Sarah A Tester, PhD, LMFT,LPC Marital and Family Therapist

                                              Clinical Member, American Association for Marriage and Family Therapy

                         1186 Fremaux Avenue Slidell, LA 70458         Phone: (985)643-5145   Fax: (985)643-1440

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Declaration of Practice and Procedures


This declaration is designed to inform you about the therapeutic process into which you are entering. As an individual with rights and responsibilities, you should be informed about the treatment process and give your informed consent to that treatment.


Therapist-Client Relationship

The psychotherapy relationship is one in which you and I come together to work as a team, to understand and trust one another. Our purpose is to define the present problem situations and to develop goals for an improved life. We will work in a systematic fashion to realize your treatment goals. The counseling relationship does not include my making decisions for the client. It is the right and responsibility of the client to make his/her own decisions about such things as divorce, reconciliation, marriage, contact with children, and relationship with children. Instances of extreme violence within the marriage or family may lead to my recommending that certain family members not live together.


I am committed to providing a high quality of Family Systems Psychotherapy that always views the client in context, emphasizes your strengths, promotes your self-direction, promotes a clearer sense of who you are as an individual, and enhances relations with others. My approach also draws upon structural family theory, cognitive behavioral theory, and communications theory.



· PhD in Marriage and Family Therapy, Florida State University

· Ms in Counseling University of Tennessee

· Clinical Fellow, American Association for Marriage and Family Therapy

· Member Louisiana Association for Marriage and Family Therapy

· Licensed Marital and Family Therapist in Louisiana #338

Louisiana Licensed Professional Counselor #2188

Louisiana LPC/LMFT Board of Examiners, 8631 Summa Avenue, Suite A

Baton Rouge, LA 70809; telephone 225.765.2515.


Areas of Expertise

· Couples, Family, and Individual Psychotherapy

· Family of Origin & Family Structure

· Helping Teens Make Healthy Choices

· Managing Effects of Severe and Chronic Mental Illness

· Domestic Violence Evaluation & Treatment

· Divorce & Separation

· Child Custody Evaluations—Assessment, Deposition & Trial

· Treatment for Depression & Anxiety

· The Medically Fragile Client


Insurance and Payment for Service

I accept insurance payment and my office will file primary insurance claims for you. Insurance carriers pay a portion of the fees, and you are expected to pay your deductible and co-pay at the time of service. For those without insurance, fees may be negotiated. I am not a participating provider for Medicare and Medicaid. See website for discussion of insurance information.



Explanation of the Types of Service Offered and Client Served

(1) I provide individual, couples, and family psychotherapy services, primarily serving adults and adolescents age 13 and older. The initial assessment focuses on what leads the client to seek help and what s/he wants to accomplish. My work is considered short-term, generally within 20 sessions. Those persons with trauma experiences and those coping with major disorders such as Bipolar Disorder and/or Schizophrenia, will by necessity require long term intervention.


(2) Family, social and medical information through Health History is gathered in the first session. Effects of trauma, addiction, depression, and anxiety are evaluated. With this information the therapist and client develop the treatment plan together. Assessment for marital and premarital counseling may include individual sessions with each partner before joint appointments.


(3) If there is a history of physical aggression or severe verbal aggression, each participating family member is offered a confidential individual appointment to discuss matters pertaining to safety—safety at home and in counseling. For those who want to stay together even though they may have a history of physical violence, I will work with selected couples. Both must agree to a carefully designed safety plan.


(4) Homework assignments to be completed between sessions are often an integral part of treatment. For the client to get the most from counseling, completion of the assignment is necessary.


Code of Ethics

As a Louisiana Marital and Family Therapist [MFT] and Licensed Professional Counselor [LPC], I am required to adhere to the LPC Code of Conduct and the MFT Code of Ethics as proscribed by Louisiana LPC Board of Examiners and Louisiana law. Additionally, I am required to adhere to the ethical principles of the American Association for Marriage and Family Therapy. These codes of ethics are available upon request. You may refer to;;


Privileged Communication and Confidentiality

The confidential relations and communications between a Licensed Professional Counselor and/or Licensed Marital and Family Therapist, are placed upon the same basis as those provided by Louisiana statute between an attorney and client. Nothing in the rules governing Psychotherapy should be construed to require such privileged communications be disclosed.


Information will be released to healthcare providers and others upon your written consent. Verbal authorization for release of information is acceptable only in case of emergency.



Exceptions to Confidentiality

· I am required by law to report to authorities suspected cases of child abuse and neglect, elder abuse and neglect, abuse and neglect of the disabled.


· If you use insurance, information you have authorized the therapist to disclose may be available for retrieval or review. Information such as diagnosis, history and treatment plan is routinely obtained by insurance companies, when they approve your use of insurance benefits and payment for services.


· I am required by law to report to authorities instances of danger to self or others when reasonably necessary to protect the client and others from a clear and imminent threat of serious physical harm.


· In the conduct of marital and/or family therapy when more than one person is involved, a signed authorization is required for information to be discussed by the clinician with participating family member(s). Efforts will be made for the therapist and Spouse A to avoid withholding information from Spouse B. Dr. Tester may specifically recommend to one party that s/he disclose certain information to another participating family member.


· In the event a participant in marital and/or family therapy wishes information to be disclosed to a third party, and the information references another participating family member, this requires cooperation and a signed authorization from all participating family members.


· A court order can mandate disclosure of information. I will first ask if a Treatment Summary is acceptable.


· Psychotherapy material obtained during Marital and Family Therapy may be shared with a spouse or other family members only with the client’s permission. All parties who participated in a session must agree to sign a release of information. Any material obtained from a minor client may be shared with the client’s parent or guardian. Minors are advised that parents must be told of activity that represents a danger to him/her.


· Short-term disability claims, long term disability claims, worker compensation claims, social security disability claims, automobile liability that includes coverage for medical payments require that I submit Psychotherapy Notes, for the purpose of validating applicant’s claim. These are not covered by HIPAA privacy protections (federal law).


· When questions arise regarding workplace safety, OSHA regulations take precedent over HIPAA protections, as they pertain to Psychotherapy Notes.



Client Records


In accordance with Louisiana law, Psychotherapy Records also known as medical records are maintained six years for adult clients. Client records for those under the age of 18 are maintained seven years past the age of majority. Paper records are destroyed in a timely manner through a professional document destruction service. When a third party sends a properly executed Release of Information, or when records are requested through a properly executed Subpoena, Dr. Tester personally prepares the material.



Office Hours and Appointments


Weekday appointments generally last 45-50 minutes and are made in advance--usually on a weekly or bi-weekly schedule. Hours are 9AM - 6PM Monday, Tuesday, & Thursday. The time is reserved for you.


Dr. Tester will return a call to schedule a first appointment when a new client communicates via landline telephone. For those new clients utilizing a cellular telephone, Dr. Tester will respond to their request for an appointment via text message. For those who request an intake via email, Dr. Tester will respond by email. Appointment reminders are sent via text message.


You will be charged for any appointment not cancelled 24 hours in advance. Cancellations are made through the Answering Service @985.643.5145. Cancellations may be made through text message to Dr. Tester.


Missed appointments are not billed to insurance and are the sole responsibility of the client. Weekend sessions and lengthier sessions may be arranged.




Charges: Insurance plans base payment on a 45-minute hour.


Initial Psychotherapy Evaluation & Assessment (45 minutes) $ 115.00

Psychotherapy (45-50 minutes) $ 115.00

Psychotherapy (30 minutes) $ 57.50

Hospital Consultation weekdays & weekends, per hour $ 115.00

Custody Evaluation (face to face time) $ 150.00

Custody Evaluation Retainer, per parent $1500.00

Deposition & Court Testimony, per hour $ 150.00

Travel, per hour $ 62.50

Missed Appointments and Late Cancellations $ 100.00

Letters & Reports, per hour $ 115.00


Dr. Tester does not engage in balance billing. Insurance statements sent to the client and to

Dr. Tester determine what the insurance carrier will pay and, the portion of the allowed fee for which the client is responsible.



Emergency Situations

All persons whom I have accepted as clients may receive after-hours assistance by calling 985.643.5145. The Answering Service will immediately reach out to me utilizing several available communication methods. Upon request, the Answering Service will call me directly and patch through the caller. I may not read a text message or an email in a timely manner. If your situation requires that you speak with me, placing a call through the Answering Service 985.643.5145 is the best option. I will respond.


If I am not available in a timely manner and/or if immediate response is needed, go directly to Ochsner Northshore Medical Center Emergency Room at 104 Medical Center Drive or Slidell Memorial Hospital Emergency Room at 1001 Gause Boulevard. Do not hesitate to call 911 if you feel unable to transport yourself to a hospital. I will cooperate with emergency personnel given appropriate authorization.



Client Responsibilities

· Payment at time of service.

· Follow office procedure regarding appointments.

· Notify me of ongoing relationships with other mental health professionals.

· Allow permission for me to contact any physician or other mental health professional currently treating you.

· If you plan to terminate services with me, prior notification is required before you secure services with another professional.

· Your honesty and effort is essential to success.

· Allow me to assist you with referral to another mental health provider who may better serve you.

· Avoid withholding information that can directly effect assessment and the outcome of treatment.


Physical Health

I recommend that you have a complete physical examination if you have not had one within the past year. Each client is asked to complete a detailed health history, listing prescription medications and over-the-counter preparations currently in use—as required by insurance companies.



Potential Risks of Psychotherapy

· Your informed choice at all times will facilitate the best possible counseling outcome.

· At any time, you may ask for an explanation of why information is gathered or a new approach is recommended.

· Research and family studies teaches how to minimize and steer around emotionally charged issues early in therapy.

· As a result of counseling, you may realize that you have additional concerns, which may not have surfaced prior to the onset of the psychotherapy relationship. This is particularly relevant for those persons with a history of trauma.

· In marital therapy as one partner changes, additional strain may be placed on the marital relationship particularly if the other partner does not accommodate reasonable change, or if s/he refuses to do their part to lift the strain on the relationship.

· It is likely that strain on the marriage will increase if one or both parties pursue individual therapy with different therapists, as a means of addressing marital conflict.


It is possible that the problem you initially sought help for may not be completely resolved through psychotherapy.








My questions were answered prior to signing this declaration. I have read and understand this Declaration Statement.




________________________________­­______ __________________________________

Client/Parent Signature Date Client Signature Date







Sarah A. Tester, PhD Date

Marital and Family Therapist

Revised 6-6-19