LPCA Professional Disclosure Statement

Jena Plummer, MS, LPC-A

Office: 336-621-3381
E-mail: jenas@fellowshiphall.com
My Qualifications
I received a Masters of Art degree in Clinical Mental Health Counseling from Wake Forest University
in 2016. I am currently a Licensed Professional Counselor Associate in North Carolina (LPCA, TBD). I
completed a yearlong internship and practicum at Fellowship Hall in Greensboro, NC where I am
currently providing services to chemically dependent adults.
Restricted Licensure
I am currently under supervision as a Licensed Professional Counselor Associate in North Carolina.
As an LPCA, I am working under the direct clinical supervision of Mr. Gregory Moore, MS, LPCS; 5410
Dunstan Road, Greensboro, NC 27415; (336) 621-3381.
Counseling Background
At Fellowship Hall, my clientele includes men and women over the age of 18 years old with mental
health and relational and/or spiritual issues that relate directly to substance abuse/dependence. I
have worked with both individuals and groups. My theoretical approach is person-centered, with
elements of Dialectical Behavioral Therapy (DBT). Person-centered therapy focuses on the
uniqueness and inherent value of the individual, with emphasis placed on unconditional
acceptance. DBT focuses on the relationships among the individuals thoughts, feelings and
behaviors, with emphasis placed on the acceptance or validation of uncomfortable thoughts.
Risks and Benefits
Counseling is an intensely personal process, which can bring unpleasant memories or emotions to
the surface. There are no guarantees that counseling will work for you. Clients can sometimes make
improvements only to go backwards after a time. Progress may happen slowly. Counseling requires
active effort on your part. In order to be most successful, you will have to work on things we discuss
outside of sessions.
However, there are many benefits to counseling. Counseling can help you develop coping skills,
make behavioral changes, reduce symptoms of mental health disorders, improve the quality of your
life, learn to manage feelings and emotions, learn to live in the present and many other
advantages.
Session Fees and Length of Service
Therapy sessions are normally 45-50 minutes and will be provided two times per week as per the
requirements of Fellowship Halls intensive inpatient program. Fees are included in your tuition. You
are expected to attend each scheduled session and complete homework as assigned. We will meet
approximately 8 times before you transition to outpatient services.
Use of 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 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 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. You will be screened by our on-site psychiatrist before any diagnosis is made. Any
diagnosis made will become part of your permanent insurance records.
Confidentiality

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Material revealed during counseling sessions becomes part of the clinical record, which is
accessible to you upon request (unless doing so would be psychologically harmful). Information you
share during our sessions will remain strictly confidential except under the following circumstances
in accordance with state law:

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(1) You give consent in writing for disclosure to a third party.
(2) You express intent to hurt yourself or someone else,
(3) There is a reasonable suspicion of abuse/neglect against a minor child, elderly person
(65 or older), or a dependent adult,
(4) A subpoena or other court order is received directing the disclosure of information,
(5) I am working collaboratively with other professionals where disclosure of personal
information is necessary to provide optimal care,
(6) You are a minor for whom confidentiality is limited to the extent exercised by your legal
guardian/parent. Otherwise I will not give information about you without your full
knowledge and a signed consent of release of information specifying exactly what is to
be released and to whom.

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 Professional Counselors
P.O Box 77819
Greensboro, NC 27417
Phone: 844-622-3572 or 336-217-6007
Fax: 336-217-9450
Email: complaints@ncblpc.org

Acceptance of Terms
I agree to these terms and will abide by these guidelines.
Client: ___________________________________________________ Date: ___________
Counselor: ________________________________________________ Date: ___________