THERAPISTS ONLY - Professional Disclosure Statement Template
for LMFT, LCSW, CPCC, LMHC Professionals and Pre-licensed Professionals
Save your valuable time with this thorough and professional template. This Professional Disclosure Statement covers...
- Education
- Services and Theoretical Orientation
- Client Responsibilities
- Professional Boundaries
- Confidentiality
- Electronic Communication
- Social Media Policy
- Risks and Benefits of Therapy
- Physical Health
- Crisis
- Limits on Psychological Testing
- Limits on Custody, Visitation and Court Cases
- Fees
- Damage to Property
- Scheduling
- Length of Treatment
- Termination
- Consumer Protection
By using this document, you agree to hold Family & Children's Services, Inc., Melinda Haynes, staff and associates harmless. You acknowledge that you are responsible for reviewing and editing materials according to the laws of your country, state, county and /or territory.
If you chose to use this document, you agree to remove contact information related to Family & Children's Counseling Services, Inc. and/or Melinda Haynes. The document you create based off of the template provided shall be your own. You are responsible for the content you create and the contracts you sign with your clients.
Do NOT download the document unless you agree to these terms.
Your Instructor
Melinda Haynes, MA, LMFT is a licensed marriage and family therapist, Director and Clinical Supervisor for Family & Children's Counseling Services, Inc. in Northern California. She began her career in the helping profession as an entry-level support counselor and has been working with families in transition since the 1990s.
During her career, Melinda continued her education and eventually obtained a bachelor's degree in Sociology and a master's degree in Psychology. Melinda has been licensed and owned private practices in Oklahoma and California.
Melinda has been called as an Expert Witness in a custody trial involving supervised visitation services, and is the author of the Supervised Visitation Provider training course. She is looking forward to assisting you in your new career as a Provider of Supervised Visitation Services.
Melinda is licensed in three states: CA 10238 | OK 1153 | NC 2143