North Carolina Administrative Code
Title 21 - OCCUPATIONAL LICENSING BOARDS AND COMMISSIONS
Chapter 53 - CLINICAL MENTAL HEALTH COUNSELORS
Section .0200 - DEFINITIONS AND CLARIFICATION OF TERMS
Section 53 .0204 - PROFESSIONAL DISCLOSURE STATEMENT REQUIREMENTS FOR LCMHCA AND LCMHC

(1) name of licensee or applicant;

(2) the licensee's or applicant's highest relevant degree, year degree received, discipline of degree, and name of institution granting the degree;

(3) names and numbers of all relevant credentials licenses, certificates, or registrations;

(4) number of years of counseling experience;

(5) description of services offered and populations served;

(6) length of sessions, specific fee or range of fees charged per session, if no fee is charged, a statement to that effect, and methods of payments for services, including information about billing or insurance reimbursement;

(7) an explanation of confidentiality, including responsibilities and exceptions such as, child or elder abuse, court order;

(8) a statement of procedure for registering complaints, including the full name, address, and telephone number of the Board's office;

(9) signature and date spaces for both the client and licensee; and

(10) level of licensure and whether the licensee is under supervision. If under supervision, include name of supervisor.

A current copy of this statement shall be provided to each client prior to the performance of professional counseling services. An updated Professional Disclosure Statement shall be submitted at the time of renewal to the Board's office at 2-C Terrace Way, Greensboro, NC 27403 or electronically by uploading on the Board's website at https://portal.ncblcmhc.org/.The counselor shall retain a file copy of the Professional Disclosure Statement signed by each client.