SUPERVISION PROFESSIONAL DISCLOSURE STATEMENT

Courtney B. Walters, MA, LPCS, NCC

ELPHD Counselor Education
North Carolina State University
Poe Hall 414, Box 7801
Raleigh, NC 27695
Phone: 910-736-2915
cbwalte2@ncsu.edu

I am pleased that you have selected me to be your clinical supervisor. This document is designed
to inform you about my background and to ensure that you have a clear understanding of our
professional relationship.

QUALIFICATIONS
I received a Master of Arts degree in Service Agency Counseling from the University of
North Carolina at Pembroke (UNCP) in 2005, and I am currently a full-time student in the
doctoral program in Counseling and Counselor Education at North Carolina State University
(NCSU).
I am currently licensed as a Licensed Professional Counselor Supervisor (LPCS) in North
Carolina. I completed Clinical Supervision for the Helping Professions (CNSS 5050), a graduate
course at UNCP, in 2014. I have also completed 12 hours of continuing education activities
specifically related to clinical supervision since 2014. I have been providing clinical supervision to
practicum and internship students in the Clinical Mental Health Counseling Program at UNCP
since January 2015.
I have successfully met the professional counseling standards established by the North
Carolina Board of Licensed Professional Counselors (LPCS #S7375) and the National Board for
Certified Counselors (NCC #257326). I have been a licensed/certified counselor since 2009.

COUNSELING BACKGROUND
I have experience working with individuals, groups, couples, families, children and adolescents,
and substance abuse. I have worked in university, hospital, and agency settings. Special
populations that I have experience with include college students and military service members,
veterans, and families.
I have chosen to integrate several theories and techniques into my counseling approach.
The cognitive-behavioral approach aims at changing underlying thoughts and beliefs that are
affecting emotions and behaviors, therefore leading to psychological problems. The Adlerian
approach emphasizes that humans are largely influenced by social factors, that we are not
controlled by biological factors alone, and that we are in control of our lives. The existential
approach stresses factors such as choice, freedom, responsibility, and self-determination. The
person-centered or humanistic approach asserts that humans are capable of changing, and that
the counselor assists (rather than directs) clients in making changes to improve their daily lives.
It emphasizes the clients feeling empowered to take charge and striving to become a better
person. The reality/choice theory approach states that we are in control of our lives, and that we
choose what we do and how we react in order to get what we want.
 The common theme among these approaches that I have described is the emphasis
placed on the clients responsibility in the counseling relationship. The direction and the
outcome of counseling is dependent on the clients wants, needs, and willingness to participate.
Only we can change ourselves, and only we can get what we want for ourselves. I do what I can
to assist my clients as they make that journey.

NATURE OF SUPERVISION
I subscribe to the developmental model more than any specific theoretical model of clinical
supervision. The basic concept behind this model is that a supervisees needs will change as
he/she progresses, becomes more competent, and develops more complex counseling skills.
Initially, you will need more direct guidance, modeling of behaviors, and teaching of theories
and techniques. You will also need more encouragement and positive feedback. As you gain
more confidence, you will be able to accept constructive criticism and options/suggestions more
easily. As your clinical supervisor, I will gradually be changing roles from teacher to consultant. I
will constantly reevaluate you to determine where you are at (level/stage of development) and
use that to determine how I can assist you.
Just as I have chosen an eclectic theoretical orientation in my counseling practice, I am
also drawn to an integrated model of supervision. The Rogerian or person-centered model of
clinical supervision places emphasis on the supervisor-supervisee relationship. There are three
personal supervisory traits or attitudes that are important to forging this relationship: empathy,
genuineness, and unconditional positive regard. With good rapport/trust and a feeling of
security, you will grow and develop as a therapist, and you confidence in your abilities will
increase. According to the attachment supervision model, it is the supervisors responsibility to
pay attention to the supervisees needs and to nurture the emotional bond. Working with this
model could increase your own self-awareness as the process may assist you in recognizing your
own attachment patterns both healthy and unhealthy. The Rational Emotive Behavioral
Therapy (REBT) supervision model involves challenging irrational beliefs and replacing those
with healthier, more productive thoughts. The purpose is twofold: to increase your awareness of
your own negative thought patterns, and to model/teach you cognitive-behavioral methods.
This model will be useful when you express negative thoughts about your work with clients or
abilities as a counselor.
I prefer eclectic approaches to both counseling and clinical supervision because I do not
believe there is one theory or set of techniques that work for every client and/or every
supervisee. I think that it is important that I have a variety of tools to work with so that I can
provide better services to my clients/supervisees. The relationship (both supervisor-supervisee
and counselor-client) is important and is the foundation of all growth and improvement.
Successful outcomes of counseling and clinical supervision from my perspective include
the following similar concepts: self-awareness, growth, increasing confidence, and
eventually/ultimately independence. These are evident throughout my chosen theoretical
orientations as both a counselor and a clinical supervisor.
According to NC Administrative Code, each supervision must include raw data from
clinical work which is made available to the supervisor through such means as direct (live)
observation, co-therapy, audio and video recordings, and live supervision (21 NCAC 53 .0208).
Live observation and/or co-therapy will always be scheduled in advance. Audio/video recordings
of your sessions with clients will be reviewed during regularly scheduled supervision meetings.
We will work together to establish goals for supervision and will evaluate your progress
towards those goals during supervision meetings. Unless provided with a formal evaluation tool
by your licensing board or graduate program, I will use a form adapted from Site Supervisors
Evaluation of Student Counselors Performance by Russell-Chapin (2012) and Therapist
Evaluation Checklist by Hall-Marley (2000).

CONFIDENTIALITY
The issues you discuss in supervision will be confidential with the following exceptions:
1. Your performance and conduct in this clinical experience will be described in general
terms when I submit quarterly reports and verification of supervision forms to the NC
Board of Licensed Professional Counselors and other credentialing boards or when
consultation with another professional is necessary.
2. If I am asked to provide information about your clinical experience in the form of a
recommendation for a job, licensure, or certification.
3. Disclosures made in triadic or group supervision cannot be absolutely guaranteed as
confidential. Although I will take every measure to encourage confidentiality and act
appropriately if confidentiality is not upheld.

SESSION FEES AND LENGTH OF SERVICE

Individual supervision meetings are 60 minutes in length, and triadic/group supervision
meetings are scheduled for 90 minutes. In the event that you are unable to keep an
appointment, please call to cancel or reschedule at least 24 hours in advance.
Individual supervision costs $80 per hour. Triadic or group supervision costs $50 per
session, per person. I accept payments by cash, check, or Paypal. I am willing to take your
personal circumstances into account when determining supervision fees. Supervision of
graduate students is provided at no cost.

EXPECTATIONS

Supervisee Responsibilities
Understand the requirements of your licensing board and/or graduate program and
provide me with the information that is necessary to track your progress.
Be knowledgeable of and adhere to the American Counseling Association (ACA) Code of
Ethics.
Maintain professional liability insurance at all time (minimum $1 million per
occurrence/$3 million annual aggregate) and provide me with proof of coverage.
Arrive to supervision meetings on time and prepared.
Bring audio or video recordings of client sessions to each supervision meeting.
Keep me informed regarding all client issues and progress.
Complete supervision record at each supervision session.

Supervisor Responsibilities
Arrive to supervision meetings on time and prepared.
Maintain my own credentialing and licensure requirements to provide clinical supervision.
Review audio/video recordings, client case notes, and any other relevant materials.
Provide meaningful feedback during each supervision session.
Provide formal evaluations as required by your graduate program or licensing board.
Complete supervision record at each supervision session.
EMERGENCY CONTACT
In case of emergency, you can reach me on my cell phone at 910-736-2915.

COMPLAINTS
I abide by the NBCC, ACA, and NCBLPC Code of Ethics as well as the CCEs Standards for the
Ethical Practice of Clinical Supervision. Although supervisees are encouraged to discuss any
concerns with me first, you may file a complaint against me with any of these organizations
should you feel I am in violation of any of these codes of ethics.

North Carolina Board of Licensed Professional Counselors

P.O. Box 77819
Greensboro, NC 27417
Phone: 844-622-3572 or 336-217-6007
Fax: 336-217-9450
E-mail: Complaints@ncblpc.org

SUPERVISION ARRANGEMENTS
Day/time of weekly supervision meetings: __________________________________________________

ACCEPTANCE OF TERMS
We agree to these terms and will abide by these guidelines.

Supervisee signature: _______________________________________ Date: ____/____/____

Supervisor signature: _______________________________________ Date: ____/____/____