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LPCA Professional Disclosure Statement

Brian Mann
Journey Through Life, PLLC
3722 Benson Drive, Suite 101, Raleigh, NC 27609
My Qualifications
I am pleased you have selected me as your counselor. This is to inform you about my background and to ensure that
you understand our professional relationship. I have earned a Master of Arts degree in Clinical Mental Health
Counseling from Wake Forest University in 2015.
Restricted Licensure
I am pursuing licensure as a Professional Counselor Associate in North Carolina, and am currently working under
the supervision of Brian Purnell, M.Ed., LPCS, NCC, ACS.
Counseling Background
People can make better decisions if they have enough information and understanding about how something works.
Here are some aspects of counseling and therapy as I see and practice it:
Counseling involves your active involvement as well as efforts to change your thoughts, feelings and behaviors. You
will have to work both in and out of the counseling sessions. There are no instant, painless or passive cures, no
magic pills. Instead there will be homework assignments, exercises, writing and journals and perhaps other
projects. Most likely, you will have to work on the relationship and make long-term efforts. Sometimes, change is
swift and easy, but more often it will be slow and deliberate; effort may need to be repeated.
I have what is called an eclectic approach, working with people and their problems. What this essentially means is I
borrow concepts and ideas from many different areas of psychology. I believe in individual concepts as well as
family systems. I believe no person stands alone, but is influenced by people he or she was brought up with or now
shares a life.
If we are to work together we can specify the goals, methods, risks and benefits of treatment, the approximate time
commitment involved, and other aspects of your particular situation. Before going further, I expect us to agree on a
plan to which we will both adhere. Periodically, we will evaluate our progress and, if necessary, re-design our
treatment plan, goals and methods.
As with any powerful intervention, there are both benefits and risks associated with counseling and therapy. Risks
might include experiencing uncomfortable levels of feelings like sadness, guilt, anger or frustration or, having
difficulties with other people. Some change may lead to what seems to be worsening circumstances or even losses
(for example, counseling will not necessarily keep a marriage intact). I do not take on clients whom in my
professional opinion I cannot help using the techniques I have available to me. I will enter our relationship with
optimism and an eagerness to work with you. I have special interests in children and adolescents. My area of
specialization includes diversity issues, anxiety, and aggression, communication in relationships, and depression,
working with children, adolescents, and families.
Session Fees and Length of Service
Individual sessions are 50 minutes in length.
THIRD PARTY (INSURANCE) BILLING AND YOUR RESPONSIBILITIES

If you wish, we will bill your insurance and have their payments sent directly to us, and you will be responsible for
any deductible or co-payment. After insurance pays its portion, youre responsible for the remaining balance, with
some exceptions. Many insurance companies, because of our contractual agreements with them, limit the amount
that can be billed for therapy (the allowed amount), and place a limit on what clients must pay.
We encourage you to call your insurance company with some questions about your policy (see the document
Calling Your Insurance Company), take notes, and bring the form to your first therapy visit. If your insurance
changes, please let us know as soon as possible, to avoid your insurance company denying coverage.
NON-INSURANCE-FEE-FOR-SERVICE (THE CASH-PAY DISCOUNT)
If you have no insurance, or wish not to have your insurance billed, you may opt for a fee-for-service or cash-pay
discount. If all monthly charges are paid at the time of service, well discount our standard fees by 10% (Ten
percent)
CANCELLATIONS AND MISSED APPOINTMENTS
If you need to cancel an appointment, please let us know at least 24 hours in advance. If you miss a scheduled
appointment or cancel with less than 24-hour notice, you will be billed $50 (this late cancellation fee is not
reimbursed by insurance companies). We do not charge for missed appointments or late cancellations due to illness.
PAYMENT AND BILLING
I prefer that you pay at the time of service, but I am willing to send you a monthly invoice if that is more convenient.
Payments by check, cash and credit card are accepted
Use of Diagnosis
Some health insurance companies will reimburse clients for counseling services and some will not. In addition, most
will require that a diagnosis of a mental-health condition and indicate that you must have an illness before they
will agree to reimburse you. 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 before we submit the diagnosis
to the health insurance company. Any diagnosis made will become part of your permanent insurance records.
Confidentiality
I regard the information you share with great respect so I want us to be as clear as possible about how it will be
handled. Generally, I will tell no one what you tell me. The privacy and confidentiality of our conversations, and my
records is a privilege of yours and is protected by state law and my professions ethical principles, in all but a few
circumstances. There are two circumstances in which I cannot guarantee confidentiality, legally and/or ethically: (1)
when I believe your intend to harm yourself or another person; and (2) when I believe a child or elder person has
been or will be abused or neglected. In rare circumstances, professional counselors can be ordered by a judge to
release information. Otherwise, I will not tell anyone about your treatment, diagnosis, history, or even that you are a
client, without your full knowledge and usually a signed release of information form.
Explanation of Dual-Roles
Although our sessions may be intimate psychologically, it is important for you to realize that we have a professional
relationship, rather than a social one. Our contact will be limited to sessions you will arrange with Journey Through
Life, PLLC and Brian Purnell, M.Ed., LPCS, NCC, ACS. Please do not invite me to social gatherings, offer me gifts,
or ask me to relate to you in any way other than in a professional context of our counseling sessions. You will be
best served while I am seeing you for counseling and therapy if our relationship stays strictly professional and if our

sessions concentrate exclusively on your concern. You will learn a great deal about me as we work together during
your counseling experience. However, it is important for you to remember you are experiencing me in my
professional role.
Complaint Procedure
If you are dissatisfied with any aspect of our work, please inform me immediately. This will make our work together
more efficient and effective. If you think you have been treated unfairly or unethically by me or any other counselor
and cannot resolve his problem with me, you can contact the Journey Through Life, PLLC and/or Brian Purnell,
M.Ed., LPCS, NCC, ACS, CEO at 919.448.6105 for clarification of client rights as I have explained them or even to
lodge a complaint. If you have any questions, feel free to ask.
Although clients are encouraged to discuss any concerns with me, you may file a complaint against me with the
organization below should you feel I am in violation of any of these codes of ethics. I abide by the ACA Code of
Ethics (http://www.counseling.org/Resources/aca-code-of-ethics.pdf).

North Carolina Board of Licensed Professional Counselors


P.O. Box 77819
Greensboro, NC 27417
Phone: 844-622-3572 or 336-217-6007
Fax: 336-217-9450
E-mail: Complaints@ncblpc.org
Acceptance of Terms
We agree to these terms and will abide by these guidelines

Client: __________________________________________

Date: ________________

Counselor: _______________________________________ Date: __________________