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741. 742. 743. 744. 745. 746. 747. 748. 749. 750. 751. 752. 753. 754. 755. 756. 757. 758. 759. 760. 761. 762. 763. 764. CLIENT INFORMATION AND AGREEMENT 765. FOR COUNSELORS EMPLOYED IN AN AGENCY 766. 767. ___________________ Community Mental Health Center 768. address 769. city, state, zip 770. telephone number 771. 772. ___________________, M.Ed., NCC 773. Licensed Professional Counselor (LPC) 774. 775. 776. _____________ Community Mental Health Center will be providing counseling services to you and I have been assigned as your counselor. This document is designed to inform you about the services provided by this agency and my background. 777. 778. ______________ Community Mental Health Center offers a variety of services which include the following: ___________________________. All residents of ________ County are eligible for services. Theodore P. Remley, Jr., JD, PhD, LPC, LMFT ∞ Our Lady of Holy Cross College ∞ New Orleans, Louisiana [email protected] Page 71
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779. 780. I am licensed as a Professional Counselor by the _____________ Board of Examiners for Licensed Professional Counselors. In addition, I am certified by the National Board of Certified Counselors, a private certifying agency that recognizes counselors who have distinguished themselves through meeting the board's standards for education, knowledge, and experience. 781. 782. I hold a Master’s (M.Ed.) degree in counseling from the University of ____________. The graduate program I completed is accredited by the Council on Accreditation of Counseling and Related Educational Programs (CACREP). 783. 784. I have been a counselor since _____. A counseling relationship between a Professional Counselor and client is a professional relationship in which the Professional Counselor assists the client in exploring and resolving difficult life issues. I believe that as people become more accepting of themselves, they are more capable of finding happiness and contentment in their lives. Self-awareness and self-acceptance are goals that sometimes take a long time to achieve. While some clients may need only a few counseling sessions to feel complete, others may require months or even years of counseling. Clients are in complete control and may end our counseling relationship at any point and I will be supportive of that decision. If counseling is successful, clients should feel that they are able to face life's challenges in the future without my support or intervention. 785. 786. My counseling services are limited to the scheduled sessions we have together. In the event you feel your mental health requires emergency attention or if you have an emotional 787. 788. crisis, you should report to the emergency room of a local hospital and request mental health services. 789. 790. Although our sessions will be very intimate, it is important for you to realize that we have a professional, rather than a personal, relationship. Our contact will be limited to the paid session you have with me. Please do not invite me to social gatherings, offer gifts, or ask me to relate to you in any way outside our counseling sessions. You will be best served if our relationship stays strictly professional and if our sessions concentrate exclusively on your concerns. You will learn a great deal about me as we work together during your counseling experience
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