1.     LPC/Counselor Intern’s name, mailing address, and telephone number.

2.     Qualifications: 

           a. include degrees earned and institution(s) attended;

           b. give your license number, specifying the LPC Board of Examiners including address and 

               telephone number as the grantor of your license.

           c. an individual under supervision must refer to him/herself as a Counselor Intern and include

               the name and address of his/her Board approved supervisor.

3.     Counseling Relationship: 

           a. provide a general statement about the dynamics of the counseling relationship;

           b. include general goals for clients.

4.     Areas of Expertise:

           a. list your areas of expertise such as career counseling, marriage, family counseling, and adolescents, etc.

           b. list your national certification in counseling.

5.     Fee Scales:

           a. list your fees and describe your billing policies; 

           b. describe your policy on scheduling and breaking appointments; 

           c. state your policy on insurance payments.

6.     Explanation of the Types of Services Offered and Clients Served: 

           a. include the theoretical basis and the type of techniques and/or strategies that you use in therapy; 

           b. specify the modality you use such as group and/or individual therapy;

           c. specify the type(s) of clients you serve.

7.     Code of Conduct: state that you are required by state law to adhere to a Code of Conduct for your

practice which is determined by the Louisiana Licensing Board, and a copy of this Code is available on request.

8.     Privileged Communications: describe the rules governing privileged communication and include the

limits of confidentiality.

9.     Emergency Situations: describe your policy for emergency client situations.

10.   Client Responsibilities: list client responsibilities, e. g. clients are expected to follow office

procedures for keeping appointments, clients must pay for services at the time of each

visit, and clients must (terminate the counseling relationship before being seen by another

mental health professional) notify the counselor of any other ongoing professional mental

health relationship. If a client is seeing another mental health professional (psychologist,

board certified social worker, etc.), then permission must be granted by the first therapist

for the second to work with the same client. (See Code of conduct)

11.   Physical Health: Suggest that client have a complete physical examination if he/she has not

had one within the past year. Also have client list any medications that he/she may be taking.

12.   Potential Counseling Risk: indicate that as a result of mental health counseling, the

client may realize that he/she has additional issues which may not have surfaced prior to

the onset of the counseling relationship. The counselor may also indicate possible risk

within specific specialty areas. (i. e. marriage and family – As one partner changes,

additional strain may be placed on the marital relationship if the other partner refuses to work.

13.   It is also required that a place be provided for the signatures of the counselor/counselor intern, the

client(s), and the counselor intern’s supervisor. A general statement indicating that the

client has read and understands the declaration statement and the date of the signature

must also be included.