-Professional Disclosure Form for Daija Prather, Resident Intern-Therapist
Daija Prather, MA, Resident Intern-Therapist
Counseling Agreement – Informed Consent
Office: 980-613-8312 | Fax: 888-972-4998 | E-mail: dprather@mysoulcare.org
Taking the initial step to enter the counseling relationship is not taken lightly. This document is meant to inform clients of the counseling process and provide a high-level overview of various therapeutic options that may arise during the therapeutic process. The following information describes policies and services offered from this provider so that clients can make an informed decision. Clients are encouraged to ask questions in order to fully understand this documents and clients must also agree in writing to these provisions before mental health services are provided.
Background and Training
I am currently a graduate student in my final year pursuing a Masters degree in Clinical Mental Health Counseling from Liberty University. I received a Bachelors degree from University of North Carolina at Chapel Hill in 2009 majoring in Psychology with a minor in Religious Studies. Most of my counseling experience has been within my graduate program where I began my clinical training in 2021 with Liberty University. This resident intern position will allow me to sharpen my counseling skills and work to serve the client’s I am assisting. As a Resident Intern with Soul Care, PLLC, I am under supervision of the Clinical Director and Owner Chantelle Johnson, MA, LCMHCS.
Counseling Services Provided
As I do not believe in a “one-sized fits all approach”, I believe a holistic and integrative approach works best. Services provided include theoretical orientations that will be best suited and appropriate for the individual who I am working with in order to cater to a myriad of situations. Psychological orientations include Cognitive-Behavioral, Solutions Focused, and Rational-Emotive theoretical orientations while incorporating mindfulness-based practices. Types of techniques used will include journaling and deep breathing to practice relaxation; guided imagery and humor; and exploring options that may not have been explored to find solutions to life’s dilemmas. With respect to your religious or spiritual orientation, we will work on how integration works best in our sessions together. This will be your choice if that is something you seek during this counseling relationship.
Client Population
I agree to work with individuals despite age, race, culture, disability, gender, religion, orientation, marital or socio-economic status. A referral will only be completed if a client decides that the working relationship is or will not best serve them; if I feel that I cannot help someone or if they would better benefit from receiving services from another professional. If a referral is needed, I will assist in providing necessary information regarding services based on the client’s consideration.
Therapist’s Responsibility
As this is a professional therapeutic relationship, I will abide by the ethical standards outlined by the American Counselors Association and North Carolina LPC Board code of ethics. Our contact will be bound to the sessions we have scheduled and are best kept professional. It is important to note that I am in the role of the helper best suited to provide a clinical, therapeutic relationship as a professional therapist. Please remember this is a collaborative process and I am here to help.
Client’s Responsibility
Our initial sessions will be used as the opportunity to build our working relationship in an effort to understand your current situation so that we can then work together to develop goals, methods, and techniques within an appropriate timeframe. It is essential that you come with an open mind and plan to be open and honest with me so that we can work on the goals we have identified. The majority of the session will involve you talking about any current issues or symptoms while I listen and find ways to assist you in processing and understanding your thoughts, feelings and behaviors. Please note that this is an active process and will include work in and out of the counseling session which may involve homework, self-assessment, and practice. A further responsibility is to attend each scheduled session on time.
Session Fees and Length of Service
Once we initially meet, we may begin to work on a consistent basis and decide on a regular frequency which is typically once a week at a specified time. Sessions are generally 45-50 minutes long. The length of treatment varies depending on therapist, client(s), and nature of problems identified.
The leadership of Soul Care PLLC determines the counseling fee structure. 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.
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 for Resident's Services. If a qualifying diagnosis is appropriate in your case, I will inform you of the diagnosis before you/we submit the diagnosis to the health insurance company. Any diagnosis made will become part of your permanent insurance records.
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.
Confidentiality
The verbal statements and written documents from counseling sessions are considered to be confidential. All information shared with me as well as notes and assessment results will not be released to any outside person or agency without your authorization and consent. The following are circumstances in which I am unable to guarantee confidentiality either legally or ethically:
1. If there is abuse (potential or actual) of children, elderly, and/or persons with disabilities.
2. If you have reported potential harm 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 my direct Clinical 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.
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).
Soul Care PLLC
Attn: Chantelle Johnson, MA, LCMHCS, Clinical Supervisor
Phone: 980-613-8312
Fax: 888-972-4998
E-mail: cjohnson@mysoulcare.org
INFORMED CONSENT TO AUDIO/VIDEO TAPE
I will audio/video tape 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. Following feedback from my clinical supervisor, the tapes will be erased.
Acceptance of Terms
I hereby give my permission and consent to Daija Prather and Soul Care PLLC to provide counseling treatment to Client listed below.
I understand that I am fully responsible for payment for any services which I have received. I understand that I will be charged for any appointment not canceled within 24 hours notice. I am aware that I may terminate my treatment at any time without consequence. I am also aware and consent to being audio/video taped for clinical supervision purposes.
Counseling Agreement – Informed Consent
Office: 980-613-8312 | Fax: 888-972-4998 | E-mail: dprather@mysoulcare.org
Taking the initial step to enter the counseling relationship is not taken lightly. This document is meant to inform clients of the counseling process and provide a high-level overview of various therapeutic options that may arise during the therapeutic process. The following information describes policies and services offered from this provider so that clients can make an informed decision. Clients are encouraged to ask questions in order to fully understand this documents and clients must also agree in writing to these provisions before mental health services are provided.
Background and Training
I am currently a graduate student in my final year pursuing a Masters degree in Clinical Mental Health Counseling from Liberty University. I received a Bachelors degree from University of North Carolina at Chapel Hill in 2009 majoring in Psychology with a minor in Religious Studies. Most of my counseling experience has been within my graduate program where I began my clinical training in 2021 with Liberty University. This resident intern position will allow me to sharpen my counseling skills and work to serve the client’s I am assisting. As a Resident Intern with Soul Care, PLLC, I am under supervision of the Clinical Director and Owner Chantelle Johnson, MA, LCMHCS.
Counseling Services Provided
As I do not believe in a “one-sized fits all approach”, I believe a holistic and integrative approach works best. Services provided include theoretical orientations that will be best suited and appropriate for the individual who I am working with in order to cater to a myriad of situations. Psychological orientations include Cognitive-Behavioral, Solutions Focused, and Rational-Emotive theoretical orientations while incorporating mindfulness-based practices. Types of techniques used will include journaling and deep breathing to practice relaxation; guided imagery and humor; and exploring options that may not have been explored to find solutions to life’s dilemmas. With respect to your religious or spiritual orientation, we will work on how integration works best in our sessions together. This will be your choice if that is something you seek during this counseling relationship.
Client Population
I agree to work with individuals despite age, race, culture, disability, gender, religion, orientation, marital or socio-economic status. A referral will only be completed if a client decides that the working relationship is or will not best serve them; if I feel that I cannot help someone or if they would better benefit from receiving services from another professional. If a referral is needed, I will assist in providing necessary information regarding services based on the client’s consideration.
Therapist’s Responsibility
As this is a professional therapeutic relationship, I will abide by the ethical standards outlined by the American Counselors Association and North Carolina LPC Board code of ethics. Our contact will be bound to the sessions we have scheduled and are best kept professional. It is important to note that I am in the role of the helper best suited to provide a clinical, therapeutic relationship as a professional therapist. Please remember this is a collaborative process and I am here to help.
Client’s Responsibility
Our initial sessions will be used as the opportunity to build our working relationship in an effort to understand your current situation so that we can then work together to develop goals, methods, and techniques within an appropriate timeframe. It is essential that you come with an open mind and plan to be open and honest with me so that we can work on the goals we have identified. The majority of the session will involve you talking about any current issues or symptoms while I listen and find ways to assist you in processing and understanding your thoughts, feelings and behaviors. Please note that this is an active process and will include work in and out of the counseling session which may involve homework, self-assessment, and practice. A further responsibility is to attend each scheduled session on time.
Session Fees and Length of Service
Once we initially meet, we may begin to work on a consistent basis and decide on a regular frequency which is typically once a week at a specified time. Sessions are generally 45-50 minutes long. The length of treatment varies depending on therapist, client(s), and nature of problems identified.
The leadership of Soul Care PLLC determines the counseling fee structure. 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.
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 for Resident's Services. If a qualifying diagnosis is appropriate in your case, I will inform you of the diagnosis before you/we submit the diagnosis to the health insurance company. Any diagnosis made will become part of your permanent insurance records.
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.
Confidentiality
The verbal statements and written documents from counseling sessions are considered to be confidential. All information shared with me as well as notes and assessment results will not be released to any outside person or agency without your authorization and consent. The following are circumstances in which I am unable to guarantee confidentiality either legally or ethically:
1. If there is abuse (potential or actual) of children, elderly, and/or persons with disabilities.
2. If you have reported potential harm 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 my direct Clinical 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.
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).
Soul Care PLLC
Attn: Chantelle Johnson, MA, LCMHCS, Clinical Supervisor
Phone: 980-613-8312
Fax: 888-972-4998
E-mail: cjohnson@mysoulcare.org
INFORMED CONSENT TO AUDIO/VIDEO TAPE
I will audio/video tape 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. Following feedback from my clinical supervisor, the tapes will be erased.
Acceptance of Terms
I hereby give my permission and consent to Daija Prather and Soul Care PLLC to provide counseling treatment to Client listed below.
I understand that I am fully responsible for payment for any services which I have received. I understand that I will be charged for any appointment not canceled within 24 hours notice. I am aware that I may terminate my treatment at any time without consequence. I am also aware and consent to being audio/video taped for clinical supervision purposes.
