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Supervision Professional Disclosure Statement

Bredell Moody, NCC, LPC-A

Doctoral Student, Counselor Education, North Carolina State University
Office: 2815 Cates Avenue at Dan Allen Drive
Cell: 910 850-8669

As your University supervisor for practicum, I am responsible for the individual supervision you receive
this quarter. This statement is to be used in conjunction with your syllabus, which spells out all the
requirements of this course. My purpose in presenting this to you is to acquaint you with some of my
goals for supervision, to provide you with an overview of the supervision process, and to outline some
of the conditions under which we both must operate.


I received my Bachelors of Science in Psychology from the University of North Carolina at Pembroke in
2013. I received my Masters in Clinical Mental Health Counseling from the University of North Carolina at
Pembroke in 2016. I have over 3 years of experience in the fields of mental health and substance abuse as an
intern and LPC-A. I am pursuing licensure as a Licensed Professional Counselor. I am currently a Licensed
Professional Counselor Associate with North Carolina Board of Licensed Professional Counselors and a
Nationally Certified Counselor with the National Board of Certified Counselors. I am currently working to obtain
my doctorate in counseling and counselor education from North Carolina State University. I am required to
complete Counselor Supervision: Theory and Research (ECD 735) and an Internship in Supervision (ECD 847).
After obtaining my LPC, I will pursue licensure as a licensed professional counselor supervisor.

LPC-A (A13082)
NCC (831238)

Nature of Supervision

Clinical supervision has two goals: the development of the counseling skills of the supervisee
(counselor-in-training) and the protection of the client. My desire is to respect the development of your
theoretical approach to counseling. I am devoted to providing supervision that respects and nurtures
your development as a counselor.

I utilize a common factors approach to supervision that allows me to focus on the domains of
supervision. These domains include: Assisting supervisees with developing clinical skills, clinical
knowledge, learning to function as a professional, personal growth, and achieving autonomy and

We will have weekly hour-long individual sessions and weekly hour-long group supervision with.
Group and individual supervision are opportunities to learn and receive feedback. Both individual and
group supervision are explained in greater detail in your syllabus. It is your responsibility to turn in the
required tapes and paperwork as identified on the syllabus. Please refer to your course syllabus and
confirm how many tapes are required for your course. It is my responsibility to coordinate your
supervision from me and your other supervisors.
As outlined in the syllabus, the supervisee will be evaluated in terms of a rubric developed based on the
professional skills of the supervisee. Evaluation forms will be used to give you specific, formative

Supervisee’s Responsibilities in Supervision

1) Prepare for and attend sessions.

2) Complete homework or assignments.
3) Watch videotapes of counseling sessions and complete a tape critique.
4) Keep supervisor informed regarding all client issues and progress.
5) Maintain liability insurance at all times (minimum $1M single incident/ $3M aggregate)
6) Complete supervision record at each supervision session.

Supervisor’s Responsibilities in Supervision

1) Prepare for and attend all sessions.

2) Provide feedback each session and a formal evaluation at each quarter and at the end of the supervision
3) Review client case notes and other materials for quality control purposes.
4) Complete supervision record at each supervision session.
5) Maintain licensure as a clinical supervisor in NC and status as a NBCC approved clinical supervisor.

Counseling Background

I have worked with diverse populations - people from different ethnicities, cultures, and different stages of
development. My time as a counselor has been spent working predominately with economically-disadvantaged
minority clients. This has provided me with invaluable insight into the key mental health concerns in these
communities. My time with these clients has been spent addressing anger control concerns, substance abuse and
dependence, emotional, behavioral, and cognitive concerns through psychoeducational and outpatient therapy. I
am invested in assisting my clients become the person they envision themselves to be. I am to assist
through support and service.

Although my theoretical orientation is centered on cognitive behavioral therapy, that examines how emotions,
thoughts, and behaviors influence each other; I like to take an eclectic approach to counseling that is meant to
acknowledge the unique qualities of each client. Through empathy, respect, and confidentiality I hope to cultivate
a space that allows clients to freely express themselves.

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.

Emergency Contact
If a client emergency arises your first point of contact will need to be your site supervisor. After
attempting to contact your site supervisor you can contact me by phone at (910) 850-8669.


I abide by the NBCC, ACA, and NCBLPC Code of Ethics as well as the CCE’s 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
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

Acceptance of Terms <This section should remain the same>

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

Supervisee: _________________________ Date: ___________

Supervisor: _________________________ Date: ___________