Demah S.

Payne III
Professional School Counselor
Dp0531@yahoo.com

PROFESSIONAL DISCLOSURE STATEMENT

I am a professional school counselor licensed by the Department of Public Instruction in

North Carolina. I provide academic, career, and personal/social support to all students in
order to ensure that each student receives an educational experience that allows him or
her to become academically proficient, a responsible citizen, a productive worker, and a
continuous learner.

I received my Masters Degree (MS) in Counselor Education from the East Carolina
University in May 2011. I have a total of four years of counseling experience (two as a
crisis counselor and two as a school counselor) The approach that I feel best suits my
counseling style is based on brief counseling, rational emotive- behavior therapy and
gestalt counseling theories. I treat each student with respect and as a unique individual. I
use goal-directed strategies to help students resolve issues that hinder their educational
success. Delivery of counseling services may be in the form of individual sessions, group
counseling, classroom guidance, consultation, coordination, and/or referral. I am
currently pursuing licensure for my LPC-A.

I currently serve students (clientele) ranging in ages from 5- 14 (K- 8). If a student
requires more extensive counseling, I am knowledgeable of many community agencies
that provide a variety of support and I will assist the student in finding outside counseling
services. When a student receives outside counseling services, neither I nor the Wake
County School District accepts responsibility for the payment of those counseling fees. If
a student receives a diagnosis this information will become a lasting part of that student
(clients) record.

My hours are from 7:45 until 3:00 p.m. Students can schedule an appointment with me
before or after school, during the day (excluding core class periods), or you may walk-in
during their lunch breaks. I am also available to meet with students, parents, teachers,
administrators, and other faculty.

I have also volunteered as a Crisis Counselor for two years at REAL Crisis Intervention
located in Greenville, NC. Real Crisis Intervention is located at 1011 Anderson
St. Greenville, NC 27858 and their phone number is (252) 758-4357.

The information shared between a student and counselor is confidential. I will respect
that privacy as much as is permitted by law, ethics, and school rules. I cannot guarantee
confidentiality in a group setting, though all group members are reminded of a persons
right to privacy. I am obligated to break confidentiality when (1) I become aware of
potential harm to the student or someone else, (2) a student asks me to tell someone else,
(3) I suspect child abuse and/or neglect, and (4) student records are requested for court
testimony.
I will occasionally consult school professionals when I believe consultation is necessary
to support a students academic, career, and/or personal/social development. When
consultation is necessary and in the educational interest of a student, I will refrain from
providing extra information to enhancing the students development. Moreover, when I
feel I must share information about a student, I will first inform the student of my intent
to discuss his or her situation with others.

I do keep objective notes regarding sessions and store them in a secure place to assure
confidentiality. As a school counselor, I respect the rights of custodial and non-custodial
parents and may share information with them about their child. I am sensitive to cultural
diversity, and I recognize that parents have certain rights and responsibilities for the
welfare of their child(ren). The use of a diagnosis will become a permanent part and of
the clients record.

I abide by all federal and state laws pertaining to the ethical treatment of minors and
adhere to Code of Ethics of the American Counselor Association and the American
School Counselor Associations Ethical Standards. I am further governed by the policies
and procedures of the Wake County School District.

If I am not able to help you, or if you wish to obtain further information or file a
complaint, you may contact the principal of my school, or the North Carolina Board of
Licensed Professional Counselors, P.O. Box, 1369, Garner, North Carolina 27529, (919)
661-0820, (919) 779-5642 fax, www.ncblcp.org.

Client Signature ____________________________________ Date _____________

Counselor Signature _________________________________ Date _____________