Peggy S. Arcement, MS, MA, LDN, LPC, NCC Licensed Professional Counselor Baton Rouge Christian Counseling Center 763 North Boulevard, Baton Rouge, Louisiana 70802 Phone: 225-387-2287 Fax: 225-383-2722 Declaration of Practices and Procedures I am pleased that we will be working together and am committed to helping you reach your goals in counseling. This statement is designed to inform you of my background and to insure that you understand our professional relationship. After reading this document, please sign and date the last page. 1. Counseling Relationship: It is my desire to provide a warm and trusting environment where you feel free to examine patterns of behavior, thoughts, or emotions that are causing you concern. I see the counseling relationship as one that must be based on mutual trust, respect, and honesty. Goals are established through collaboration with you, the client. I will help you think through possibilities and consequences of decisions, but my role is not to make decisions for you. Assignments may be given to continue the therapeutic process between sessions. It is my hope that you will complete the assignments and view them as a vital part of your therapy. My approach to counseling is integrative which means I use a variety of theoretical approaches in an attempt to match the client, the issue and the counseling method to achieve client goals. I primarily employ techniques based in Cognitive-Behavioral Theory. Intervention strategies are utilized which help to modify patterns of thought and actions to promote mental health, wellness, and personal growth. Your first session involves information gathering and becoming acquainted. I will obtain historical information and review the events that brought you in to see me. Feel free to ask any questions you may have. The nature of your need will be discussed and recommendations made concerning future appointments or outside referrals if I am unable to provide the service appropriate for you. As a Christian counselor, I believe that God loves us and is eager to help in our quest for personal and spiritual growth. I seek God s guidance and use Scripture and prayer when appropriate. It is not necessary that you share my views. I will always respect your personal beliefs and will address spiritual concerns if you express such a desire. 2. Qualifications: I hold a Master of Arts degree in Community Counseling from Louisiana State University. I am a Licensed Professional Counselor (LPC) #3750 registered with the Licensed Professional Counselors Board of Examiners, 8631 Summa Avenue, Suite A, Baton Rouge, Louisiana 70809, (225) 765-2515 and a National Certified Counselor (NCC) granted by the National Board of Certified Counselors, 5999 Stevenson Avenue, Alexandria, Virginia 22304. 3. Areas of Expertise: I have a general counseling practice with specialization in the treatment of eating disorders, women s issues, adjustment to major life transitions, anxiety, depression, grief and loss, relationship issues and health and wellness. I also have a M.S. degree in nutrition from Louisiana State University and a B.S. degree in dietetics from Louisiana Tech University. I am a licensed dietitian/nutritionist (LDN) #75 with the Louisiana Board of Examiners in Dietetics and Nutrition, 11930 Perkins Rd., Suite B, Baton Rouge, LA 70809, (225) 763-5490 and a registered dietitian (RD) with the Commission on Dietetic Registration, 12- South Riverside Plaza, Suite 2000, Chicago, IL 60606. 4. Session Fees: Fees are due at the time service is rendered. Fees are $125.00 for the initial session, $100 per 60 minute session, $90.00 per 45-50 minute session, and $50.00 for 30 minute sessions. Payment can be made by check, cash, or credit card.
Cancellations: If you have to cancel an appointment, the office must be notified AT LEAST 24 hours in advance, preferably more, or you will be charged. A fee of $35 will be assessed for the first missed appointment or late cancellation, and the full session fee will be charged for each missed or late cancellation thereafter. If the office is not open, and you need to cancel, you can leave a message in our voice mail at (225)387-2287 and the time will be registered. We aim to confirm appointments, but do not always have ample staff to do so. Responsibility for remembering appointments rests with the client. 5. Services Offered and Clients Served: I work with individuals, couples and families providing services to adults and adolescents 16 years of age and older. 6. Code of conduct: As a Licensed Professional Counselor, I am required by state law to adhere to codes of conduct for practice that have been adopted by my licensing boards. Copies of these codes of conduct are available upon request. 7. Privileged Communications: Information shared by you in the counseling relationship is confidential. I do not disclose client confidences and information to any third party except under the following circumstances in accordance with state law: 1) The client signs a written release of information indicating informed consent of such release, 2) The client expresses intent to harm him/herself or someone else, 3) There is a reasonable suspicion of abuse/neglect against a minor child, elderly person (60 years or older), or a dependent adult, or 4) A court order is received directing the disclosure of information. It is my policy to assert privileged communication on behalf of the client and the right to consult with the client if at all possible, except during an emergency, before mandated disclosure. I will endeavor to apprise clients of all mandated disclosures as conceivable. When working with couples, families, or groups I cannot disclose any information outside of the treatment context without a written authorization from all individuals competent to sign such authorization. When working with a couple or family, information shared by individuals in sessions, when other family members are not present, must be held in confidence (except for mandated exceptions already noted) unless all individuals involved sign written waivers at the outset of therapy. Litigation Limitation: Given that certain types of litigation (such as child custody suits) may lead to the courtordered release of information without your consent, it is expressly agreed that should there be legal proceedings (such as, but not limited to, divorce and custody disputes, injuries, lawsuits, etc) neither you or any attorney, or anyone else acting on your behalf, will ask me to testify in a deposition or in court or any other proceedings, nor will a disclosure of the medical record and/or psychotherapy notes be requested. 8. Emergency Situations: In case of emergency, call 911, the Crisis Intervention Center (The Phone) at (225) 924-3900, a psychiatric hospital, and/or go to the nearest emergency room. 9. Client Responsibilities: You are responsible for keeping appointments, paying your bill, and following office procedures. In order to receive the most benefit from the counseling relationship it is essential that you are honest and put forth effort in the counseling process. If you have any concerns about the goals and process, it is your responsibility to discuss this with me so that any necessary adjustments can be made. If you are currently receiving services from another mental health professional, I expect you to inform me of this and grant me permission to share information with this professional so that we may coordinate services. If it develops that you would be better served by another mental health provider, I will help you with the referral process. 10. Physical Health: As a part of the initial evaluation you will be asked to give the name of your primary care physician, describe your medical history and list all medications you are currently taking. It is recommended that you have a physical examination if you have not had one in the last year. 11. Potential Counseling Risk: Your participation in outpatient therapy is strictly voluntary and can pose some risk to you. Therapy can involve a wide range of emotions, which may be experienced as both positive and negative. In addition, because of the growth process, you could experience changes in relationships with others that may be a source of strain or difficulty. During the course of treatment, additional problems may surface that you were not aware. If this occurs, please discuss any new concerns with me.
I have read and understand the Practices and Procedures for the counseling agreement as described above. I have asked my questions and have received answers to those questions. I am aware of the counseling relationship and responsibilities, and my rights of confidentiality. I realize that there is benefit and risk involved in counseling. I accept the stated fees. I have a copy of the phone numbers I may call in the event of an emergency. Client Signature Counselor Signature CONSENT FOR A MINOR I, (parent or legal guardian) give permission for Peggy S. Arcement to conduct counseling with my (relationship), (name of minor). Signature Parent / Guardian
BATON ROUGE CHRISTIAN COUNSELING CENTER...a ministry of First Presbyterian Church Counselor: DX CODE: TO HELP WITH YOUR FIRST SESSION, PLEASE FILL OUT THE FOLLOWING INFORMATION AS COMPLETELY AS YOU CAN. PLEASE NOTE: ALL INFORMATION WILL BE KEPT CONFIDENTIAL : Birth : Name: (if a couple, please each fill out forms) Address: City/St Zip: Your Phone # s: (Home), (Work) (Cell): Email Address: Your Employment/Job Title: Person responsible for your bill, if different than above: Name/Address: If using Insurance, (you also need to fill out the Insurance Questions Form) Name of Ins. Co.: ANY CHURCH MEMBERSHIP: Briefly describe your spiritual life: Last year of school completed: or GED College: 1 2 3 4 Degree: Other: Single Married Separated Divorced Remarried Widowed Total number of prior marriages for you for your spouse/partner Spouse s name: Age of spouse: #of yrs. married Spouse s employment: WHO REFERRED YOU TO US? Is it ok to call your home & leave message: Yes No ; At your work: Yes No Person to contact in case of an emergency (name/phone): BRIEFLY describe your reason for seeking counseling:
Page 2 Do you have children? Yes No If yes: First Name Age Sex Relationship to you Live in your home? (biological/step/adopted/foster) Your Parents :(Father) Age: or Deceased (Mother) Age: or Deceased Number of Brothers: Number of Sisters: Has anyone in your family ever had counseling before? If so, for what? Any history of drug/alcohol abuse for self, father, mother, siblings? Yes No If yes, please describe: Any history of physical or sexual abuse to you or your brothers / sisters? Yes No If yes, please describe: Do you use alcohol or nonprescription drugs? Yes If yes, describe frequency and type: No Have you ever experienced any sexual difficulties: Yes No If yes, describe: Have you ever had counseling before? Yes No If yes, describe and list counselor, rough number of sessions, any psychiatric hospitalizations:
Page 3 Describe any major changes that have occurred to you or your family in the last few years? (moves, changes in number of family members, marital status, situation or income) List any major health problems for which you have received treatment for in the last 24 months: Primary Care Physician: Phone: Are you taking any prescription drugs at this time? Yes No If yes, what type, for what purpose, and who prescribed? PLEASE CIRCLE or CHECK ANY OF THE FOLLOWING PROBLEMS WHICH PERTAIN TO YOU: Nervousness Depression Fear Shyness Sexual Problems Suicidal Thoughts Separation Divorce Finances Drug Use Alcohol Use Friends Anger Self-Control Unhappiness Sleep Stress Work Relaxation Headaches Tiredness Legal Matters Memory Ambition Energy Insomnia Making Decisions Loneliness Inferiority Feelings Concentration Education Career Choices Health Problems Temper Nightmares Marriage Children Appetite Stomach Problems
Baton Rouge Christian Counseling Center Phone (225) 387-2287 763 North Boulevard Fax (225) 383-2722 Baton Rouge, LA 70802 NOTICE OF PRIVACY PRACTICES CONSENT FORM Effective April 14, 2003 a federal regulation, commonly known as the HIPAA Privacy Rule, requires that we must provide all of our clients with a detailed notice, in writing, of our privacy practices. We have this lengthy Notice of Privacy Practices available in our waiting room and it is also on our web site: www.brchristiancounseling.com. A written copy of this policy is available upon request. I understand that as a condition to my receiving treatment, Baton Rouge Christian Counseling Center may use or disclose my personally identified health information for treatment, to obtain payment for the treatment provided, and as necessary for the operations of this office. These uses and disclosures are more fully explained in the Privacy Notice that has been provided to me, and which I have had the opportunity to review. I understand that the privacy practices described in the Notice of Privacy Practices may change over time, and that I have a right to obtain any revised Privacy Notices, if requested. I also understand that I have the right to request BRCCC to restrict how my health information is used or disclosed. BRCCC does not have to agree to my request for the restriction, but if BRCCC does agree, BRCCC is bound to abide by the restriction as agreed. Finally, I understand that I have the right to revoke/withdraw this consent in writing, at any time. My revocation/withdrawal will be effective except to the extent that BRCCC has taken action in reliance on my consent for use or disclosure of my health information. Provision of future treatment may be withdrawn if I withdraw my consent. Signature Signature Signature
Last Name, First Name: BRCCC Appointment Confirmation Consent Form In accordance with BRCCC s policy, there is a charge for missed appointments that are not cancelled with 24 hour s notice. (whether appointments are confirmed or not) I,, do NOT want my appointments confirmed. I,, hereby give permission to have my counseling appointments confirmed. Our preferable choice! E-mail: @ (INITIAL) Telephone number(s): (INITIAL) ( ) HOME ( ) CELL ( ) WORK If someone else -ANYONE else, presently or in the future, answers at ANY of these phone numbers listed above OR If voicemail / answering service/answering machine picks up: It IS permissible to leave a message, OR It is NOT permissible to leave a message *Note-BRCCC may show up on your caller ID. Signature of Client Signature of Spouse (if applicable) NOTE: DUE TO FLUCTIATIONS IN STAFF, WE ARE NOT ALWAYS ABLE TO CONFIRM APPOINTMENTS. Remembering appointments is the responsibility of the client.