This form was developed for you, my client, to provide information regarding your
rights as a client and my professional practice of information. You are encouraged
to read and understand information. You are also encouraged to ask me any questions
regarding this material.
I am dedicated to providing all people, regardless of sex, age, race, religion, or
national origin, with a service involving application of clinical counseling principles,
methods, or procedures for the purpose of achieving social, personal, career and
emotional development. My goal is to promote and enhance healthy self actualizing
and satisfying lifestyles. I agree to respect the rights of those persons seeking
my assistance, and make reasonable efforts to ensure that my services are used appropriately.
I have a primary obligation to respect the confidentiality of my client and the information
obtained during the clinical sessions. I will reveal such information to others
only with the consent of the person or the person’s legal representative, except
in those unusual circumstances in which not to do so would result in a clear danger
to the person or two others. There are certain situations in which information about
clients may be released with or without their permission. The situations are as follows:
1. Where children are physically abused, neglected, or sexually abused, the proper
authorities (e.g., police, Child Protective Services, Family Independence Agency)
must be notified.
2. In an emergency situation when the client or others may be in danger, as with
suicide or homicide, confidentiality may be broken.
The fee for a 1-hour session is $120.00. There could be other charges, for example,
reports, lengthy phone calls and interpretation of evaluation instruments administered
to assess an individual’s aptitudes, interests, attitudes, abilities, achievements,
and personal characteristics for development purposes. Payment is expected at time
of service, unless other arrangements are specifically made.
I received my Master of Arts degree in Community and Agency Counseling from Wayne
State University in Detroit, Michigan on December 18, 1997. I received my Bachelor
of Science degree in Psychology from Midwestern State University in Wichita Falls,
Texas on May 13, 1995. I completed a two-year post-graduate specialization in Mental
Health/Psychological Testing from Oakland University in May 2001. I hold an A.B.D.
in Clinical Psychology from Walden University and expect my Ph.D. by December 2010.
I am currently a therapist providing professional client services including individual
and group counseling, treatment planning and development, diagnostic testing and
assessment procedures, family consultation, case consultation and crisis intervention.
My professional experiences include rendering personal and career counseling services
for general and special student populations including abused and emotionally, physically,
and academically impaired adult and teenage students.