Professional Disclosure Statement for

Ima Sample
The purpose of this statement is to inform you of my role as a school counseling intern in the educational development of students.  My goal is to facilitate students achieving their full academic potential through guidance activities related to personal/social, career, and academic concerns.  Please contact me if you have any further questions after reading this statement.
Educational Background B.A. from the University of Iowa - 1991

M.A. from the University of Iowa - pending May 2005
Counseling Approach My approach to counseling students is based on brief counseling, strength-based counseling, and cognitive-behavioral counseling theories.  Delivery of services may include group counseling, individual counseling, classroom guidance lessons, consulting, coordination, and/or referral.  By using one of the theories and services, I attempt to help students identify and develop plans to address issues, thoughts, or emotions that may interfere with their educational goals.
Availability Please contact me through email, stopping by one of my offices, or by scheduling an appointment with the guidance secretary to meet with me in person.  I am available to consult with students, parents, teachers, administrators, and other faculty.
Confidentiality

The information shared between a student and counselor is confidential.  I will guard that privacy as much as is permitted by the law, ethics, and school rules.  You should know that there are exceptions where I am obligated to break confidentiality. These include:

 

· Potential harm to the student or someone else

· If you ask me to tell someone else

· Student records requested for court testimony

 

Counselors occasionally consult with other school professionals, but, in such cases, only information necessary to achieving the goals of the conference will be shared with your permission. In addition, I keep informal notes regarding sessions and store them in a secure place to assure confidentiality. 

 

You and/or your guardians may be asked to sign a waiver allowing me to share taped sessions with my University supervisors.  This is completely at your discretion whether you choose to allow the taping or prefer to remain confidential.