Professional Disclosure

Statement
Jamie M. Washington
3362 Dogwood Rd.
NE Leland, NC 28451
Phone: 910-550-7392
washjml3@wfu.edu
Qualifications: I currently hold a Master of Arts (MA) degree in Mental Health
Counseling from Wake Forest University (2015), and in the application process for
provisional licensure. I earned my Bachelor of Arts degree in Psychology from the
University of North Carolina at Charlotte (2003). I have been a qualified mental health
profess ional in the state of North Carolina for over nine years; and am a member or the
American Counseling Association and also Chi Sigma Iota International Honor Society. In
my time as a mental health professional I have worked with children and adults dealing with
various mental health issues. In my affiliation with t h e WFU counseling program, I am
qualified to counsel under the supervision of a program faculty member and an internship
site supervisor at Coastal Horizons Center, Inc., where Im currently in internship. My formal
education has prepared me to utilize skills that I have practiced in my counseling skills
classes. I am qualified to provide counseling services to adults, adolescents, and children.
Counseling Background: In my master's program, under supervision, I have practiced
counseling skills in triads with classmates, one-on-one with professors in mock counseling
sessions, and have completed capstone requirements demonstrating what I have learned. As
a professional counselor I have; (1) provided services through community agencies and inhome services to support family preservation; (2) delivered one-on-one interventions such
as skill building activities, intervened with positive behavioral supports, enhanced clients
knowledge of interpersonal and community relational skills; (3) delivered services in a
wide range of community settings; (4) provided 24/7/365 crisis response; (5) performed
ongoing assessment and evaluation of the social and daily living needs of clients to ensure
seamless transition between services; and (6) provided supportive and informational
counseling to include crisis intervention, case management, and the development of
collateral contacts.
Session Fees and Length of Service: Sessions are either 30 or 60 minutes. For 30
minute sessions the fee is $50; for 60 minute sessions the fee is $100.
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 mentalhealth 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. 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.
Confidentiality: All of our communication becomes part of the clinical record, which is
accessible to you upon request. I will keep confidential anything you say as part of our
counseling relationship, with the following exceptions: (a) you direct me in writing to disclose
information to someone else, (b) it is determined you are a danger to yourself or others

(including child or elder abuse), or (c) I am ordered by a court to disclose information. You have
the right to review your client file in the presence o your counselor, the supervisor, or Clinical
Director. You may ask for a copy of your file and will be charged a per-page copy fee. You
may also ask for corrections or clarifications of the content in the file and that will be recorded in
the notes. You may ask to review university and agency HIPPA procedures. You mak ask for a
meeting with a HIPPA compliance officer (the Clinical Director or Quality Management
Director).
X
I have read the above statements and understand my rights regarding my
participation and confidentiality.
Client Rights: Some clients achieve their goals in only a few counseling sessions, whereas
others may require months or even years or counseling. As a client, you are in complete
control and may end our counseling relationship at any time. If you choose to end the
counseling relationship, I ask that you participate in a termination session. You also have the
right to refuse or to discuss modification of any of my counseling techniques or suggestions
that you believe might be harmful. I render counseling services in a professional manner
consistent with accepted ethical standards. If at any time for any reason you are dissatisfied
with my services, please let me know. If I am not able to resolve your concerns, you may
report your complaints to my supervisor(s) listed on page one.
X __ I have been informed of my privacy rights under HIPPA and understand how to
access my client file.

Client's Signature

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Counselors Signature
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Supervisor's Signature

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