Professional Disclosure Statement

Nora Goddard, LPC, MA

Office:  301-717-6932

Fax: 203-123-4567

E-mail:  fairfieldbeachcounseling@gmail.com 

Qualifications 

I completed my counseling degree in Clinical Mental Health Counseling from Fairfield University in December 2023. In addition, I have a MA in school counseling K-12 from Boston College (May 2014). In January 2025, I became a Licensed Professional Counselor (LPC) in CT. Prior to becoming an LPC, I worked in Fairfield, CT as an LPC-A at a group counseling practice and as a school counselor. 

Counseling Background 

My counseling work has focused on children, adolescents, adults, and parents with a specific focus on anxiety, depression, developmental milestones, grief and loss, family changes, self-esteem, and developing a well-balanced life to support mental health. I approach the counseling relationship from a wellness and strengths based perspective. My counseling practice integrates multiple theories, including Cognitive Behavioral Therapy, Person-Centered Therapy, Motivational Interviewing, and Multicultural Counseling. This means that I meet you where you are to develop a strong therapeutic relationship and integrate evidence-based strategies to help you reach your personal and professional goals. 

Although our sessions may be very intimate emotionally and psychologically, please understand that ours is a professional relationship rather than a social one. Maintaining professional boundaries for both client and counselor is a vital component in the therapeutic relationship, and I will uphold those boundaries in order to ensure an appropriate therapeutic relationship and a more positive therapeutic outcome.  

Session Fees and Length of Service 

Sessions last 50 minutes. The duration of counseling varies widely among clients depending on their needs and preferences. When we begin our counseling relationship together, you will receive a document that outlines expected cost based on varying durations of counseling. You may choose to terminate therapy at any time, and I recommend that we have a final session together once you decide to terminate so that I am best able to help you prepare for and process the conclusion of our work together.  

Fees: 

1 time 20 minute consultation: no charge

Initial session (1.25 hours): $150

Subsequent sessions (50 minutes): $125

Cancellations: I understand that cancellations occur. Please notify me via email, text, or phone call within 24 hours of your scheduled appointment to avoid a $50 cancellation fee. 

Payments accepted: credit card, check, or cash

Communication with Clients and Emergencies 

With your written permission, I may use email and/or texts to communicate with you regarding scheduling matters. Please note that email/texts are NOT a secure form of communication and that I cannot guarantee confidentiality of emails/texts. Please do not send information via email/texts that you wish to remain confidential or that requires immediate attention. 

I do not communicate (including “friending”) with clients over any form of social media, including but not limited to Facebook, Instagram, and TikTok. 

In the event that a psychological emergency should occur, please call 911 or go to the nearest Emergency Department.   

Use of Diagnosis 

Some health insurance companies will reimburse clients for counseling services and some will not. In addition, most will require 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 

All of our communication becomes part of the clinical record, which is accessible to you upon request. I will keep confidential anything you say as part of our counseling relationship, with the following exceptions:  

(a) you direct me in writing to disclose information to someone else 

(b) it is determined you are a danger to yourself or others (including child, persons with disabilities, or elder abuse)

(c) I am ordered by a court to disclose information

Complaints 

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 (2014) (http://www.counseling.org/Resources/aca-code-of-ethics.pdf).

Connecticut Department of Public Health

410 Capitol Ave., MS# 12HSR

Hartford, CT 06134-0308

Phone: (860) 509-7552

Fax: (860) 707-1916 or (860) 509-7535

Email: dph.pliscomplaints@ct.gov

Acceptance of Terms 

We agree to these terms and will abide by these guidelines.

Client:  ________________________________   Date: ___________

 

Counselor:  ____________________________   Date: ___________