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Peace of Mind, Inc. |
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817 West Front Street P.O. Box 2088 Lillington, NC 27546-2088 Phone: (910) 814 - 2197 Fax: (910) 814 - 2167 |
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Jacqueline D. Grantland M. Ed, LPC, NCC, CSOTP PEACE OF MIND, INC. 817 West Front St. P.O. Box 2088 Lillington, NC 27546-2088 Office: (910) 814-2197 Fax: (910) 814-2167 Emergency Cell: (910) 910-8557
Web Site: www.peace-of-mind-inc.com E-mail: jacqui@peace-of-miind-inc.com
PROFESSIONAL DISCLOSURE STATEMENT This document contains important information, and you are asked to review and retain it for future reference.
Qualifications: Licensed Professional Counselor licensed in the state of North Carolina, License No. 5199, License No. 0085271, National Certified Counselor, Certification No. 86515. In 2003, I graduated from Texas Tech University with a Master of Education majoring in Community Counseling. I received a Bachelor of Science degree in Psychology and an Associate of Arts degree in Management Studies from the University of Maryland in 2000. Professional affiliations include American Counseling Association, Chi Sigma Iota (counseling honor society), Licensed Professional Counselors Association of North Carolina, and National Association of Forensic Counselors. I am trained in EMDR Level I and II, and am a Certified Sex Offender Treatment Provider.
Experience: My work experience includes providing outpatient individual, family, and marital counseling to adults, children, and adolescents. I have worked as an independent private contractor in a group private practice for the last two years. Additional work experience includes counseling adolescents in a substance abuse residential treatment center and adolescents placed in treatment foster care, teaching anger management and the Men’s Batterer Intervention Program, treating victims of sexual assault and domestic violence, and working with military soldiers and their families. I have worked in the mental health field for over seven years, six years practicing as a counselor. Prior to pursuing a career as a counselor I served in the U.S. Air Force for seven years.
Theoretical Orientation: My theoretical orientation is Eclectic with emphasis on Cognitive- Behavioral/Solution Focused and Client Centered Theory. As an eclectic counselor I believe that no single theory can effectively treat all the different emotional, behavioral, and mental disorders. As your counselor I will apply the best theoretical orientation based on your specific needs and issues.
INFORMED CONSENT
Counseling Relationship/Services: During the time together, we will meet weekly for approximately 45-minute sessions. A diagnosis will be used to help specialize your counseling treatment and will be placed in your medical records. Although our sessions may be very intimate psychologically, ours is a professional relationship rather than a social one. You will best be served if our sessions concentrate exclusively on your concerns and contact is limited to therapeutic concerns only.
Payments and Cancellations: Payments will be accepted in the form of cash or check. We accept most insurance. Co-payment is due at the time we render services. If you must cancel an appointment please notify the office at least 24 hours prior to the appointment. You will be responsible for any missed or un-cancelled appointments. If you are late for the appointment the session will still need to end on time and you will be responsible for the full payment.
Effects of Counseling: At any time, you may initiate a discussion of possible positive or negative effects of entering, not entering, continuing, or discontinuing counseling. While benefits are expected from counseling, specific results are not guaranteed. Counseling is a personal exploration and may lead to major changes in your life perspectives and decisions. These change my affect significant relationships, your school, job, and/or your understanding of yourself. Some of these changes could be temporarily distressing. The exact nature of these changes cannot be predicted. Together we will work to achieve the best possible results for you.
Records and Confidentiality: All of our communication becomes part of the clinical record. Most of our communication is confidential, but the following limitations and exceptions do exist: a.) I am using your case records for the purposes of supervision, professional development, and research. In such cases, to preserve confidentiality, I will identify you by your first name only; b.) I determine that you are a danger to yourself or someone else; c.) you disclose abuse, neglect, or exploitation of a child, elderly, or disabled person; d.) you disclose sexual contact with another mental health professional; e.) I am ordered by a court to disclose information; f.) you direct me to release your records; or g.) I am otherwise required by law to disclose information.
Registering Complaints: I assure you that my services will be rendered in a professional manner consistent with accepted legal and ethical standards. If at any time for any reason you are dissatisfied with my services, please let me know. If you wish to file a complaint against a North Carolina licensed professional counselor, you may do so by placing that complaint in writing and sending it to the NCBLPC. You may place your concerns in writing, citing the ACA ethical codes you believe to have been broken, and submit your letter to the board. The address to send the complaints to is North Carolina Board of Licensed Professional Counselors, P.O. Box 1369, Garner NC 27529. For further information please refer to the website. http://www.ncblpc.org/complaints.html
NAME ________________________ MR # __________________
PROFESSIONAL DISCLOSURE ACKNOWLEDGEMENT:
Please feel free to ask questions at any time.
By signing below, you are agreeing that an opportunity has been provided to discuss any concerns you may have prior to committing to Counseling. The invitation to open discussion will remain in effect throughout the relationship.
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By your signature below, you are indicating that you read and understood this statement, or that any questions 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.
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Jacqueline D. Grantland M. Ed, LPC, NCC Independent Contractor |