ALL LICENSSES OF
THE BOARD ARE REQUIRED TO HAVE A DISCLOSURE STATEMENTS BY SECTION 4757.12 OF
THE OHIO REVISED CODE AND RULE 4757-5-12.
M. Dorsey, LPCC, NCC
License Professional Clinical Counselor (E.0700625)
Certified Counselor (NCC.700625)
This document is designed to provide you with
information concerning your counselor’s competence and chosen techniques to
ensure that you understand the professional relationship of counselor and
South University, Master of Arts in Clinical Mental
South University, Bachelor of Science in Legal Studies
South University, Associate of Science in Paralegal
Remington College, Associate of Applied Science in
of Competence & Services Provided
My areas of specialty include:
Shame and Anger Management
and Family Counseling
Abuse and Neglect
Behavior Issues/Difficulties in school and/or home
and Court Ordered Counseling
I do not prescribe medications to clients. I will support you in finding a
psychiatrist or medical professional if medication is needed.
I do not provide letters of fitness or make evaluative statements concerning
child custody situations or issues relating to divorce or separation, nor will
I provide ‘expert testimony’ in these situations. These services may be
obtained from a clinical psychologist. Please speak with me about a referral to
another provider for this purpose.
Counseling fee are billed is $150.00 per hour for
initial sessions and $125.00 for ongoing 45 minute sessions. An additional 15
minutes is included for reviewing and preparing note and any needed
communications. Due to the time commitment I make to you, if you fail to show
without having given at least 24 hours’ notice, you will be charged $95
appointment fee. You may leave message 24-hours a day at 216-466-7723 in case
an appointment must be broken.
Please be aware that most insurance companies do not reimburse for sessions
longer than 45 minutes.
All of our communication becomes part of the clinical
record, which is accessible to you upon request. Confidentiality will be
maintained in accordance with the standards of the American Counseling
Association and the National Board for Certified Counselors. I will keep
confidential anything you say as part of our counseling relationship, with the
performance and conduct in this clinical experience will be described in
general terms when I submit quarterly reports and verification of supervision
forms to the Ohio Board of Licensed Professional Counselors and other
credentialing boards or when consultation with another professional is
I am asked to provide information about your clinical experience in the form of
a recommendation for a job, licensure, or certification; Disclosures
made in triadic or group supervision cannot be absolutely guaranteed as confidential.
Although I will take every measure to encourage confidentiality and act
appropriately if confidentiality is not upheld; You
direct me in writing to disclose information to someone else; It
is determined you are a danger to yourself or others (including child or elder
abuse); and I
am ordered by a court to disclose information.
have the right to be treated by me in a competent, ethical, and respectful
have the right to a personal, individualized assessment of your treatment needs
in which your expertise about yourself is as important as is my professional
opinion about you.You
have the right to referrals to other competent professions and services when
this is indicated by your treatment needs.You
have the right to ask questions about the approach and methods we use and to
decline the use of certain therapeutic techniques.You
have the right to confidential treatment except in the circumstances already
described. This means that you determine the amount of information to be
released to anyone outside this setting by signing a permission form that is
specific to each situation that determines the length of time in which the
information may be released, and that may be canceled by you at any time.You
have the right to stop receiving therapy from me without any obligation other
than to pay for the services you have already received unless you are a danger
to yourself or to someone else.You
have the right to resume service following termination with my expressed
have the right to discuss your treatment, concerns, questions, complaints, or
any other matter with me.
If you need to contact me by phone, please don’t
hesitate. You will not be charged for phone calls unless our conversation lasts
beyond ten (10) minutes. If I am unavailable, leave a message on my voicemail.
I usually return all calls within 24 hours and once daily on holiday and
weekends. In case of an emergency, your first resource is the emergency room of
your nearest hospital or 911 is life-threatening.
signing this Professional Disclosure Statement, I affirm that the above information
has been provided to me verbally and in writing during my initial session with
Tamara M. Dorsey, LPCC, NCC.
have read the preceding information and understand my right as a client. I
hereby consent to and agree to receive counseling services and acknowledge that
I have received a copy of this Professional Disclosure Statement.
Signature of Client (ages
15 and older) Date
Signature of Client (ages
15 and older) Date
Parent/Guardian (clients under 15) Date
Signature of Tamara M.
Dorsey, LPCC, NCC Date
Please include the name and phone number of any
person(s) you wish for me to contact in case of an emergency or crisis.
INFORMATION IS REQUIRED BY THE COUNSELOR, SOCIAL WORKER, AND MARRIAGE AND
FAMILY THERAPIST BOARD OF OHIO WHICH REGULATES ALL LICENSED AND REGISTERED
COUNSELOR AND SOCIAL WORKERS.
State of Ohio Counselor, Social Worker, and Marriage and Family Therapist Board
South High Street, 24th floor