COUNSELOR-CLIENT CONTRACT by WillLawrence

VIEWS: 185 PAGES: 5

									                        COUNSELOR-CLIENT CONTRACT

                               Information and Consent

Education:
       Bachelor of Arts Degree in Psychology from University of Maryland in College
Park and a Master of Science Degree in Pastoral Counseling from Loyola College in
Maryland. I am certified by the National Board of Certified Counselors #226491 and
licensed by the state of Maryland as a Licensed Graduate Professional Counselor
#LC3224

Client/Counselor Relationship:
        Counseling is a professional relationship and our contact will be limited to the
paid sessions we have agreed upon. Between session exchanges via email will be
discussed in advance and acknowledged that they may not constitute an actual therapeutic
session.

Counseling Sessions:
        Sessions are fifty minutes and are usually scheduled on a weekly basis. You are
in control of what you want to accomplish in counseling and goals are determined and
evaluated weekly.
        Counseling services are offered through a variety of mediums to include face to
face office sessions, or Distance Counseling via secured Skype web-cam, chat or phone
consultations and secured Hushmail email exchanges. These will be agreed upon by the
client and the therapist.
        Formal and informal “homework” are often used to augment the therapy
experience.

Referrals:
       If at any time for any reason you are dissatisfied with my services, please let me
know and we will discuss your concerns. If I am not able to resolve your concerns, I will
provide you with at least two names for you to contact.

Symptoms and Medication:
        If you are experiencing physical symptoms of any kind, a medical physical is
recommended to rule out medical conditions. Upon your authorization, I will work
closely with your physician to coordinate treatment and services.

Confidentiality:
        I will keep confidential everything you say to me, with the following exceptions:
a) I determine that you are in danger of harming yourself or others,
b) You direct me in writing to tell someone else,
c) a court subpoena is issued and I am court-ordered to disclose information,
d) I am mandated by the state of Maryland to disclose to appropriate social agencies any
current or past child abuse and names of abusers that you reveal to me.
**Please note that while Skype and Hushmail are encrypted and secure, thus reducing the
possibility of interception, other programs and modalities may be a higher risk and will
not be used by this counselor.

Fees and Cancellation Policy:
         The fee for service is __________dollars for fifty minutes. Payment may be made
in cash, check or credit card at the end of each session.
Distance Counseling services will be paid for at the beginning of the session in a secured
manner. Difficulty in payment must be discussed prior to the session.
         If you must cancel an appointment, you must notify me at least 24 hours in
advance by calling 443-223-5889 and leaving a message with the answering service.
If I do not receive advanced notice, you will be charged for the appointment.
When emergencies arise we will discuss the issue of payment.

Phone Calls and Extra Sessions Between Regular Sessions:
        Routine calls for the purpose of scheduling are part of my service. You may do so
by calling 443-223-5889. My phone consultation time between sessions is only ten
minutes so if you experience a crisis and you feel like you want to hurt yourself or
someone else, Call 911 or go to your nearest emergency room immediately.

Vacation Policy:
        I will inform you about my plans to be away from the office and, if necessary, I
will arrange for another counselor to cover for me.

Impediments and Responses to Counseling:
        Counseling is a growth-producing activity and can create some anxiety along with
change. Tell me when this happens. Some clients use self-defeating means to manage the
anxiety which can undermine growth. If you arrive intoxicated I will not work with you
in the session and you will be asked to pay for the session. If you arrive late, I will work
with you during whatever amount of time is left in your session.

Please note:
       If you feel that I have violated an ethical or legal standard, you may report
your complaint to the Board of Professional Counselors in Maryland at 410-764-
4732 or the National Board of Certified Counselors in Greensboro, NC at 910-547-
0607.

Summary:
        I welcome the opportunity to work with you in a professional counseling
relationship. By your signature below, you are indicating that you have read and
understand the information, and that any questions you have about this statement have
been answered to your satisfaction. Your signature indicates that you agree with the
conditions of counseling that are stated here and that you commit yourself to compliance
with them.
Counseling for a Minor:
       Your signature below indicates that you are the parent/legal guardian of
____________________(Minor’s name) and authorize me to provide her/him with
professional counseling.


________________________________                  ________________________
Cheryl Fisher, M.S., NCC, LGPC/ Date              Your Signature/ Date


____________________________                      ________________________
      Parent/Guardian Signature                         Print Your Name
                         Cheryl Fisher & Associates
          Cheryl Fisher, M.S., NCC, LGPC-645 Baltimore-Annapolis Blvd.
                      Severna Park, MD/21146/443-223-5889


                                Disclosure Statement


Education:
      Bachelor of Arts in Psychology      University of Maryland, College Park
      Masters of Science in Pastoral Counseling Loyola College of Maryland
      PhD-Candidate in Pastoral Counseling       Loyola College of Maryland


Credentials:
      National Certified Counselor (NCC) National Board for Certified Counselors
      Licensed Graduate Professional Counselor (LGPC)
                            Maryland Board of Professional Counselors and Therapists

Experience:
        Twenty years of providing counseling to individuals and families in the area of
grief and loss; life transitions; depression; anxiety; and trauma.


Fee:
       The fee for service is __________dollars for fifty minutes. Payment may be
made in cash, check or credit card at the end of each session or prior to Distance
Counseling sessions. Difficulty in payment must be discussed prior to the session.




This information is required by the Board of Professional Counselors and
Therapists which regulates all certified and licensed counselors and therapists.

                  4201 Patterson Ave/ Baltimore, Maryland/ 21215
                                   410-764-4732

								
To top