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JEAN POLLOCK, MA, MHC, NCC Psychotherapist Solar Hill 229 Western Avenue Brattleboro, VT 05301 - page 1 / 1

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JEAN POLLOCK, MA, MHC, NCC Psychotherapist Solar Hill 229 Western Avenue Brattleboro, VT 05301

Dear Client:

Vermont state law requires all independent mental health practitioners to provide each client, within the first three visits, a disclosure statement outlining their qualifications to practice, information about what constitutes unprofessional conduct and how to file a complaint with the Office of Professional Regulation. The law further requires me to obtain a signed form from you acknowledging that you have received the required information. This form would be kept in your file in my office.

Please feel free to discuss this requirement with me.

Sincerely,

Jean Pollock

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I acknowledge that I have been given a disclosure statement by Jean Pollock, MHC showing qualifications to practice Clinical Mental Health Counseling, information about unprofessional conduct items and how to file a complaint with the Office of Professional Regulation.

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Client Signature

Date

2nd Client signature

date

_______________________________

Jean Pollock, MHC, NCC

Date

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