Professional Disclosure Statement & Client’s Informed Consent for Henretta Jackson, D.Min, MACC, MS Licensed Marriage & Family Therapy Associate
Licensed Marriage and Family Therapy Associate - LMFTA #10410A
Supervised by: Dr. Byron Coley, LMFT
License #: 10410A
Phone: 704-242-1268
Email: [email protected]
1. Professional QualificationsI am a Licensed Marriage and Family Therapy Associate (LMFTA) in the State of North Carolina. I earned a Doctor of Ministry Degree in Marriage and Family Therapy from Gordon Conwell Theological Seminary and am practicing under the clinical supervision of Dr. Byron Coley, LMFT (#1810), as required by the North Carolina Marriage and Family Therapy Licensure Board.
2. Scope of PracticeI provide therapy to individuals, couples, and families, addressing emotional, psychological, relational, and spiritual concerns. My work is grounded in systems theory, which recognizes that individuals are deeply influenced by the relationships, roles, and patterns within their families and broader contexts. I integrate evidence-based practices and, when desired, clients’ spiritual beliefs and values, to support holistic growth, healing, and well-being.
My therapeutic approach includes:
I do not prescribe medication, provide psychiatric evaluations, or conduct forensic assessments. All treatment is guided by ethical standards and supervision, with a focus on supporting clients in achieving their goals in a safe, respectful environment.
3. SupervisionAs an LMFTA, I am under supervision by a fully licensed Marriage and Family Therapist in accordance with state regulations. My supervisor, Dr. Byron Coley, may review aspects of our work together to ensure effective treatment. Your identity and details will remain confidential within this context.
4. ConfidentialityAll client information is confidential with the following exceptions:
- You give written consent to release information
- There is reasonable suspicion of abuse or neglect of a child, elderly person, or dependent adult
- You express intent to harm yourself or someone else
- A court order or subpoena legally requires disclosure
- To comply with professional supervision requirements
5. Risks and Benefits of TherapyTherapy may lead to improved mood, clarity, and healthier relationships. It may also involve discussing difficult emotions and topics that can cause temporary discomfort. Progress varies based on client participation and presenting concerns. No specific outcomes are guaranteed.
6. Fees and PaymentFees vary based on the type of service offered along with the degree and license type of the therapist. Please call the office for specific amounts. 7. Cancellation and No-Show PolicyPlease provide at least 24 hours’ notice for cancellations. Missed appointments or late cancellations may incur a fee of $25 for no-shows and $35 for late cancellation. Repeated no-shows may result in referral to another provider.
8. Professional BoundariesOur relationship is strictly professional and limited to scheduled therapy sessions and relevant therapeutic contact (e.g., emails or phone calls related to scheduling or clinical concerns). We will not engage in dual relationships, including social or business interactions, to maintain ethical boundaries and ensure the integrity of the counseling process.
9. Client RightsAs a client, you have the right to:
- Ask questions about any aspect of therapy
- Decline or withdraw from treatment at any time
- Request access to your treatment records (with legal limitations)
- Be treated with respect, dignity, and confidentiality
10. Complaint ProcedureIf you have concerns about your treatment, I encourage you to discuss them with me directly. If your concern is unresolved, or you believe I have acted unethically or outside the scope of my license, you may file a complaint with:
North Carolina Marriage and Family Therapy Licensure Board
Phone: (919) 469-8081
Website: www.ncbmft.org
Mailing Address: PO Box 37669, Raleigh, NC 27627
Supervised by: Dr. Byron Coley, LMFT
License #: 10410A
Phone: 704-242-1268
Email: [email protected]
1. Professional QualificationsI am a Licensed Marriage and Family Therapy Associate (LMFTA) in the State of North Carolina. I earned a Doctor of Ministry Degree in Marriage and Family Therapy from Gordon Conwell Theological Seminary and am practicing under the clinical supervision of Dr. Byron Coley, LMFT (#1810), as required by the North Carolina Marriage and Family Therapy Licensure Board.
2. Scope of PracticeI provide therapy to individuals, couples, and families, addressing emotional, psychological, relational, and spiritual concerns. My work is grounded in systems theory, which recognizes that individuals are deeply influenced by the relationships, roles, and patterns within their families and broader contexts. I integrate evidence-based practices and, when desired, clients’ spiritual beliefs and values, to support holistic growth, healing, and well-being.
My therapeutic approach includes:
- Cognitive Behavioral Therapy (CBT): A structured, goal-oriented approach that helps clients identify and change unhelpful thoughts, beliefs, and behaviors to reduce distress and improve functioning—while considering the impact of family and relational dynamics on these patterns.
- Narrative Therapy: A collaborative method that views clients as separate from their problems and helps them re-author their life stories by emphasizing strengths, values, and preferred identities, often in the context of their family, culture, and faith.
- Emotional Regulation Skills: Practical strategies to help clients recognize, manage, and respond to intense emotions in healthy ways—individually and within their relationships. Techniques may include mindfulness, grounding, and coping tools tailored to the individual or family system, as well as faith-aligned practices when appropriate.
- Spiritual Integration: I offer space to explore how their faith, spiritual questions, or sense of meaning influence their mental health, relationships, and family life. This may include incorporating prayer, scripture, spiritual reflection, or aligning therapeutic goals with their spiritual convictions—always respecting each client’s unique beliefs and preferences.
I do not prescribe medication, provide psychiatric evaluations, or conduct forensic assessments. All treatment is guided by ethical standards and supervision, with a focus on supporting clients in achieving their goals in a safe, respectful environment.
3. SupervisionAs an LMFTA, I am under supervision by a fully licensed Marriage and Family Therapist in accordance with state regulations. My supervisor, Dr. Byron Coley, may review aspects of our work together to ensure effective treatment. Your identity and details will remain confidential within this context.
4. ConfidentialityAll client information is confidential with the following exceptions:
- You give written consent to release information
- There is reasonable suspicion of abuse or neglect of a child, elderly person, or dependent adult
- You express intent to harm yourself or someone else
- A court order or subpoena legally requires disclosure
- To comply with professional supervision requirements
5. Risks and Benefits of TherapyTherapy may lead to improved mood, clarity, and healthier relationships. It may also involve discussing difficult emotions and topics that can cause temporary discomfort. Progress varies based on client participation and presenting concerns. No specific outcomes are guaranteed.
6. Fees and PaymentFees vary based on the type of service offered along with the degree and license type of the therapist. Please call the office for specific amounts. 7. Cancellation and No-Show PolicyPlease provide at least 24 hours’ notice for cancellations. Missed appointments or late cancellations may incur a fee of $25 for no-shows and $35 for late cancellation. Repeated no-shows may result in referral to another provider.
8. Professional BoundariesOur relationship is strictly professional and limited to scheduled therapy sessions and relevant therapeutic contact (e.g., emails or phone calls related to scheduling or clinical concerns). We will not engage in dual relationships, including social or business interactions, to maintain ethical boundaries and ensure the integrity of the counseling process.
9. Client RightsAs a client, you have the right to:
- Ask questions about any aspect of therapy
- Decline or withdraw from treatment at any time
- Request access to your treatment records (with legal limitations)
- Be treated with respect, dignity, and confidentiality
10. Complaint ProcedureIf you have concerns about your treatment, I encourage you to discuss them with me directly. If your concern is unresolved, or you believe I have acted unethically or outside the scope of my license, you may file a complaint with:
North Carolina Marriage and Family Therapy Licensure Board
Phone: (919) 469-8081
Website: www.ncbmft.org
Mailing Address: PO Box 37669, Raleigh, NC 27627
