Oregon Board of Licensed Professional Counselors and Therapists
PROFESSIONAL DISCLOSURE STATEMENT WAIVER REQUEST
I am conducting crisis work only.
I am serving residential psychiatric patients.
I am working as a counselor at a correctional institution, prison or jail.
My agency’s informed consent or other documents contain all of the
information required for a professional disclosure statement.
I conduct intak
e only.
Distribution
is a safety issue.
Please provide a description of your circumstances that support your request for a waiver:
Name _______________________________ Signature________________________________ Date ___________
Supervisor ___
_________________________ Signature________________________________ Date __________
(Required for Registered Associates)
Law and rules require that you distribute your professional disclosure statement to each client during
your first counseling or therapy session. Some work environments are not conducive to PDS distribution.
The following are examples of situations that likely would receive a waiver:
Submit this completed form via the Board's Portal.
If the Board grants a waiver, it will be valid until your work situation changes, e.g., duties or change of
jobs. At that time, you must submit a new PDS or waiver request.
More information about the PDS requirement may be found on the Board's PDS Webpage.
Still have questions? Email: lpct.board@mhra.oregon.gov
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