Declaration of Practices and Procedures Ashley Fletcher, LPC 1904 West Pinhook Road Suite 203 Lafayette, LA 70508

(337) 366-1626 Qualifications: I have earned a Masters of Science degree from the University of Louisiana at Lafayette in 2008. I am a LPC #4833 registered with the Licensed Professional Counselors Board of Examiners located at 8631 Summa Avenue, Baton Rouge, LA 70809 Telephone (225) 765-2515. I am a LPC in TX #65319 registered with the Texas State Board of Examiners of Professional Counselors located at P.O. Box 149347, MC 1982, Austin, TX 78714 Telephone (512) 834-6658. Counseling Relationship: I view the counseling relationship as a professional relationship between you, the client, and I, the counselor. This relationship is a process whereby we agree to work together, trust one another, explore and determine issues regarding your present problem situation, develop treatment goals for the future to improve your life, and work systematically toward reaching those goals. Areas of Expertise: I have a general practice, Acadian Counseling Center, LLC, and focus on clients with individual, family and relational issues. I work with clients on a variety of issues including grief and loss, life transitions, relational issues, depression, and assisting in career exploration. Fee Scales: The fees for my services will be based on a sliding scale, ranging from $60 to $120 depending on the clients ability to pay, number of clients in the session and the length of the session. For individual sessions, the sliding scale will be determined by taking 15% of the your income to have an estimate of where you will fall on the scale. For family or couples sessions, the scale will be 15% of the family income. I can only work on a sliding scale if payment is made at the time of the service provided. Fees will be adjusted up or down according to the fluctuations in your income. Those who are not able to make the minimum fee of $60 per hour are asked to donate an hour of community service per session for a discounted rate. Those clients who are the higher end of the scale can reduce their fee by $10 for every hour of community service they provide to a minimum fee of $60. I am also available to you on the phone when a call is made to set up the initial appointment. If you choose to call me, the first 10 minutes are free. 15-30 minute phone consultations will be billed at the rate of one half of a session; 30-45 minutes at a full session rate. There is no charge for missed or cancelled appointments provided 24 hours notice is given. If you do not show up for your scheduled appointment and you have not contacted us at least 24 hours in advance, you will be required to pay the cost of the treatment as booked. We do this in order to ensure that we can help as many people as possible. All payments, including co-payments, deductibles and co-insurance amounts are due at the time services are rendered unless prior arrangements have been made. Services Offered and Clients Served: I take an eclectic approach to providing therapy. I

have an Adlerian perspective in that I view clients as creative and unique individuals requiring individual treatment goals. I stress the development of empathy and collaboration in the counseling relationship as tools to overcoming relational issues. Additionally, I use cognitive behavioral techniques to empower and work with the client on ways to understand barriers and to develop appropriate solutions. I also utilize behavior modification, psychoeducation, crisis management, and supportive maintenance to help the client understand the connections between thinking, feeling and behaving. The modalities of therapy used include individual, family, couples and group therapy. I serve a wide variety of clientele including all races, creeds, sexual orientations and socio-economic backgrounds. I do not work with children in individual therapy under the age of 12. Code of Conduct: As an LPC, I am required to adhere to the Code of Conduct when practicing that is determined by the Louisiana Licensing Board, and a copy of this Code of Conduct is available to you upon request. Privileged Communications: The relationship between the counselor and the client is considered by law as confidential and will be held in strict confidence. All records kept by the counselor are confidential. In accordance to state law the exceptions to privileged communication exist if it pertains to: 1) The client signs a written release of information indicating informed consent of such release, 2) The client expresses an intent to harm himself or herself or has expressed serious intent to harm another person, 3) There is reasonable suspicion of abuse or neglect against a minor, elderly person (60 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 my client and ensure that steps are taken to prohibit the disclosure or have it limited as narrowly as possible. Whenever possible, my client will always be informed before any confidential information may be revealed. In the event of marriage or family counseling, material that is given by an adult to the therapist will only be shared with that individuals permission. Any material that is received from a minor child may be shared with the parent or guardian. Emergency Situations: If an emergency should arise, you may seek help through local hospital emergency room facilities or by calling 911. Client Responsibilities: The counseling process is a cooperative effort on the part of the client and the counselor. For the process to work, the client needs to be motivated to change and be responsible for his or her behavior and feelings. Clients are expected to be honest with the counselor and work toward resolving problems for which help was sought. Ultimately, the responsibility for setting and accomplishing any specific goal in counseling rests with the client. The client needs to recognize that meaningful change is never an easy task, and at times, could be difficult and painful as well as rewarding. It is also important to recognize that as a result of the counseling process, the client may realize that additional issues exist which may not have surfaced prior to the onset of the counseling relationship. You, the client, are expected to follow the office procedures for keeping appointments, payment at the time of service, and informing or terminating therapy if you begin seeing another mental health professional. This is to help coordinate our services as professionals in order to optimize your treatment.

Physical Health: Physical health can be an important factor in your emotional well-being. If you have not had a physical examination in the last year, it is recommended that you do so and to list any medications that you are now taking. Potential Counseling Risk: Clients should be aware that participation in counseling presents potential risks. In the course of working with me in treatment, additional problems or issues may arise that the client was not aware of before entering the therapeutic process. If additional problems or issues do arise, please feel free to discuss these new concerns with me. I have read and understand the above information. Client Signature________________________________________ Date____________ Counselor Signature_____________________________________ Date____________ I, signature of parent or guardian __________________________, give permission for Ashley Fletcher, LPC to conduct counseling with my (relationship)_________________ (Name of Minor)_______________________________________