RSM 1, Attachment 1000-1: Sample Professional Disclosure Statement

Welcome to DORS! My name is Marion F. Travers, Jr. and I will be working with you to determine eligibility and, if you're eligible, work with you to develop a plan to achieve employment consistent with your interests, capabilities and talents. The Division of Rehabilitation Services, often called DORS, has a long history of assisting people with disabilities to achieve and to maintain employment and independence. Depending on your needs and your employment goal, there are a lot of services that we can provide or arrange to assist you. My qualifications: I have over fifteen years of professional experience involving addiction, mental health, family, and rehabilitation counseling. I have a master's degree from the University of Maryland Eastern Shore in Rehabilitation Counseling and I am a Certified Rehabilitation Counselor, Licensed Clinical Professional Counselor and a Professional Vocational Evaluator. As your rehabilitation counselor, I will help you explore available resources and services to meet your needs. In addition, we will look at different kinds of employment that may be of interest to you and develop a plan for services. It is very important that we stay in contact with one another to be sure your rehabilitation plan is successful. We will continue working with you until you have achieved employment, unless you decide to discontinue or can't make progress for some reason.

DORS Brochures: I have provided and we reviewed the following DORS brochures:

• Opening DORS to Employment – This describes our services and the rehabilitation process.

• Client Assistance Program – The Client Assistance program (1-800-638-6243) can help if you have concerns about your program.

• Informed Choice – I will help you explore various options for employment, services and providers, and will make every effort to honor your choices.

Confidentiality: DORS takes confidentiality of personal information very seriously. I will keep information you share with me in your record of services and will keep it private, unless it is needed directly related to your rehabilitation program, you have signed a release of information, or if there is a possibility of harm to yourself or others. DORS uses an electronic case management system which has a number of security features.

Friending: Please be aware that I will be unable to accept friend or contact requests from current or former clients on any social networking site (Facebook, LinkedIn, etc.) as this could compromise your confidentiality and our respective privacy and may blur the boundaries of our relationship.

How to reach me:

Office address: 116 West Main Street Suite 403, Salisbury, MD 21801

Office phone: 410-546-1580

Email address: [email protected]; since email is not secure, you may want to talk to me about personal issues via phone or in person. I check email at least daily unless I am away from the office. RS-1m Professional Disclosure Statement – Salisbury Page 1 of 2 Office Hours: Our office is open from 8:00 am to 5:00 pm weekdays except for State holidays.

My Work Hours: I am usually in the office from 7:00 am to 3:30 pm.

Office Supervisor: Our office supervisor is Robert Fairbank. He can be reached at 410-546-1580 or at [email protected].

Please sign/date that we have reviewed and you have received this information:

RS-1m Professional Disclosure Statement – Salisbury Page 2 of 2