Professional Disclosure Statement

Sazshy Valentine
E-mail: Sazshy.valentine@gmail.com
Phone: 804-347-6989
My Qualifications
Education, Licensure & Certification: I, Sazshy Valentine, am currently a Master of Arts in
Counseling student in good standing at Wake Forest University. My expected date of graduation
is May 16, 2016. Upon graduation I will pursue status as a Resident in Counseling in Virginia.
Experience: I have one and one half years of counseling experience as a practicum and
internship student. My clinical experiences include a 600-hour supervised internship experience
and a 200-hour supervised practicum experience both at Mood Treatment Center in WinstonSalem, NC.
Restricted Licensure
I am currently pursuing provisional licensure in Virginia. Once this license is obtained, I will be
under supervision as a Resident in Counseling. I will practice under supervision from a
Qualified Professional approved by the Virginia Board of Counselors. A contract indicating this
supervisory relationship will be on file with the Board, and I will update this Professional
Disclosure statement to reflect this change.
Areas of Competence: I am competent in Person-Centered Counseling.
Therapeutic Relationship: Although the client and counselor may develop a close working
relationship, it is important for us to maintain firm boundaries both within and outside of
sessions. Clients are asked not to seek me out on social media, present me with gifts, or invite
me to social events. Maintaining these boundaries will help ensure a therapeutic experience for
the client. In case of emergency, please call 911. Though I check email and voicemail regularly
and will do my best to respond within 48 hours, at times it may take longer. I appreciate your
patience with me in this regard.
Session Fees & Length of Service
Session Length & Frequency: Individual sessions are 50 minutes in length, typically at a
frequency of one session per week. If more or less frequent sessions are required, client and
counselor will discuss a frequency that meets the clients needs and schedule. Group sessions
are typically 90 minutes in length at a rate of one session per week.
Fees & Payment: The fee for a 50-minute individual counseling session is $80. Payment is
made at the time of services rendered. Cancellations must be made at least 24 hours in advance
of scheduled appointment, otherwise client is charged the full session rate. Cash or check
accepted. At this time, I do not accept insurance or Medicaid.

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Use of Diagnosis
Diagnosis: The use of diagnosis in my counseling services is included as a means of helping
clients understand symptoms, and as a way of helping them to formulate effective strategies for
reducing symptoms. It is important that clients understand that this diagnosis becomes a
permanent part of their client record.
Confidentiality & Complaint Procedure
All of our communication becomes part of the clinical record, which is accessible to you upon
request. In adherence to State law and professional ethical principles, I will keep confidential
anything you say as part of our counseling relationship, with the following exceptions:
1. If you are a minor or dependent, confidentiality is limited and information shared could
be disclosed to your parent/guardian if necessary
2. If you direct me in writing to disclose information to someone else
3. If it is determined you are a danger to yourself or others (including child or elder abuse)
4. If physical or sexual abuse regarding a minor, aged, or incompetent person is known or
suspected
5. If I am ordered by a court to disclose information.
Although 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 (http://www.counseling.org/Resources/aca-code-ofethics.pdf).

Virginia Board of Counseling

Perimeter Center
9960 Mayland Drive, Suite 300
Henrico, Virginia 23233-1463
Phone: 804-367-4610
Fax: 804-527-4435
Complaints: 800-533-1560
E-mail: coun@dhp.virginia.gov
Acceptance of Terms

We agree to these terms and will abide by these guidelines.

Clients Signature:___________________________________________ Date:____________
Parent or Guardians Signature:_________________________________ Date:____________
Counselors Signature:________________________________________ Date:____________