PROFESSIONAL SUPERVISION DISCLOSURE STATEMENT

Samantha Simon Lohorn, MA.Ed., LPCA, NCC

Counselor, NC State Counseling Center
Doctoral Student, Counselor Education

As your University supervisor for practicum, I will provide your individual and group
supervision for this semester. Specific requirements for course content will be outlined in your
syllabus. This document will provide you with more information about my clinical background,
terms of supervision, and my personal supervision style.

Academic Background

I received my BA in Psychology with a minor of Child Development and Family

Relations from East Carolina University in 2014. From there, I attended The University of North
Carolina at Pembroke where I received a Master’s in Education in Clinical Mental Health
Counseling. I am currently a second-year doctoral student in the Counselor Education program at
North Carolina State University, with an interest in counselor training and supervision.

Clinical Theoretical Orientation & Experience

I come from a person-centered and solution-focused framework in my clinical practice. I

incorporate expressive arts and creative therapy techniques to build rapport and process
subconscious thoughts and behaviors. I have experience working in outpatient mental health,
academic coaching, and college counseling settings. I am a licensed professional counseling
associate (LPCA), license #A13168. Once I complete 3,000 clinical supervised hours, I will
apply to be a Licensed Professional Counselor (LPC). I am also a Nationally Certified Counselor
(NCC).

Supervision

While this is my first experience in a clinical supervisory role, I am concurrently getting

supervision to provide the best experience for you as the student. You will work with two
supervisors this semester, your site supervisor, and myself. You will be videotaped during this
experience and will need to provide the recommended number of videotapes for this class. Please
refer to your syllabus for specific course requirements and assignments. Clinical supervision has
two goals: the development of the counseling skills of the supervisee and the protection of the
client. These are always operating simultaneously when supervision is occuring. Most of the
focus will be on your developing counseling skill set, and if there are areas in need of
improvement supervision will be more in-depth.
 Because you are a student in a counselor training program, I cannot guarantee
confidentiality of information gained in supervision if it is relevant to your overall progress in
the program. This means that I will be in contact with all of your relevant supervisors (site
supervisors, individual supervisors, and instructors) as needed to provide the most
comprehensive supervision possible and to ensure your professional progress. I can, however,
commit to honoring and respecting all information I receive in supervision about you and/or your
clients and keeping all such information confidential to the degree possible. Occasionally, there
are situations that occur that make confidentiality impossible. These include:
1. threats to harm self or others;
2. reasonable suspicion of abuse of a child or other vulnerable person; and
3. when ordered by the court.

Your supervisory experience may be created using a multitude of different supervision

models. I come from a humanistic and solution-focused framework in supervision and expect
each supervisee to develop at least three goals that will help develop their professional skill set.
The supervision you receive will be developmentally appropriate, culturally sensitive, and will
be framed by the goals that you set for yourself. An important developmental part of supervision
is being challenged in a supportive, respectful, and safe environment, which I plan to create for
you. If at any time you do not feel supported, respected, or safe please talk with me personally so
we can address any and all concerns.

If a client emergency arises your first point of contact would be your site supervisor and
than myself. Throughout the duration of your practicum experience please call/text me at
___________ if you have a concern about a client that you feel cannot wait until our next group
or individual session. For regular communications, please email me at sjsimon2@ncsu.edu, as it
is the easiest and fastest way to contact me. In case of an emergency when I am out of town, you
will be advised regarding who is the most appropriate contact person in my absence.

Although it is a rare occasion, a student may feel that he/she/they has not received
adequate supervision or a fair evaluation. If this should occur, your first step is to attempt to
resolve this issue with me. If you remain dissatisfied, this course is protected by the same appeal
procedure as any other course as it is outlined in the Counselor Education Department materials
and the School of Education catalogue. If you believe I have acted unethically in any way, you
may report your complaint to my direct supervisor, __________________.

The main function of this course and supervisory experience is for you to develop the
fundamental counseling skills that will aid your overall professional development as a counselor.
I encourage you to provide feedback that is engaging and helpful to the class discussion and
personal development of each student. This will be a challenging, yet rewarding experience and I
look forward to working with you along this semester journey.
Please sign, date and return one copy of this form.

___________________________ ____________________________
Practicum Instructor Signature Student Signature

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Date Date