Oregon VR Professional Disclosure Form
Welcome to Vocational Rehabilitation (VR). VR has successfully helped thousands of people with
disabilities to meet their work goals. Your goal may be to keep a job you have now. You may want
to return to a job you have done before or find a job in a new field. You and your counselor will
work together to find a job that is as close as possible to your vocational goal. That job will also be
one that you are physically and mentally able to do.
One of the most important services we provide at VR is counseling and guidance. We do this
throughout the rehabilitation process. Counseling and guidance may include services that I provide
to you directly. It may also be information about or referral to other resources. I want you to know
that I have the skills and abilities to provide you with excellent counseling services. Here is more
information about my training and experience as a counselor:
•
•
•
•
<select one>
I have a
degree in
I have worked in this field for <select range>
years.
I have had special training in rehabilitation counseling.
I have earned these additional certification(s): (check all that apply)
.
Certified Rehabilitation Counselor
(CRC)
Certified Vocational Evaluation
Specialist (CVE)
Certified Work Adjustment Specialist
(CWA)
Certified Career Assessment
Associate (CCAA)
Certified Disability Management
Specialist (CDMS)
Certified Case Manager (CCM)
Certified Alcohol Drug Counselor
(CADC I, II or III)
Certified Prevention Specialist (CPS)
Certified Recovery Mentor (CRM)
Master Addictions Counselor (MAC)
Licensed Professional Counselor (LPC)
Licensed Clinical Social Worker
(LCSW)
National Certified Counselor (NCC)
Certified Clinical Mental Health
Counselor (CCMHC)
Licensed Marriage and Family
Therapist (LMFT)
As long as you are making progress toward your job goal, I can provide you with counseling and
guidance. Your file will not be closed due to “successful employment” until you have a job that
matches your vocational goal and have been working for at least 90 days. I will check with you
before I close your file, to see if you need any more help from VR. If for any reason you are not
making progress toward employment, we will talk about options available to you at that time.
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I will use a variety of counseling techniques to meet your individual needs.
These include: (check all that apply)
Psychoanalytic
Adlerian
Analytical Psychotherapy
Existential
Cognitive
Person-Centered
Choice/New Reality
Behavioral
Feminist
Constructivist
Motivational Intervention
Multicultural/Non-Western
Integrative
I know that “one size does not fit all” and your needs may be quite different than someone else's. I
will meet with you as regularly as is needed and schedule times that are convenient for us to meet.
The counseling and guidance I provide is related to employment. We might talk about other
concerns or issues too, but my main focus is on helping you to get and keep a job that matches your
goal. Sometimes you may feel uncomfortable talking about things that bother you or that you feel
strongly about. I encourage you to be as open and honest as possible. A successful counseling
relationship is based on trust and mutual respect. If for any reason I cannot continue as your
counselor, a VR Branch Manager will transfer your case to another counselor.
There is no charge to you for the counseling services I provide at VR. I will ask you to complete a
financial statement. That will show if you can pay anything for other VR services or services
provided by another agency or provider. If you need to pay for any services, we will work together
to decide which services those are.
To be sure I am doing my job properly, there may be times that l talk with my supervisor about your
case. Your case may also be reviewed by other VR staff. This can include staff in our
Administration office in Salem, and our federal partner, the Rehabilitation Services Administration.
All information in your file is private. This information will be kept private except:
•
If you have signed a release of information form that allows information to be
shared. That form will state who receives what information.
§ While your signature is voluntary, you need to be aware that your decision not to
sign means that information cannot be shared with VR or other providers. This
may limit VR's ability to help you reach your job goal.
•
If VR or I are sued or court ordered.
§
•
If a properly issued subpoena is received, information in your file may be released.
If you are younger than 18 or are not your own legal guardian.
§
The information in your file may be available to your parent(s), legal
guardian or advocate.
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There are some instances I am required by law to report to a law enforcement agency (with or
without your permission). If this happens I will inform you at the time. The rare situations I am
required to report are:
• If I have good reason to believe that you will harm another person.
§ I must try to contact that person and warn them of your intentions.
§ I must also contact the police and ask them to protect your intended victim.
• If I have good reason to believe you are abusing or neglecting a child or vulnerable adult,
or if you give me information about someone else who is doing this.
§ If this happens I must tell the police, Child Protective Services or Adult
Protective Services.
§ I have to do this within 24 hours of becoming aware of the situation.
• If I think you are going to hurt yourself.
§ I will try to contact a member of your support system.
§ I may also call the police or the county crisis team.
It is important to remember that my goal as your VR Counselor is to help you find a satisfactory job
and that all VR services must be related to that goal. It is also important to know that I will, at all
times, try to act in your best interest and protect you from unnecessary risk, including risk related to
email and other electronic communication.
If you are not satisfied for any reason with the services you receive at VR, let me know, or ask to
talk with my supervisor so we can work together to solve the problem.
Client statement:
I have read this disclosure statement and have been given the opportunity to ask questions about its
contents. I understand what it says and have answers to my questions about this form.
Signature of Customer
Date
Signature of Legal Guardian
Date
Signature of VR Counselor
Date
This statement meets the requirements for a counselor professional disclosure statement as is required in the
Commission on Rehabilitation Counselor Certification Code of Ethics (effective January 1, 2010). For more
information about the Certified Rehabilitation Counselor (CRC) credential, visit http://www.crccertification.com
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