Declaration of Practices and Procedures

 

Cheryl Lacoste, M.A., NCC, LPC-S

Crescent City Counseling and Associates

701 Papworth Street Suite 201

Metairie, La.  70006

504-874-4626

 

Qualifications:  I earned a Masters of Arts degree in Mental Health Counseling from Our Lady of

Holy Cross College in 2010. I am licensed as a Licensed Professional Counselor- Supervisor

# 4785 with the Louisiana LPC Board of Examiners, 8631 Summa Avenue, Baton Rouge,

La, 70809, (225)765-2515. I am a Board – Approved supervisor of Provisional Licensed

Professional Counselors (PLPCs).

 

Counseling Relationship: I see counseling as a process in which you the client, and I, the

Counselor having come to understand and trust one another, work as a team to explore and

define present problem situations, develop future goals for an improved life and work in a

systematic fashion toward realizing those goals.

 

Areas of Focus: My areas of focus are trauma and abuse in particular,

sexual abuse. In addition to being licensed as a LPC-S  in Louisiana, I hold a national

certification as a National Certified Counselor (NCC#266255)

 

Fees and Office Procedures: The fee for services is $90.00 per session and paid directly to me.

Payment for service is due at the close of each session. I am an approved provider for many

insurance companies. If you would like to use your insurance please discuss it with me.

Appointments are typically set at the close of each session. I have morning, afternoon, and

evening appointments available Monday through Friday. Also, morning and afternoon on

Saturday. Appointments may be scheduled, rescheduled or cancelled with me Monday

through Saturday. Failure to give notice for any appointment not cancelled 24 hours in

advance may result in a charge for the time reserved for you.

 

Services Offered and Clients Served: I approach counseling from a cognitive-behavioral

perspective in that patterns of thoughts and actions are explored in order to better understand

the clients’ problems and to develop solutions. I work with clients in a variety of formats,

including individually, as couples and as families. I also conduct group therapy. I see clients

of all ages and backgrounds with the exception that I do not work individually with children

under twelve years of age.

 

Code of Conduct: As a Counselor, I am required by law to adhere to the Code of Conduct for

practice that has been adopted by my licensing Board; The Louisiana LPC Board of

Examiners. A copy of the Code of Conduct is available to you upon request.

 

Confidentiality: Material revealed in counseling will remain strictly confidential

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.

  1. The client expresses intent to harm him/herself or someone else.
  2. There is reasonable suspicion of abuse/neglect against a minor child, elderly

person (60 or older), or dependent adult.

  1. A court order is received directing the disclosure of information.

 

In the event of marriage or family counseling, material obtained from an adult client

individually may be shared with the client’s spouse or other family members with the

client’s written permission. Any material obtained from a minor client may be shared

with the client’s parent or guardian.

 

Privileged Communication: 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.

 

 

Emergency Situations: When I am unavailable to answer calls, you may leave a voice mail

message on my phone and I will return your call as soon as possible. In an emergency

situation when an immediate response is necessary, you may call the cope line at 211,

or you may seek help through hospital emergency facilities or by calling 911.

 

Client Responsibilities: You, the client are a full partner in counseling. Your honesty and effort

are essential to success. As we work together, if you have suggestions or concerns about

your counseling, I expect you to share these with me so that we can make the necessary

adjustments. If I determine that you would be better served by another mental health

provider, I will help you with the referral process. 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 our services

to you.

 

Physical Heath: Physical health can be an important factor in the emotional well-being of an

individual. If you have not had a physical examination in the last year, it is recommended

that you do so. Also, please provide me with a list of any medications that you are currently

taking.

 

Potential Counseling Risk: The client should be aware that counseling poses potential risks. In

the course of working together, additional problems may surface of which you were not

initially aware. If this occurs, you should feel free to share these concerns with me.

 

I have read the Declaration of Practices and Procedures of Cheryl Lacoste, M.A., NCC, LPC-S

and my signature below indicates my full informed consent to services provided by Cheryl

Lacoste, M.A., NCC, LPC-S.

 

 


Client Signature                                                            Date

 


Cheryl Lacoste, M.A.,NCC,LPC-S                              Date

 

 

 

 

 

Parent/Guardian Consent for Treatment of a Minor:

I, _____________________________, give my permission for Cheryl Lacoste, M.A.,NCC,LPC-S

    (Name of parent or legal guardian)

To conduct therapy with my________________, ______________________________________                                               

                          (Relationship)                    (Name of Minor)

 


Signature of parent or legal guardian                                                              Date

 

 

 

 

 

  • Client Information Form
    Name_________________________________ Date of Birth______________________
    Client Contact Information
    Name_____________________________________________
    Phone_____________________________________________
    Address____________________________________________
    Emergency Contact
    Name_________________________________ Relatonship_______________________
    Phone______________________________________________
    Address_____________________________________________
    Employment__________________________________________________________________
    Schooling (highest level completed) ____Elementary School ____High School ____College
    ____ Post College ____Trade-School ____GED
    Marital Status ___Single ___Living with significant other ___Married ___Separated ___Divorced
    Persons living with you
    Name Age Relatonship Employed As
    ____________________ ______ ___________________ __________________
    ____________________ ______ ___________________ __________________
    ____________________ ______ ___________________ __________________
    Religion_________________________________________________

 

 

  • Name_________________________________________
    Have you been a victm or perpetrator of abuse? ____No
    ____Yes ____victm ____sexual ____emotonal ____physical
    ____Yes ____perpetrator ____sexual ____emotonal ____physical
    Do you have suicidal thought or thoughts about hurtng yourself? ____yes____no
    Do you have thoughts about hurting other people? ____yes ____no
    Please describe your symptoms:
    ____depression ____anxiety ____suicidal thoughts ____homicidal thoughts
    ____sleep problems ____eating problems ____fears ____crying ____sexual problems
    ____panic atacks ____anger/temper ____relationship problems ____addictions
    ____hearing voices/seeing things ___inability to focus/concentrate ___cutting/hurting yourself
    ____obsessive-compulsive behavior ____behavior problems ____not completing work/tasks
    Other:_______________________________________________________________________
    Are you involved in legal problems? ____yes ____no
    ____custody ____divorce/separation ____parole ____probation____lawsuit
    Other:_______________________________________________________________________
    Please explain why you are seeking counseling:______________________________________
    ____________________________________________________________________________

 

 

 

  • Name_________________________________________
    Military service:_________________________________
    Have you received counseling or therapy before? ____yes ____no
    ____psychiatrist ____psychologist ____social worker ____minister ____counselor
    Physician:_________________________________ Phone:______________________________
    Medications currently taken:
    Name Length of time Condition being treated
    _________________________ ____________ ______________________________
    _________________________ ____________ ______________________________
    _________________________ ____________ ______________________________
    Substance Use Information:
    Please check all substances used.
    Type When How often
    ____alcohol ____past ____present ____daily ____weekly ____monthly
    ____prescription ____past ____present ____daily ____weekly ____monthly
    Medications
    ____marijuana ____past ____present ____daily ____weekly ____monthly
    ____heroine ____past ____present ____daily ____weekly ____monthly
    ____cocaine ____past ____present ____daily ____weekly ____monthly
    ____hallucinogens ____past ____present ____daily ____weekly ____monthly
    Other:____________ ____past ____present ____daily ____weekly ____monthly
    Are you sexually active? ____yes ____no