-Professional Disclosure Form for Jasmine Johnson, Resident Intern-Therapist
Jasimine Johnson, MA, Resident Intern Personal Disclosure Statement
This form provides information relative to Jasimine Johnson, Internship I, enrolled in our graduate program for Clinical Mental Health. This document provides the client with written information regarding the student’s (counselor-in-training) preparation, information about the counseling relationship, client rights and responsibilities, and the limits of confidentiality. This document must be signed by the client or by the client’s parent/legal guardian before counseling may begin.
Student Training
Prior to/concurrent with beginning her clinical experience at the practicum or internship site, the student has completed core counseling courses such as introduction to counseling, human growth and development, personality theories and psychopathology, counseling theories and practice, and family counseling. The practicum and internship courses are a developmental sequence in which the student applies his knowledge under intensive supervision. This is the third clinical rotation for this Resident Intern, who is pursuing a Master of Arts in Professional Clinical Mental Health Counseling from Lindenwood University in Saint Louis, MO.
Counseling Relationship and Client Responsibility
Counseling is based on a relationship characterized by trust and respect. The counselor-in-training and the client work together to identify goals for counseling and approaches to meet those goals. The counselor’s primary theoretical orientations are Solution-Focused Therapy and Emotion-Focused Therapy. Solution-Focused Therapy involves helping clients discover and utilize resources within themselves or their environment to take steps towards finding solutions to challenges. Alternatively, Emotion-Focused Therapy emphasizes understanding the client’s emotions and helping the client self-regulate his emotions. Therefore, counseling sessions may include exploring feelings, emotions and thoughts, beliefs, attitudes and behaviors regarding self and others, personal history, including family of origin, communication style and other personal needs. The success of the counseling relationship depends on your willingness to be open, honest and involved in the process. The counseling experience can evoke changes in attitudes, beliefs, emotions, behaviors, coping skills and personal views. This can sometimes affect those close to you as they adjust to the new perspectives and positive behavioral changes that occur during counseling.
During the internship, the counselor-in-training receives an hour of supervision once a week from the clinical sites’ designated supervisor and one and a half hours every week from an assigned GCTS counseling department faculty member, and peers. Supervisors are qualified licensed mental health clinicians trained/experienced in the area of counseling and supervision.
Confidentiality
As a way to further the training needs and professional development of the Resident Intern and to insure that the client is receiving best practice and ethical services, under supervisory review, your counselor-in-training may ask to record some or all of your counseling sessions. After further discussion regarding recording, the client has the right to allow or to refuse this process. If you agree, the counselor-in-training will provide you with a written consent form for you to sign. Every effort is taken to protect confidentiality and the safekeeping of all recordings. All recordings are destroyed at the end of the semester in which services are provided.
As a client, it is your right to receive counseling in which your dignity, worth, and uniqueness are respected. Your counselor-in-training will provide you with quality informed services under close supervision. Clients have the right to receive services that are confidential, HIPPA compliant and follow the ethical and legal codes of the state licensure board and the American Counseling Association.
Limits of Confidentiality
All counselors-in-training, their supervisors, and group supervision members will not disclose information except under the following conditions, which include but are not limited to:
The counselor-in-training is a mandated reporter and must comply with laws and ethical code that require reporting harm to oneself or others, abuse to children, elderly or disabled persons, a court-order, and other conditions.
Informed Consent to Audio and Video RecordAs a counselor-in-training, I audio/video record all counseling sessions (unless otherwise specified) for training purposes and in order to improve my clinical counseling skills. The counselor-in-training will be video recorded, and the client(s) will be audio recorded. Confidentiality concerning such recordings is considered the same as the counseling sessions themselves. I take the utmost care to insure the safekeeping of all recordings. Recordings are properly destroyed after consultation and feedback from my clinical supervisor and my University advisor.
I, the client(s), give my consent for my counseling sessions to be Audio and Video recorded by Jasimine Johnson, MA, Resident Intern, for clinical training purposes and supervision review. I understand that I may rescind this consent at any time.
This Resident Intern will provide services under the supervision of:
Chantelle Johnson |5501 Executive Center Drive Suite #215 Charlotte, NC 28212 |704-909-8025
Clinical Supervisor Name: Address: Phone:
This form provides information relative to Jasimine Johnson, Internship I, enrolled in our graduate program for Clinical Mental Health. This document provides the client with written information regarding the student’s (counselor-in-training) preparation, information about the counseling relationship, client rights and responsibilities, and the limits of confidentiality. This document must be signed by the client or by the client’s parent/legal guardian before counseling may begin.
Student Training
Prior to/concurrent with beginning her clinical experience at the practicum or internship site, the student has completed core counseling courses such as introduction to counseling, human growth and development, personality theories and psychopathology, counseling theories and practice, and family counseling. The practicum and internship courses are a developmental sequence in which the student applies his knowledge under intensive supervision. This is the third clinical rotation for this Resident Intern, who is pursuing a Master of Arts in Professional Clinical Mental Health Counseling from Lindenwood University in Saint Louis, MO.
Counseling Relationship and Client Responsibility
Counseling is based on a relationship characterized by trust and respect. The counselor-in-training and the client work together to identify goals for counseling and approaches to meet those goals. The counselor’s primary theoretical orientations are Solution-Focused Therapy and Emotion-Focused Therapy. Solution-Focused Therapy involves helping clients discover and utilize resources within themselves or their environment to take steps towards finding solutions to challenges. Alternatively, Emotion-Focused Therapy emphasizes understanding the client’s emotions and helping the client self-regulate his emotions. Therefore, counseling sessions may include exploring feelings, emotions and thoughts, beliefs, attitudes and behaviors regarding self and others, personal history, including family of origin, communication style and other personal needs. The success of the counseling relationship depends on your willingness to be open, honest and involved in the process. The counseling experience can evoke changes in attitudes, beliefs, emotions, behaviors, coping skills and personal views. This can sometimes affect those close to you as they adjust to the new perspectives and positive behavioral changes that occur during counseling.
During the internship, the counselor-in-training receives an hour of supervision once a week from the clinical sites’ designated supervisor and one and a half hours every week from an assigned GCTS counseling department faculty member, and peers. Supervisors are qualified licensed mental health clinicians trained/experienced in the area of counseling and supervision.
Confidentiality
As a way to further the training needs and professional development of the Resident Intern and to insure that the client is receiving best practice and ethical services, under supervisory review, your counselor-in-training may ask to record some or all of your counseling sessions. After further discussion regarding recording, the client has the right to allow or to refuse this process. If you agree, the counselor-in-training will provide you with a written consent form for you to sign. Every effort is taken to protect confidentiality and the safekeeping of all recordings. All recordings are destroyed at the end of the semester in which services are provided.
As a client, it is your right to receive counseling in which your dignity, worth, and uniqueness are respected. Your counselor-in-training will provide you with quality informed services under close supervision. Clients have the right to receive services that are confidential, HIPPA compliant and follow the ethical and legal codes of the state licensure board and the American Counseling Association.
Limits of Confidentiality
All counselors-in-training, their supervisors, and group supervision members will not disclose information except under the following conditions, which include but are not limited to:
- The client or guardian gives written consent to release information to a designated individual or agency
- The client makes specific violent threats to harm him or herself or to harm an identifiable person
- The counselor-in-training and/or his supervisors are named as defendants in a civil, criminal, or disciplinary action, lawsuit or case arising from the counseling session
- The counselor-in-training receives an authentic subpoena backed by judicial authority that requires the disclosure of information
- The counselor-in-training has reasonable cause to believe that a child, elder, or an adult with a disability has suffered abuse or neglect
- The client is diagnosed with a life-threatening communicable disease and is not taking necessary precautions
- When reimbursement or laws necessitate disclosure
- The counselor-in-training will discuss the content of counseling sessions in individual and group supervision under the direction of a qualified supervisor who is held to the same professional standards of confidentiality and its limits
The counselor-in-training is a mandated reporter and must comply with laws and ethical code that require reporting harm to oneself or others, abuse to children, elderly or disabled persons, a court-order, and other conditions.
Informed Consent to Audio and Video RecordAs a counselor-in-training, I audio/video record all counseling sessions (unless otherwise specified) for training purposes and in order to improve my clinical counseling skills. The counselor-in-training will be video recorded, and the client(s) will be audio recorded. Confidentiality concerning such recordings is considered the same as the counseling sessions themselves. I take the utmost care to insure the safekeeping of all recordings. Recordings are properly destroyed after consultation and feedback from my clinical supervisor and my University advisor.
I, the client(s), give my consent for my counseling sessions to be Audio and Video recorded by Jasimine Johnson, MA, Resident Intern, for clinical training purposes and supervision review. I understand that I may rescind this consent at any time.
This Resident Intern will provide services under the supervision of:
Chantelle Johnson |5501 Executive Center Drive Suite #215 Charlotte, NC 28212 |704-909-8025
Clinical Supervisor Name: Address: Phone:
