Checklist for the Statement of Practice

For Licensed Marriage and Family Therapist

Applicant:                                                                                                                        Date:

This is the checklist used by the Board to find items that are missing from or were incorrect on a Statement of Practice. Please check to be sure you have all  the items incorporated into your statement. You can refer to the directions in §4720 and the sample statement on www.lpcboard.org

______ 1.) Identification

______ 2.) Qualifications

                    ______ LPC Board Address & Phone (or in 7.)

_______ 3.) Clients Served

_______ 4.) Specialty Areas

______ 5. What to Expect

______ 6. Clients' Responsibility

                        ______ Clients must make own decisions

______ 7.) Code of Ethics

______ 8.) Privileged Communications

                        ______ Professional practice standards

                        ______ Written consent or waiver required except for mandated or permitted exceptions:

                        ______ Emergency verbal authorization only

                        ______ Child abuse/neglect

                        ______ Elder abuse/neglect

                        ______ Disabled abuse/neglect

                        ______ Danger to self or others

                        ______ Court-ordered release

                        ______ Third party insurers

                        ______ Cannot release information for one client unless all clients in the therapy unit sign

                       ______ Information obtained in individual sessions cannot be shared with others unless prior

                                    written consent                                   

______ 9.) After Hours and Emergencies

______ 10.) Fees and Office Procedures

                    _____ Fees

                    _____ Office Procedures

______ 11.) Potential Benefits and Risks

______ 12.) Additional Info: Not required

______ 13.) Clients have read and understand

                        ______ Client Signatures/Dates

                        ______ Your Name, Degree, LMFT, Signature Line