Client Disclosure of Supervised Status

Associate Information

Disclosure Statement

I am practicing as a Licensed Professional Counselor Associate (LPC-Associate), credentialed by the Texas Behavioral Health Executive Council. Working under supervision is a standard, required step that every LPC in Texas completes on the way to full independent licensure — it reflects where I am in that process, not the level of care or attention you can expect from our work together.

As part of this requirement, my clinical work — including case conceptualization, treatment planning, documentation, and case consultation — is regularly reviewed by my LPC-Supervisor for training and quality oversight. Relevant information about our work together may be discussed with or shared with my Supervisor as part of this review, consistent with applicable confidentiality laws and ethical standards.

In practice, this means your care benefits from the added perspective of an experienced, fully licensed supervisor — effectively a second set of trained eyes helping ensure your treatment is well-considered and on track.

My Supervisor and I do not have an employment or business relationship. I am self-employed and operate my own independent practice; my Supervisor is not my employer, boss, or business partner. The supervisory relationship exists solely to fulfill the clinical training and oversight requirements of my LPC-Associate license.

Authorization to Release Information for Supervision

I authorize my Associate counselor to discuss and share information from my treatment record — including case notes, diagnostic impressions, treatment plans, and other clinical material — with the named Supervisor above, solely for the purpose of clinical supervision, training, and quality oversight.

This authorization remains in effect for the duration of my treatment with the Associate under this supervisory relationship, or until I revoke it in writing. I understand that I may revoke this authorization at any time, except to the extent information has already been shared in reliance on it, by notifying the Associate or Supervisor in writing.

Client Acknowledgment