STATEMENT OF PROFESSIONAL DISCLOSURE

FOR MENTAL HEALTH CLINICIANS

We are pleased you have chosen VirtualCare Medical Group, P.A. and its affiliated provider groups (“VCMG”) for your tele-behavioral health needs. This statement of professional disclosure is intended to inform you of what you can expect of your mental health clinician in terms of his or her credentials and in connection with your treatment. After you have carefully read this disclosure statement and had an opportunity to have your questions answered, certain state laws mandate that you must sign and date it before commencing services.

IMPORTANT NOTICE

Telehealth is not appropriate for a mental or behavioral health emergency. In an emergent situation, you can: (i) call 911; (ii) go to the nearest emergency room; (iii) contact your local crisis center; (iv) if applicable, call the National Suicide Prevention Lifeline (1-800-272-8255); or (v) if applicable, contact the Crisis Text Line (text “GO” to 741-741).

YOUR CLINICIAN’S CREDENTIALS

Your mental health clinician’s credentials were made available to you before scheduling an appointment and prior to receipt of this disclosure statement. If you have any questions about the credentials, please direct them to your mental health clinician. For those states that require it, you can find an explanation of the levels of regulation applicable to mental health clinicians under the STATE REGULATIONS section of this disclosure statement.

TREATMENT BY TELE-BEHAVIORAL HEALTH

VCMG offers individual, scheduled counseling sessions by means of tele-behavioral health. This fancy term simply means treatment by mental health clinicians via telecommunications technology. Our mental health clinicians include skilled and experienced Licensed Professional Counselors, Licensed Clinical Social Workers, Marriage and Family Therapists, Psychiatrists, and equivalent licensed professionals. They each use a collaborative treatment process wherein they work with you on identified goals for overall improvement and changes you deem important or necessary to improve the quality of your life.

Effective treatment is founded on a mutual understanding and good rapport between you and your mental health clinician. Your first session with your clinician will consist of an initial assessment in which the two of you will determine your concerns, assess the applicability of tele-behavioral health for your needs, and start to develop a customized treatment plan, if appropriate. Your clinician will also review with you his or her credentials, therapeutic approaches, and overall treatment philosophy.

In order for you to make progress and accomplish your goals, you will need to be an active participant in the counseling process by exploring and discussing your thoughts, feelings, and behaviors with your clinician. You may be asked to engage in self-reflection regarding the past, present, or future. You may also be asked to think about difficult topics or experiences, complete homework, or even try new activities. While treatment can be uncomfortable at times, this is normal and to be expected. Your clinician will be there to assist and support you throughout the process. However, you have the right to refuse any recommended treatment or to withdraw consent to treatment and to be advised of the consequences of refusal or withdrawal at any time. Some of the potential treatment benefits patients may experience with their counseling sessions include, but are not limited to: improvement in mood and overall quality of life; enhanced personal awareness, insight, or overall development; improved interpersonal relationships; significant reduction in feelings of distress; increased satisfaction; and resolution of specific problems. Some of the potential treatment risks patients may experience with their counseling sessions include, but are not limited to: remembering unpleasant events; an arousal of uncomfortable feelings (e.g., sadness, guilt, anger, frustration); and
making changes that can be stressful, disruptive to relationships, or just anxiety provoking.

Generally speaking, tele-behavioral health offers benefits such as improved access to care by enabling patients to remain in their local site (e.g., home or work) while their clinician consults and/or obtains test results at distant/other sites, efficient mental health evaluation and management, and the expertise of specialists that patients otherwise might not have. As with any medical procedure, however, there are potential risks associated with tele-behavioral health.

These risks include, but may not be limited to: in rare cases, the clinician may determine that the transmitted information is of inadequate quality, thus necessitating a face-to-face meeting with the patient, or at least a rescheduled video consult; delays in medical evaluation and treatment could occur due to deficiencies or failures of the equipment; in very rare instances, security protocols could fail, causing a breach of privacy of personal medical information; in rare cases, a lack of access to complete medical records may result in adverse drug interactions or allergic reactions or other judgment errors; and, it may become clear that tele-behavioral health is not an appropriate treatment format given a patient’s presenting symptoms or level of functioning, resulting in a recommendation that the patient obtain an additional in-person evaluation or seek treatment services in the community.

PATIENT/CLINICIAN RELATIONSHIP AND CONFIDENTIALITY

You should be aware that your treatment relationship with your mental health clinician is completely confidential and protected by law. You and your clinician have a professional relationship existing exclusively for medical or therapeutic treatment. This relationship functions most effectively when it remains strictly professional and involves only the medical or therapeutic aspect. In a professional relationship, sexual intimacy is never appropriate and should be reported to the board that licenses, registers, or certifies the licensee, registrant, or certificate holder. Your clinician can best serve your needs by focusing solely on therapy/treatment and avoiding any type of social or business relationship.

If you choose to communicate about your treatment via email, you should know that email communication is not completely confidential. All emails are retained in the logs of the internet service provider. While under normal circumstances no one looks at these logs, they are, in theory, available to be read by the system administrator(s) of the internet service provider. As a result, any email communication with your clinician should be through a secure means (i.e. password protected format) in order to maintain privacy and should be limited to addressing scheduling issues or sharing necessary documents (i.e. releases of information). Again, if email communication is utilized, please minimize any content of a sensitive or personal nature. This information is best addressed in the counseling session.

At times, your clinician may seek supervision or consultation with other VCMG clinicians regarding your treatment, to enhance the services being provided to you given the multiple perspectives, experiences, and treatment philosophies. All team members are ethically and legally bound to maintain your privacy and confidentiality in this scenario and none of your personal information will be shared or disclosed externally with any other individual without your consent. Exceptions to confidentiality do exist in certain situations, such as: threat of serious harm to self or others; reasonable suspicion of

abuse or neglect of a child, or abuse, neglect, or exploitation of an incapacitated or dependent adult; court order and/or subpoena; permission from the clientor guardian (i.e. voluntary release signed by the client or guardian); during supervisory consultations; diagnosis and dates of service shared with an

insurance company to collect payments; information released as outlined VCMG’s Notice of Privacy Practices; and as otherwise required by law. VCMG and its clinicians may have professional networking accounts (Facebook, Instagram, LinkedIn, or other blogs/apps/websites) in order to share information and practice updates with other social media users. We recommend that you only follow these professional sites if you are comfortable with

your name and information being connected to the account. VCMG does not require any patients to follow VCMG accounts or a clinician’s professional accounts, nor does it request testimonials, ratings, or endorsements from patients on these sites. These sites are not places for discussion concerning your treatment. Furthermore, it would be unethical for clinicians to follow, contact, or friend any former or current patient on any social networking site (Facebook, LinkedIn, Twitter, blogs, or other apps/websites). Adding patients as friends is a therapeutic boundary violation and it can compromise your confidentiality.

HANDLING OF PROTECTED HEALTH INFORMATION
We understand that medical information about you and your health is personal. We are dedicated to maintaining the privacy and integrity of your protected health information (“PHI”), which is information about you that may be used to identify you (such as your name, social security number, or address), and that relates to (a) your past, present, or future physical or mental health or condition, (b) the provision of health care to you, or (c) your past, present, or future payment for the provision of health care. In providing services, we will receive and create records containing your PHI. We need these records to provide you with quality care and to comply with certain federal and state legal requirements.

We are required by law to maintain the privacy of your PHI and to provide you with notice of our legal duties and privacy practices with respect to your PHI. To the extent required by law, when using or disclosing your PHI or when requesting your PHI from another covered entity, we will make reasonable efforts not to use, disclose, or request more than the minimum necessary set of your PHI or, if needed by us, no more than the minimum amount of PHI necessary to accomplish the intended purpose of the use, disclosure, or request, taking into consideration practical and technological limitations. The VCMG HIPAA Compliance Officer oversees record-keeping systems to maintain and dispose of all required documentation in compliance with HIPAA policies and procedures.

To review your records, you need to submit a request in writing to VCMG’s HIPAA Compliance Officer at 157 W 18th St, 2nd Floor, New York, NY 10010. Since these are professional records, they can be misinterpreted and even upsetting to an untrained reader. Therefore, it is always best to review your records with your mental health clinician or VCMG’s Clinical Director, so that clarification and explanation can be provided if necessary. For more information regarding confidentiality, privacy practices, and authorization to release information, please review VCMG’s Notice of Privacy Practices available on its website. The Notice further describes how medical information may be used, accessed, or disclosed. Additional resources regarding the governance of treatment related information can be found in the Health Insurance Portability and Accountability Act (HIPAA) which addresses protected health information and the Health Information Technology for Economic and Clinical Health ACT (HITECH) which addresses the exchange of electronic protected health information.

DIAGNOSIS, TREATMENT PLANNING, AND TERMINATION OF TREATMENT

During your intake process and throughout your sessions, your mental health clinician will assess your symptoms and concerns through direct questions, screenings, etc. This process helps your clinician appropriately diagnosis you. A diagnosis is a collection of symptoms, emotions, feelings, and behaviors that a patient is experiencing. It is an important tool that will help you and your clinician identify your treatment options. Once the diagnosis is identified, you and your clinician will collaboratively develop your treatment plan. A treatment plan is an individualized plan that identifies goals and objectives to addresses a patient’s needs. Throughout the counseling process, you and your clinician will measure your treatment progress and revise your treatment plan as needed.

The process of counseling must eventually end. Termination of treatment ideally occurs once you and the clinician agree that the treatment goals have been achieved or it’s decided that another treatment option may be more appropriate for you. Other reasons for termination of treatment include, but are not limited to: if the scope of your treatment needs can’t be met through tele-behavioral health; if you fail to participate or adhere to treatment recommendations; if your behavior towards your clinician becomes verbally aggressive, threatening, or harassing; if you miss a scheduled session without any communication regarding the missed session or there are no attempts to reschedule it; or if there is no communication from you beyond a reasonable period of time. If any of these reasons warrant termination of treatment, you will be provided with appropriate referrals to other sources of care; however, VCMG can’t guarantee the timeliness of the other services to be provided or if any particular service providers will accept you as a patient. While you have the right to withdraw from treatment at any time, it is recommended that you have a final session with your clinician to develop an aftercare plan since your treatment goals would not have been attained in that scenario.

PATIENT RIGHTS
You have the right to:

Be treated with dignity and respect

Ask questions and get answers about treatment services

Refuse to answer any questions or give any information

Participate in all phases of treatment, request changes to treatment, and choose the treatment modality which best suits your needs (if the modality is not available, you will be helped in the referral process)

Be informed of your progress, treatment choices, benefits of treatment, and risks/limitations of treatment

Consent to, withdraw, or refuse treatment (except in an emergency or by court order) and be informed of any potential consequences Request or seek a second opinion at any time

Know that certain mental disorders can have medical or biological origins, and therefore may require consultation with a physician Receive a copy of the code of ethics to which your clinician adheres (e.g., American Counseling Association, National Association of Social Workers, or American Association for Marriage and Family Therapy)

Not be subjected to verbal, physical, emotional, sexual, or financial abuseBe informed of the clinician’s qualifications, licenses, education, training, experience, and membership in professional groups and limits of his or

her practice

Receive written information, before entering therapy, about: confidentiality and limitations to confidentiality; fees; payment methods; insurance coverage; substitute therapists (in cases of vacation and emergencies); and cancellation policies

Review or ask for a copy of your medical records, and ask that they be amended or corrected

Decide who may be involved in your treatment

Be informed as to what behaviors or violations could result in termination of services

File a grievance or make suggestions about how services could be improved

Request services from someone with training or experience from a specific cultural, spiritual, or gender orientation (if these services are not available, you will be helped in the referral process)

TREATMENT AND CONFIDENTIALITY OF MINORS

In accordance with state laws, consent for treatment of a minor can only be authorized by a current legal guardian for the minor. If the parents of a minor are separated, treatment is provided to the minor only with the written consent of both parents. If the parents of the minor are divorced, consent for treatment of the minor may be given by the parent authorized to make medical decisions for the minor. If a court of law has ordered that medical decisions for the minor are to be made jointly by the minor’s parents, then consent of both parents is required for treatment of the minor.

In the case of minors, as defined by state law, parents may request information about their child’s diagnosis or treatment. While release of this information will be provided, it is best that the process be a collaborative one involving the minor, parent, and clinician in order to maintain the rapport established between the minor and clinician since rapport is vital to treatment success. Therefore, unless there is a safety concern, the minor would be consulted about the disclosure and encouraged to share the information with the parent first in order to establish better communications within the family structure.

FEES AND BILLING ARRANGEMENTS

The fees for VCMG’s tele-behavioral health services will be communicated to you before any appointment, consultation, or delivery of services. You are expected to pay all fees for your tele-behavioral health services upfront at the time of service; however, you are not obligated to pay any fees for which another party (e.g., your employer or health plan) has contractually agreed with VCMG to pay on your behalf.

If you believe any of the fees you have been charged are incorrect, you must immediately contact us in writing regarding the amount in question to be eligible to receive a refund. You irrevocably waive your right to challenge the accuracy of any charge, or otherwise receive a refund, if you fail to notify VCMG in writing within fifteen (15) calendar days after the charge, that you believe the charge is inaccurate (setting forth an explanation of why).

STATE REGULATIONS

Alaska

AS 08.29.220. Disclosure Statement.

A client may not be charged a fee for professional counseling services unless, before the performance of the services, the client was furnished a copy of a professional disclosure statement that contained

the name, title, business address, and business telephone number of the professional counselor;
a description of the formal professional education of the professional counselor, including the institutions attended and the degrees received from them; (3) the professional counselor’s areas of specialization and the services available;
the professional counselor’s fee schedule listed by type of service or hourly rate;
at the bottom of the first page of the statement, the following sentence: “This information is required by the Board of Professional Counselors which regulates all licensed professional counselors,” followed by the name, address, and telephone number of the board’s office. 12 AAC 62.930 – Written Notice with Disclosure Statement – In addition to the professional disclosure statement required by AS 08.29.220, a licensee must provide written notice to the client that the treatment program may be discussed with other professionals and, if that occurs, the client’s confidentiality will be maintained; and the name and identity of the client will be disclosed only in compliance with AS 08.29.200.

“This information is required by the Board of Professional Counselors which regulates all licensed professional counselors.” Board of Professional Counselors

Division of Corporations, Business & Professional Licensing

P.O. Box 110806

Juneau, AK 99811-0806

Phone: (907) 465-2551Colorado

The practice of licensed, registered, and/or certified mental health practitioners is governed by Colorado’s Mental Health Practice Act, § 12-43-101 et seq. The practice of licensed psychotherapy is regulated by the Mental Health Licensing Section of the Division of Professions and Occupations. The following boards regulate the different types of mental health clinicians and can be reached at 1560 Broadway, Suite 1350, Denver, Colorado 80202, (303) 894-7800:
State Board of Licensed Professional Counselor Examiners, State Board of Social Work Examiners, State Board of Marriage and Family Therapist Examiners, State Board of Addiction Counselor Examiners, and State Board of Psychologist Examiners.

The levels of regulation applicable to mental health professionals under the Mental Health Practice Act and the differences between licensure, registration, and certification, including the educational, experience, and training requirements applicable to the particular level of regulation, are as follows: A Registered Psychotherapist is a psychotherapist listed in the State’s database and is authorized by law to practice psychotherapy in Colorado, but is not licensed by the state and is not required to satisfy any standardized educational or testing requirements to obtain a registration from the state. A Certified Addiction Counselor I (CAC I) must be a high school graduate or equivalent, complete required training hours and 1,000 hours of supervised experience.

A Certified Addiction Counselor II (CAC II) must be a high school graduate or equivalent, complete the CAC I requirements, and obtain additional required training hours, 2,000 additional hours of supervised experience, and pass a national exam.

A Certified Addiction Counselor III (CAC III) must have a bachelor’s degree in behavioral health, complete CAC II requirements, and complete additional required training hours, 2,000 additional hours of supervised experience, and pass a national exam.

A Licensed Addiction Counselor must have a clinical master’s degree, meet the CAC III requirements, and pass a national exam. A Licensed Social Worker must hold a master’s degree from a graduate school of social work and pass an examination in social work. A Licensed Clinical Social Worker must hold a master’s or doctorate degree from a graduate school of social work, practiced as a social worker for at least two years, and pass an examination in social work.

A Psychologist Candidate, a Marriage and Family Therapist Candidate, and a Licensed Professional Counselor Candidate must hold the necessary licensing degree and be in the process of completing the required supervision for licensure.

A Licensed Marriage and Family Therapist must hold a master’s or doctoral degree in marriage and family counseling, have at least two years post-master’s or one year post-doctoral practice, and pass an exam in marriage and family therapy.

A Licensed Professional Counselor must hold a master’s or doctoral degree in professional counseling, have at least two years post-master’s or one year post-doctoral practice, and pass an exam in professional counseling.

A Licensed Psychologist must hold a doctorate degree in psychology, have one year of post-doctoral supervision, and pass an examination in psychology.

Indiana

State Regulations for Professional Conduct

The State of Indiana Department of Health as well as the Indiana Professional Licensing Agency oversees and regulates the practice of mental health counselors in order to ensure the health and safety of the public. If you believe that a provider has acted unethically or unprofessionally, you have the right to file a complaint with the state:

Office of the Attorney General

Consumer Complaint Division

402 West Washington Street, 5th Floor

Indianapolis, IN 46204

232-6330/1-800-382-5516

http://www.indianaconsumer.com/filecomplaint.asp

Maine

Client Bill of Rights

Clients have the right
To expect that a counselor has met the licensure or registration requirements of state law and rule;

To examine a counselor’s licensing credentials;

To obtain a copy of the Code of Ethics of the Board of Counseling Professionals Licensure;

To file a complaint against a counselor with the board;

To be informed of the cost of professional services before receiving services;

To expect complete confidentiality except as required by law; and

To refuse any recommended services and to be advised of the consequences of this action.

The practice of counseling is regulated by the Board of Counseling Professionals Licensure. The board is authorized by law to discipline counselors who violate the board’s law or rules. To learn about the complaint process, or to file a complaint against a counselor, contact: Complaint Coordinator

Office of Licensing and Registration

35 State House Station

Augusta, ME 04333Tel: (207) 624-8660

Web: www.maine.gov/professionallicensing

Minnesota

Consumers of marriage and family therapy services offered by marriage and family therapists licensed by the state of Minnesota have the right: (1) to expect that a therapist has met the minimal qualifications of education, training, and experience required by state law; (2) to examine public records maintained by the Board of Marriage and Family Therapy that contain the credentials of a therapist; (3) to report complaints to the Board of Marriage and Family Therapy;

to be informed of the cost of professional services before receiving the services;
to privacy as defined and limited by rule and law;
to be free from being the object of unlawful discrimination while receiving services;
to have access to their records as provided in Minnesota Statutes, sections 144.291 to 144.298, except as otherwise provided by law or prior written agreement; and
to be free from exploitation for the benefit or advantage of a therapist.

New Hampshire

For patients receiving mental health services in the State of New Hampshire, New Hampshire law (N.H. Admin. R. Ann. Mhp 502.02) contains the following Mental Health Bill of Rights:

Mhp 502.02 Mental Health Bill of Rights.

The board shall provide each licensee with a client bill of rights to read as follows:

“This Mental Health Bill of Rights is provided by law to persons receiving mental health services in the State of New Hampshire. Its purpose is to protect the rights and enhance the well being of clients, by informing them of key aspects of the clinical relationship. As a client of a New Hampshire Mental Health Practitioner, you have, without asking, the right:

To be treated in a professional, respectful, competent and ethical manner consistent with all applicable state laws and the following professional ethical standards:

for psychologists, the American Psychological Association;

b for independent clinical social workers, the National Association of Social Workers;

for pastoral psychotherapists, the American Association of Pastoral Counselors;
for clinical mental health counselors, the American Mental Health Counselors Association; and
for marriage and family therapists, the American Association for Marriage and Family Therapists.

To receive full information about your treatment provider’s knowledge, skills, experience and credentials.
To have the information you disclose to your mental health provider kept confidential within the limits of state and federal law. Communications between mental health providers and clients are typically confidential, unless the law requires their disclosure. Mental health providers will inform you of the legal exceptions to confidentiality, and should such an exception arise, will share only such information as required by law. Examples of such exceptions include but are not limited to:

abuse of a child;
abuse of an incapacitated adult;
Health Information Portability and Accountability Act (HIPAA) regulation compliance;
certain rights you may have waived when contracting for third party financial coverage;
orders of the court; and
significant threats to self, others or property.

To a safe setting and to know that the services provided are effective and of a quality consistent with the standard of care within each profession and to know that sexual relations between a mental health provider and a client or former client are a violation of the law (RSA 330-A:36). (5) To obtain information, as allowed by law, pertaining to the mental health provider’s assessment, assessment procedures and mental health diagnoses (RSA 330-A:2 VI).(6) To participate meaningfully in the planning, implementation and termination or referral of your treatment. (7) To document informed consent: to be informed of the risks and benefits of the proposed treatment, the risks and benefits of alternative treatments and the risks and benefits of no treatment. When obtaining informed consent for treatment for which safety and effectiveness have not been established, therapists will inform their clients of this and of the voluntary nature of their participation. In addition, clients have the right to be informed of their rights and responsibilities, and of the mental health provider’s practice policies regarding confidentiality, office hours, fees, missed appointments, billing policies, electronic communications, managed care issues, record management, and other relevant matters except as otherwise provided by law. (8) To obtain information regarding the provision(s) for emergency coverage.
To receive a copy of your mental health record within 30 days upon written request (except as otherwise provided by law), by paying a nominal fee designed to defray the administrative costs of reproducing the record.
To know that your mental health provider is licensed by the State of New Hampshire to provide mental health services. a. You have the right to obtain information about mental health practice in New Hampshire. You may contact the Board of Mental Health Practice for a list [of] names, addresses, phone numbers and websites of state and national professional associations listed in Mhp 502.02(a)(1)(a-e). b. You have the right to discuss questions or concerns about the mental health services you receive with your provider. c. You have the right to file a complaint with the Board of Mental Health Practice.”

A licensee shall post a copy of the above mental health bill of rights in a prominent location in the office of the mental health practitioner and provide a copy upon request.
A licensee shall provide a copy of the mental health bill of rights to the client and/or agency if the assessment, consultation or intervention is provided outside the office.
A licensee shall, when a client is under the age of 18, assure these rights are applied through, and to, the parent or guardian of their client, unless limited by a court order.

Oklahoma

Mental health practitioners practicing in Oklahoma are licensed by the State Board of Behavioral Health Licensure. The licensing website is
www.ok.gov/behavioralhealth where you can access the laws and regulations that govern the practitioner’s license. The practitioner will furnish you with printed materials about the requirements of his/her licensure if you so desire. You may contact (without giving your name), the State Board of Behavioral Health Licensure at:

State Board of Behavioral Health Licensure

3815 North Santa Fe, Suite 110

Oklahoma City, OK 73118

Telephone: (405) 522-3696

Oregon

As a client of an Oregon licensee, you have the following rights:

To expect that a licensee has met the qualifications of training and experience required by state law;

To examine public records maintained by the Board and to have the Board confirm credentials of a licensee;

To obtain a copy of the Code of Ethics (Oregon Administrative Rules 833-100);

To report complaints to the Board;

To be informed of the cost of professional services before receiving the services;

To be assured of privacy and confidentiality while receiving services as defined by rule or law, with the following exceptions: 1) Reporting suspected child abuse; 2) Reporting imminent danger to you or others; 3) Reporting information required in court proceedings or by your insurance company, or other relevant agencies; 4) Providing information concerning licensee case consultation or supervision; and 5) Defending claims brought by you against your mental health practitioner;

To be free from discrimination because of age, color, culture, disability, ethnicity, national origin, gender, race, religion, sexual orientation, marital status, or socioeconomic status.

To obtain additional information about your mental health practitioner or to file a complaint, you may contact the Board at: The Board of Licensed Professional Counselors and Therapists

3218 Pringle Rd SE, #120,

Salem, OR 97302-6312

Telephone: (503) 378-5499

Email: lpct.board@state.or.us

Website: www.oregon.gov/OBLPCT

Pennsylvania

This information is required by the Pennsylvania Board of Social Workers, Marriage and Family Therapists and Professional Counselors, which regulates marriage and family therapists and professional counselors.

State Board of Social Workers, Marriage and Family Therapists and Professional Counselors

P.O. Box 2649, Harrisburg, PA 17105-2649717-783-1389

South Carolina

The majority of this document is mandated by both South Carolina State law and Public Law 104-191; it is provided for your protection. VCMG has tried to anticipate any risks you may face as a result of being in therapy. If you have any questions regarding the documents you have received, please feel free to discuss them with your assigned mental health practitioner.

The information you share in psychotherapy is protected health information and is generally considered confidential by both South Carolina state law and federal regulations. Your therapy file can be subpoenaed in South Carolina through a court order (signed only by a judge) but is considered privileged in the
federal court system. Your mental health practitioner is mandated by standards - through Duties to Warn - to breach confidentiality if: (1) you are threatening self-harm or suicide; (2) you are threatening to harm another or homicide; (3) a child has been or is being abused or neglected; and/or (4) a vulnerable adult has been or is being abused or neglected. Finally, if you wish your protected health information to be released to another party, you must sign a specific Release of Information.

To obtain additional information about your mental health practitioner or to file a complaint, you may contact the South Carolina Board of Examiners for The Licensure of Professional Counselors, Marriage and Family Therapists, and Psycho-educational Specialists at:

South Carolina Board of Examiners for The Licensure of Professional Counselors,

Marriage and Family Therapists, and Psycho-educational Specialists

P.O. Box 11329,

Columbia, South Carolina 29211-1329

Telephone: 803-896-4652

Vermont

Office of Professional Regulation Notice

The Office of Professional Regulation provides Vermont licenses, certifications, and registrations for over 56,000 practitioners and businesses. Forty-six professions and occupations are supported and managed by this office. A list of professions regulated is found below. Each profession or occupation is governed by laws defining professional conduct. Consumers who have inquiries or wish to obtain a form to register a complaint may do so by calling (802) 828-1505, or by writing to the Director of the Office, Secretary of State’s Office, 89 Main Street, 3rd Floor, Montpelier, VT 05620-3402.

Upon receipt of a complaint, an administrative review determines if the issues raised are covered by the applicable professional conduct statute. If so, a committee is assigned to investigate, collect information, and recommend action or closure to the appropriate governing body. All complaint investigations are confidential. Should the investigation conclude with a decision for disciplinary action against a professional’s license and ability to practice, the name of the license holder will then be made public.

Complaint investigations focus on licensure and fitness of the licensee to practice. Disciplinary action, when warranted, ranges from warning to revocation of license, based on the circumstances. You should not expect a return of fees paid or additional unpaid services as part of the results of this process. If you seek restitution of this nature, consider consulting with the Consumer Protection Division of the Office of the Attorney General, retaining an attorney, or filing a case in Small Claims Court.

Accountancy

Acupuncture

Architects

Athletic Trainers

Auctioneers

Audiologists

Barbers & Cosmetologists

Boxing Control

Chiropractic

Dental Examiners

Dietitians

Drug and Alcohol Counselor
Electrolysis

Professional Engineering

Funeral Service

Hearing Aid Dispensers

Land Surveyors

Landscape Architects

Marriage & Family Therapists

Clinical Mental Health Counselors

Midwives, Licensed

Motor Vehicle Racing

Naturopaths

Nursing

Nursing Home Administrators

Occupational Therapists

Opticians

Optometry

Osteopathic Physicians and Surgeons

Pharmacy

Physical Therapists

Private Investigative & Security Services

Psychoanalyst

Psychology

Psychotherapist, Non-licensed

Radiologic Technology

Real Estate Appraisers

Real Estate

Respiratory Care

Social Workers, Clinical

Tattooists

Veterinary

Chapter 78: Roster of Psychotherapists Who Are Nonlicensed

§ 4090. Disclosure of Information

The board shall adopt rules requiring persons entered on the roster to disclose to each client the psychotherapist’s professional qualifications and experience,

those actions that constitute unprofessional conduct, and the method for filing a complaint or making a consumer inquiry, and provisions relating to themanner in which the information shall be displayed and signed by both the rostered psychotherapist and the client. The rules may include provisions for

applying or modifying these requirements in cases involving institutionalized clients, minors and adults under the supervision of a guardian. (Added 1993, No. 222 (Ajd. Sess), §§ 17; amended 1997, No. 40, §§ 69.)

The Vermont Statutes Online

Title 3: Executive
Chapter 5: SECRETARY OF STATE

Sub-Chapter 3: Professional Regulation

3 V.S.A. § 129a. Unprofessional conduct

§ 129a. Unprofessional conduct

In addition to any other provision of law, the following conduct by a licensee constitutes unprofessional conduct. When that conduct is by an applicant or person who later becomes an applicant, it may constitute grounds for denial of a license or other disciplinary action. Any one of the following items, or any combination of items, whether or not the conduct at issue was committed within or outside the State, shall constitute unprofessional conduct: (1) Fraudulent or deceptive procurement or use of a license.

Advertising that is intended or has a tendency to deceive.
Failing to comply with provisions of federal or state statutes or rules governing the practice of the profession.
Failing to comply with an order of the board or violating any term or condition of a license restricted by the board. (5) Practicing the profession when medically or psychologically unfit to do so.
Delegating professional responsibilities to a person whom the licensed professional knows, or has reason to know, is not qualified by training, experience, education, or licensing credentials to perform them, or knowingly providing professional supervision or serving as a preceptor to a person who has not been licensed or registered as required by the laws of that person’s profession.
Willfully making or filing false reports or records in the practice of the profession; willfully impeding or obstructing the proper making or filing of reports or records or willfully failing to file the proper reports or records.
Failing to make available promptly to a person using professional health care services, that person’s representative, or succeeding health care professionals or institutions, upon written request and direction of the person using professional health care services, copies of that person’s records in the possession or under the control of the licensed practitioner, or failing to notify patients or clients how to obtain their records when a practice closes. (9) Failing to retain client records for a period of seven years, unless laws specific to the profession allow for a shorter retention period. When other laws or agency rules require retention for a longer period of time, the longer retention period shall apply.
Conviction of a crime related to the practice of the profession or conviction of a felony, whether or not related to the practice of the profession. (11) Failing to report to the office a conviction of any felony or any offense related to the practice of the profession in a Vermont District Court, a Vermont Superior Court, a federal court, or a court outside Vermont within 30 days.
Exercising undue influence on or taking improper advantage of a person using professional services, or promoting the sale of services or goods in a manner which exploits a person for the financial gain of the practitioner or a third party.
Performing treatments or providing services which the licensee is not qualified to perform or which are beyond the scope of the licensee’s education, training, capabilities, experience, or scope of practice.
Failing to report to the office within 30 days a change of name or address.
Failing to exercise independent professional judgment in the performance of licensed activities when that judgment is necessary to avoid action repugnant to the obligations of the profession.

Failure to practice competently by reason of any cause on a single occasion or on multiple occasions may constitute unprofessional conduct, whether actual injury to a client, patient, or customer has occurred. Failure to practice competently includes:

performance of unsafe or unacceptable patient or client care; or
failure to conform to the essential standards of acceptable and prevailing practice.

The burden of proof in a disciplinary action shall be on the State to show by a preponderance of the evidence that the person has engaged in unprofessional conduct.
After hearing, and upon a finding of unprofessional conduct, a board or an administrative law officer may take disciplinary action against a licensee or applicant, including imposing an administrative penalty not to exceed $1,000.00 for each unprofessional conduct violation. Any money received under this subsection shall be deposited in the Professional Regulatory Fee Fund established in section 124 of this title for the purpose of providing education and training for board members and advisor appointees. The Director shall detail in the annual report receipts and expenses from money received under this

subsection.(e) In the case where a standard of unprofessional conduct as set forth in this section conflicts with a standard set forth in a specific board’s statute or rule,

the standard that is most protective of the public shall govern. (Added 1997, No. 40, § 5; amended 2001, No. 151 (Adj. Sess.), § 2, eff. June 27, 2002; 2003, No. 60, § 2; 2005, No. 27, § 5; 2005, No. 148 (Adj. Sess.), § 4; 2009, No. 35, § 2; 2011, No. 66, § 3, eff. June 1, 2011; 2011, No. 116 (Adj. Sess.), § 5.) Clinical Mental Health Counselors (26 V.S.A. § 3271)

§ 3271. Unprofessional conduct

Unprofessional conduct means the following conduct and conduct set forth in 3 V.S.A. § 129a.

using dishonest or misleading advertising;
misusing a title in professional activity;
conduct which evidences unfitness to practice clinical mental health counseling;
engaging in any sexual conduct with a client, or with the immediate family member of a client, with whom the licensee has had a professional relationship within the previous five years;
harassing, intimidating, or abusing a client;
entering into an additional relationship with a client, supervisee, research participant, or student that might impair the licensed clinical mental health counselor’s objectivity or otherwise interfere with the clinical mental health counselor’s professional obligations;
independently practicing outside or beyond a clinical mental health counselor’s area of training, experience or competence without appropriate supervision.

After hearing, and upon a finding of unprofessional conduct, the board may take disciplinary action against a licensed clinical mental health counselor or applicant. (Added 1987, No. 245 (Adj. Sess.), § 1; amended 1993, No. 98, § 17; 1993, No. 222 (Adj. Sess.), § 10; 1997, No. 40, § 57; 1997, No. 145 (Adj. Sess.), § 53; 2007, No. 29, § 45.)

Psychotherapists Who Are Nonlicensed And Noncertified (26 V.S.A. § 4093)

§ 4093. Unprofessional conduct

Unprofessional conduct means the following conduct and conduct set forth in 3 V.S.A. § 129a:

Providing fraudulent or deceptive information in an application for entry on the roster.
Conviction of a crime that evinces an unfitness to practice psychotherapy.
Unauthorized use of a protected title in professional activity.
Conduct which evidences moral unfitness to practice psychotherapy.
Engaging in any sexual conduct with a client, or with the immediate family member of a client, with whom the psychotherapist has had a professional relationship within the previous two years.
Harassing, intimidating, or abusing a client.
Entering into an additional relationship with a client, supervisee, research participant, or student that might impair the psychotherapist’s objectivity or otherwise interfere with his or her professional obligations.
Practicing outside or beyond a psychotherapist’s area of training, experience, or competence without appropriate supervision. (b) After hearing, and upon a finding of unprofessional conduct, the board may take disciplinary action against a rostered psychotherapist or an applicant. (Added 1993, No. 222 (Adj. Sess.), § 17; amended 1997, No. 40, § 71; 1997, No. 145 (Adj. Sess.), § 61; 1999, No. 52, § 37.)
Washington

Certified counselors and certified advisers practicing in the State of Washington must provide the following disclosures to each client prior to starting a program of treatment (WAC 246-810-031):

Counselors practicing counseling for a fee must be credentialed with the department of health for the protection of the public health and safety. Credentialing of an individual with the department of health does not include a recognition of any practice standards, nor necessarily imply the effectiveness of any treatment.

The purpose of the Counselor Credentialing Act, chapter 18.19 RCW, is to: (A) Provide protection for public health and safety; and (B) Empower the citizens of the state of Washington by providing a complaint process against those counselors who would commit acts of unprofessional conduct. Clients have the right to choose counselors who best suit their needs and purposes.

A copy of the acts of unprofessional conduct in RCW 18.130.180 can be found on the Washington State Legislature’s website at this address

http://apps.leg.wa.gov/RCW/default.aspx?cite=18.130.180; a copy is also included below for your convenience.Here is the name, address, and contact telephone number within the department of health for complaints.

Washington State Department of Health

Health Professions Quality Assurance

P.O. Box 47865

Olympia, WA 98504-7865

236-4700

RCW 18.130.180. Unprofessional conduct.

The following conduct, acts, or conditions constitute unprofessional conduct for any license holder under the jurisdiction of this chapter: (1) The commission of any act involving moral turpitude, dishonesty, or corruption relating to the practice of the person’s profession, whether the act constitutes a crime or not. If the act constitutes a crime, conviction in a criminal proceeding is not a condition precedent to disciplinary action. Upon such a conviction, however, the judgment and sentence is conclusive evidence at the ensuing disciplinary hearing of the guilt of the license holder of the crime described in the indictment or information, and of the person’s violation of the statute on which it is based. For the purposes of this section, conviction includes all instances in which a plea of guilty or nolo contendere is the basis for the conviction and all proceedings in which the sentence has been deferred or suspended. Nothing in this section abrogates rights guaranteed under chapter 9.96A RCW;

Misrepresentation or concealment of a material fact in obtaining a license or in reinstatement thereof;
All advertising which is false, fraudulent, or misleading;
Incompetence, negligence, or malpractice which results in injury to a patient or which creates an unreasonable risk that a patient may be harmed. The use of a nontraditional treatment by itself shall not constitute unprofessional conduct, provided that it does not result in injury to a patient or create an unreasonable risk that a patient may be harmed;
Suspension, revocation, or restriction of the individual’s license to practice any health care profession by competent authority in any state, federal, or foreign jurisdiction, a certified copy of the order, stipulation, or agreement being conclusive evidence of the revocation, suspension, or restriction; (6) Except when authorized by RCW 18.130.345, the possession, use, prescription for use, or distribution of controlled substances or legend drugs in any way other than for legitimate or therapeutic purposes, diversion of controlled substances or legend drugs, the violation of any drug law, or prescribing

controlled substances for oneself;

Violation of any state or federal statute or administrative rule regulating the profession in question, including any statute or rule defining or establishing standards of patient care or professional conduct or practice;
Failure to cooperate with the disciplining authority by:

Not furnishing any papers, documents, records, or other items;
Not furnishing in writing a full and complete explanation covering the matter contained in the complaint filed with the disciplining authority; (c) Not responding to subpoenas issued by the disciplining authority, whether or not the recipient of the subpoena is the accused in the proceeding; or (d) Not providing reasonable and timely access for authorized representatives of the disciplining authority seeking to perform practice reviews at facilities utilized by the license holder;

Failure to comply with an order issued by the disciplining authority or a stipulation for informal disposition entered into with the disciplining authority; (10) Aiding or abetting an unlicensed person to practice when a license is required;
Violations of rules established by any health agency;
Practice beyond the scope of practice as defined by law or rule;
Misrepresentation or fraud in any aspect of the conduct of the business or profession;
Failure to adequately supervise auxiliary staff to the extent that the consumer’s health or safety is at risk;
Engaging in a profession involving contact with the public while suffering from a contagious or infectious disease involving serious risk to public health;
Promotion for personal gain of any unnecessary or inefficacious drug, device, treatment, procedure, or service;
Conviction of any gross misdemeanor or felony relating to the practice of the person’s profession. For the purposes of this subsection, conviction includes all instances in which a plea of guilty or nolo contendere is the basis for conviction and all proceedings in which the sentence has been deferred or suspended. Nothing in this section abrogates rights guaranteed under chapter 9.96A RCW;
The procuring, or aiding or abetting in procuring, a criminal abortion;
The offering, undertaking, or agreeing to cure or treat disease by a secret method, procedure, treatment, or medicine, or the treating, operating, or prescribing for any health condition by a method, means, or procedure which the licensee refuses to divulge upon demand of the disciplining authority; (20) The willful betrayal of a practitioner-patient privilege as recognized by law;(21) Violation of chapter 19.68 RCW; (22) Interference with an investigation or disciplinary proceeding by willful misrepresentation of facts before the disciplining authority or its authorized representative, or by the use of threats or harassment against any patient or witness to prevent them from providing evidence in a disciplinary proceeding or any other legal action, or by the use of financial inducements to any patient or witness to prevent or attempt to prevent him or her from providing evidence in a disciplinary proceeding;
Current misuse of:

Alcohol;
Controlled substances; or
Legend drugs;

Abuse of a client or patient or sexual contact with a client or patient;
Acceptance of more than a nominal gratuity, hospitality, or subsidy offered by a representative or vendor of medical or health-related products or services intended for patients, in contemplation of a sale or for use in research publishable in professional journals, where a conflict of interest is presented, as defined by rules of the disciplining authority, in consultation with the department, based on recognized professional ethical standards; (26) Violation of section 1 of this act.

West Virginia

Upon request, your counselor will provide you with a copy of the Statement of Code of Ethics. Any questions, concerns, or complaints relating to the delivery of service by your counselor may be directed to:

1-800-520-3852
West Virginia Board of Examiners in Counseling

815 Quarrier Street, Suite 212

Charleston, West Virginia 25301

www.wvbec.org

This information is required by the Board of Examiners in Counseling which regulates all Licensed Counselors.

Wyoming

This disclosure statement is required by the Wyoming Mental Health Professions Licensing Act:

As of March 1, 1999 Wyoming has implemented a privileged communication statute. This law states that, when involved in legal proceedings (civil, criminal or juvenile) clients retain the right to privacy, unless these specific circumstances exist:

abuse or harmful neglect of children, the elderly or disabled or incompetent individuals is known or reasonably suspected b) the validity of a will of a former client is contested
information related to counseling is necessary to defend against a malpractice action brought by a client d) an immediate threat of physical violence against a readily identifiable victim is disclosed to the counselor
in the context of civil commitment proceedings, where an immediate threat of self-inflicted harm is disclosed to the counselor f) the client alleges mental or emotional damages in civil litigation or his/her mental or emotional state becomes an issue in any court proceeding concerning child custody or visitation
the patient or client is examined pursuant to a court order
in the context of investigations and hearings brought by the client and conducted by the board, where violations of this act are at issue. In my capacity as your mental health clinician, I will adhere to the Code of Ethics of the National Association of Social Workers; American Counseling Association; American Association of Marriage and Family Therapy; or National Association of Alcoholism and Drug Abuse Counselors, whichever is applicable for my profession.

To file a complaint, contact:

Wyoming Mental Health Profession Licensing Board

2001 Capitol Ave, Room 105

Cheyenne, WY 82002

Tel: (307) 777-3628

Fax: (307) 777-3508

wyomhplb@wyo.gov