Professional

Disclosure Statement

CHERY M JONES, LAC, NCC, CSC, LM, NBCT

MARRIAGE & FAMILY THERAPIST

NPI 1467185462

Disclosure Statement and Consent to Treatment

I am excited to welcome you to my counseling practice. This information is intended to inform you about my professional background, services provided, my professional disposition, and the business policy essential in establishing a strong and trusting therapeutic relationship.

Please read it carefully. Return one signed copy to me for my files and keep the additional copy for yourself. When you sign this document, it will represent an agreement between us and your consent for services. Please feel free to ask any questions you may have regarding this document.

Professional Qualifications:

I am a Licensed Associate Counselor, National Certified Counselor and a Board Certified School Counselor in New Jersey. I am Certified in Crisis Intervention and Prevention in School Counseling WS2.

I have a Master of Arts Degree in Clinical Mental Health Counseling with School Counseling Certification from New Jersey City University (NJCU) in Jersey City, New Jersey. This program is accredited by the Council for Accreditation of Counseling and Related Educational Programs (CACREP). I have a Bachelor of Arts in Psychology and Art Therapy.

I am also a NJ State Certified Teacher of Art (K-12) with over 5 Years of Teaching Experience.

I have worked with children and youth (Prek -12) adults, elderly, families, international students and groups in K-12 schools, higher education, nursing homes, substance abuse recovery centers, churches and other non-profit organizations.

Professional Memberships:

I maintain and enhance my skills on an ongoing basis by attending, participating, and facilitating workshops and conferences at the state and national levels.

I am an active member of the following organizations: American Art Therapy Association, American Counseling Association, Chi Sigma Iota Honor Society, New Jersey Education Association, and the American School Counseling Association.

Philosophy:

I provide services for children, youth, adults, and families. I specialize in Cognitive Behavior Therapy, Art Therapy, Person Centered Therapy and Gestalt Therapy. I offer an eclectic approach to counseling utilizing techniques tailored to the individual needs of each client in both short-term and long-term therapy. I provide a warm and safe place for my clients. Together, we will explore your unique experiences, thoughts and feelings. We will establish goals and develop a treatment plan that works to best suit your needs and accomplish your goals. I will assist you in empowering yourself through awareness, knowledge, balance, resilience and skills that enable you to gain a sense of meaning and joy in your life. If you do not live in the NJ/NY Tri-state area, I offer online distance counseling services.

Confidentiality: Please read my Notice of Privacy Policies document for further details.

If you wish for me to be in contact with other persons or parties to discuss your treatment and coordinate care, please request a Release of Information authorization form from me, and we will discuss any release of information.

Online Communication

In order to protect your confidentiality and maintain professional boundaries with you, I do not accept friend, contact, or follow requests on any social media platforms by current or former clients, nor do I submit such requests. If you have questions or concerns, please bring them up during our meetings.

Fees

It is important for our therapeutic relationship that we have clear financial agreements. Currently I do not have any In-Network Insurance Agreements. All services are self-pay/out of pocket. If your insurance covers Out of Network Providers, my NPI # is 1467185462, please contact your insurance company to see if you will be reimbursed for therapy services provided or set up a payment plan with my office.

Cancellations

Cancellations must be made at least 24 hours in advance. If you are unable to cancel 24 hours in advance you will be charged 50% of your usual fee for the first time and 100% thereafter.

Emergencies

Please call one of the following numbers for assistance:

General Emergencies: Please call 911
National Crisis Line: 800-784-2433 or 800-273-8255

Concerns about my provision of services

I am an active member of the American Counseling Association. I am a Licensed Associate Counselor (LAC) and Certified School Counselor (CSC). If you have any questions about any aspect of our professional relationship or about the specifics of those ethical standards of care, please discuss them with me. If you feel that I have not responded in a satisfactory manner, you can bring your concern against me by contacting the following agency:

DEPARTMENT OF EDUCATION

Office of Licensure & Credentials

PO Box 500, Trenton, NJ 08625-0500

(609) 292-2070

AMERICAN COUNSELING ASSOCIATION

6101 Stevenson Ave, Suite 600. Alexandria, VA 22304

Phone: 800-347-6647 | Fax: 800-473-2329

Statement of Understanding and Consent to Treatment

I understand that by signing below I am giving consent to Chery M Jones to provide counseling services. I acknowledge that I have read the above information and I understand what it says. I have been offered a copy of a professional disclosure statement.

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Client Name (Print)

__________________________________________ __________________________

Client Signature Date

If client is a minor:

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Parent/Guardian Name (Print) Date