Checklist for the Statement of Practice

 For Marriage and Family Therapy Interns

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:

a) Supervision

b) Waiver 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 sign

______            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, MFT Intern

______          Supervisor Information

Comments: