PROFESSIONAL DISCLOSURE STATEMENT

Tabitha R. Haynes, MA, LPC, LCAS, NCC

COUNSELING PRACTICE
Counseling services are provided to individuals, youth, adults, and families in the areas of, but
not limited to depression/anxiety, anger management, life transitions, and personal growth. I
have over 6 years of professional counseling experience, including practicum and internship
practice. My training is in mental health counseling with an additional specialization in issues
of substance abuse and at-risk populations. My areas of experience include: depression,
anxiety, crisis intervention, co-occurring disorders, behavioral management, personal growth
and life transitions. In the counseling process, clients can be helped to understand themselves
better, set personal goals, and be supported in the process of working toward those goals. If
the client and/or counselor decide this counseling practice is not appropriate for the clients
needs, the client will receive assistance in contacting an appropriate referral source which can
better meet their needs.
Most clients can expect to benefit from counseling, making positive changes in their thoughts,
feelings, behaviors, and styles of coping. Some, however, may not find counseling profitable.
Even the most successful counseling and therapy may at times be painful or distressing, as the
client deals with emotionally difficult issues.
My theoretical style is a blend of cognitive behavioral therapy, motivational interviewing, and
person-centered practices depending on the needs of the client. Techniques include individual,
couple, and family counseling (talk therapy), screening and assessment and interpretation of
assessments, provision of appropriate information and facilitation of decision making, and goal
setting. In addition, group counseling and facilitation may be offered and homework exercises
may be given when necessary.
EDUCATION
Masters Degree in Agency Counseling (CACREP Accredited), 2010
North Carolina Central University
Durham, NC
Bachelors Degree in Psychology, 1998
UNC-Wilmington
Wilmington, NC
CREDENTIALS AND MEMBERSHIPS
Licensed Professional Counselor #8690
Licensed Clinical Addictions Specialist #2719
National Certified Counselor #275116
Member, American Counseling Association
Member, Chi-Sigma Iota
EXPERIENCE
The BruSon Group, Inc., Knightdale, NC
Strategic Behavioral Center, Garner, NC
Freedom House Recovery-Durham Center Access, Durham, NC
COUNSELING FEES

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If you are seeking services through one of my contract agencies, payment is received through
their business offices. Our offices may file the bill directly with your health insurance for the
services provided. In such instances, your health insurance company will inquire about the
type(s), cost(s), date(s), diagnosis, and information of any services or treatments received. Fees
may be accepted by several insurance companies, including Blue Cross Blue Shield, Aetna,
Tricare, Health Choice, and Medicaid. Currently, I am also accepting private pay fees to
include:
- Initial session: $100.00 (55 minutes)
- Therapy session: $70.00 (45 minutes)
Payment in full (or co-payments if using health insurance) is due at the time service is rendered.
Cash or personal checks only are accepted. There will be a $35 service charge for all returned
checks. Non-payment of fees can result in termination of professional services and collection
activity for any outstanding balances. If this should change, expected fees, payment schedule,
and acceptable methods of payment will be discussed.
COUNSELING SESSIONS
Sessions are typically 45 minutes to 55 minutes long, unless otherwise arranged. When an
appointment is made, that time is set aside for you and will not be given to someone else unless
you specifically cancel the appointment within 24 hours. Therefore, it is very important that
appointments be kept. Please be on time to avoid losing treatment time. Schedules generally
will not allow making up time if you are late.
AS YOUR COUNSELOR:
1. Informed Consent: I will inform you of the purposes, goals, techniques, and procedures under
which you may receive counseling (ACA Code of Ethics, Section A.2.b). Prior to assessment, I
will explain the nature and purposes of assessment tools and the specific use of results (ACA
Code of Ethics, Section E.3.a). Results will become a permanent part of the client's record.
2. Confidentiality: I will protect the confidentiality of information received in our counseling
relationship as specified by federal and state laws, written policies and ethical standards. For
any of the following matters, legally and ethically, I may break confidentiality and involve others
who can help: (ACA Code of Ethics is cited in parentheses.)
A. if mandated by a court of law (Section B.2.d); note: a subpoena is not a court order
B. if disclosure is required to prevent clear and imminent danger to yourself and/or
others (Section B.2.a):
C. if I am made aware of the potential or actual occurrence(s) of physical/sexual abuse of
minors, persons with disabilities or senior citizens (Section B.2.a);
D. I will disclose information to an identified third party who is at high risk of contracting
a disease from you that is both communicable and fatal, providing that you have not
already informed him/her or are not intending to do so (Section B.2.c).
3. DSM-V (Diagnostic and Statistical Manual) is used for the diagnosis of mental health and
related disorders, and become part of the individuals file and permanent record.
CONCERNS REGARDING LICENSURE
Should you have concerns regarding ethical issues in therapy, please ask me or contact:
American Counseling Association
6101 Stevenson Avenue Ste. 600
Alexandria, VA 223O4
Should you have any concerns regarding licensure and/or practice, please ask me or contact:
NC Board of Licensed Professional Counselors
P. O. Box 77819
Greensboro, NC 27417
844-622-3572

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ACKNOWLEDGEMENT
I have read the above in its entirety. I am informed about the policy regarding confidentiality of
information I may provide during counseling and the limits of that confidentiality. With full
understanding of these provisions, I give my informed consent to receive counseling services.
Signed_______________________________________________(Client or Legal Guardian)
Date_______________
Signed_____________________________________________(Counselor)
______________

Date

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