Professional Disclosure Statement - LMFT
This Professional Disclosure Statement (PDS) is for Licensed Marriage and Family Therapists or LMFT as overseen by the North Carolina Marriage and Family Therapy Licensure Board. Please fill in the information below and your Counseling Professionals Professional Disclosure Statement that will be sent to each client for intake and posted on your profile on our website. You can update this statement at any time by going to Provider Resources on the Counseling Professionals PLLC website.

Please enter Email twice. Once where you would like to receive a copy of your document and your Counseling Professionals email. The first email address will receive a copy of your document.
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Email *
Counseling Professionals Email *
Provider First Name
Provider Last Name
License Type (LCMHC-A, LCMHC, or LCMHC-S) *
Required
Name of Provider on PDS
Please use your full name, but if you go by a different name, please put your full name in parenthesis:
 C. J. Leach (Christopher Jason Leach) MS NCC LCMHC
Provider Full and Name and Credentials *
Scheduling Phone Number *
Which Office will be your main Counseling Professionals PLLC Office
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Qualifications
In the question below, write your qualification similar to the example. Feel free to copy the example and update with your information.

Example:
I have a MS in Mental Health Counseling from Walden University, which I obtained in November 2011.  I started working as an intern in 2010 at the North Carolina State University (NCSU) Counseling Center.  This internship ended in August of 2011 and I was invited back to work as a counselor at NCSU until May of 2012.  The population I served during my time at NCSU was young adult to adult of varying ethnic, cultural, and sexual orientations and backgrounds.  I began working at Lifescapes Counseling Associates PLLC in July of 2012 to November of 2017. I started Counseling Professionals PLLC in February 2016 as a corporation to meet the counseling needs of the area and I work there at present. I have experience at all locations with individual counseling as well as group work and psycho-educational outreach.

I passed my National Counseling Certification exam in October, 2011 (National Certified Counselor #292279).  Completion of this exam and my master’s degree allowed me to practice as a Licensed Clinical Mental Health Counselor Associate (LCMHCA) in North Carolina.  I acquired my licensure as an LCMHCA in June of 2012 (North Carolina Board of Licensed Clinical Mental Health Counselors (NCBLCMHC) # A9420).  I also obtained certification as a BASICS Trainer by the North Carolina Substance Abuse Professional Practice Board in 2010 (Certification #10-499-5).  I obtained by Licensed Clinical Mental Health Counselor (LCMHC)  licensure on June 16, 2015. License Number 9420 and I have been a therapist and counseling to present.

Your Qualifications Section *
Counseling Services/Theoretical Approaches
In the question below, write your qualification similar to the example. Feel free to copy the example and update with your information.

Example:
I mainly work with career professionals who face high stress and operate in progress driven environments. I focus on time management, balance, and self-awareness using a mixture of multiple fields of thought. I also work with clients of all backgrounds in an outpatient setting from 6-years-old and up. I work with clients younger than 13 with family involvement using family structure therapy to aid with educational objectives, learning disabilities, and behavioral problems. I work with men and women of all ethnic, cultural, and sexual orientations. I also work with couples dealing with communication and relationship issues, included co-parenting through separation and after divorce. The only clientele I do not work with are clients who have been diagnosed as bipolar.

My theoretical approach to counseling is broad and includes brief solution focused counseling services for specific issues based on problems or issues that are specific to the setting and situation.  For deeper issues, I take a psychodynamic perspective for more thorough counseling needed by specific clients.  I also use cognitive behavioral techniques and person centered modalities based on client needs, issues, and situation presentation.  All progress and pacing of counseling sessions are determined based on the drive and effort of the client to accomplish their stated goals both during and between sessions. I set my pace and approach in therapy based on the desire and comfort of the client.

Counseling Services/Theoretical Approaches *
Associate Level Supervisor Information
Supervisor Information only for Associate levels
Supervisors Full Name and Credentials
Supervisors Full Mailing Address
Supervisors Public Use Phone Number
Supervisor's Public Use Email
Insurance Panels
Please select all that you currently take and return to this form when you are accepted into new panels to update your PDS.
Which Insurance Panels are you on? *
Required
What would you like to set your Cancellation Fee at? (60 is Counseling Professionals Standard) *
Counseling Hours
In the question below, write your times similar to the example. Feel free to copy the example and update with your information.

Example:
I am in the office Monday from 3 pm to 6 pm, Tuesday through Friday from 3 pm to 9 pm, and I work on Saturdays between 8 am and 5 pm. Adjustments can be made by requests and on exception. Openings on my schedule can be found at https://cppllc.mytherabook.com/appointments/new. Holiday times may adjust availability.
Regular Hours of Counseling Are *
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