Professional Disclosure Statement

Robert J. Ksiazkiewicz, LPC, CDCA

Name of employer
Address of employer
Employer’s phone number
Professional email

Formal Education:
Wake Forest University
Master’s in Clinical Mental Health Counseling
December 2019

University of Pittsburgh
Master’s in Public and International Affairs
May 2010

The Pennsylvania State University

Bachelor of Arts in Political Science and Bachelor of Arts in Sociology
December 2007

My Qualifications:
I am a Licensed Professional Counselor (LPC) by the Ohio Counselor, Social Worker and
Marriage & Family Therapist Board. I also am recognized as a Chemical Dependency Counselor
Assistant (CDCA) by the Ohio Chemical Dependency Counselor Professionals Board.

I am a graduate of Wake Forest University my master’s degree in Clinical Mental Health

Counseling – December of 2019. To complete my degree, I completed over 48 hours of
classroom experience; over 150 hours of practicum experience; and, over 600 hours of clinical
internship experience.

Areas of Competence:
• Chemical Dependency Counseling
• Assessment
• Case Management
• Consultation
• Diagnosis and Treatment of Mental Health & Emotional Disorders
• Individual and Group Counseling
• Screening
 • Trauma & Crisis Intervention

These areas of competence were developed during my graduate work at Wake Forest University
as well as my clinical practicum/internship experience at Talbot Hall at The Ohio State
University Wexner Medical Center. As per state of Ohio requirements, you may request that I
provide you with reliable and substantial evidence of my work in developing my competencies in
the areas above.

As per state of Ohio code, I can only practice only within the competency areas for which I am
qualified by education and training. If you need other services outside of my scope of practice or
beyond my competence, I will be able to make a referral to an individual that can best serve your
needs. If I am developing a new skill in specialty areas, I will ensure that the competence of my
work and to protect the clients from possible harm.

Counseling Philosophy & Theoretical Approach:

My counseling philosophy centers on creating a nurturing, open, and safe environment that
empowers my clients to help the patient in their attempt to make meaningful changes to
improving present relationships and circumstances. While we cannot control the words and
actions of others, we can take control of improving own lives by learning to make better choices
that align with our individual values and utilizing mindfulness to deal with strong emotions and
thoughts that keep us from living a life aligned with those values. Due to this style of counseling,
you should be aware that the counselor will respectfully challenge some of your beliefs. Please
note that it is impossible to guarantee any specific results regarding your counseling goals.
However, we will work to achieve the best possible results for you.

I believe that meaningful change occur when both client and counselor work together to develop
and achieve treatment goals. My counseling philosophy also includes following the ACA Code
of Ethics by using good judgment and reviewing its guidelines when I experience unusual
situations and dilemmas.

My integrated theoretical approach is driven primarily by three counseling approaches –

Acceptance and Commitment Therapy, Cognitive Behavioral Therapy and Solution Focused
Therapy. Through the lens of three approaches, we will work together to identify unhelpful
cognitive distortions and behaviors. Next, we will work to improving emotional regulation, and
the development of personal coping strategies that target solving current problems through
psychotherapy, homework tasks, and other counseling techniques. Finally, we will work to
develop solutions that help you live a life that aligns with your stated individual values and
goals. These approaches also will drive the type of techniques and tasks that will be utilized
during counseling sessions. I also may integrate techniques and interventions from other
theoretical approaches when appropriate.

While the therapeutic relationship is an intimate one, a strong therapeutic relationship is based
upon strong professional boundaries between the client and the counselor. This means that the
relationship will be focused on your goals and concerns. We also will not engage in with clients
socially and the only form of contact will be in person at the site or via phone using the site’s
main contact number.
I will not text or email with clients for both your confidentiality and to maintain professional
boundaries. I also will not accept any gifts or social invitations. If we would see each other in a
public situation, I will not acknowledge you first. However, I will acknowledge you if engaged.

Session Fees and Length of Services:

I assure you that my services will be rendered in a professional manner consistent with
accepted ethical standards. Individual sessions are approximately 45 minutes in duration.
Recovery group session typically last between 60 to 75 minutes. If you are unable to keep
an appointment, please call to cancel or reschedule at least 24 hours in advance. If I do not
receive such advance notice, you may responsible for the cost of the the session that you
missed. My fees are governed by my site’s current fee schedule which is available on the
site’s website. Those payments may be made via cash, check, or credit card at the site’s
front desk. Please speak with a billing specialist to discuss your billing options as well as
insurance reimbursement.

Diagnosis:
In the therapeutic process, the diagnosis of mental health disorder may be an appropriate step in
the treatment process. There are typically two reasons that a diagnosis is made. First, it is done to
help in the development of the client’s treatment plan. It also may be necessary for insurance to
reimburse the client for counseling services rendered.

If a diagnosis is rendered and submitted to insurance, it will become part of your permanent
insurance records. For that reason, before the diagnosis is submitted, I will inform you of the
diagnosis to ensure that you wanted it to be submitted.

It is out of my scope of practice to prescribed medication. If medication-assisted treatment is

warranted, I will make a referral a psychiatrist, physician, or nurse practitioner for the
appropriate treatment.

Confidentiality:
All communication becomes part of the clinical record, this includes any of my professional
notes, any official forms that you or I complete, and any voicemails that you may leave my
office phone. They will be made available to you at any time, upon request. I will keep
confidential anything you say as part of our counseling relationship, with the following
exceptions:
• You direct me in writing to disclose information to someone else;
• Evidence of possible abuse or neglect of a minor or dependent adult;
• Evidence of possible danger to the client or identified others; and,
• A court order for disclosure.

At this site, we also ensure that all means of communication are in accordance with federal
HIPAA requirements and Ohio confidently requirements. I also adhere to the ethical standards of
the American Counseling Association.
In accordance with state of Ohio code, I also will take reasonable and appropriate steps to ensure
that the confidentiality of information transmitted to other parties.

Communication and Social Media Policy:

As discussed above, all communication will either be conducted in person at this site or via
contacting the site via the primary contact phone number. If I am unavailable to speak with you
over the phone, you may leave a voicemail and I will make a reasonable effort to respond to your
voicemail within 24 hours. If you are facing an emergency, please call 9-1-1 or go directly to
your nearest emergency room.

I also promise to communicate information in ways that are both developmentally and culturally
appropriate. If you are having difficulty understanding what I am saying, you have the right to
receive necessary services (e.g., arranging for a qualified interpreter or translator) to ensure
comprehension.

I do not maintain any social media accounts. However, if this changes, I would not accept
requests or respond to any communication sent from clients. This is done to ensure a strong
professional boundary as well as to maintain both of our confidentiality and privacy.

Complaints:
If you are dissatisfied or concerned with any aspect of the therapeutic relationship, I would
appreciate if you informed me as soon as possible so that we can address your concerns. You
also may contact my supervisor to address your concerns. Their contact information is available
at: (insert supervisor’s contact information).

It also is within your rights to contact the Counselor, Social Worker, and Marriage & Family
Therapist Board or the Ohio Chemical Dependency Professionals Board with any concerns.

Counselor, Social Worker, and Marriage & Family Therapist Board

77 South High Street, 24th Floor, Room 2468,
Columbus, OH 43215-6171
Tel: (614) 466-0912 Fax: (614) 728-7790
www.cswmft.ohio.gov
Email: cswmft.info@cswb.ohio.gov

Ohio Chemical Dependency Professionals Board

77 South High Street, 16th Floor,
Columbus, OH 43215
Tel: (614) 387-1110 Fax: (614)387-1109
Email: info@ocdp.ohio.gov

Termination & Non-Discrimination Policies:

I will terminate services only after giving careful consideration to factors affecting the
relationship and making effort to minimize possible adverse effects. If an interruption or
termination of services is anticipated, I will make sure that reasonable notification and
appropriate referral for continued services shall be provided to you.
In accordance with Ohio code, I will not practice, condone, facilitate or collaborate with any
form of discrimination based on race, ethnicity, national origin, color, sex, sexual orientation,
gender identity or expression, age, marital status, political belief, religion, veteran status,
immigration status, or mental or physical challenge.

Authorization for Services:

I understand my rights and responsibilities and those of the counselor. I agree to the conditions
of this agreement and give my informed consent for services.

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

____________________________ ____________________________
Client's Signature Date of Signature

____________________________ ____________________________
Counselor's Signature Date of Signature

This information is required by the State of Ohio Counselor, Social Worker, & Marriage &
Family Therapist Board, which regulates the practices of professional counseling, social work, &
marriage & family therapy in this state.

Counselor, Social Worker, and Marriage & Family Therapist Board

77 South High Street, Ohio 24th Floor, Room 2468 Columbus, OH 43215-6171
Tel: (614) 466-0912 Fax: (614) 728-7790
www.cswmft.ohio.gov
Email: cswmft.info@cswb.ohio.gov