Sheridan County Schools #1

DISCLOSURE STATEMENT

NAME: ALEXIS N. WALTER

TITLE: SCHOOL COUNSELOR

BUSINESS ADDRESS AND PHONE:
CENTRAL OFFICE
SHERIDAN COUNTY SCHOOL DISTRICT NUMBER 1
1127 DAYTON STREET, P.O. BOX 819
RANCHESTER, WYOMING 82839
(307) 655-9477

FORMAL PROFESSIONAL EDUCATION:
BACHELOR OF PSYCHOLOGY - UNIVERSITY OF WYOMING 2015
MASTER OF SOCIAL WORK (MSW) -   WESTERN NEW MEXICO UNIVERSITY 2019

LICENSENSURE STATUS:
LICENSED CLINICAL SOCIAL WORKER, LCSW-1579
EXPIRATION 10/05/2025

STATEMENT OF CONFIDENTIALITY:
A PRIMARY OBLIGATION IS TO SAFEGUARD INFORMATION ABOUT INDIVIDUALS OBTAINED IN THE COURSE OF TEACHING, PRACTICE, AND RESEARCH. PERSONAL INFORMATION IS COMMUNICATED TO OTHERS ONLY WITH THE PERSON’S CONSENT (OR PARENT/GUARDIAN CONSENT) OR IN THOSE CIRCUMSTANCES WHERE THERE IS CLEAR AND IMMINENT DANGER TO THE STUDENT, TO OTHERS, OR TO SOCIETY. DISCLOSURE OF INFORMATION FROM COUNSELING IS RESTRICTED TO WHAT IS NECESSARY, RELEVANT, AND VERIFIABLE. CONFIDENTIALITY CANNOT BE GUARANTEED IN GROUP COUNSELING, MEMBERS OF THE GROUP ARE ALWAYS ADMONISHED TO MAINTAIN CONFIDENTIALITY, BUT THIS CANNOT ALWAYS BE ENSURED. I RESPECT THE INHERENT RIGHTS AND RESPONSIBILITIES OF PARENTS AND MAY SHARE INFORMATION WITH THEM ABOUT THEIR CHILD. I WILL ADHERE TO THE LAWS AND LOCAL GUIDELINES AS THEY PERTAIN TO FACILITATING STUDENTS MAXIMUM DEVELOPMENT AND WELFARE.

STATEMENT OF SEXUAL INTIMACY INAPPROPRIATENESS:
SEXUAL INTIMACY WITH A STUDENT IS NEVER APPROPRIATE

CODE OF ETHICS:
I WILL ADHERE TO THE NATIONAL ASSOCIATION OF SOCIAL WORKERS (NASW) CODE OF ETHICS.

REQUIREMENT OF DISCLOSURE STATEMENT:
THIS DISCLOSURE STATEMENT IS REQUIRED BY THE MENTAL HEALTH PROFESSIONS LICENSING ACT BY THE MENTAL HEALTH PROFESSIONS LICENSING BOARD
2001 CAPITOL AVENUE, RM 105
CHEYENNE, WYOMING 82002
(307) 777-7788

SUPERVISOR:
KATHY POWERS, BIG HORN ELEMENTARY SCHOOL PRINCIPAL
333 U.S. HIGHWAY 335, P.O. BOX 490
BIG HORN, WYOMING 82833
PHONE: (307) 674-8190
FAX: 307-672-5306

SIGNATURES:

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STUDENT/PARENT/ GUARDIAN                                                                                      DATE:

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ALEXIS N. WALTER- MSW, LCSW                                                                                  DATE: