Professional Disclosure Statement

Jordan R. Whitley jordanwhitley.jpcs@gmail.com

Hello and thank you for allowing me to be a part of your counseling experience. This Professional Disclosure Statement will help to inform you of my background, counseling approaches, and your rights as the client. This document is mandated by both North Carolina Administrative Codes Rule .0204 of Chapter 53, Title 21 and the NC GS 90-343. If you have any questions, please feel free to discuss them with me at any time.

My Qualifications

In 2022, I graduated with my Bachelor of Science in Psychology degree from High Point University, and in 2024 I graduated from Catawba College with my Master of Health Science in Clinical Mental Health Counseling degree. I completed 8 months of supervised counseling experience during my practicum and internship process. My formal education has prepared me to counsel individual adults, adolescents, and children; groups; couples; parents; families.

Restricted Licensure

I currently hold an active license as a Clinical Mental Health Counselor Associate in North Carolina. As a Licensed Clinical Mental Health Counselor Associate (LCMHCA) I am practicing under supervision from a Qualified Professional approved by the North Carolina Board of Licensed Clinical Mental Health Counselors. A contract indicating this supervisory relationship is currently on file with the NCBLCMHC.

Professional Services & Theoretical Orientation

I am prepared to work with a range of issues that include but are not limited to: behavioral issues at home and/or school, anxiety, depression, social skills development, self-harm, suicidal ideation, physical and sexual abuse, and other specific mental health concerns you feel comfortable working on. The primary models of therapeutic intervention that I use are Cognitive-Behavioral Theory (CBT), Behavioral Theory, and Person-Centered. I feel that all of these theories mentioned recognize how there are many things that can influence a person's mental health, whether it be cultural aspects, behaviors, thoughts, feelings, etc. Each of these theories also show that at the end of the day, I am mainly there to help guide your personal discovery and to be a source of support for you. However, I also recognize that every individual is different and there is not just one way of helping those who seek counseling services. I am prepared to implement other therapeutic interventions if necessary to help my clients achieve their goals through empowering them and providing them with conditions for personal growth.

Patient Rights and Record of Diagnosis

Every client has the right to accept or decline any therapeutic modality presented during the counseling process. The termination of the counseling relationship will be made by a collaborative decision unless there is a therapeutic need. For most insurance plans, a clinical diagnosis is required to authorize payment coverage. Please note that if a diagnosis is rendered via counseling, this diagnosis becomes a permanent part of your records. All records that are created during the counseling process are my property and are securely stored. If you would like to request a copy of records, this may be permitted for a processing fee.

Confidentiality

It is one of my utmost responsibilities and desires that I respect your right to privacy, and anything shared in our sessions will remain confidential. There are some exceptions, however, to confidentiality. These exceptions include: (a) you direct me in writing to disclose information to someone else, (b) it is determined you are a danger to yourself or others (including child or elder abuse), or (c) I am ordered by a court to disclose information, (d) I am working collaboratively with other professionals where disclosure of personal information is necessary to provide optimal care, and/or (e) you are a minor for whom confidentiality is limited to the extent exercised by your parent/legal guardian. In the instances where one may participate in group counseling, I cannot guarantee confidentiality from other group members. However, I will do everything I can to ensure all group members understand confidentiality policies and that breaching confidentiality results in automatic dismissal from the group.

Session Fees and Length of Service

Services will be rendered in a professional manner consistent with accepted ethical standards of the counseling profession. Your first session will last approximately one hour, and each subsequent session will range between 30-60 minutes with the fees ranging between $125-$210. The fees/co-pay are due upon service, and these can be paid by cash, check or card. All clients are responsible for copays and coinsurance payments. As a courtesy we will bill your insurance company, HMO, responsible party or third-party payer for you if requested. If your insurance company denies payment or does not cover counseling, we request that you pay the balance due. Ifyou need to cancel or reschedule an appointment, please notify me at least 24 hours before your scheduled appointment time. Three missed appointments without prior notice can result in the termination of service (at the discretion of the counselor

Complaints

If you are not satisfied with any aspect of your counseling experience, please discuss this with me immediately. If you feel that you have been treated unethically and cannot resolve the problem with me, you may contact my supervisor, Jodi Province. If a resolution still cannot be met or you feel a need to register a complaint, you may contact the North Carolina Board of Licensed Clinical Mental Health Counselors at the following: P.O. Box 77819 Greensboro, NC 27417, phone: 844-622-3572.

If you have any questions or concerns about the information provided above, please discuss them with me. To indicate that you have read and understand this information and agree to the terms outlined in this professional disclosure statement, please sign and date the form below. A copy of the signed form will be returned to you, and one will be kept by this site in your confidential records.