Professional Disclosure Statement

K​ATELYN​ S J​ANVRIN
​(704) 644-9516​ ​◆ ​skinko17@wfu.edu​ ​◆​ ​130 Shovelhead Lane​ ​◆ ​Statesville, NC 28625  
 

QUALIFICATIONS
I am currently a graduate counseling student at Wake Forest University pursuing a Master of Arts in
Clinical Mental Health Counseling. As a part of my education I am completing my practicum and internship
at Higher Ground Psychological Services as well as the Carolina Center for Evaluation and Treatment. I
received a Bachelor of Science in both Psychology as well as Criminal Justice from the University of North
Carolina at Charlotte in May of 2015.

RESTRICTED LICENSURE
As previously mentioned, I am currently a graduate counseling student at Wake Forest University pursuing
my licensure as a Licensed Professional Counselor Associate in North Carolina. My expected graduation
date is May of 2020 and at that time I will receive my Master of Arts in Clinical Mental Health Counseling
and will have completed 60 credit hours. As a practicum student I am being supervised by three licensed
supervisors—Two at my site (Dr. Thea O. Silva de Souza and Dr. Rebecca Parnell) and one at Wake Forest
University (Dr. Joseph Avera). All three of my supervisors are ready and available to answer any and all
questions at any time throughout this process. The contact information for those who are supervising me
can be found below.

UNIVERSITY SUPERVISOR
Name: Dr. Joseph Avera
Email: averaj@wfu.edu

SITE SUPERVISORS
Name: Dr. Thea O. Silva de Souza
Number:704-495-4435
Email:dr.silvadesouza@gmail.com

Name: Dr. Rebecca Parnell

Number: 704-756-1615
Email: dr.rebeccaparnell@gmail.com

COUNSELING BACKGROUND
I have served a wide range of populations including but not limited to children, adolescents, adults,
couples, and families. I currently provide intake assessments, individual counseling, couples counseling,
family counseling and group counseling. My experience thus far has been in a private practice setting. I
utilize Person-Centered Counseling as a foundation for my work amongst Cognitive Behavioral Therapy
and Dialectical Behavior Therapy interventions.

SESSION LENGTH AND FEES

Length of sessions ranges from forty-five to sixty minutes. A sliding scale will be used that varies from
case to case in terms of each client’s financial means and frequency of sessions. The agreed upon fee for
this client is .​ We accept all methods of payment (cash, check, credit card, etc).

USE OF DIAGNOSIS
Some health insurance companies will reimburse clients for counseling services and some will not. In
addition, most companies require that a diagnosis must be rendered if the client is going to be
reimbursed. Some conditions for which people seek counseling do not qualify for diagnosis. If a qualifying
diagnosis is appropriate in your case, I will inform you of the diagnosis before we submit the diagnosis to
the health insurance company. Any diagnosis made will become part of your permanent insurance records.
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CONFIDENTIALITY
All of our communication becomes part of the clinical record, which is accessible to you upon request. 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.

COMPLAINTS

Although clients are encouraged to discuss any concerns with me or my supervisor directly, you may file a
complaint against me with the organization below should you feel I am in violation of any of these codes
of ethics. I abide by the ACA Code of Ethics
(​http://www.counseling.org/Resources/aca-code-of-ethics.pdf​).

North Carolina Board of Licensed Clinical Mental Health Counselors

P.O. Box 77819
Greensboro, NC 27417
Phone: 844-622-3572 or 336-217-6007
Fax: 336-217-9450
E-mail: ​complaints@ncblpc.org

ACCEPTANCE OF TERMS
We both are in agreement of these terms and will abide by these guidelines.

Client: ________________________________________________ Date: _____​ ​___

Counselor: _____________________________________________ Date: _____​ ​___