Checklist for the Statement of Practice

For Licensed Marriage and Family Therapist

The checked items were missing from or were incorrect on your Statement of Practice. Please refer to the directions and sample statement on www.lpcboard.org and add or correct these sections.

(A short line after each section indicates that the section has been included and is correct.)

______ 1.) Identification

______ 2.) Qualifications

_______ 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 (9 items)

______ Professional practice standards

______ Third party disclosures:

______ 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

______ When all are not present

______ 9.) After Hours and Emergencies

______ 10.) Fees and Office Procedures

______ 11.) Potential Benefits and Risks

______ 12.) Additional Info: Not required

______ 13.) Clients have read and understand

______ Supervision Statement

______ Client Signatures/Dates

______ Name, Degree, LMFT

______ Supervisor Information

The Statement is approved with the understanding that the required changes will be made for the final printed copy that you give to your clients..