1.  Name, Counselor Intern

                                                                    Address of Employment

                                                                    Telephone Number

3. Counseling Relationship: I see counseling as a process in which you, the client, and I, the Counselor Intern, having come to understand and trust one another, work as a team to explore and define present problem situations, develop future goals for an improved life and work in a systematic fashion toward realizing those goals.

4. Areas of Expertise: I focus on clients with marriage and family issues. In addition to being registered as a Counselor Intern in Louisiana, I hold a national certification as a National Certified Counselor (NCC).

5. Fee Scales: The fee for services is $70.00 per session. Payment is due at the time of service. Clients will be charged for appointments that are broken or canceled without 24-hour notice. Payment is not accepted from insurance companies.

6. Services Offered and Clients Served: I approach counseling from a cognitive-behavioral perspective in that patterns of thoughts and actions are explored in order to better understand the clients' problems and to develop solutions. I work with clients in a variety of formats, including individually, as couples and as families. I also conduct group therapy. I see clients of all ages and backgrounds with the exception that I do not work individually with children under six years of age.

7. Code of Conduct: As a Counselor Intern, I am required by law to adhere to the Code of Conduct for practice that has been adopted by my licensing board. A copy of this Code of Conduct is available to you upon request.

8. Privileged Communication: Material revealed in counseling will remain strictly confidential except for material shared with my supervisor and under the following circumstances in accordance with state law: 1) The client signs a written release of information indicating informed consent of such release, 2) The client expresses intent to harm him/herself of someone else, 3) There is a reasonable suspicion of abuse/neglect against a minor child, elderly person (60 or older), or a dependent adult, or 4) A  court order is received directing the disclosure of information.

It is my policy to assert privileged communication on behalf of the client and the right to consult with the client if at all possible, except during an emergency, before mandated disclosure. I will endeavor to apprise clients of all mandated disclosures as conceivable.

In the event of marriage or family counseling, material obtained from an adult client individually may be shared with the client's spouse or other family members only with the client's written permission. Any material obtained from a minor client may be shared with the client's parent or guardian.

9. Emergency Situations: If an emergency situation should arise, you may seek help through hospital emergency room facilities or by calling 911.

10. Client Responsibilities: You, the client, are a full partner in counseling. Your honesty and effort is essential to success. If as we work together you have suggestions or concerns about your counseling, I expect you to share these with me so that we can make the necessary adjustments. If it develops that you would be better served by another mental health provider, I will help you with the referral process. If you are currently receiving services from another mental health professional, I expect you to inform me of this and grant me permission to share information with this professional so that we may coordinate our services to you.

11. Physical Health: Physical health can be an important factor in the emotional well-being of an individual. If you have not had a physical examination in the last year, it is recommended that you do so and to list any medications that you are now taking.

12. Potential Counseling Risk: The client should be aware that counseling poses potential risks. In the course of working together additional problems may surface of which the client was not initially aware. If this occurs, the client should feel free to share these new concerns with me.

13. I have read and understand the above information.

Client signature _______________________________________________     Date ___________

Supervisor signature _{___________________________________________________    Date _____________}

(Counselor Interns seeing minor clients should provide a parental authorization section. See example below.)

I,                                               , give permission for Sigmund F. Boudreaux to conduct counseling

with my (relationship) _________________________________________

name of minor_______________________________________________