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Terms and Policy

Stacey Guidry, LPC-S Declaration


Epiphany Therapeutic Services, LLC

Stacey Guidry, LPC-S

985.226.5677     504 Cherry Street     Thibodaux LA  70301

Qualifications:  I earned a Master's of Arts in Psychological Counseling from Nicholls State University in 2005. I am a Licensed Professional Counselor (LPC-S) # 3641 with the Licensed Professional Counselors Board of Examiners.  8631 SUMMA AVENUE, BATON ROUGE, LOUISIANA 70809 (225)765-2515.

Code of Conduct:  As a Licensed Professional Counselor, I am required by state law to adhere to the Code of Conduct for practice that has been set forth by The Louisiana LPC Board of Examiners. A copy of the Code of Conduct is available upon request.  As a member of the Louisiana Counseling Association, I am also required to follow the Code of Ethics of the Association in order to maintain membership.

Counseling Relationship:  Counseling will provide you, the client, with a safe, confidential and unbiased atmosphere in which you may explore your experiences and feelings.  Counseling provides you an opportunity to take control of your life and set desired goals.  As your counselor, my job is to assist you in your goals while promoting independence. 

Areas of Focus: I have general experience with working with individuals (ages 5 and up), families, and couples. I also have general experience in several areas such as anxiety, depression, interpersonal relationships, disabilities, college students, addictions and women who have been victims of violence.

Services offered and Clients served:  I approach counseling with a client-centered/ emotional focus.  Services offered to clients include but are not limited to self-exploration, goal setting, relation techniques, play therapy and life skills.  Therapy may occur under an individual or group setting.  I strive to promote your welfare by respecting your values, sexual orientation, religion, and dignity.

Procedures and Fees:  Clients are seen by appointment only.  Appointments can be made by calling the office at 985-226-5677 between the hours of 9am to 5pm, Monday through Friday.  A response to any voicemails with be made within 48 hours. 

Appointments must be cancelled within 24 hours of the scheduled appointment or the client will be responsible for a cancellation fee of $75.00. 

The fee for counseling services is $120.00 per 55-minute session.   You are responsible for any fees not covered by insurance. These fees are due at the time of service. It is your responsibility to know the coverage of counseling services before your initial session and understand you will be held responsible for the determined amount.  I will not contact insurance companies on your behalf unless it is a coding error or diagnosis code error on my behalf.  Insurance claims will be submitted to insurance companies that I am in network with.  For all out-of-network sessions you are responsible for full payment at time of service.  You will be provided with a Payment Statement to file with your insurance company.

You will be required to place a qualified card (debit, credit, HAS) on file at your first session.  Your card information will be held in your paper file in a locked file room and in your electronic file. 

If any payments made are insufficient, you will be responsible for charges incurred by Epiphany Therapeutic Services and an additional $20.

Custody:  If there are court proceedings regarding custody the parent(s)/legal guardian will be required to provide a copy of the legal documents outlining the custody arrangements.  If custody has not been determined, the Declaration must be signed by both parents.  Future appointments will not be scheduled until the documents are provided for review.  I encourage parents/guardians to be involved in the counseling process.  My interest is in what's best for the client.

Confidentiality: Anything exposed in the counseling session remains strictly confidential except under the following circumstances, in accordance with state law:

1.        The client or the client's guardian signs a consent form to release information.

2.        The client expresses intent to harm him/herself or someone else.

3.        There is reasonable suspicion of abuse/neglect against a minor, elderly person (60 or older), or dependent adult.

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

In the event of couples or family counseling, material obtained from an adult client individually may be shared with the client's spouse or other family members only with the client's written permission.  Any information obtained from a minor client may be shared with that client's parent or guardian.

Therapy notes and phone messages are confidential.  The electronic medical records program used for therapy notes and insurance is password protected and meets HIPPA requirements.

Colleague Consultation:  In keeping with generally accepted standards of practice, I frequently consult with other Licensed Professional Counselors and mental health professionals regarding the management of cases. The purpose of the consultation is to assure quality care while client confidentiality is respected.

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:  If an emergency situation should arise, you may seek help through hospital emergency room facilities or by calling 911 or Thibodaux Regional Medical Center at (985)447-5500.

Client Responsibilities:  Your participation in the counseling process is essential for a positive outcome.  You are encouraged to take an active role in the counseling process through sharing with me your thoughts, emotions, difficulties you have or had experienced in your life, and relationship issues that you want to improve on.  You also have to apply the information and skills you gain through the counseling process to your life outside of the counseling sessions.  If you have any concerns or suggestions during the counseling process, please bring them to my attention.  I also need to be made aware if you are receiving services from another mental health provider.  With your written consent, I am able to collaborate with the provider to coordinate services to fully meet your needs.  If I see that you may be better suited for another counselor I will help you with the referral process.

Physical Health:  It is imperative that your physical health be assessed as this can be an important factor in your emotional well-being.  It is recommended that you receive a complete physical evaluation with your physician, if one has not been done within the last year.  Also, please provide me with a list of all current medications you are taking and what they are being used to treat.

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 the client was not initially aware.  If this occurs, feel free to share these new concerns with me.

Electronic Communications:  Counseling will not be provided via e-mail or text.  Your individual client portal through CounSol (EMR) provides confidential messaging if you choose not to call the office.  If you are in a state of crisis report to the nearest emergency room or call 911.  Electronic communications via e-mail or text will be utilized for appointment scheduling and appointment changes ONLY.

Special Circumstances: In the event of counselor absence, whether by retirement or death, your client portal can provide you access to your client files.

Clinical Supervision:  I am a board approved supervisor for counselor interns.

I have read the Declaration of Practices and Procedures of Stacey Guidry, LPC-S (revised January 1, 2017), and my signature below indicates my complete informed consent to services provided by

Stacey Guidry, LPC-S.  I also attest that she fully answered any questions I had in regards to this Declaration of Practices and Procedures.

( Type Full Name )




Effective January 31, 2011

Information will only be released in accordance with state and federal laws and the ethics of the counseling profession.

This notice describes policies related to the use and disclosure of your, the client's, healthcare information.

Use and disclosure of protected health information for the purposes of providing services. Providing treatment services, collecting payment and conducting healthcare operations are necessary activities for quality care. State and federal laws allow us to use and disclose your health information for these purposes.

The use and disclosure of health information may be needed for TREATMENT to provide, manage or coordinate care, consult with other healthcare professionals and to communicate with referral sources. 

For example, information may be shared with providers to create a treatment plan specifically to meet your needs.

The use and disclosure of health information may be needed for PAYMENT to verify insurance/ coverage and to process claims and collect fees.  For example, information may be shared with Blue Cross/ Blue Shield to cover services rendered.

The use and disclosure of health information may be needed for HEALTHCARE OPERATIONS to review treatment procedures and business activities, certification, training, and compliance and licensing activities.  For example, staffing with another LPC may occur to explore treatment options.

The use and disclosure of health information may be needed forOTHER USES AND DISCLOSURES WITHOUT YOUR CONSENT such as mandated reporting, emergencies, criminal damage, appointment scheduling, treatment alternatives and as required by law.  For example, if a child is being physically abused, as a mandated reporter, the authorities must be contacted.


The following is to inform you, the client, as to your rights under state and federal law.

1.     You have the right to request where I contact you (ex: home, work, cell phone or any other means you prefer).  This information was identified in your initial intake.  You maintain the right to change this at any time.

2.     You have the right to request the release of your medical records. 

a.     In order for you records to be released, you will need to provide written authorization to release the records (ex: changing to a new counselor for therapeutic services). 

b.     You have the right to revoke this release by submitting a written request

c.     Revocation is not valid to the extent that you have acted in reliance on such previous authorization.  In other words, information disclosed with the release cannot be undone with revocation.

For example, your counselor may want to consult with your physician in regards to medication management. 

3.     You maintain the right to inspect and copy your medical billing records.  In most cases, you maintain the right to review or request copies of you records.  You may be charged for the costs associated such as copying and/ or mailing. 

4.     You have the right to add information or amend you medical records.  You may request to amend your record in writing, and provide a reason for your request.  While the counselor may deny this request, you have the right to file a disagreement statement.  Your disagreement statement and response will be filed in the record.  Any amendment request must be in writing.

5.     You have theright to accounting of disclosures for a 6 year period beginning with the date January 2012.  Exceptions include:

a.     Disclosure for treatment, payment or healthcare operations

b.     Disclosures pursuant to a signed release

c.     Disclosure made to client

d.     Disclosures for national security or law enforcement

6.     You maintain the right to request restrictions on uses and disclosures of your healthcare information.  In other words, you have the right to request to limit how your information is used or disclosed.  This request must be in writing and you must identify what information you want to limit and to whom you want the limits to apply.  You can request in writing for the limit to be terminated.  The counselor is not obligated to agree.

7.     You maintain the right to complain.  Please contact your counselor, Stacey Guidry, first to discuss; however, if you are not satisfied, you have the right to complain to the U.S. Dept. of Health and Human Services.  If you file a complaint, you maintain the right for no retaliation by your counselor.

8.     You maintain the right to receive a notice of changes of policy that affect you on or after the effective date of change.

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