PROFESSIONAL DISCLOSURE STATEMENT

Daniel R. Cruikshanks, Ph.D.

Supervising Professional Clinical Counselor (PCC-S), License # E.0003431-SUPV  EXP.1/19/2009

National Certified Counselor, Certified Diplomat of the American Psychotherapy Association

Professional Associations: American Counseling Association, American Psychotherapy Association, American Mental Health Counselors Association, Association for Counselor Educators and Supervisors, Ohio Counseling Association, Ohio Association for Counselor Educators and Supervisors, North Central Association for Counselor Educators and Supervisors, Northwestern Ohio Counselors Association.

Current Employment

Associate Professor & Clinical Coordinator Graduate Studies in Counseling Heidelberg College 310 E Market Street Tiffin, OH 44883 (419)448-2308 dcruiksh@heidelberg.edu	Professional Clinical Counselor Harris & Associates PO Box 430 34 W. Market Street Tiffin, OH 44883 (419)448-0221
Clinical Supervisor Christian Counseling Center 300 Melmore Street Tiffin, OH 44883 (419)447-8111	Clinical Supervisor St. Francis Home, Inc. 182 Saint Francis Ave Tiffin, OH 44883 (419) 447-2723

FORMAL PROFESSIONAL EDUCATION

University	Degree	Dates Attended	Date Received
Cal State University, Sacramento University of Missouri, St. Louis Saint Louis University	B.A. Psychology M.Ed. in Counselor Education Ph.D. in Counseling and Family Therapy	1990-1992 1992-1994 1996-2000	6/92 8/94 5/2000

AREAS OF COMPETENCE

Career counseling, adolescent counseling, personal and social counseling, educational counseling, marriage counseling, family counseling, gerontological counseling, rehabilitation counseling, employee assistance counseling, mental health counseling, consultation, supervision, administration, and may independently diagnosis and treat mental and emotional disorders.

May also provide training supervision to individuals seeking licensure as professional clinical counselors.

RATES (Actual reimbursement will vary depending on insurance agreements)

Initial Diagnostic Evaluation Psychological Evaluation Individual Counseling/psychotherapy Marriage, Couples, and/or Family Therapy

90 minutes for each additional hour for interview(s) & testing 45-55 minutes 45-55 minutes

$210 $138 $138 $138

THIS INFORMATION IS REQUIRED BY THE COUNSELOR AND SOCIAL WORKER BOARD WHICH REGULATES ALL LICENSED AND REGISTERED COUNSELORS AND SOCIAL WORKERS.

Ethical concerns or complaints or reports of inappropriate treatment or professional behavior should be addressed to the state licensing board listed below.

THE STATE OF OHIO COUNSELOR AND SOCIAL WORKER BOARD

50 West Broad Street, 10^th Floor
Columbus, Ohio 43215-5919
Tel: (614) 466-0912 : Fax: (614) 728-7790