Client/Guardian Authorization for Use and Disclosure of Protected Health Information (PHI)

Shelwilbed O. Wray, NCC, CAS, LCAS, AADC, LMHC, LCMHC-Supervisor

Professional Disclosure Statement


Adult, kids (14 y/o and older) individual, couple, family & group counseling is conducted with a client-centered, solution focused brief therapeutic approach, addressing concerns of grief & loss, addiction, family stress, marital conflicts, adjustments to and military deployment events. This Professional Disclosure Statement will outline my education, qualifications, methods of treatment, and mutual expectation of our professional relationship. It is provided to assist you, the patient, in determining if the services provided are suitable for you and your family’s needs. Please discuss any questions or concerns you may have prior to the start of our first session.

Credentials & Experiences

I have nearly 30 years of clinical experience. My undergraduate studies awarded a Bachelor of Science degree in Psychology. I hold a Master’s degree from Delta State University – 1990 (with a concentration in Community and Agency Counseling that is certified by the Council for Accreditation of Counseling and Education Related Programs (CACREP). I am credentialed as a Licensed Clinical Mental Health Counselor Supervisor (LCMNC-S) in North Carolina S7538 awarded in 2016, and a Licensed Clinical Addictions Specialist (LCAS)1945 also in NC, awarded in 2011. I hold the esteemed credential of Advanced Alcohol & Drug Counselor (AADC) from the International Certification & reciprocity Consortium (IC&RC 206591). I am also a National Board Certified Counselor (NCC), awarded in 1999 (NBCC 60544). Further I am certified as an Addictions Specialist (CAS C4372 awarded in 2002) in the areas of eating disorders, alcohol and drug abuse/dependence from the American Academy of Health Care Providers in the Addictive Disorders. Lastly, I was inducted into the South Carolinas Addictions Professionals as a Fellow in 2007. I am a U.S. Army Reserve Colonel with deployments to Uzbekistan, Afghanistan, Iraq, & Africa.

Our Relational Commitment

Trust remains the crucible of my professional relationship with you and your family. Your need for understanding and desire for change in your life or the lives of loved ones are important to me. As such, it is important that I make available to you every opportunity to share, be heard and understood throughout our interactions. For real change to occur, it is paramount that I not only remain committed to employing every therapeutic technique, intervention, or *appraisal tool appropriate, and available, but also to ensure that in such employment, you and your family both trust in the technique and further agree to seize each opportunity afforded in our sessions to use the tools and strategies suggested. Through a thorough and careful diagnosis of your expressed and /or demonstrated symptoms, based upon careful screenings, evaluations and/or assessments, treatment plans are developed with your input, to ensure your treatment goals are satisfied. To support this, a research- based tool, known as the Diagnostic & Statistical Manual is utilized. These efforts will be meticulously documented in your confidential client record.

Life circumstances are often painful. It is with this understanding and empathy, that I approach your challenges, using the utmost patience, humility, grace and gentility. In our times together, there may be times when things appear insurmountable. In over 30 years of clinical practice, I have remained in awe at the strength of the human spirit and the resilience of hope. Together, with your continued willingness to seek healing, change can and will occur.

Your Rights and Responsibilities

You have the right to request a full explanation of any suggestions, recommendations, and/or procedures used in assisting you and your family. You also have the right to refuse to follow these suggestions and recommendations and/or to terminate our professional relationship at any time for any reason. If you choose to not follow my suggestions and recommendations, I have the right and ethical responsibility to terminate counseling and offer a referral to another service provider. Either of us may request a final session to discuss the reasons for termination, and to decide on an appropriate consistent treatment for you and your family.

You have the right to confidentiality in the counseling relationship as described below:

Effective healing and change will only occur through continued commitment to change and continuity. Should you be unable to make scheduled appointments, it is critical that I be given a 24-hour notification. Payment for missed appointments will remain your responsibility. Late arrivals (more than 15- minutes) may also be chargeable. Of course, exceptions will be considered for emergencies. Being on time for scheduled sessions is important and are usually scheduled immediately following each session or at the time of rescheduling. Should you have to be late, your session may or may not end at the original time. You will still be responsible for payment of a full session. Session extensions may be granted under special circumstances and billed accordingly. Family and marital sessions are usually scheduled and billed for 60 minutes.

My Responsibility as your Therapist

I adhere to the Code of Ethics and Standards of Practice approved by the Maryland Board of Professional Counselors and Therapists, The National Board of Certified Counselors, the American Academy of Health Care Providers in the Addictive Disorders, the North Carolina Board of Licensed Professional Counselors and the North Carolina Substance Abuse Professional Practice Board. These ethics and standards are intended to protect the welfare of both my clients and the community served. Paramount in these codes is my responsibility to protect your right to privacy:

While techniques employed during your sessions are largely eclectic in nature, a holistic approach remains prevalent. Both directive and non-directive views are used to offer a balanced perspective to the healing process. This includes but is not limited to: relapse prevention, tenants of the 12-Step principles, guided imagery, client-centered and solution focused therapies/techniques. As an example, Solution-Focused Brief Therapy is a process that helps people change by constructing solutions rather than dwelling on their past.

Fees for Services

All clients not using insurance are direct pay: cash or check for session or co-payment is due at the beginning of each session. Sliding fees may be arranged ONLY under special circumstances and must be negotiated PRIOR to the start of your session. Please make checks payable to: Kardia Counseling & Consulting, PLLC.

Regular Session 45-50 minutes $140
Regular Session 51-60 minutes $160
Crisis Session 75-90 minutes $190
Crisis Initial +60 minutes $220
Crisis Other +30 minutes $190
Couples/Family Session 60 minutes $160
Extended Couples 75-90 minutes $190
Conjoint Couple 45-50 minutes $160
Extended Conjoint 75-90 minutes $225
Full time student (no insurance) 45-50 minutes $65
Assessments 75-90 minutes $225
Appraisals alone $225

Please check here and e-sign below indicating that you have read, understand and agree with all the information in this document.

Client/Guardian E-Signature:


Client/Spouse E-Signature:


Termination of Services

The client may terminate services at any time.

The counselor may terminate services as follows:

Goals have been achieved; At the request of the individual, either verbally or in writing; Client no-show with no follow-up contact from the individual within 4 weeks of the no-show; The counselor does not believe the services to be beneficial to the individual; The needs of the individual are outside the counselor’s scope of practice; Another service is more appropriate to meet the needs of the client; Non- payment for services; Inability to pay for services; Conflict of Interest; Issues that directly or indirectly compromise the counselor’s safety or the safety of the counselor’s family; Violation of any therapeutic contract (for example, a safety contract); Harassment by the client or client’s family members; Any issue impacting the best interest of the client.

While the counselor will make every effort to discuss termination plans with you in advance, issues may arise that could interfere with this. If termination occurs due to conflict of interest, the counselor may not elaborate on such as this may violate the confidentiality of others. If the counselor recommends termination or referral, the client or guardian may discuss any concerns they have about this with the counselor. However, the counselor may proceed with the termination process. Disagreement regarding termination and/or referral may not necessarily lead to continuing with counseling services with this counselor or with Oasis Counseling Center, Inc.


Please do not hesitate to speak with me if you have any questions or concerns about the counseling services you receive. I will make every effort to resolve any conflicts that may arise. The American Counseling Associations’ Ethical Guidelines suggests that individuals attempt to resolve complaints directly with the counselor. You may communicate your concern verbally or in writing. I will make every effort to immediately address your concerns and all concerns will be responded to within 10 business days. If your counselor is unable to help resolve the issue, you may place your concerns in writing to the North Carolina Board of Licensed Professional Counselors. Please specify which ACA ethical codes you believe to have been broken, and submit your letter along with a completed NCBLPC Complaint Form to the board:

North Carolina Board of Licensed Clinical Mental Health Counselors
PO Box 77819
Greensboro, NC 27417
Phone: 844-622-3527

Complaint Registration

Should you feel that your rights as a client as stated above have been violated, it is also within your rights to register a complaint to the current licensing board. The full contact info is as follows:

NC Board of Licensed Clinical Mental Health Counselors
P.O. Box 77819
Greensboro, NC 27417


Physical Address:
7D Terrace Way
Greensboro, NC 27403

Or email:

Phone: 844.622.3572
Fax: 336.217.9450

North Carolina Substance Abuse Professional Practice Board
P. O. Box 10126
Raleigh, NC 27605

Phone: 919.832.0975
Fax: 919.833.5743

Thank you for your time and effort.