MHC-Limited Permit Professional Disclosure Statement

Rachel Carter, M.A., NCC, MHC-LP

Email: rachel.carter@rochester.edu

Site
University of Rochester Counseling Center
River Campus Office, Third Floor, UHS building
738 Library Road, Susan B. Anthony Circle, Rochester, New York
Appointments: (585) 275-3113
UCC On-Call: (585) 275-3113
Fax Number: (585) 442-0815

My Qualifications
In May of 2017, I earned a Masters degree in Clinical Mental Health Counseling from Wake
Forest University with a concentration in Clinical Mental Health Counseling. My Bachelors
degree was earned from Eastern University in Psychology in 2015. Additionally, I am a
Nationally Certified Counselor and am currently pursuing my PhD in Counseling and Counselor
Education at the Warner School of Education at University of Rochester.

Restricted Licensure
I am pursuing licensure as a Mental Health Counselor in New York, though I am currently
working with a limited permit. My limited permit number is #0000. As a Mental Health
Counselor with a limited permit, I will be under the supervision of a Counseling Psychologist
named Joellen Popma, Ph.D., who is the Director of the Counseling Center at the University of
Rochester. Should you wish to get in contact with her, her email is jpopma@ur.rochester.edu.

Counseling Background
I have been counseling for the past two years and I have served adolescents and adults. I
completed my practicum on the Child and Adolescent Psychiatric Unit at the Wake Forest
Baptist Hospital and completed my internship at the Wake Forest Department of Family and
Community Medicine which is an integrated care unit. I have experience and am comfortable
working with individuals surrounding the following issues: Relationships, Communication,
Boundaries, Anxiety, Depression, PTSD, Eating Disorders, Trauma, Stress, Substance use,
Spirituality, Sexuality, Sex, Grief, and Loss. My particular areas of interest are Trauma, PTSD,
Eating Disorders and Relationship issues.

Counseling Approach
As a client in the counseling process, you are the expert on yourself, and thus you play the lead
role in working to reconcile your concerns. Some clients need a few counseling sessions to work
on their presenting concerns and achieve their goals, while others may require months or years of
a counseling relationship. The frequency and number of sessions will be discussed in our first
meeting, and evaluated ongoing as needed, to best serve your unique needs.
My theoretical orientation is built upon a Person-Centered framework. I also draw on
conceptualization and interventions from a variety of other theories and treatments including, but
not limited to: Acceptance and Commitment Therapy, Feminist Therapy, Narrative Therapy,
Motivational Interviewing, Relational Psychoanalysis and Family Systems Therapy. As such,
some of my goals as a counselor are to foster the therapeutic relationship, understand the systems
and relationships that are a part of your life, focus on the here-and-now, learn about your unique
perspective, and create a safe space for you to be fully yourself. Some of our overarching
therapeutic goals may include increasing self-awareness, developing healthy coping skills,
developing sensory awareness, increasing mindfulness, enhancing your ability to recognize the
systems in your life and the role that you play in them, recognizing and addressing dysfunctional
relational patterns, and enhancing your ability to use your own voice. I view counseling as a
vehicle for promoting holistic health including but not limited to cognitive, emotional, social,
spiritual, and physical aspects of wellness.

Depending on your needs I may introduce a range of techniques including mind-body awareness
exercises, mindfulness exercises, role-playing exercises, journaling exercises, a genogram
exercise and more. We will work together to determine what is most helpful for you including
what out-of-session activities, homework, may be most beneficial.

There are important challenges to be aware of in counseling. It is important for you to know that
sometimes participation in counseling involves the exacerbation of symptoms, however, over
time, the goal is that you should see improvement. Simply put, people often feel worse before
they feel better. You may discover that you have difficult thoughts or feelings about people or
situations that you had previously been unaware of. You may be experiencing something, or
have had experiences in the past, that must be reconciled, and sometimes that process can be
uncomfortable and tiring.

This discomfort is partially responsible for resistance that many clients experience at various
stages of counseling. Resistance is usually a healthy, normal response to potential change, often
signaling an opportunity for growth and healing. For instance, resistance may show up as
thoughts like I am too busy I cant change anything or this is just the way I am. In
choosing to move through resistance to your next level of awareness, you choose to expand your
opportunities for healing and growth. Still, it is important to note that though we will attempt to
work toward positive outcomes, there is no guarantee of positive outcomes in the counseling
process.

Therapeutic Relationship
Throughout the counseling process, we will work together to evaluate our progress, discuss your
experience with the process, and to work toward goals and desired counseling outcomes.
Though the therapeutic relationship is an intimate one, our relationship is entirely professional.
You will be best served in counseling by a strictly professional therapeutic relationship, and with
sessions that focus exclusively on your goals and concerns. I do not engage with clients socially
nor participate in social media of any kind as I believe it could compromise confidentiality and
privacy which would have a negative impact on our therapeutic relationship. I do not text clients
and prefer to not to use email. Email is not a completely secure or confidential means of
communication. You should know that any emails I receive from you and any response I send
become a part of your medical record. I request that you limit contact to the methods outlined in
the availability section below.
As further protection for you and the therapeutic relationship, it is not appropriate to extend
social invitations or gifts to me or ask me to relate to you in any other way outside the
professional context of our therapy. These limits are designed with your welfare in mind and
allow for all efforts to be directed toward your therapeutic concerns only. Also, because we may
live in the same community, if I see you in a public setting, my intention is that I will not
acknowledge you unless you first acknowledge me. I think it is best that any public discussions
ae kept to short, polite interactions. Please do not take offense and know that this policy is an
extension of my respect for you and my desire to protect your confidentiality and preserve the
integrity of our therapeutic relationship.

Availability
Although I try to arrange initial assessments promptly, longer wait times are common during
busy periods of the year. If you consider your situation an emergency that will not allow a delay,
please inform our staff at the University Counseling Center. For after-hours urgent needs, call
our main number at 585-275-3113 and request to speak to the Counselor On-Call. Please be sure
to wait for the return call which will appear on your phone as an unidentified number or 000-
0000. If you have an emergency where you or someone else is at risk, call Public Safety at *13
from any U of R phone (if on campus) or dial 911 (if off campus) or go to the nearest emergency
room.

Schedule, Fees, and Payment

Payment is due at the time of services. The fee for an intake session is $100.00. Sessions are a
minimum of 30 minutes and can extend as far as 60 minutes in duration and will be scheduled at
mutually agreed upon times. The fee for a standard 30-60 minute session is $125.00. Sessions
that extend past 60 minutes in duration will be billed at
$135.00. I accept cash, check, and credit card payments but do not accept insurance at this time.

If you must cancel your appointment, please do so promptly so that your appointment time may
be given to someone else. There is no charge for cancellations made more than twenty-four (24)
hours in advance. For a cancellation made within 24 hours of the appointment, or if the
appointment is missed with no notice of cancellation, you will be charged for the appointment.
Insurance companies do not reimburse for missed appointments. A recurring problem with late
notice cancellations, no shows, and/or nonpayment for services may result in termination of
services.

I understand that there may be a rare time where you need to call me between sessions. If your
call is more than 15 minutes or a combination of calls is more than 15 minutes, you will be
charged on a prorated basis relative to the hourly fee originally agreed upon. Insurance
companies do not reimburse for calls.

If I am summoned to court on your behalf, you are responsible to pay the agreed upon hourly
rate for any associated time and efforts. This includes, but is not limited to, time spent
transcribing records, in court, travel, meals, and any wait time preceding the actual court
appearance. Insurance will not pay for court appearances.
If I need to cancel I will make every effort to inform you of the necessity to cancel an
appointment as quickly as possible. Inclement weather, illness or another emergency may
necessitate rescheduling, and every effort will be made to reschedule within one week. I will
inform you at least 1 week in advance of scheduled vacations.

Use of Mind-altering Drugs or Alcohol - No smoking is allowed in the building. Please do not
appear for a session under the influence of any mind-altering drug, including alcohol. Should the
situation occur, the therapy session will not take place, and you will be charged in full for the
session. Such an occurrence may be considered grounds for termination of therapy.

When insurance is utilized for therapy services, clients should be aware of the limits of
confidentiality and the fact that filing for insurance necessarily requires a diagnostic statement to
be placed in your insurance records. The forms must be signed by you in order to authorize the
release of confidential information. If you wish to be informed of the diagnosis before it is
submitted to your health insurance company, please make me aware of this, and we will discuss
the diagnosis. Typically, insurance companies require the following information: diagnosis, dates
of service, the kind of service you received (i.e. individual, group, family, etc.), and the name of
the client. Some managed care companies require additional information. Thus, you may not
have the extent of confidentiality that you might otherwise expect. Signing this agreement
authorizes the release of information to your insurance company.

Diagnosis
If a diagnosis is therapeutically necessary, I will talk with you about your concerns and make a
diagnosis to help aid in treatment. A diagnosis is required for third-party reimbursement. Some
conditions for which people seek counseling do not qualify for third-party reimbursement. If a
qualifying diagnosis is appropriate in your case, I will submit the diagnosis to the health
insurance company. Diagnosis has limits and is only a description of behavior. Further,
psychiatric diagnoses may differ between clinicians and clinical settings. Any diagnosis made
will become part of a clients permanent medical records. Diagnoses are not evidence of a brain
defect, genetic defect, or chemical imbalance (unless a true brain disease process exists e.g.,
Alzheimers, tumor, stroke, etc.). It is important to emphasize that I am not a medical doctor and
do not prescribe medication. If warranted, a referral to a physician or a nurse practitioner will be
made upon request and consultation. Please talk with me about any questions or concerns you
have about your diagnosis.

Some health insurance companies will reimburse clients for counseling services. In addition,
most will require a diagnosis of a mental-health condition 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.

Confidentiality
In keeping with ethical standards of our professional staff as well as state and federal law, all
services provided by the staff of UCC are kept confidential except as noted below. All
information shared with the clinicians at UCC is confidential. No information will be released
without your consent. UCC treatment records are electronic and stored on a secure server as part
of your UHS treatment records. Access to UCC records by UHS providers and vice versa is done
only on a need to know basis for purposes of collaborative care (e.g., referral for medication,
evaluations for eating disorders, etc.). In all other circumstances, consent to release information
is given through written authorization. Verbal consent for limited release of information may be
necessary in special circumstances. There are specific and limited exceptions to this
confidentiality which include the following:
A. When there is risk of imminent danger to yourself or to another person, the clinician is
ethically bound to take necessary steps to prevent such danger.
B. When there is suspicion that a child or elder is being sexually or physically abused or is
at risk of such abuse, the clinician is legally required to take steps to protect the child, and
to inform the proper authorities.
C. When a valid court order is issued for medical records, the clinician and the agency are
bound by law to comply with such requests.
D. Also, as a counselor I will be receiving supervision from a Licensed Supervisor. If any
information is shared during supervision, it will be discussed for professional purposes
only and every effort will be made to protect my clients identity. Additionally, all of our
communication becomes part of the clinical record, which is accessible to you upon
request.
E. UCC does not provide clinical information or release records to government agencies,
current or future employers or others, even with your permission. We highly recommend
that you talk with your therapist about the potential consequences of releasing your own
records for purposes other than continuity of care by other health care professionals. We
will, at your request, provide clinical information to another health professional for the
purposes of your further treatment.

Complaints
Although clients are encouraged to discuss any concerns with me and/or my supervisor, 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-of-ethics.pdf).

NY State Education Department

Office of the Professions
State Board for Mental Health Practitioners
89 Washington Avenue, Albany, New York 12234-1000
518-474-3817 ext. 450 (voice)
518-486-2981 (fax)
mhpbd@nysed.gov
Acceptance of Terms:

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

Client: __________________________________________ Date: _______________

Counselor: ______________________________________ Date: _______________