Professional Disclosure Statement and Informed Consent

Central Michigan Professional Counseling Associates

307 E. Michigan St

Mt. Pleasant, MI 48858

989-772-5833

Counseling Practice:Central Michigan Professional Counseling Associates (CMPCA) is an Employee Assistance Program (EAP) and a private counseling practice. Our goal is to provide quality counseling services to our companies and our clients. We provide service to individuals, couples, and families for a variety of issues. Our sessions generally last 50 minutes. For our self paying clients we will do our best to bill your insurance. If there are any un-met deductibles or out of pocket co-pays you will be responsible for payment. The self pay cost is $95 per session. There will be a $95 fee for appointments not canceled prior to 24 hours of appointment time. There will be a $95 fee for not attending your scheduled appointment. For further information or questions please ask CMPCA staff. As our clients, you have the right to know our qualifications, how we work, and what to expect from us as your counselors.

Philosophy and Approach: CMPCA counselors adhere to a client-centered approach to counseling, but we are also strongly influenced by cognitive-behavioral therapy, systems theory, and a variety of other approaches as they are appropriate to use with our clients. We at CMPCA strive to create a comfortable, therapeutic environment where a safe, collaborative relationship between client and counselor can be established. The partnership between counselor and client facilitates the ability to examine issues, set goals, and work together to achieve those goals. We believe positive change or outcomes are possible and that you possess untapped, inner resources to help you directly deal with your concerns and problems. Counselors do not have the ability to fix your problems; that power belongs to you. For counseling to be effective, you must make a commitment of time and energy and be an active participant in the process. Your involvement both during and between sessions will be required. Homework may involve reading, writing exercises, or practicing new behaviors.

It is important you realize there are risks involved with any type of counseling. You may feel worse before you feel better. You may experience uncomfortable emotions such as anger, frustration, or fear. It is also not possible to make any guarantees about counseling outcomes.

CMPCA is also a teaching facility, in that part or all of your counseling experience may be conducted with a master-level counseling intern. Our interns bring fresh ideas and new approaches to the counseling process, which we find invaluable. Interns have already completed many hours of supervised therapy, and they continue to receive close supervision and consultation from our full-time licensed counselors. You are free to contact the intern’s supervisor if you have any questions or concerns regarding your counseling experience.

Professional Roles/Boundaries: The counselors at CMPCA have many different roles in the local community, including, but not limited to, the following: workshop presenters, mediators, business owners, church members, club members, and parents.

You may, therefore, encounter your therapist outside the counseling setting. When this happens, we will protect your confidentiality by not acknowledging our counseling relationship unless initiated by you or, for professional reasons, warranted by us.

Client Rights:You have the right to refuse any suggestion(s) we may give you during your counseling sessions. You have the right not to talk about something if you don’t want to. You also have the right, at any time or for any reason, to decide you do not want to continue counseling. In that case, we request that you inform us of your decision and schedule a final session to bring closure to our work together.

Minors: Except during sessions, all minors must be accompanied by a parent or guardian. When a minor is in session with his/her therapist a parent or guardian must be present in the waiting room.

Telehealth Counseling: There may be times and circumstances that qualify a client to participate in video or audio counseling sessions.

Missed or Cancelled Appointments: We would appreciate being contacted whenever you need to cancel an appointment. Missing a scheduled appointment without notification greatly inconveniences your counselor and other clients who are waiting to get in for an appointment. Our policy is that we will wait 15 minutes after your scheduled appointment time before we consider you a “No-Show.” Should you arrive more than 15 minutes after your scheduled appointment time, your appointment will be rescheduled.

Confidentiality: Your therapy sessions are strictly confidential except under certain circumstances when your counselor is required by law to report information you have shared. These exceptions to confidentiality include:

Report of child or elder abuse or neglect
The intent to harm yourself or someone else
Court-ordered subpoenas
Report of your intent to commit a felony

We may also consult with other professionals about your circumstances and how we might proceed in order to help you, but we will do so without using your name or any other identifying information. You have the right to ask your counselor not to consult with anyone.

Counselors:

Brenda Dunham, MA, LPC, NCC

M.A. Counseling - Central Michigan University

B.S. Psychology - Central Michigan University

License # 6401009188

Marisa Bullard LLMSW

Limited License Masters Social Work - Central Michigan University

Bachelors Ltd. Social Work - Ferris State University

License # 6801100958

Jake Lazarov

M.A. Counseling - Central Michigan University

B.S. Psychology - Central Michigan University

License # 6401014715

Professional Affiliations:

Employee Assistance Program Association, American Counseling Association, Michigan Counseling Association, Michigan Association for Counselor Education and Supervision.

Questions or Concerns:

If you have any concerns about this disclosure statement or the counseling provided by this agency, please feel free to discuss them with your counselor. You may also direct your concerns to: Michigan Department of Community Health, Health Regulatory Division, P.O. Box 30670, Lansing, MI 48909. Phone: 517-373-9196.

Consent to Treatment:

I understand the above issues and agree to receive counseling services from Central Michigan Professional Counseling Associates.

By signing below, I also acknowledge a copy of the Privacy Practices has been made available to me or have had an opportunity to review the Privacy Practices for CMPCA.