Professional Disclosure Statement/informed Consent printable pdf download

Monica Morales Polonyi, Ph.D.

250 Ed English Drive, Bldg. 3- Suite B4

Shenandoah, TX 77385

(936)524-7092

Professional Disclosure Statement/Informed Consent

BACKGROUND INFORMATION

Thank you for choosing me as your child’s family counselor. This will serve as an introduction and

address some questions that you may have about the therapeutic process and my training and

approach. If you have additional questions, feel free to ask at any point.

I have worked in the field of counseling since 2001. I hold a Ph.D. in Counseling and I am a Licensed

Professional Counselor, Counselor Educator, and Clinical Supervisor, licensed by the Texas

State Board of Examiners of Professional Counselors. I have extensive clinical experience having

worked in a variety of settings including public schools, universities, hospitals, agencies, and

churches. The populations in these settings have included individuals with various concerns and

needs and from diverse social and multicultural backgrounds. In addition to my private practice,

I serve as a contributing faculty member at Sam Houston State University and at Walden

University where I teach graduate counseling courses.

The majority of my practice consists of working with individuals, adolescents and families,

through the process of Christian based psychotherapy. This is the truths of the Bible including

all the teachings of Scripture but especially those that bear on our relationship with God and one

another, and the tools of the mental health profession to assist individuals and/or families in living

life in a more meaningful way.

Generally, appointments are scheduled weekly or every other week until sufficient progress

warrants less frequent sessions. Many families come to see me in response to a crisis or loss; others

come simply because they want their child and family to live happier, more productive lives.

Some wish to address problems in relationships, and some want assistance in dealing with

specific symptoms such as anxiety, depression, or anger. Whatever reason you are here, there are

emotional, physical, spiritual and relational benefits to therapy. If I do not believe that I am the

best fit for your child and/or family, I will gladly provide you with community referrals.

My desire is to assist your child and/or family lead an emotionally healthier life. This can be

accomplished through the exploration of feelings and by identifying self-defeating thought patterns

that limit him or her, as well as identifying behavioral patterns that are harmful or destructive. Often

times these unhealthy patterns and habits can be changed through the combined process of individual

and family counseling; thereby, allowing your child and family to have more satisfying relationships

and live life in accordance with your family’s beliefs and values.

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Professional Disclosure Statement/informed Consent