Professional Disclosure and Consent Form

Cicely H. Maynard, BS
Outpatient Therapist Intern
Carolina Outreach
2670 Durham-Chapel-Hill Blvd.
Durham, NC 27707
919.251.9001 ext. 175 (office)
919.451.0602 (cell)
cicelymaynard@carolinaoutreach.com

Professional Disclosure Statement

Qualifications: I am a graduate student in the counseling program at Wake Forest University working
towards completion of a masters degree. In my affiliation with the Wake Forest counseling program, I am
qualified to counsel under the supervision of a program faculty member and my site supervisor at my
field placement. My formal education has prepared me to counsel individual adults, adolescents, and
children; groups; couples; parents; and families.
Counseling Background: I am currently in a 2 semester-long internship at Carolina Outreach, where I
am actively counseling 10-12 clients, most of whom are adults. As a foundation, Cognitive Behavioral
Therapy is the basis for all of my counseling. Other theoretical orientations I am able to implement are
techniques from Dialectical Behavioral Therapy, Cognitive Processing Therapy, Developmental
Counseling Therapy, Mindfulness, and Motivational Interviewing.
Session Fees and Length of Services: Both the session fees and length of services depend on if you have
insurance and what type of insurance. We accept IPRS, Medicaid, Medicare, Tricare, and Blue Cross and
Blue Shield. Carolina Outreach accepts Mastercard, Visa, personal checks, and cash.
Use of Diagnosis: Some health insurance companies will reimburse clients for counseling services and
some will not. In addition, most companies require that a diagnosis must be rendered if the client is going
to be reimbursed. Some conditions for which people seek counseling do not qualify for diagnosis. If a
qualifying diagnosis is appropriate in your case, I will inform you of the diagnosis before we submit the
diagnosis to the health insurance company. Any diagnosis made will become part of your permanent
insurance records.
Permission to Participate and Confidentiality: I am a counselor-in-training in the counseling program
at Wake Forest University and am under the direct supervision of supervisors listed on page one. All our
counselor sessions are confidential. This means that no information will be released to persons or
agencies regarding the fact that counseling has been received or the nature of the concerns without written
consent. Danger to self and/or others (i.e. suicide or homicide) may necessitate the breaking of
confidentiality. In addition, by law suspected child abuse and/or neglect and elder abuse and/or neglect
communicated by clients must be reported to appropriate agencies by counseling staff.

Professional Disclosure and Consent Form

X _____ I have read the above statements and understand my rights regarding my participation and
confidentiality.
Complaints: If there are any client concerns, both my site supervisor and university supervisor are
available. Dr. Katie Duckworth (duckwoke@wfu.edu) and/or Marissa Touhey (919) 251-9001.
Acceptance of Terms: By your signature below, you are indicating that you read and understand this
statement, that any questions you had about this statement were answered to your satisfaction, and that
you were furnished a copy of this statement. By my signature, I verify the accuracy of this statement and
acknowledge my commitment to conform to its specifications.
Clients Signature

Date

Counselors Signature

Date

Supervisors Signature

Date