APCC Professional Disclosure Statement

Samantha Zaitz Rudin, Associate Professional Clinical Mental Health Counselor

Office:
Email:

Qualifications & Counseling Background

I graduated from Cornell University in 2015 with a Bachelor of Science and from Wake Forest
University in 2023 with a Master of Arts in Clinical Mental Health Counseling. My relevant coursework
at Wake Forest University included: Theories & Models of Counseling, Research & Statistical Analysis
in Counseling, Professional Orientation to Counseling, Lifespan Development: Implications for
Counseling, Group Procedures in Counseling, Family Counseling, Cultures & Counseling, Career
Development & Counseling, Basic Counseling Skills & Techniques, Advanced Counseling Skills &
Crisis Management, Psychopharmacology for Counselors, Clinical Mental Health Counseling,
Consultation & Program Development in Counseling, Classification of Mental and Emotional Disorders,
Professional Ethical & Legal Issues in Counseling, Case Formulation, Addiction Counseling, Crisis
Prevention & Response and Appraisal Procedures for Counselors.

I am an associate professional clinical counselor (APCC) pursuing licensure as a Professional Clinical

Counselor (LPCC) in the state of California. During my graduate clinical experience, I interned at Maple
Counseling in Los Angeles where I primarily worked with adults and provided individual counseling to
clients utilizing both psychodynamic and person-centered theoretical approaches and techniques.
Currently, I work with children, adolescents and adults and have incorporated cognitive behavioral
techniques into my approach. In my practice, I always abide by the ethical guidelines of the California
Board of Behavioral Sciences and ACA Code of Ethics (http://www.counseling.org/Resources/aca-
code-of-ethics.pdf).

As an associate, I am under the supervision of a site supervisor. Please find my supervisors’ contact
information and availability below should you have any complaints or contact needs.

At_____, I am under the supervision of_______.

Phone:
Availability:

Session Fees & Length of Services

The length of each individual therapy session is 50 minutes long and the fee per session is ____.
Accepted payment methods include ___.

Cancellation Policy

If you need to cancel or reschedule an appointment, please contact me at least 24 hours in advance to
avoid a late cancellation charge. If you cancel outside of the 24-hour window, excluding emergency
situations, you will be charged the full session fee if we cannot reschedule your appointment for another
time that same week. No-shows will also be charged the total amount of the missed session.
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Use of Diagnosis

If your health insurance company reimburses for counseling services, they will most likely require a
diagnosis of a mental-health condition and indication of “illness” before they will agree to reimburse.
However, some conditions for which people seek counseling do not qualify for reimbursement. If a
qualifying diagnosis is appropriate in your case, I will inform you of the diagnosis before providing you
with a superbill to submit to insurance for reimbursement. Any diagnosis made will become part of your
permanent insurance records.

Confidentiality

All of our communication is confidential and becomes part of the clinical record, which is accessible to
you upon request. This means that outside of supervision, I will not discuss your case orally or in writing
without your expressed written permission. However, I have an ethical and legal obligation to break
confidentiality under the following circumstances:
a. If there is a reason to believe there is an occurrence of child, elder, or dependent adult
abuse or neglect.

b. If there is reason to believe that you have serious intent to harm yourself, someone else,
or property by a violent act you may commit.
c. If you disclose that you knowingly develop, duplicate, print, download, stream, or access
through any electronic or digital media or exchanges, a film, photograph, video in which
a child is engaged in an act of obscene sexual conduct.
d. If you introduce your emotional condition into a legal proceeding.
e. If there is a court order for release of your records.

Acceptance of Terms

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

Client: ___________________________________________________ Date: ___________

Counselor: ________________________________________________ Date: ___________