Courtney Moore, MSW, LCSWA
Client Disclosure Statement
(Information and Consent for Treatment)
The decision to enter into a counseling relationship is a serious commitment that can be a life-changing experience. Research has
shown that individuals who understand the counseling process are more likely to achieve favorable results. This document is
designed to inform you of the counseling process, the various therapeutic modalities that I use, the benefits and risks involved in
counseling, confidentiality, our professional relationship and my background. It will also document your understanding of and
consent to treatment.
Background and Training
I have completed a Masters degree in Social Work (MSW) from University of Central Florida. I received a Bachelors degree from
Missouri State University in 2018. I have my LCSWA (Licensed Clinical Social Work Associate) License. My previous therapy
experience has been at My Positive Tranformation under supervision while obtaining a Masters degree and attaining a clinical
associate license. The experience I have comes from working with individuals, children and families. Clients with whom I work
generally seek counseling for difficulties associated with common life and trauma. This includes: depression, anxiety, grief, loss,
adjustment difficulties, abuse, trauma, self-identity issues, life goals, relationship issues, and substance abuse issues.
Counseling Services Offered
With respect to my theoretical orientation and worldview for counseling, I believe that we are whole persons, with physical,
psychological, social and spiritual aspects, so therefore I am committed to an integrated approach of psychotherapy. These
psychological perspectives of psychotherapy include: Client-Centered Therapy, Psychodynamic Therapy, Family Systems
approach, Cognitive-Behavioral Therapy, Interpersonal Psychotherapy, Solution Focused Therapy, Emotionally Focused
Therapy, and Narrative Therapy. These models are regarded as established, well-researched and effective methods of therapy. I
respect your religious/spiritual orientation and therefore whether we include discussion of the spiritual dimension of life in our
time together will be entirely up to you.
Guiding Principles and Practices
My approach to counseling is: Goal-oriented; Experiential; Multidimensional; Designed to enhance awareness and understanding:
Collaborative: and means for accomplishing them; Continuous; Spiritually/religiously sensitive; and Contemplative:
Client Population
I will agree to meet with a potential client regardless of age, color, culture, disability, ethnic group, gender, race, religion, sexual
orientation, marital status or socio-economic status. I may decline meeting with a client if I feel, in my professional opinion, that I
cannot help them or if they would be better served with the services of another professional. If a referral elsewhere is needed, I
will provide information regarding services for the client’s consideration.
Therapist’s Responsibility
As a professional, I will uphold and abide by the standards of the National Association of Social Workers (NASW) code of ethics.
Our relationship is a professional one. Our contact will be limited to the sessions you arrange with me. You will be best served
while I am seeing you for counseling if our relationship stays strictly professional and if our sessions concentrate exclusively on
your concerns. You may learn more about me as we work together, but it is important for you to remember that you are
experiencing me as a professional therapist.
Client’s Responsibility
The beginning sessions involve understanding your situation so that together we can develop specific, realistic goals, methods to
accomplish them and the approximate length of time needed. It is important for you to be as open and honest with me as possible
and work toward the goals we have agreed upon. The majority of the counseling session will consist of you talking about the
issues you present and employing methods that can help make a positive difference in your life. This requires effort and active
involvement on your part to understand and change your thoughts, feelings and behaviors. It will include work in and out of the
counseling sessions and may include homework assignments, self-observation and practicing new behaviors. It is important for
you to attend all of your scheduled appointments on time.
Confidentiality
I regard the information you share with me with great respect. All information that you share with me including notes and records
as well as assessment results is confidential and will not be released to any outside person or agency without your written
authorization and consent.
The following are circumstances in which I cannot guarantee confidentiality, either legally or ethically:
1. If there is abuse (potential or actual) of children, persons with disabilities, and/or senior citizens. The law requires the
therapist to report it to the appropriate authorities.
2. If disclosure is required to prevent clear and imminent danger to yourself and/or others.
3. If mandated by a court of law.
In order to improve my clinical skills and obtain additional training I may audio/video tape counseling sessions. These sessions
may be discussed with and reviewed by a licensed clinical LPC supervisor. Confidentiality concerning such tapes is considered
the same as the counseling sessions themselves. Following the feedback of my supervisor(s) the tapes will be destroyed.
Session and Fees
I can assure you that my services will be provided in a professional manner and will be consistent with accepted ethical standards.
After we decide on the frequency of appointments (generally once a week) and the appointment time, I will reserve this time for
you. Sessions are usually 45 – 50 minutes long. It is possible to adjust the length of a session if necessary and should be agreed
upon in advance. The length of treatment varies depending on the therapist, the client (s) and the nature of the problems.
Typically treatment will last 8-12 sessions for relatively specific problems but may be longer or shorter depending upon the nature
of treatment.
The leadership of Soul Care PLLC determines the counseling fee structure. Clients may use their insurance if applicable. Please
note that your insurance company may require information regarding diagnosis, symptoms, treatment goals and methods. Any
diagnosis provided to your insurance company becomes a part of your permanent medical record. Please understand that you, the
client, are fully responsible for payment of fees for services provided regardless of any insurance coverage you may have.
Counseling fees are accepted in the form of cash, check, debit and/or credit card(s). Please note that if your check is returned for
insufficient funds, you will be responsible for the bank charges incurred. Cancellation of appointments must be made 24 hours
prior to your appointment. If the appointment is not canceled within this time period or if you do not show up for your
appointment, you will be charged a $35 missed appointment fee.
In Case of Emergency
If you try to contact me by phone and I am not available, please leave a message on my voice mail. I will return calls
within 24 hours. If you are unable to reach me in an emergency, contact 911 or go to the nearest hospital emergency room.
Social Media and Electronic Communications
Social Media is neither private nor confidential. Therefore, I will not seek out or accept “friend” requests or “follow” any current
or former client on any social media platform. With this being said, I will not engage you in any public forums over the Internet,
because to do so could blur the professional nature of our relationship and could compromise the privacy that I seek to guard.
Electronic communications (E-mail, texting (SMS), etc.) are not encrypted or secure and may not be received in a timely manner.
The best method is to contact the office or the phone number given.
Complaint Procedure
If you are dissatisfied with any aspect of our work, the most effective and productive way to deal with the situation and hopefully
resolve it is to discuss it in our sessions together. Please feel free to ask any questions or clarify any confusion you may have
about our work. For clarification of client rights as I have explained them or to lodge a complaint if you think that you have been
treated unfairly or unethically by me, contact the:
Client Rights Committee:
Soul Care
5501 Executive Center Drive
Suite #215
Charlotte, NC 28212
Tel: 980-613-8312
North Carolina Legal Assistance:
2113 Cameron Street
Suite #218
Raleigh, NC 27605
Advocacy and Customer Service
Department at the Division of
MH/DD/SAS
3724 National Drive, Suite 100
Raleigh, NC 27612
Toll-Free: 877-235-4210
_______________________________________________________________________________________
I hereby give my permission and consent to Courtney Moore and Soul Care PLLC to provide counseling treatment.
_____________________________________________________________________________
INFORMED CONSENT TO AUDIO/VIDEO TAPE
I will audio/video tape some counseling sessions for the purpose of improving my clinical skills and to obtain additional clinical training. Confidentiality concerning such tapes is considered the same as the counseling sessions themselves. Before a session is recorded, therapist will notify the client and ask for consent. Following feedback from my clinical supervisor, the tapes will be erased.
shown that individuals who understand the counseling process are more likely to achieve favorable results. This document is
designed to inform you of the counseling process, the various therapeutic modalities that I use, the benefits and risks involved in
counseling, confidentiality, our professional relationship and my background. It will also document your understanding of and
consent to treatment.
Background and Training
I have completed a Masters degree in Social Work (MSW) from University of Central Florida. I received a Bachelors degree from
Missouri State University in 2018. I have my LCSWA (Licensed Clinical Social Work Associate) License. My previous therapy
experience has been at My Positive Tranformation under supervision while obtaining a Masters degree and attaining a clinical
associate license. The experience I have comes from working with individuals, children and families. Clients with whom I work
generally seek counseling for difficulties associated with common life and trauma. This includes: depression, anxiety, grief, loss,
adjustment difficulties, abuse, trauma, self-identity issues, life goals, relationship issues, and substance abuse issues.
Counseling Services Offered
With respect to my theoretical orientation and worldview for counseling, I believe that we are whole persons, with physical,
psychological, social and spiritual aspects, so therefore I am committed to an integrated approach of psychotherapy. These
psychological perspectives of psychotherapy include: Client-Centered Therapy, Psychodynamic Therapy, Family Systems
approach, Cognitive-Behavioral Therapy, Interpersonal Psychotherapy, Solution Focused Therapy, Emotionally Focused
Therapy, and Narrative Therapy. These models are regarded as established, well-researched and effective methods of therapy. I
respect your religious/spiritual orientation and therefore whether we include discussion of the spiritual dimension of life in our
time together will be entirely up to you.
Guiding Principles and Practices
My approach to counseling is: Goal-oriented; Experiential; Multidimensional; Designed to enhance awareness and understanding:
Collaborative: and means for accomplishing them; Continuous; Spiritually/religiously sensitive; and Contemplative:
Client Population
I will agree to meet with a potential client regardless of age, color, culture, disability, ethnic group, gender, race, religion, sexual
orientation, marital status or socio-economic status. I may decline meeting with a client if I feel, in my professional opinion, that I
cannot help them or if they would be better served with the services of another professional. If a referral elsewhere is needed, I
will provide information regarding services for the client’s consideration.
Therapist’s Responsibility
As a professional, I will uphold and abide by the standards of the National Association of Social Workers (NASW) code of ethics.
Our relationship is a professional one. Our contact will be limited to the sessions you arrange with me. You will be best served
while I am seeing you for counseling if our relationship stays strictly professional and if our sessions concentrate exclusively on
your concerns. You may learn more about me as we work together, but it is important for you to remember that you are
experiencing me as a professional therapist.
Client’s Responsibility
The beginning sessions involve understanding your situation so that together we can develop specific, realistic goals, methods to
accomplish them and the approximate length of time needed. It is important for you to be as open and honest with me as possible
and work toward the goals we have agreed upon. The majority of the counseling session will consist of you talking about the
issues you present and employing methods that can help make a positive difference in your life. This requires effort and active
involvement on your part to understand and change your thoughts, feelings and behaviors. It will include work in and out of the
counseling sessions and may include homework assignments, self-observation and practicing new behaviors. It is important for
you to attend all of your scheduled appointments on time.
Confidentiality
I regard the information you share with me with great respect. All information that you share with me including notes and records
as well as assessment results is confidential and will not be released to any outside person or agency without your written
authorization and consent.
The following are circumstances in which I cannot guarantee confidentiality, either legally or ethically:
1. If there is abuse (potential or actual) of children, persons with disabilities, and/or senior citizens. The law requires the
therapist to report it to the appropriate authorities.
2. If disclosure is required to prevent clear and imminent danger to yourself and/or others.
3. If mandated by a court of law.
In order to improve my clinical skills and obtain additional training I may audio/video tape counseling sessions. These sessions
may be discussed with and reviewed by a licensed clinical LPC supervisor. Confidentiality concerning such tapes is considered
the same as the counseling sessions themselves. Following the feedback of my supervisor(s) the tapes will be destroyed.
Session and Fees
I can assure you that my services will be provided in a professional manner and will be consistent with accepted ethical standards.
After we decide on the frequency of appointments (generally once a week) and the appointment time, I will reserve this time for
you. Sessions are usually 45 – 50 minutes long. It is possible to adjust the length of a session if necessary and should be agreed
upon in advance. The length of treatment varies depending on the therapist, the client (s) and the nature of the problems.
Typically treatment will last 8-12 sessions for relatively specific problems but may be longer or shorter depending upon the nature
of treatment.
The leadership of Soul Care PLLC determines the counseling fee structure. Clients may use their insurance if applicable. Please
note that your insurance company may require information regarding diagnosis, symptoms, treatment goals and methods. Any
diagnosis provided to your insurance company becomes a part of your permanent medical record. Please understand that you, the
client, are fully responsible for payment of fees for services provided regardless of any insurance coverage you may have.
Counseling fees are accepted in the form of cash, check, debit and/or credit card(s). Please note that if your check is returned for
insufficient funds, you will be responsible for the bank charges incurred. Cancellation of appointments must be made 24 hours
prior to your appointment. If the appointment is not canceled within this time period or if you do not show up for your
appointment, you will be charged a $35 missed appointment fee.
In Case of Emergency
If you try to contact me by phone and I am not available, please leave a message on my voice mail. I will return calls
within 24 hours. If you are unable to reach me in an emergency, contact 911 or go to the nearest hospital emergency room.
Social Media and Electronic Communications
Social Media is neither private nor confidential. Therefore, I will not seek out or accept “friend” requests or “follow” any current
or former client on any social media platform. With this being said, I will not engage you in any public forums over the Internet,
because to do so could blur the professional nature of our relationship and could compromise the privacy that I seek to guard.
Electronic communications (E-mail, texting (SMS), etc.) are not encrypted or secure and may not be received in a timely manner.
The best method is to contact the office or the phone number given.
Complaint Procedure
If you are dissatisfied with any aspect of our work, the most effective and productive way to deal with the situation and hopefully
resolve it is to discuss it in our sessions together. Please feel free to ask any questions or clarify any confusion you may have
about our work. For clarification of client rights as I have explained them or to lodge a complaint if you think that you have been
treated unfairly or unethically by me, contact the:
Client Rights Committee:
Soul Care
5501 Executive Center Drive
Suite #215
Charlotte, NC 28212
Tel: 980-613-8312
North Carolina Legal Assistance:
2113 Cameron Street
Suite #218
Raleigh, NC 27605
Advocacy and Customer Service
Department at the Division of
MH/DD/SAS
3724 National Drive, Suite 100
Raleigh, NC 27612
Toll-Free: 877-235-4210
_______________________________________________________________________________________
I hereby give my permission and consent to Courtney Moore and Soul Care PLLC to provide counseling treatment.
_____________________________________________________________________________
INFORMED CONSENT TO AUDIO/VIDEO TAPE
I will audio/video tape some counseling sessions for the purpose of improving my clinical skills and to obtain additional clinical training. Confidentiality concerning such tapes is considered the same as the counseling sessions themselves. Before a session is recorded, therapist will notify the client and ask for consent. Following feedback from my clinical supervisor, the tapes will be erased.
