Professional Disclosure Statement
(Information and Consent)
Angie Rink, MS, NCC, LAPC
A counseling relationship has common characteristics as other personal relationships with
some unique features. The relationship is built on trust, honesty, integrity, and respect in
efforts to strengthen client’s personal relationships. The relationship is short term with
the intention of long lasting effects. The relationship requires a level of commitment from
both parties with a higher feeling of risk for the client. For instance, the risk of feeling
judged, disclosing painful or difficult information, and worrying you will be
misunderstood by the counselor. I value the risk you took when deciding to come to
counseling. Additionally, I am honored you choose me as your counselor; I look forward
to working with you.
Please read the document entirely and feel free to ask any questions regarding the
following information. Prior to counseling you should fully know our policies regarding
confidentiality, privacy, payment, and/or filing complaints and your rights as a client. In
addition, I will provide a brief summary of my credentials, qualifications, theoretical
orientations, and logistics of the counseling process.
Education and Experience
I am a graduate from the master’s program at North Georgia College & State University.
I am a licensed professional counselor in the state of Georgia. I have worked with wide
range of disorders and life transitional stages. I have worked for over several years with
children in a wide range of techniques: Play therapy, solution focus therapy, and reality
therapy to name a few. I value my relationships between my clients and self; I believe
communication is a vital part of that counseling relationship. I look forward to beginning
our journey.
I am an active member of the following associations: LPCA, PSI CHI, and Pi Gamma
Mu.
Counseling Philosophy
I believe counseling is a holistic approach; I feel the mind, body, and soul operate in
harmony to create balance within the being. When one or all of these elements are not in
sync stress, frustration, and other emotional turmoil may appear. As a counselor, I will
help clients recreate balance using a variety of techniques and theories tailored to fit that
client. A few theories I use: Existential Theory allows clients to discover meaning and
happiness while developing a deeper understanding of life and death. Reality Theory will
help clients work in the present to problem solve and work toward a better future. PersonCentered Theory allows me to experience the clients’ reality. Furthermore, I believe a
person’s well being can be affected by health and fitness. Medication, foods, and exercise
may influence a person’s emotions, feelings, and thoughts; therefore, I will encourage my
clients to examine this part of their life for possible thorns.
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Confidentiality
Confidentiality is my professional commitment to you that the information you convey in
counseling sessions or through written documentation will not be mishandled or
disclosed without prior approval from you, except as noted below.
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Counselors are legally obligated to break confidentiality when the client is at high
risk of committing self harm or harm to others.
Legally if a minor is being sexual abused and/or neglect counselors are lawfully
obligated to report the incidents.
If a client makes legal claims against a counselor, counselors are not bonded to
confidentiality in the proceedings.
Confidentiality may or may not apply in cases involving legal proceedings
affecting parent-child relationship.
Counseling Process and Sessions
I feel the counseling process requires a commitment between the counselor and the client.
As a counselor, I am committed to do all I can within my abilities to help you in your
time of need. Additionally I expect my clients to be committed to the counseling process.
At any time you have the right to decline any assignments or suggestion such denial may
delay or hinder the healing process.
Clients Rights to Records
ACCARES makes every effort to maintain records in a secure location that only our
authorized personal may access. At any time if you want to review and/or discuss your
records with me, I am happy to assist you. In the event of family/couple sessions, only
the records pertaining to the requesting party will be disclosed in efforts to maintain the
other members’ confidentiality. In addition, legally only the records that will not cause
harm may be disclosed.
Fees and Insurance Reimbursement
Clients are expected to make payment at time of counseling session. If clients have
insurance ACCARES will be happy to process your claim. If the insurance company
denies or pays a smaller portion of your claim then you are responsible for the payment
or remaining total. Additional, clients are expected to contact their insurance company
and verify their benefits prior to the counseling session. Clients should obtain their
payment portion and allowable number of sessions. Payment outline is as followed:
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Session Fee $130
Admin Cost $30 one time cost
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Here at ACCARES, we realize you may have to cancel or reschedule an appointment due
to unforeseeable circumstances. Because our appointment slots are so limited, we require
at least a cancellation notice 48 hour in advance. Missed appointments without notice
will be charged at the regular session fee
If a check and/or credit card are rejected or sent back unpaid there will be a $25 NSF for
each occurrence
*In case of hardship please contact ACCARES to discuss possible financial options.*
Emergencies
I realize you may face situations where you need immediate assistance, and you may not
be able to wait until normal office hours. In such cases I urge you to contact either
Laurelwood Hospital 200 Wisteria Drive Gainesville, GA 30501 contact number 770219-3800, call 911, or go to your nearest hospital.
Complaints
Filling a formal complaint against me, you may contact the Georgia Board of
Professional Counselors:
237 Coliseum Drive
Macon, GA 31217-3858
(478) 207-2440
Or
Online Complaints:
https://secure.sos.state.ga.us/myverification/SubmitComplaint.aspx
By signing below, you are agreeing that you understand and accept all aspects of this
document, and you consent to counseling services offered by Angie Rink, B.S.
Client Name (Print)
Signature of Counselor
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Signature of Client
Date
Date