Daniel S. Yearick, LPC-S
Individual & Family Therapy
PO Box 509
Waynesville, North Carolina 28786
(828) 456-4588
CLIENT DISCLOSURE STATEMENT
EXPERIENCE & QUALIFICATIONS
I hold a Bachelors Degree in Social Work from Roberts Wesleyan College (Rochester,
New York) which I received in 1983. I earned a Masters Degree in Counselor Education from
The State University of New York College at Brockport in 1990.
I am credentialed as a Licensed Professional Counselor (LPC) and also as Licensed
Professional Counselor Supervisor (LPC-S) by the North Carolina Board of Licensed
Professional Counselors (License numbers 2850 and S2850). I am also credentialed as a
National Certified Counselor (NCC) by the National Board for Certified Counselors
(Certificate number 27588). I have been in practice as a counselor since 1987
My counseling experience includes children, adolescents and adults for individual,
marital, family and group therapy. I work with issues of depression, loss & grief, identity
issues, abuse recovery, parenting and recovery from troubled backgrounds. I have worked
not only in private counseling settings but also in agencies and community mental health
centers.
NATURE OF COUNSELING
Counseling includes active involvement as well as efforts to change thoughts, feelings
and behaviors. You will have to work both in and out of the counseling sessions. There are
no instant, painless, passive cures; no “magic pills’. Instead there will be homework
assignments, exercises, journaling and perhaps other projects. People usually have to work
on relationships, making long-term efforts to achieve desired results. Change is generally
slow and may require repeated effort on an ongoing basis. It can, however, come swiftly after
acquiring a new perspective.
I accept clients who have the capacity to resolve their own problems with my
assistance. I use a psychodynamic approach to therapy, and borrow from various theorists.
My theoretical basis for counseling is derived primarily from Adlerian Therapy, created by
Alfred Adler. I believe that our first task is to develop a therapeutic relationship whereby you
will feel understood. We will work to help you understand yourself as a result of your past,
and use this understanding to help you make changes in your present life in order to reach
your desired goal.
I also use methods of Frederick Perls’ Gestalt Therapy that replicate experience and
feelings to move you through this process. I also take a Systems Approach to this process,
believing that individuals function as part of a larger system (i.e. their families). I then
integrate these methods with Biblical truths, but only if this is your frame of reference. These
are well established, researched and respected therapies. You are encouraged to become
knowledgeable about their goals, methods and effectiveness.
Our first task will be to specify the goals, foci & methods, risks & benefits of
treatment, cost and other aspects of your particular situation. Before going further, we will
need to agree on a plan to which we will both adhere. Periodically we will evaluate our
progress and, if necessary, redesign our treatment plan, goals and methods.
Clients with whom I work have the capacity to be psychologically and emotionally
“healthy”. They seek counseling for difficulties due to life events. I do not take clients who,
in my professional opinion, I cannot help using the techniques I have available. I regard the
information that you share with me with the greatest respect. The privacy and confidentiality
of our interactions and my records are a privilege of yours and is protected by state law and
my profession’s ethical principles. There are two circumstances in which I cannot guarantee
confidentiality, legally or ethically: (1) when I believe you intend to harm yourself or another
person; and (2) when I believe a child or an elderly person has been, or will be, neglected or
abused. In rare circumstance, Professional Counselors can be ordered by a judge to release
information. Otherwise, our relationship is completely confidential and information will be
shared only with your written consent.
Although our sessions may be psychologically intimate, it is important for you to
realize that we have a professional relationship. You will be best served while I am seeing
you for counseling if our relationship remains professional and if our sessions concentrate on
your concerns.
LENGTH OF SESSIONS
Sessions are normally 45-55 minutes in duration, unless we agree to have an
extended session. If you are unable to keep an appointment please call to cancel or
reschedule at least 24 hours in advance. If I do not receive such advance notice, you
will be responsible for paying for the missed session(s).
FEE & METHOD OF PAYMENT
My cost per session is $120. I will collect payment at the conclusion of each session
in either cash or check. (Many insurance companies will allow me to charge you only your
portion and bill them for the remainder.) You will be charged an additional cost for checks
returned for insufficient funds.
Some insurance companies will reimburse clients for my services and some will not.
Most insurance companies require that I diagnose your mental health condition and indicate
that you have an “illness” before they will agree to reimburse. 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 that I plan to render before I
submit it to the health insurance company. Any diagnosis made will become part of your
permanent insurance record.
COURT TESTIMONY
Fee for court testimony starts at $500.00 and are paid in advance
COMPLAINT PROCEDURES
If you are dissatisfied with any aspect of my work, please inform me immediately. If
you feel you have been treated unethically or unfairly, and we are unable to resolve the issue,
you can contact the North Carolina Board of Licensed Professional Counselors at P.O. Box
1369, Garner, NC 27529-1369, or call (919) 661-0820 for clarification of client’s rights as I
have explained them, or to lodge a complaint.
If you have questions, feel free to ask. Please sign and date this form; I will keep a
copy for my records and provide a copy for you, if you wish.
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Client Signature
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Date
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Daniel S. Yearick, LPC-S
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Date
Revision 01/05/2012