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:
- The client signs a written release of information indicating informed consent of
such release.
- The client expresses intent to harm him/herself or someone else.
- There is reasonable suspicion of abuse/neglect against a minor child, elderly
person (60 or older), or dependent adult.
- 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
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Client Information FormName_________________________________ Date of Birth______________________Client Contact InformationName_____________________________________________Phone_____________________________________________Address____________________________________________Emergency ContactName_________________________________ Relatonship_______________________Phone______________________________________________Address_____________________________________________Employment__________________________________________________________________Schooling (highest level completed) ____Elementary School ____High School ____College____ Post College ____Trade-School ____GEDMarital Status ___Single ___Living with significant other ___Married ___Separated ___DivorcedPersons living with youName Age Relatonship Employed As____________________ ______ ___________________ ______________________________________ ______ ___________________ ______________________________________ ______ ___________________ __________________Religion_________________________________________________
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Name_________________________________________Have you been a victm or perpetrator of abuse? ____No____Yes ____victm ____sexual ____emotonal ____physical____Yes ____perpetrator ____sexual ____emotonal ____physicalDo you have suicidal thought or thoughts about hurtng yourself? ____yes____noDo you have thoughts about hurting other people? ____yes ____noPlease 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/tasksOther:_______________________________________________________________________Are you involved in legal problems? ____yes ____no____custody ____divorce/separation ____parole ____probation____lawsuitOther:_______________________________________________________________________Please explain why you are seeking counseling:__________________________________________________________________________________________________________________
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Name_________________________________________Military service:_________________________________Have you received counseling or therapy before? ____yes ____no____psychiatrist ____psychologist ____social worker ____minister ____counselorPhysician:_________________________________ 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 ____monthlyMedications____marijuana ____past ____present ____daily ____weekly ____monthly____heroine ____past ____present ____daily ____weekly ____monthly____cocaine ____past ____present ____daily ____weekly ____monthly____hallucinogens ____past ____present ____daily ____weekly ____monthlyOther:____________ ____past ____present ____daily ____weekly ____monthlyAre you sexually active? ____yes ____no