STATEMENT OF PROFESSIONAL DISCLOSURE

LICENSED PROFESSIONAL COUNSELOR

STATES OF MICHIGAN AND WEST VIRGINIA

Counselor’s Name:  Jennifer L. Sayers

Business Name:  Dark Hope Counseling, LLC

Utilizing HIPAA Compliant Telehealth and billing through Headway.com

Address: 5969 Bayour Dr., Cheboygan, MI 49721

Phone Number: 304-476-0397

MI LPC NUMBER: 6401225835

WV LPC Number: 2670

Any questions, concerns, or complaints relating to the delivery of service by the counselor listed above, which occur in the state of Michigan, may be directed to:

1-517-241-0205

 MICHIGAN DEPARTMENT OF LICENSING

AND REGULATORY AFFAIRS

Bureau of Professional Licensing Investigations & Inspections Division

P.O. Box 30670

Lansing, MI 48909

Any questions, concerns, or complaints relating to the delivery of service by the counselor listed above, which occur in the state of West Virginia, may be directed to:

1-800-520-3852

WEST VIRGINIA BOARD OF EXAMINERS IN COUNSELING

815 Quarrier Street, Suite 212

Charleston, West Virginia 25301

FORMAL PROFESSIONAL EDUCATION

Degree: B.S. Biology                  Lake Superior State University               Date: Dec 2000

Degree: B.S Psychology              Fairmont State University                       Date: May 2014

Degree: M.A. Counseling            West Virginia University                        Date: May 2017

Degree: M.A. Public Theology   Methodist Theological School in Ohio   Date: May 2026

PROVIDING COUNSELING IN THE FOLLOWING AREAS:

Clinical Mental Health and Pastoral Care

Note:  The Board of Examiners in Counseling does not screen for qualifications in individual counseling specialties.

As an LPC, my areas of competence include individual counseling, group counseling, couples counseling, marital and pre-marital counseling, and chemical dependency counseling. I am not able to prescribe medications to clients.

I believe that clients have the ability to choose how to resolve their own problems, can make their own decisions with my assistance as a facilitator, and are responsible for their own behaviors, thoughts, and feelings. As a counselor, I encourage my clients to develop greater self-awareness and mental health through their life experiences, building increased confidence and self-esteem.

Some clients need only a few counseling sessions to achieve these goals, while others may require more counseling. As a client, you maintain control of yourself. You may end our counseling relationship at any point, and I will be supportive of that position. If you are dissatisfied with my work, I will help you find another counselor with whom you might be able to work effectively.

As your mental health care provider, it is my obligation to provide you with the information you need in order to decide whether to consent to the treatment that I have recommended. The purpose of this form is to verify that you have received this information and give consent to treatment. I hold the following credentials: Licensed Professional Counselor (2670, WV). Please read this form carefully before signing. Therapy is a process where mental health distresses and disorders are assessed, evaluated, and treated.

TECHNIQUES

There are a variety of techniques that can be used to provide relief and/or treat the mental health issues that have led you to seek therapy. These techniques and the therapy process have both benefits and risks. During our sessions, we will discuss the nature of your mental health concerns, the goals of treatment, and any treatments I recommend. This discussion will also include the potential benefits, risks, or side effects of any recommended treatment. Possible risks include the experience of uncomfortable feelings (such as sadness, guilt, anxiety, anger, frustration, loneliness, or helplessness) or the recall of unpleasant events in your life. Potential benefits include significant reduction in feelings of distress, better relationships, better problem-solving and coping skills, and a resolution of specific problems. Given the nature of therapy, it is difficult to predict what exactly will happen, but I will use my best efforts to address the risks and benefits. We will discuss the likelihood of achieving our treatment goals and reasonable alternatives, and you will be actively involved in your therapy journey. You fully acknowledge that any benefit from therapy is directly dependent upon your participation and my progression through therapy. However, no guarantees can be made regarding outcomes. At any time, you may refuse a recommended treatment or revoke your consent to the treatment altogether.

Because I believe that a client’s self-awareness and choices are key to developing self-direction and independence, my techniques will be primarily be drawn from the Acceptance and Commitment Therapy Model, Cognitive-Behavioral Model, Dialectical Behavior Therapy Model, Mindfulness, and Motivational interviewing Models. These techniques will provide methods to solve problems utilizing the client’s own strengths and experiential learning to meet their needs. Occasionally, other approaches will be used such as role playing, work to be done at home, and guided imagery when deemed appropriate for the client(s).

PROFESSIONAL RELATIONSHIP

While our sessions might be very intimate psychologically, it is important for you to understand that we have a professional relationship rather than a social relationship. Our contacts, other than chance meetings, will be limited to appointments you arrange with me. Understand that I will not attend your social gatherings, accept gifts from you, or relate to you in any other way than in the professional context of our counseling sessions. You will be best served if our relationship remains strictly professional and our sessions concentrate exclusively on your concerns. While you might learn much about me as we work together, it is important for you to remember that you are experiencing my professional role.

Our relationship is, and will always remain, professional. We will treat each other with respect at all times. You acknowledge that you have received information about me, including my qualifications and credentials and that you may ask about my qualifications and credentials either during our sessions, or by contacting Headway. If, at any time, you have concerns or complaints about your treatment, you may direct them to me or Headway.

CONFIDENTIALITY

Our interactions will be confidential. There may be situations, however, where I am required by law to disclose certain information to certain parties, such as state agencies or law enforcement agencies. Information you share with me may be entered into records in written form. Additionally, I will keep confidential the things you tell me, with the following exceptions: (a) thorough written consent you direct me to share information with someone else; (b) if you are a danger to yourself or ; (c) I am ordered by a court to disclose information; (d) you disclose abuse of a child, a disabled person, or an elderly person (e) you disclose that a previous therapist sexually exploited you; or, (f) other reasons as specified in laws of this state. Confidentiality also does not extend to criminal proceedings or to legitimate subpoenas in a civil proceeding. My responsibility to you is to maintain all identifiable information about you in confidence and not to release it to any person or facility without your written permission, except in the instances noted above in accordance with current ACA Ethical Guidelines.

RECORDS

Your records will be stored securely for a minimum of seven years. Should you ever need access to your records, please contact Headway. You acknowledge that you have received Headway’s Notice of Privacy Practices, which outlines our record-keeping and confidentiality procedures.

Headway partners with a third-party platform to streamline its electronic prescribing services. If you use Headway for medication management, you consent to the use and disclosure of your healthcare information for this purpose. Your information will be handled in accordance with applicable federal and state privacy laws and used solely to facilitate electronic prescribing purposes.

COMMUNICATION

I require that all communication be conducted through the secure Headway patient portal. I do not receive phone calls, texts, or emails directly to my private number as these lines are not secured. Business-related calls that do not contain any Personal Health Information can be made to Dark Hope Counseling, LLC at 231-445-2540. This included messaging, video, email, and voice communication. If you do not want your information viewed by anyone else, you must make sure that no one else can access your text messages/email or Headway account. By providing your private and secure mobile#/email address, you are giving Headway consent to text/email you at any time. I recommend you do not use your work mobile#/email address because your employer may be able to view your texts/emails.

TERMINATION AND FOLLOW-UP

You are free to work on a specific problem, not return for a period of time, and then resume therapy later. On the rare occasion that you have achieved your treatment goals but want to continue to see me anyway, I may make the decision to terminate your treatment based on my ethical obligation not to prolong therapy when it is no longer necessary. I will not become your friend, client, customer, supervisor, teacher, or have any relationship with you after termination. I may also terminate with you if I cannot provide therapy that fits your specialized treatment needs, if you do not comply with the mutually developed treatment goals and procedures, if you are not benefitting from therapy, if you do not pay your bill, if you become violent, abusive, or litigious, or if the therapy relationship is compromised in any way due to unforeseen circumstances. Any non-voluntary termination will be accompanied by an appropriate referral.

FEE POLICIES AND INSURANCE

You have received information on the fees that are charged for my services through Headway. You understand that you are financially responsible for charges that are not covered or paid by your insurance, and that there is no guarantee of reimbursement or payment by an insurance company or other payor. You hereby consent to the release of information to third-party payors or their representatives as deemed necessary by Headway to determine benefits entitlement and to process payment claims for services provided. You authorize and direct that payment of any health insurance or healthcare benefits otherwise payable to you for health care services will be paid directly to Headway for the charges for which Headway is authorized to bill in connection with the services provided to you. You certify that the information given by you in applying for payment is correct. You acknowledge full responsibility for, and agree to pay, all charges not otherwise paid by your insurance company or other payor. Charges are due and payable upon receipt of the bill.

Cancellations and “No-Shows” are handled as per Headway’s agreement with you. You will be charged a $50 no-show fee if you do not contact our office 24-hours prior to cancelling an appointment or within 24 hours following a no-show due to an emergency situation that prohibited you from accessing your phone or Headway account, such as a medical emergency resulting in hospitalization or legal arrest.

CLIENT RIGHTS

You have the right to be treated by me in a competent, ethical, and respectful manner.

You have the right to a personal, individualized assessment of your treatment needs in which your expertise about yourself is as important as is my professional opinion about you.

You have the right to referrals to other competent professionals and services when this is indicated by your treatment needs.

You have the right to ask questions about the approach and methods we use and to decline the use of certain therapeutic techniques.

You have the right to confidential treatment except in the circumstances already described. This means that you determine the amount of information to be released to anyone outside this setting by signing a permission form that is specific to each situation, which determines the length of time during which the information may be released, and that may be canceled by you at any time.

You have the right to stop receiving therapy from me without any obligation other than to pay for the services you have already received, unless you are a danger to yourself or to someone else.

You have the right to resume service following termination with my expressed agreement. You have the right to discuss your treatment, concerns, questions, complaints, or any other matter with me.

QUESTIONS

If you have questions, you are encouraged and expected to ask them before you sign this form. Your signature on this form indicates that you have read and understand this document and that you have had the opportunity to ask questions about anything in this form. By signing below, you authorize and consent to the performance of the treatment.

Client Name:

Client Date of Birth:

Typed Signature:

Date:

If signed by someone other than the patient, indicate the relationship