1.) Name, LMFT

Address of Employment

Telephone

2.) Qualifications—I have a Master of Marriage and Family Therapy (MMFT) from Abilene Christian University.

I hold License # MFT as a Licensed Marriage and Family Therapist with the LPC Board of Examiners, 8631 Summa Avenue, Baton Rouge, LA 70809.

3.) Clients Served—I provide therapy for individuals, couples, and families. I work with children and adults. I occasionally offer couples group therapy.

4.) Specialty Areas— I specialize in the practice of marriage and family therapy and am experienced in the working with problems of childhood and parenthood, marital difficulties, and life difficulties of adulthood that may relate to disturbances in family relationships. I am a Clinical Member of the American Association for Marriage and Family Therapy and a Certified PREPARE/ENRICH Counselor.

5 & 6.) What to Expect from Therapy and What I Expect from Clients—I work from an ecosystemic perspective, which means that I accept a client’s immediate family relationships and larger social context as being important resources in solving life’s problems. Goals for therapy are always established through collaboration with the client. The overall objective for therapy is always the successful resolution of the problems that are deemed the most important through that collaborative process. I work from a structural/strategic orientation, which means that I assist couples and families in organizing their relationships so that resources can be brought to bear on the problems being presented. Techniques that I often employ are instruction and modeling of communication skills, family role-playing and family sculpting, and between-session interactive assignments. This "homework" is a vital part of the therapeutic process. The completion of homework is necessary if the client is to get the most from the therapeutic experience.

Clients must make their own decisions regarding such things as deciding to marry, separate, divorce, reconcile and how to set up custody and visitation. That is, I will help you think through the possibilities and consequences of decisions, but my Code of Ethics does not allow me to advise you to make a specific decision.

Appointments are usually scheduled one time a week for approximately one hour, with the first session devoted to gathering necessary information. The entire therapy process may take on the average of eight to ten sessions.

7.) Code of Ethics—I am required by law to adhere to the Louisiana Code of Ethics for Licensed Marriage and Family Therapists. A copy of this code is available upon request.

8.) Privileged Communications—I am required to abide by the professional practice standards for licensed marriage and family therapists and Louisiana law. I do not disclose client confidences and information to any third party except for materials shared during supervision without a client’s written consent or waiver except when mandated or permitted by law. Verbal authorization will not be sufficient except in emergency situations. State law mandates that I report to the appropriate authorities suspected cases of child abuse/neglect, elder abuse/neglect, or disabled abuse/neglect and instances of danger to self or others when reasonably necessary to protect the client or other parties from a clear and imminent threat of serious physical harm.

Certain types of litigation (such as child custody suits) may lead to the court-ordered release of information without your consent. Also note that if you use third party insurers, such as health insurance policies, HMO or PPO plans, or EAP programs, you must sign a release of information and all information will be disclosed.

When working with couples, families, or groups, I cannot disclose any information outside of the treatment context without a written authorization from all individuals competent to sign such authorization. For example, I cannot release any information about either or both spouses I have seen for marital therapy to an attorney without signed authorizations from both spouses.

When working with a family or couple, information shared by individuals in sessions where other family members are not present must be held in confidence (except for the mandated exceptions already noted) unless all individuals involved sign written waivers at the outset of therapy. Clients may refuse to sign such a waiver but should be advised that maintaining confidentiality for individual sessions during couple or family therapy could impede or even prevent a positive outcome to therapy.

9.) After Hours and Emergencies

When the receptionist is not at her desk, or after office hours, you may leave a message on my answering machine and I will return your call as soon as possible. In an emergency situation when an immediate response is necessary, you may call Hope Memorial Behavioral Medicine Unit at 318-222-1111 for prompt, professional service 24 hours a day.

10.) Fees, Office Procedures, Policies for Insurance Reimbursement

Appointments—Appointments are typically set at the close of each session. I have morning, afternoon, and evening appointments available Monday through Friday. Appointments may be scheduled, rescheduled, or cancelled with the receptionist from 9:15 am to 5:00 p.m. Monday through Friday. Failure to give notice for any appointment not cancelled twenty-four hours in advance may result in a charge for the time reserved for you.

Fees—My fee is $85 an hour. Payment for services rendered is due at the close of each session.

Insurance—Consult your insurance company in advance regarding the extent of your mental health coverage. I do not file insurance from my office. The statement you receive will contain all the information you need to file a claim for reimbursement of your fee.

11.) Potential Benefits and Risks of Therapy

1. Studies suggest that counseling involving only one spouse can lead to the dissolution of the marriage instead of improving it.

2. Changes in relationship patterns that may result from family therapy may produce unpredicted and/or possibly adverse responses from other people in the client’s social system.

3. A result of family therapy may be a realization on the part of the client that there are issues that may not have surfaced prior to the onset of the counseling relationship.

[12.) Additional Information: None]

13.) I have read and understand the above information.

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Client Signature                                                                                                      Date

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Client Signature                                                                                                      Date

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Client Signature                                                                                                      Date

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Name, M.MFT., LMFT

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1.) LMFTs seeing minor clients should provide a parental authorization section. This could be incorporated into the Statement of Practice or you or your agency might want to have a separate form. For example:

I, ___________________________________, give permissions for ______________________

Signature of Parent or Guardian                                                                                  Your Name

to conduct therapy with my __________________, _______________________.

                                                      (relationship)                                   Name of Minor

2.) LMFTs who also are licensed in other disciplines that require informed consent documents may integrate the two documents. For example, for an individual dually licensed as an LPC and an LMFT:

Name, LPC. LMFT

Address of Employment

Telephone

I have an M.A. in Counseling from ________________. I hold license number _______ as a Licensed Professional Counselor and license number _______ as a Licensed Marriage and Family Therapist with the LPC Board of Examiners, 8631 Summa Avenue, Baton Rouge, LA 70809.

I am required by law to adhere to the Louisiana Code of Conduct for Licensed Professional Counselors and the Louisiana Code of Ethics for Licensed Marriage and Family Therapists. Copies of these codes are available upon request.

Etc.

Please consult §4303 Resolving Ethical Issues in Rules Needed to Apply if provisions in the Louisiana Code of Ethics for Marriage and Family Therapists differ from those in the ethical codes that regulate your other licensure.