

As the standards set by JPCS, LLC; Your verbal 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, your counselor is obligated to report this to the Department of Social Services, as well as any report that c) you the client have an infectious disease and you will intentionally spread to harm others d) where you sign a release of information to have specific information shared and e) if you provide information that informs

your counselor 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

I acknowledge that I have been given a copy of this Professional Disclosure; I understand and agree with the fees associated with Appointments and Cancellations. I understand the terms of confidentiality and how to make a complaint to the NCBLCMHC regarding ethical concerns.