1.)    Name, LPC

                                                                    Employment Address

                                                                    Telephone Number                                                                    

2.)        Qualifications: I earned an MA degree from Vermillion State University in 1990. I am licensed



TELEPHONE  (225)765-2515

3.)        Counseling Relationship: I see counseling as a process in which you, the client, and I, the counselor,

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 have a general practice, but focus on clients with marriage and family issues.

I hold a national certification as a National Certified Counselor (NCC)and as a

 Certified Clinical Mental Health Counselor (CCMHC)

5.)         Fee Scales: The fee for my services is $70.00 per session. Payment is due at the time of service.

Clients are seen by appointment only. 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 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, I am required by state 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 upon request.

8.)         Privileged Communications: Materials revealed in counseling will remain strictly confidential 

except for:

 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 dependant adult.

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 permission. Any material obtained from a minor client may be shared

with that client’s parents 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. 

Also, please provide me with a list of the medicines you are currently 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 ________________

Counselor Signature _______________________________ Date _________________

(LPC’s seeing minor clients should provide a parental authorization section. See example below.)


I, signature of parent or guardian _______________________________, give permission for

( Counselor's Name)    to conduct counseling with my (relationship), ________________

(name of minor) _______________________________.