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Our contact will be limited to the paid session your child has with me. Please do not invite me to social gatherings, offer gifts, or ask me to relate to you in any way outside our Theodore P. Remley, Jr., JD, PhD, LPC, LMFT ∞ Our Lady of Holy Cross College ∞ New Orleans, Louisiana ∞[email protected]∞Page 81
counseling and consultation sessions. You will be best served if our relationship stays strictlyprofessional and if our sessions concentrate exclusively on your child’s concerns. You will learn a great deal about me as we work together during your counseling experience. However, it is important for you to remember that you are experiencing me only in my professional role.1007.1008.My counseling practice is limited to adolescents and adults and includes career, personal, couples, marriage, and group counseling. I also am available for divorce mediation.1009.1010.I will keep confidential anything you or your child says to me with the following general exceptions: you direct me to tell someone else, I determine you or your child is a danger to self or others, or I am ordered by a court to disclose information.1011.1012.I ask you to trust me to determine whether you need to be informed of anything your child has disclosed to me in counseling sessions. In the event I believe you need to know information your child has told to me to protect your child’s health or welfare, I will inform your child I am going to disclose that information to you and will tell you. It is important for your child to feel comfortable disclosing personal information to me and I ask that you not ask the contents of my counseling sessions with your child if I do not offer to disclose such information to you. I assure you I will let you know any information that may put your child at risk for harm.1013.1014.In the event you are dissatisfied with my services for any reason, please let me know. If I am not able to resolve your concerns, you may report your complaints to ____________________, my supervisor here at the _______________ Community Mental Health Center.1015.1016.The general fee for services at ________________ Community Mental Health Center is $75 per session. However, if you apply for a reduction in fees for services based onyour family’s income, you may be eligible for a reduction in fees. If you are granted a reduction in fees, United Way, a local charitable organization pays the portion of the fees that you cannot afford. Based on your application for a reduction in fees for services, your fees for counseling for your child have been established at $_____ per session. 1017.1018.Sessions are 50 minutes in duration. It is impossible to guarantee any specific results regarding your child’s counseling goals. However, I assure you that my services will be rendered in a professional manner consistent with accepted ethical standards.