Professional Disclosure Statement

PROFESSIONAL DISCLOSURE STATEMENT: 

Contact Information

Mental Wellness and Clinical Counseling Services

• Fayona Curenton, LISW-CS, LISW-S
• Address: PO Box 173 Carlisle, SC 29031
• Phone: 864-444-9775

Fees for Services

• Intake Assessment: $180
• 60-minute session: $120
• 45-minute session: $90
• 30-minute session: $60

Educational Training

• Bachelor of Science in Human Development and Family Science (6/2001)
• Minor in Psychology (6/2001)
• Master's in Social Work from The Ohio State University (6/2009)

Areas of Competency

• Diagnostic Assessments
• Cognitive Behavioral Therapy
• Acceptance & Commitment Therapy
• Dialectical Behavior Therapy
• Motivational Interviewing
• Harm Reduction Education
• Psycho-education for individuals and groups
• Alcohol and Other Drug Risk Management
• Individual Counseling

Ethical Codes

I adhere to-

• The South Carolina Board of Examiners for Licensure of Professional Counselors, Marriage and Family Therapists, and Psycho-Educational Specialists.  
• Ohio Counselor, Social Worker, and Marriage and Family Therapist Board 

-These agencies enforce ethical standards, which include but not limited to: "sexual intimacy between a practitioner [therapist] and client is strictly prohibited."

-“This information is required by the counselor, social worker, and marriage and family therapist board, which regulates the practices of professional counseling, social work, and marriage and family therapy in this state.”  (Ohio)

Contact Information for Licensing Boards 

• Ohio Counselor, Social Worker, and Marriage & Family Therapist Board
  77 South High Street, 24th Floor, Room 2468, Columbus, OH 43215-6171
  Phone: 614‑466‑0912
  Website: www.cswmft.ohio.gov

• The South Carolina Board of Social Work Examiners

              110 Centerview Dr, Columbia, SC

              Phone: (803) 896-4664

              Website: Contact.SocialWork@llr.sc.gov

The therapeutic relationship is unique in that it is highly personal and at the same time a contractual agreement. Given this, it is important for us to reach a clear understanding about how our relationship will work, and what each of us can expect. This consent will provide a clear framework for our work together. Feel free to discuss any of this with me. Please read and indicate that you have reviewed this information and agree to it by filling in the checkbox at the end of this document.

You have taken a very positive step by deciding to seek therapy. The outcome of your treatment depends largely on your willingness to engage in this process, which may, at times, result in considerable discomfort. Remembering unpleasant events and becoming aware of feelings attached to those events can bring on strong feelings of anger, depression, anxiety, etc. There are no miracle cures. I cannot promise that your behavior or circumstance will change. I can promise to support you and do my very best to understand you, as well as to help you clarify what it is that you want for yourself. I am required to state that  sexual intimacy between a  practitoner [therapist] and a client is prohibited.   

The session content and all relevant materials to your treatment will be held confidential unless you request in writing to have all or portions of such content released to a specifically named person/persons. Limitations of such client held privilege of confidentiality are listed below:

1. If a client threatens or attempts suicide or otherwise conducts themselves in a manner in which there is a substantial risk of incurring serious bodily harm.
2. If a client threatens grave bodily harm or death to another person.
3. If the therapist has a reasonable suspicion that a client or other named victim is the perpetrator, observer of, or actual victim of physical, emotional or sexual abuse of children under the age of 18 years.
4. Suspicions as stated above in the case of an elderly person who may be subjected to these abuses.
5. Suspected neglect of the parties named in items #3 and # 4.
6. If a court of law issues a legitimate subpoena for information stated on the subpoena.
7. If a client is in therapy or being treated by order of a court of law, or if information is obtained for the purpose of rendering an expert’s report to an attorney.

Occasionally, I may need to consult with other professionals in their areas of expertise in order to provide the best treatment for you. Information about you may be shared in this context without using your name.

If we see each other accidentally outside of the therapy office, I will not acknowledge you first. Your right to privacy and confidentiality is of the utmost importance to me, and I do not wish to jeopardize your privacy. However, if you acknowledge me first, I will be more than happy to speak briefly with you. Respectfully, it is important to know that it is not appropriate to provide specific updates to me outside of our therapy sessions. This may unintentionally violate your confidentiality in a public setting, which I must help to protect.

[Adapted from Blueprint.com forms. Information can be sent electronically via Blueprint.com for clients who schedule an appointment]