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Professional Disclosure Statement

Patricia Cuddeback
Office: 336-716-3618
Fax: 336-716-9929

My Qualifications

I am a graduate counseling student from Wake Forest University. Currently, I am a substance abuse counselor on
the trauma counseling team at Wake Forest Baptist Health. I will hold a provisional counseling license
(anticipated October) and I will continue developing my counseling skills. I am being supervised by a licensed
supervisor on the counseling trauma team.

Counseling Background

I hold a Bachelor of Arts in Psychology and minor in Education. I am currently earning a Master of Arts in
Counseling from a CACREP-accredited graduate school. My anticipated graduation date is August 2017. Upon
graduation, I will have completed 60 credit hours of course work in clinical mental health counseling. My
theoretical orientation is based upon influences from Person-Centered counseling, Motivational Interviewing, and
Mindfulness. I believe in a strength-based approach to counseling which empowers clients to make choices in
collaboration with counselor to create change and accomplish goals.


I will keep confidential anything you say as part of our counseling relationship, with the following exceptions: (a)
you direct me in writing to disclose information to someone else, (b) it is determined you are a danger to yourself
or others (including child or elder abuse), or (c) I am ordered by a court to disclose information.


My site supervisor is available if you have concerns about my work. Dr. Laura Veach: 336-716-3618 I abide by
the ACA Code of Ethics (

North Carolina Board of Licensed Professional Counselors

P.O. Box 77819
Greensboro, NC 27417
Phone: 844-622-3572 or 336-217-6007
Fax: 336-217-9450

Acceptance of Terms

We agree to these terms and will abide by these guidelines.

Client: ___________________________________________________ Date: ___________

Counselor: ________________________________________________ Date: ___________