Counselor Licensure Disclosure Form

This form documents that the therapist has disclosed his/her certifications and the client has been informed that services provided by an LAC (Licensed Associate Counselor) or Masters Level Clinician are under the supervision of an LPC (Licensed Professional Counselor). This disclosure shall be kept as part of the client record and the qualified supervisor shall retain a copy for their records.

I understand that the person who will be providing my counseling and case management has the following credential(s):

By signing this document, I am showing I understand the person in charge of my primary care has the above circled licensure status. If this professional is an MA intern or an LAC, both of which require ongoing supervision in order to practice, I am giving my consent to be treated by this person and Lori O’Leary (clinical supervisor.)