Professional Disclosure Statement
Crystal V. Blair, M.S., NCC, LPCA, LCAS-A
(336) 770-3288 (o) ▪ blairc@uncsa.edu
Welcome, and thank you for allowing me to take part in your life's journey. This statement will inform you of my background,
counseling approaches, and your rights. This document is mandated by both North Carolina Administrative Codes Rule .0204 of
Chapter 53, Title 21 and the LPC Act Section 90343. If you have any questions, please feel free to discuss them with me at any
time.
Education and Experience
I earned an MS (2012) in Neuroscience from Wake Forest and an MS (2015) in Clinical Mental Health Counseling from The
University of North Carolina at Greensboro. I am a Licensed Professional Counselor Associate (LPCA #A11903) approved by
the Board of North Carolina Professional Counselors, a National Certified Counselor (NCC #630329) by the National Board of
Certified Counselors, and a Licensed Clinical Addiction Specialist Associate (LCASA #22024) by the NC Substance Abuse
Professional Practice Board. I hold certification of completion in Motivational Interviewing (MI) (NCSAPPB #13-196-S),
Acceptance & Commitment Therapy (ACT), North Carolina Disaster Response Network (NC DRN), and Applied Suicide
Intervention Skills Training (ASIST). I have additional training in American Society of Addiction Medicine (ASAM) Criteria,
LGBTQ university campus allies, Couples and Family Therapy, Wellness Counseling, and Neuro/Biofeedback. My experience is
in crisis services, substance abuse-inpatient, and college-outpatient settings.
Counseling Philosophy and Services
My therapeutic approach has a holistic framework and Family Systems foundation, integrating techniques to promote Whole-
Person Wellness within each of the eight Dimensions of Wellness; Emotional, Environmental, Financial, Intellectual,
Occupational, Physical, Social, and Spiritual. In this way, I can provide you with individualized care to meet your unique needs
while recognizing that you function as part of a larger system. Some integrated techniques are from Motivational Interviewing
(MI) to assess motivation to change and address any ambivalence towards change, Rational Emotive Behavioral Therapy (REBT)
to help address the negative, faulty, or irrational thoughts and self-talk messages, and Existential to help externalize problems and
redefine meaning and purpose. My counseling services address concerns or issues including, but not limited to:
Alcohol/drug/substance use and addiction (both with individuals and their family members)
Depression and anxiety
Shame, self-esteem, and self-image
Wellness, spirituality, and mindfulness
Grief, loss, and trauma
Gender and Sexuality
Couples and family concerns such as: conflict resolution, boundary setting, intimacy, attachment, and communication
difficulties
Developmental and life transitions
As a counselor at UNCSA, I work as part of a wellness team and am able to make referrals, as needed. A psychiatrist is available
to provide further assessment as well as a diagnosis and medication, if needed. If a qualifying diagnosis is appropriate in your
case, you will be informed before we submit the diagnosis. Any diagnosis made will become part of your permanent insurance
records.
Clientele Served, Fees, and Appointment Information
As a currently enrolled student at the University of North Carolina School of the Arts, mental health care is free and unlimited for
as long as benefit is demonstrated. Sessions are provided weekly and are 45 minutes long. There is no fee for any of my
counseling services. Fees apply for psychoeducational evaluations, which depend on type and nature of evaluation; (cash, charge
and check accepted); superbills provided upon request for insurance reimbursement. Cancellations: 24-hour notice.
Records & Confidentiality
All of our communication, including diagnoses, becomes part of the clinical record, which is accessible to you upon request
(unless doing so would be psychologically harmful). I will keep confidential anything that you say to me, with the following
exceptions: a) you direct me to tell someone else, b) I determine that you are a danger to yourself or others, c) I am ordered by a
court to disclose information, d) I suspect or am made aware of physical/sexual abuse of minors, persons with disabilities, or
seniors, e) I am working collaboratively with other professionals where disclosure of personal information is necessary to provide
optimal care, and/or f) you are a minor for whom confidentiality is limited to the extent exercised by your parent/legal guardian.
In the instances where students participate in group counseling, I cannot guarantee confidentiality from other group members.
However, I will do everything I can to ensure all group members understand confidentiality policies and that breaching
confidentiality results in automatic dismissal from the group.
Length of Sessions and Cancellation
Individual sessions last 60 minutes and group sessions last 90 minutes. Two unexcused absence to a group session is means for
dismissal from the group. If dismissed from group due to absences, you may join the next group. As a client you have the right
and responsibility to set and keep appointments. Contact me at least 24 hours in advance to cancel or reschedule appointments.
Referrals, Complaints, and Informed Consent
If for any reason you feel that I am not meeting your therapeutic needs, I encourage your feedback and will attempt to adjust my
approach. If I am not able to resolve your concerns, I am happy to provide you with referrals to other university or community
referrals. I am in compliance with the North Carolina Board of Licensed Professional Counselors (NCBLPC) and abide by the
ACA and NBCC Code of Ethics. If you feel that I am in violation of any of these codes, please inform me and my supervisor or
file a complaint with the North Carolina Board of Licensed Professional Counselors.
Clinical Supervisor, Annamarie Gallagher; Clinical Supervisor of UNCSA Counseling Center telephone: 336-770-
3288; email: gallaghera@uncsa.edu
North Carolina Board of Licensed Professional Counselors, PO Box 77819, Greensboro, NC 27417; telephone: 844-
622-3572; fax: 336-217-9450; email: LPCInfo@ncblpc.org
□ I do NOT give my consent to be videotaped for the purpose of clinical supervision
I have read, understand, and agree to the information given in this form.
_________________________________________ ________________________________________
Client’s Printed Name Client’s Signature Date
_____________________________________________________
Parent/Guardian’s Signature Date
_____________________________________________________
Crystal V. Blair, M.S., LPCA, LCAS-A, NCC Date
