›› Professional Disclosure Statement / Consent for Mental Health Counseling Supervision
David Ellis, MA, MED, PDAS, LPC, LPCS, LCAS, CCS, CSAC

Relevant Credentials/Licenses Active:

• Licensed Professional Counselor NC License # 4832
• Licensed Professional Counselor Supervisor NC License # S4832
• Certified Clinical Supervisor Certificate NC #496
• Licensed Clinical Addiction Specialist NC #1484
• Licensed School Counselor NC Standard Professional 11
• Certified Substance Abuse Counselor NC Certificate #2316
• International Reciprocity for Clinical Supervision for Certified Substance Abuse Counselors IC@RC Certification #602930
• National Certified Counselor Certification #210586
• Master Addiction Counselor Certification #507392 (NAADAC)
• Substance Abuse Professional Certification #13341 (NAADAC)

Education:

• Educational Specialist in Counselor Education, University of Bridgeport, 30 credits beyond a Masters Degree in Counseling Awarded 8/27/1980
• Masters of Arts in Counseling Awarded December 17, 1976 Pepperdine University
• Masters of Education, Awarded February 1977, Antioch University

Clinical Counseling Experience and Theoretical Orientation I have been a Clinical Therapist and Counselor Educator for over 30 years. I have supervised interns and practicum students. I have served as Director of Guidance for eight years in this capacity. I also have supervised mental health graduate students for four years as a supervisor of counseling at an adult rehabilitation center in Connecticut. The last five years I have been in private practice in North Carolina. My website is www.elliscounseling.com

As a clinician, I use a collaborative, client-centered and strengths-based approach, to promote supervision. My specific theoretical orientations include Carl Rogers person-centered therapy, Cognitive Behavioral-therapy, and behavioral therapy. My clinical experience is with varied mental health populations from ages 5 -70 year. Specialties include addictions, mental health illness, family therapy, high functioning LD and Autism behavioral concerns, and PTSD active military members and families.

It all starts with a comprehensive Biological, Psychological, Social and Behavioral History. The DSM-1V-TR will be utilized as well as other assessment tools. Diagnosis and treatment goals will be discussed with clients.

Professional Memberships and Associations

• National Board for Certified Counselors and the Association for Addiction Professionals

Theoretical Orientation for Clinical Supervision
I use an eclectic and developmental approach to Clinical Supervision. The work we do together will in large part be an exploration and development of your own individual therapeutic “style”, this will broaden your skills of any independent style you may ascribe. I believe that therapeutic techniques are important to learn. One of the most important skills to learn is the way you build and maintain relationships with your clients.

Methods and Modalities of Supervisee Training

• Individual and group weekly supervision sessions as necessary
• Group supervision, when appropriate
• Feedback and guidance on counseling techniques, application of theories, differential diagnosis, and ethics
• Review of case notes and other documentation and/or recorded client sessions, as feasible and appropriate.
• If desired Supervisees may also receive monitoring for professional development, including starting a private practice.

In Case of Emergency

• Supervisees may contact me by phone or email consultation for emergency or time sensitive situations and events. For emergencies during normal business hours please contact me at 252-447-7764. I can be reached after hours at 252-646-1170. I can be emailed at davidjeffreyellis@hotmail.com
• If you have an urgent situation that you feel needs immediate support and I am not available in my office or by phone, please contact one of the following: go to the nearest emergency room or dial 911.

Individual and Group Supervision Format

• One hour of supervision will be conducted weekly with supervisee. At the outset, sessions will be held individually. At such time more than one supervisee is under agreement with the supervisor, sessions will be in group format. Supervision shall occur on a set and agreed upon schedule. Regular business hours are (M-F, 9:am-6:pm). Supervisor can be contacted for emergencies after hours for emergencies.
• Compensation will be $100.00 per hour, payable at the beginning of the session. Cash, check, and money orders are accepted. NO credit cards are accepted.

Duration and Termination

• The period of the agreement shall be from or to start date until supervisee meets the hour and supervision requirements for licensure, or the agreement is otherwise terminated upon 30 days notice. The agreement may be immediately terminated if either party does not meet necessary qualifications or fails to meet NC LPC Board Code of Ethics.
• Sessions are confidential. The privacy and confidentiality of our conversations, and my records, is a privilege of yours and is protected by state law and my profession's ethical principles, in all but a few circumstances. There are two primary circumstances in which I cannot guarantee confidentiality, legally and/or ethically: (1) when I believe you intend to harm yourself or another person; and (2), when I believe a child or elder person has been, or will be, abused or neglected. In rare circumstances, Professional Counselors can be ordered by a Judge to release information. Otherwise, information about you or your clients’ treatment, diagnosis, or history is confidential and will not be released without your full knowledge and usually a signed "Release of Information Form". Each supervisee will give me a copy of his or her “Client Disclosure Statement” that is given to clients.

Professional and Clinical Boundaries
It is possible that we may have membership in some of the same professional organizations. These activities may include professional continuing education presentations and workshops, and social events. I don’t expect that our relationship will change as a result of our mutual involvement in any of these professional or social events. I will maintain appropriate boundaries in our professional relationship and avoid potentially compromising dual relationships such as romantic relationships with supervisees.

Adherence to ACA and ACS Codes of Ethics
I will adhere to the ACA and ACS Code of Ethics has outlined here: http://www.counseling.org/Files/FD.ashx?guid=ab7c1272-71c4-46cf-848c-f98489937dda

Limits of Supervisor Responsibility
I will provide you with consultation on your clients that you present to me through case records, audio/videotapes and case presentations. I am not responsible in any way for your entire caseload or clients that you do not present for my consultative feedback.

As your supervisor I agree to provide you with

• My Professional clinical supervision fee is $100.00 per hour for Individual and Group Therapy sessions.
• Keep a record of your individual and group supervision sessions.
• Once every three sessions evaluations concerning your counseling development will be discussed in major clinical areas.
• Consultation on your clients that you present to me. I am not responsible for your clients that you do not present for my consultative feedback.
• Provide you with training, or information on where to receive training, to increase your counseling knowledge and skills.
• Complete the necessary forms to satisfy the supervision requirement for the LPC and/or LCAS criteria in NC.

Complaint Procedures
If you are dissatisfied with any aspect of the supervisory counseling process, please inform me so we can determine if our work together can be more efficient and effective or whether referral would be appropriate. If you think I have treated you unfairly or unethically, and we cannot resolve the problem, contact:

• North Carolina Board of Licensed Professional Counselors
• P.O. Box 1369
• Garner, NC 27529-1369
• 919-661-0820