PROFESSIONAL DISCLOSURE STATEMENT

(Information and Consent)

Courtney B. Walters, M.A., LPC, NCC

I am pleased that you have selected me as your counselor. This document is designed to inform you about
my background and to ensure that you understand our professional relationship.

QUALIFICATIONS/EXPERIENCE

I received a Master of Arts degree in Service Agency Counseling from the University of North Carolina at
Pembroke in 2005. I have experience working with individuals, groups, couples, families, children and
adolescents, and substance abuse.
I have successfully met the professional counseling standards established by the North Carolina
Board of Licensed Professional Counselors (LPC #7375) and the National Board for Certified Counselors
(NCC #257326). I have been a licensed/certified counselor since 2009. Prior to licensure, I had more than
two years of supervised counseling experience.

NATURE OF COUNSELING

I accept only clients who I believe have the capacity to resolve their own problems with my assistance. I
believe that as people become more accepting of themselves, they are more capable of finding happiness
and contentment in their lives. However, self-awareness and self-acceptance are goals that sometimes take
a long time to achieve. Some clients need only a few counseling sessions to achieve these goals, while
others may require months or even years of counseling. As a client you are in complete control and may
end our counseling relationship at any point. I will be supportive of that decision. If counseling is
successful, you should feel that you are able to face lifes challenges in the future without my support or
intervention.
There are many different theories and techniques of counseling, and I have chosen to integrate
several of these into my counseling approach. The cognitive-behavioral approach aims at changing
underlying thoughts and beliefs that are affecting emotions and behaviors, therefore leading to
psychological problems. The Adlerian approach emphasizes that humans are largely influenced by social
factors, that we are not controlled by biological factors alone, and that we are in control of our lives. The
existential approach stresses factors such as choice, freedom, responsibility, and self-determination. The
person-centered or humanistic approach asserts that humans are capable of changing, and that the
counselor assists (rather than directs) clients in making changes to improve their daily lives. It emphasizes
the clients feeling empowered to take charge and striving to become a better person. The reality/choice
theory approach states that we are in control of our lives, and that we choose what we do and how we
react in order to get what we want. The common theme among these approaches that I have described is
the emphasis placed on the clients responsibility in the counseling relationship. The direction and the
outcome of counseling is dependent on the clients wants, needs, and willingness to participate. Only you
can change yourself, and only you can get what you want for yourself. I will do what I can to assist you
as you make that journey.
Although our sessions may be very intimate emotionally and psychologically, it is important for
you to realize that we have a professional relationship rather than a personal one. Our contact will be
limited to the sessions you have with me. You will be best served if our relationship remains strictly
professional and if our sessions concentrate exclusively on your concerns.
REFERRALS

If at any time for any reason you are dissatisfied with my services, please let me know. If I am not able to
resolve your concerns, you may place your complaint in writing and send to:

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
E-mail: Complaints@ncblpc.org

FEES AND CANCELLATION

Initial counseling sessions are 90 minutes in length. Follow-up appointments take place weekly or
biweekly and are 60 minutes in length. If we determine that this schedule is not best for you, we will work
together to create one that is. As an employee at the University of North Carolina at Pembroke, my
services are free of charge. In the event that you are unable to keep an appointment, please call at least 24
hours ahead of time to cancel or reschedule.
At this time, I am not eligible to accept health insurance as a method of payment. Once I am
eligible to do so, I will be happy to fill out necessary paperwork in order to serve your needs. Heath
insurance companies often require a diagnosis regarding your mental health condition before they will
reimburse you for mental health services. If a diagnosis is required, you will be informed of the diagnosis
before it is submitted to the insurance company. Any diagnosis made would then become part of your
permanent insurance records.

RECORDS AND CONFIDENTIALITY

All of our communication becomes part of the clinical record, which is accessible to you on request. I will
keep confidential anything you say to me, with the following exceptions: (1) you direct me to tell
someone else, (2) I determine you are a danger to yourself or others, (3) I see any indication of child or
elder abuse, or (4) I am ordered by a court to disclose information.
By your signature below (please sign both copies, keep one for your files and return the other copy
to me), you are indicating that you have read and understood this statement, and/or that any questions you
have had about this statement have been answered to your satisfaction.

Client signature: __________________________________________________ Date: ____/____/____

Parent/Guardian signature (for minor client): ____________________________ Date: ____/____/____

Counselor signature: _______________________________________________ Date: ____/____/____