G. Reid Doster, DMin., LPC-S, LMFT, 4 Briar Hollow, Covington, LA 70433 (985) 778-6049 email@example.com
Declaration of Practice Policies and Procedures
Counseling Relationship. Our purpose is to examine and change unhealthy behaviors.
Qualifications. I am a Licensed Professional Counselor (LPC license #1124), a Licensed Marriage and Family Therapist (LMFT license #128) and an ordained Clinical Pastoral Counselor. I hold the Bachelor of Arts (B.A.) degree from Samford University, the Master of Divinity (MDiv.) degree from The Southern Baptist Theological Seminary, and the Doctor of Ministry (DMin.) degree from Southeastern Baptist Theological Seminary. I’ve completed further studies at Regents Park College at Oxford University (England), Ruschlikon Seminary (Switzerland), Louisiana State University in Baton Rouge, The University of New Orleans, New Orleans Baptist Theological Seminary, and The University of Massachusetts.
Work Experience. For over 35 years, I’ve maintained a private practice in individual, couple and family counseling.
Counseling Techniques. Cognitive Behavioral Therapy, Family Systems Therapy, and Neurolinguistic Programming.
Professional Fee and Insurance. The fee is normally $135 for the initial assessment and $120 per 60-minute session thereafter, and I am contracted for lower rates with Blue Cross, United Health (Optum), Gilsbar, AETNA, Vantage, Humana and Beacon insurances. To verify your deductible and co-pay, call Therapy Support Services at (504) 309-7844. There is never a guarantee of reimbursement by any insurance company and, in case they do not pay the claim, you are responsible for the total professional fee. I also accept credit/debit cards, HSA accounts, cash, check or PayPal.
Cancellation Policy. If you must cancel or reschedule an appointment, please do so no later than 24 hours in advance, by texting or calling (985) 778-6049, or emailing me at firstname.lastname@example.org. Except in case of a true emergency, you agree to a $120 late cancellation fee if you do not cancel within 24 hours of our appointed time. Please initial here to confirm your understanding of the cancellation fee: _____.
Types of Services Offered and Clients Served. My counseling practice is with adults, adolescents and older children, in individual, marital or family therapy sessions, for the treatment of depression, anxiety, complicated bereavement, painful life-transitions, trauma, marital and family conflicts, habit-control and a wide range of other common human problems.
Code of Conduct. Services are provided in accordance with The Code of Conduct for Licensed Professional Counselors and Licensed Marriage and Family Therapists, as defined by the Louisiana Licensed Professional Counselors Board of Examiners. A copy is available upon request. The address of the Louisiana Licensed Professional Counselors Board of Examiners is 8631 Summa Avenue, Suite A, Baton Rouge, Louisiana 70809, and the phone number is (225) 765-2515.
Privileged Communication. Material revealed in counseling will remain confidential, with these exceptions: (1) You sign a written release of information indicating formal consent of such release; (2) You express intent to harm yourself or someone else; (3) There is a reasonable suspicion of abuse or neglect against a minor child, elderly person (65 or older), or a dependent adult; or (4) A court order is received directing the disclosure of information. Also, be aware that you have no guarantee of confidentiality in legal proceedings to determine child custody. A subpoena is not a court order and is not sufficient for automatic release. Verbal authorization will not be sufficient except in clear emergency situations. For couple or family therapy, signed authorizations will be obtained from each adult.
Emergency Situations. In case of emergency, go to the nearest emergency facility or call 911. My cell-phone number is (985) 778-6049. The National Suicide Prevention Hotline is 1 (800) 273-TALK (8255).
Seeing Another Counselor? If so, please just let me know.
Your Physical Health. If you have not had a physical examination in the past year, it is strongly recommended.
Potential Counseling Risks. As a result of mental health counseling, you might realize you have additional issues which may not have surfaced prior to the onset of the counseling relationship.
Please sign below, confirming you have read these Policies and Procedures.
G. Reid Doster, LPC-S, LMFT Date
Initial below that you authorize counseling for your minor child.
Your child’s name and relation to you: __________________________________.
Parent #1 Initials: ________
Parent #2 Initials: ________
In cases of shared custody, both parents must give permission.