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Includes sections for counseling background such as client populations, services, theoretical orientation, techniques, session fees and payment methods, diagnosis and insurance reimbursement practices, confidentiality limits, complaint procedures, and signed acceptance of terms by client and counselor.",{"@graph":63,"@context":119},[64,80,102],{"@type":65,"itemListElement":66},"BreadcrumbList",[67,71,74,77],{"item":68,"name":69,"@type":70,"position":9},"https://docshare.wps.com","Home","ListItem",{"item":72,"name":10,"@type":70,"position":73},"https://docshare.wps.com/template/",2,{"item":75,"name":41,"@type":70,"position":76},"https://docshare.wps.com/template/letters/",3,{"item":78,"name":59,"@type":70,"position":79},"https://docshare.wps.com/template/lcmhca-professional-disclosure-statement-template/176673/",4,{"url":78,"name":59,"@type":81,"image":82,"author":87,"headline":59,"publisher":90,"fileFormat":93,"inLanguage":57,"description":61,"dateModified":94,"datePublished":95,"encodingFormat":93,"isAccessibleForFree":96,"interactionStatistic":97},"DigitalDocument",{"url":83,"@type":84,"width":85,"height":86},"https://docshare.wps.com/thumbnails/lcmhca-professional-disclosure-statement-template/176673.png","ImageObject",442,249,{"name":88,"@type":89},"Anda","Person",{"url":68,"name":91,"@type":92},"DocShare","Organization","application/vnd.openxmlformats-officedocument.wordprocessingml.document","2026-10-19","2026-09-02",true,{"@type":98,"interactionType":99,"userInteractionCount":101},"InteractionCounter",{"@type":100},"ViewAction",9,{"@type":103,"mainEntity":104},"FAQPage",[105,111,115],{"name":106,"@type":107,"acceptedAnswer":108},"What education and credential information must be included in the statement?","Question",{"text":109,"@type":110},"The applicant should include the highest relevant degree, year received, discipline, and institution, plus all relevant credentials such as licenses, certificates, or registrations with their names and numbers.","Answer",{"name":112,"@type":107,"acceptedAnswer":113},"What restricted licensure and supervision statements are required?",{"text":114,"@type":110},"Applicants must state they are pursuing LCMHCA licensure in North Carolina before LCMHCA is issued, and they must state they are under supervision as a Licensed Professional Counselor Associate in North Carolina after receipt of LCMHCA, including current supervisor names and contact information.",{"name":116,"@type":107,"acceptedAnswer":117},"How are confidentiality, diagnosis use, and complaints handled?",{"text":118,"@type":110},"The statement explains that communications become part of the clinical record with confidentiality maintained except for written disclosure requests, safety-related determinations, or court orders. It also describes how diagnosis may be communicated for insurance reimbursement when appropriate, and how clients can file complaints with the North Carolina Board if ethics codes are violated.","https://schema.org",{"og:url":78,"og:type":121,"og:title":59,"og:site_name":91,"og:description":61},"article",{"robots":123,"canonical":78},"index,follow",{"doc_id":125,"site_id":56},176673,1790029735,{"code":4,"msg":5,"data":128},{"doc_id":125,"user_id":129,"nickname":88,"user_avatar":130,"doc_module":9,"category_id":40,"category_name":41,"doc_title":59,"doc_description":61,"doc_content":131,"file_id":132,"file_url":133,"file_type":134,"file_size":135,"view_count":101,"is_deleted":4,"is_public":9,"is_downloadable":9,"audit_status":9,"page_count":73,"language":136,"language_code":57,"site_id":56,"html_lang":57,"table_of_contents":137,"faqs":138,"seo_title":139,"seo_description":61,"update_tm":140,"read_time":9},962075006959,"https://ap-avatar.wpscdn.com/avatar/e0002397efbe92a78e?_k=1776741047341049297","LCMHCA Professional Disclosure Statement (Template)\n\u003CFull Name, Credentials>\nOffice:  \u003CNumber with Area code>\nFax:  \u003CNumber with Area code>\nE-mail:  \u003CEmail Address if you want clients to have one>\nMy Qualifications \u003CIn paragraph form, describe the elements below.>\nThe licensee’s or applicant’s highest relevant degree, year degree received, discipline of degree, and name of institution granting the degree.\nNames and numbers of all relevant credentials (licenses, certificates or registrations).\nNumber of years of counseling experience.\nRestricted Licensure \u003CIn paragraph form, describe the elements below.>\nA license applicant should include a statement indicating that he/she is pursuing licensure as a Clinical Mental Health Counselor Associate in North Carolina (prior to LCMHCA being issued).\nA license applicant should include a statement indicating that he/she is under supervision as a Licensed Professional Counselor Associate in North Carolina (post receipt of LCMHCA)\nA statement noting the name of current supervisor(s) and the supervisor’s contact information (must match approved supervisor on file with the Board, or it will be rejected)\nCounseling Background \u003CIn paragraph form, describe the elements below.>\nDescription of clientele (populations) served.\nDescription of services offered (include a brief description of theoretical orientation and types of techniques used).\nDescription of areas of competence (such as theoretical orientation and techniques – e.g., play therapy, EMDR, DBT, etc.).\nSession Fees and Length of Service \u003CIn paragraph form, describe the elements below.>\nLength of sessions\nSpecific fee charged for each type of session.  If a sliding scale is used, it must be included in full with a blank for the agreed upon fee.  If no fee is charged, this must be stated.\nMethods of payment accepted (cash, check, credit card, etc) and information about billing or insurance reimbursement.\nUse of Diagnosis \u003CBelow is an example. Modify to fit your preference.>\nSome health insurance companies will reimburse clients for counseling services and some will not.  In addition, most will require that a diagnosis of a mental-health 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.\nConfidentiality \u003CBelow is an example.>\nAll 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.\nComplaints \u003CThis section should remain the same>\nAlthough clients are encouraged to discuss any concerns with me, you may file a complaint against me with the organization below should you feel I am in violation of any of these codes of ethics. I abide by the ACA Code of Ethics (\u0013 HYPERLINK \"https://www.counseling.org/resources/ethics\" \u0014https://www.counseling.org/resources/ethics\u0015).\nNorth Carolina Board of Licensed Clinical Mental Health Counselors \u000bP.O. Box 77819\nGreensboro, NC 27417\u000bPhone: 844-622-3572 or 336-217-6007\u000bFax: 336-217-9450\u000bE-mail: \u0013 HYPERLINK \"mailto:Complaints@ncblcmhc.org\" \u0014Complaints@ncblcmhc.org\u0015\nAcceptance of Terms \u003CThis section should remain the same>\nWe agree to these terms and will abide by these guidelines.\nClient:  ___________________________________________________   Date: ___________\nCounselor:  ________________________________________________   Date: ___________","cbCaib9ELrP6UvUA","https://ap.wps.com/l/cbCaib9ELrP6UvUA","docx",21767,"English","# Client Information\n## Qualifications and Credentials\n## Restricted Licensure\n## Counseling Background\n## Session Fees and Length of Service\n## Use of Diagnosis\n## Confidentiality\n## Complaints\n## Acceptance of Terms","[{\"question\":\"What education and credential information must be included in the statement?\",\"answer\":\"The applicant should include the highest relevant degree, year received, discipline, and institution, plus all relevant credentials such as licenses, certificates, or registrations with their names and numbers.\"},{\"question\":\"What restricted licensure and supervision statements are required?\",\"answer\":\"Applicants must state they are pursuing LCMHCA licensure in North Carolina before LCMHCA is issued, and they must state they are under supervision as a Licensed Professional Counselor Associate in North Carolina after receipt of LCMHCA, including current supervisor names and contact information.\"},{\"question\":\"How are confidentiality, diagnosis use, and complaints handled?\",\"answer\":\"The statement explains that communications become part of the clinical record with confidentiality maintained except for written disclosure requests, safety-related determinations, or court orders. It also describes how diagnosis may be communicated for insurance reimbursement when appropriate, and how clients can file complaints with the North Carolina Board if ethics codes are violated.\"}]","LCMHCA Professional Disclosure Statement - Template | DOCX",1788325208]