Sample for a Marriage and Family Therapy (MFT) Intern
Statement of Practice
Note: Do not include information from this sample that does not apply to you. Please add or modity as needed to accurately portray your practice. You are writing this for your clients; the finished format should be professional and suitable for you to use with your clients. You do not need to use section numbers.
1.) Name, Marriage and Family Therapy (MFT) Intern
Address of Employment
Telephone
2.) Qualifications—I have an M. A. in Marriage and Family Therapy from The University of Louisiana at Monroe. I am an MFT Intern registered with the LPC Board of Examiners, 8631 Summa Avenue, Baton Rouge, LA 70809, 225/765-2515, which has approved my supervision as I work toward licensure. My supervisor is Virginia Jackson, Ph. D., 402 West Berry, Shreveport, Louisiana, 71101, 318-222-0001. Dr. Jackson is a Licensed Marriage and Family Therapist and an AAMFT Approved Supervisor.
3.) Clients Served—I provide therapy for individuals, couples, and families. I work with children and adults.
4.) Specialty Areas— I specialize in the practice of marriage and family therapy and am trained to work with problems of childhood and parenthood, marital difficulties, and life difficulties of adulthood that may relate to disturbances in family relationships. I am an Associate Member of the American Association for Marriage and Family Therapy.
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.
Note: You may want to add that you also must follow codes of ethics for specific professional associations to which you belong. You must follow these codes to maintain your membership requirements. Codes adopted by licensing boards regulate your practice in the state.
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.
Also note that certain types of litigation (such as child custody suits) may lead to the court-ordered release of information without your consent
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. If an impasse results from such confidentiality, referral to another therapist might result.
Dr. Jackson will monitor my work with clients. I will review my cases with Dr. Jackson. Part of my supervision will be group supervision where other interns also will be present. Your signature at the end of this form includes permission for audio- and videotaping of sessions and the sharing of information from my notes. Dr. Jackson, the other interns, and I will maintain the confidentiality of this shared information as described in this section.
9.) After Hours and Emergencies
When the receptionist is not at her desk, or after office hours, you may leave a message on the 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, which offers, professional service 24 hours a day.
10.) Fees and Office Procedures
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—The fee is $75 an hour due directly to _____________________________. Payment
Place of Employment
for services rendered is due at the close of each session.
11.) Potential Benefits and Risks of Therapy
1. Studies suggest that therapy 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. I understand that __________________________________
(MFT Intern)
is under supervision and that audio- and videotaping as well as verbal sharing of information will occur during this supervision.
________________________________________________________________________
Client Signature Date
Client Signature Date
Client Signature Date
________________________________________________________________________
Client Signature Date
Name, M.A., MFT Intern
________________________________________________________________________
Virginia Jackson, Ph.D., LMFT, AAMFT Approved Supervisor
[END OF SAMPLE MFT INTERN STATEMENT OF PRACTICE]
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Further Suggestions for a Statement of Practice
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 permission for_________________ to
Signature of Parent or Guardian Your Name
to conduct therapy with my _________________. _________________________.
Relationship Name of Minor
For Persons Also Under Supervision in Other Disciplines
2. MFT Interns who also are interns in other disciplines that require informed consent documents may integrate the two documents. For example, for an individual dually registered as an counselor intern and a marriage and family therapy intern:
Declaration of Practices and Procedures/
Statement of Practice
Name, Counselor Intern, Marriage and Family Therapy Intern
Address of Employment
Telephone
I have an M. A. in Counseling from _____________. I hold registration # _____
as a Counselor Intern and also am registered as a Marriage and Family Therapy Intern 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 differ from those in the ethical codes that regulate any other registration.