The Pfeiffer Institute for Marriage and Family Therapy Clinic Policies & Procedures Manual

Division of Applied Health Sciences Marriage and Family Therapy Program Pfeiffer University, Charlotte, NC

Table of Contents Table of Contents ........................................................................................................................................................... 2 Pfeiffer University ........................................................................................................................................................... 8 Mission ......................................................................................................................................................................... 8 Vision............................................................................................................................................................................ 8 Purpose and Philosophy ............................................................................................................................................ 8 Administrative Policies ................................................................................................................................................... 9 Internship MMFT690 ................................................................................................................................................ 9 Procedures to Begin PIMFT Internship ............................................................................................................. 9 Documentation Required Prior to Internship .................................................................................................. 10 Early Entry to PIMFT ......................................................................................................................................... 10 MFT Competencies .............................................................................................................................................. 11 Reflecting Team .................................................................................................................................................... 11 Role of the Supervisor ............................................................................................................................................. 11 Professional Fitness Evaluation ......................................................................................................................... 12 Live Observation Assessment ............................................................................................................................ 12 Clinical Performance Evaluation ........................................................................................................................ 13 Servant Leadership Self-Assessment ................................................................................................................. 13 Core Competency Completion ........................................................................................................................... 13 Registration for MMFT 690A ............................................................................................................................. 13 Clinical Assessment Timeline ......................................................................................................................... 14 Confidentiality ........................................................................................................................................................... 14 Social Media........................................................................................................................................................... 15 Co-therapy ................................................................................................................................................................. 15 Professional Dress Code.......................................................................................................................................... 16 Dress Guidelines ................................................................................................................................................... 16 Dress Code Requirements ................................................................................................................................... 16 Grooming Guidelines .......................................................................................................................................... 17 Unacceptable attire and accessories ................................................................................................................... 17 Front Desk Staff ................................................................................................................................................... 17

Page 2

Exceptions ............................................................................................................................................................. 18 Religion, Ethnicity, or Disability ........................................................................................................................ 18 Other products ...................................................................................................................................................... 18 Office Maintenance .................................................................................................................................................. 18 Recording Equipment .............................................................................................................................................. 18 Intern Work Room ................................................................................................................................................... 19 Computers ............................................................................................................................................................. 19 Visitors ....................................................................................................................................................................... 19 Grievance Policy ....................................................................................................................................................... 20 Therapist Intern Remediation ................................................................................................................................. 21 Gatekeeping ........................................................................................................................................................... 22 Internship Requirements ............................................................................................................................................. 24 COAMFTE Requirements ...................................................................................................................................... 24 Client Contact Hours ........................................................................................................................................... 24 Relational Hours ................................................................................................................................................... 25 Relational Group Hours ...................................................................................................................................... 25 Supervision Hours ................................................................................................................................................ 25 Field Placement ......................................................................................................................................................... 26 The Purpose of a Field Placement ..................................................................................................................... 26 The Procedures to Begin a Field Placement ..................................................................................................... 26 Who is Qualified to Begin a Field Placement................................................................................................... 27 Documentation Required before the Field Placement begins ....................................................................... 27 Supervision and Supervisory Relationship of Field Placement...................................................................... 27 Documentation Required in the External Internship ..................................................................................... 28 Completion of Field Placement .......................................................................................................................... 28 Procedures...................................................................................................................................................................... 28 Case Assignment and Scheduling ........................................................................................................................... 28 Case Assignment ................................................................................................................................................... 28 Scheduling New Clients ....................................................................................................................................... 29 Scheduling Returning Clients .............................................................................................................................. 30 Scheduling New Constellation Appointments of Returning Clients ............................................................ 30 Scheduling Therapy Appointments for Minors ............................................................................................... 30 Page 3

Greeting Incoming Calls...................................................................................................................................... 31 Scheduling Clinic Rooms for Therapy .............................................................................................................. 31 Intake Calls and Scheduling by a Third Party................................................................................................... 32 Referral Sources .................................................................................................................................................... 32 General Information ................................................................................................................................................ 32 Hours of Operation.............................................................................................................................................. 32 Directions .............................................................................................................................................................. 33 Operating Schedule .............................................................................................................................................. 33 Children at PIMFT ............................................................................................................................................... 34 Fee Schedule and Collection ................................................................................................................................... 34 Case Management & Documentation ................................................................................................................... 35 Recording Therapy Sessions ............................................................................................................................... 36 Two-way mirrors .................................................................................................................................................. 37 Obtaining and Releasing Client Information ................................................................................................... 37 Terminating a Case ............................................................................................................................................... 38 Transferring a Case to another Therapist ......................................................................................................... 38 Managing Client ‘No show’ or ‘Cancellations’ ................................................................................................. 39 Documenting Client and Supervision Hours ................................................................................................... 39 Therapist Vacations and Absences from the Clinic ........................................................................................ 40 Case Assignment Suspension Form................................................................................................................... 41 Therapist Intern Mailbox..................................................................................................................................... 41 Case File Forms............................................................................................................................................................. 41 Forms Required to Open a Case ............................................................................................................................ 41 Phone Intake Record ........................................................................................................................................... 41 Client Handbook ...................................................................................................................................................... 41 Initial Session Forms ................................................................................................................................................ 42 Informed Consent ................................................................................................................................................ 42 Research Participant Consent Form .................................................................................................................. 42 Fee Agreement ...................................................................................................................................................... 42 Assessment Packet................................................................................................................................................ 42 Client Feedback .................................................................................................................................................... 43 Outcome Rating Scale...................................................................................................................................... 43 Page 4

Session Rating Scale ......................................................................................................................................... 43 Client Satisfaction Survey ................................................................................................................................ 44 Forms to be Completed after Each Session ......................................................................................................... 44 Progress Note Template ...................................................................................................................................... 44 Forms Needed to Close a Case............................................................................................................................... 45 Case Termination Form....................................................................................................................................... 45 Case Transfer Form ............................................................................................................................................. 45 Additional Case Record Forms............................................................................................................................... 45 Case Review Form................................................................................................................................................ 45 Phone Log Sheet ................................................................................................................................................... 46 Crisis Intervention and Emergency Procedures ....................................................................................................... 46 Acute Crisis Over-the-Phone .................................................................................................................................. 46 Clinical Emergencies ................................................................................................................................................ 46 Safety Risk to Therapist ....................................................................................................................................... 47 Current or Recent Sexual or Physical Abuse .................................................................................................... 47 Intimate Partner Violence ................................................................................................................................... 48 Intoxication ........................................................................................................................................................... 49 Suicidal Ideation.................................................................................................................................................... 49 Acute Psychiatric Concerns ................................................................................................................................ 50 Expression of Homicidal Intent ......................................................................................................................... 51 Other Safety Measures for PIMFT Staff and Therapist Interns ................................................................... 52 Appendices..................................................................................................................................................................... 53 Intern Checklist ......................................................................................................................................................... 54 Application for Clinical Internship Candidacy ..................................................................................................... 55 MMFT 690: Supervision Contract for Therapist Interns ................................................................................... 58 Intern Acknowledgment of Confidentiality .......................................................................................................... 60 MFT690: MFT Competencies ................................................................................................................................ 61 Live Observation Assessment................................................................................................................................. 62 Clinical Performance Evaluation ............................................................................................................................ 65 Case Management ...................................................................................................................................................... 65 Field Placement Site Requirements ........................................................................................................................ 68

Page 5

Field Placement Site Supervision Agreement ....................................................................................................... 69 Field Placement Site Supervisor Application ........................................................................................................ 73 Field Placement Site Evaluation ............................................................................................................................. 76 Intern Evaluation of Field Placement Supervision .............................................................................................. 80 Recording Therapy Sessions ................................................................................................................................... 84 Final Report of Internship – Client & Supervision ............................................................................................. 85 Intern Self Evaluation .............................................................................................................................................. 86 Index Cards................................................................................................................................................................ 89 Phone Log Sheet ....................................................................................................................................................... 90 Informed Consent Form ......................................................................................................................................... 91 Phone Intake Form .................................................................................................................................................. 93 Assessment Packet .................................................................................................................................................... 94 Outcome Rating Scale ............................................................................................................................................ 103 SRS/ORS Graph .................................................................................................................................................... 104 Session Rating Scale ............................................................................................................................................... 105 Room Reservation Binder ..................................................................................................................................... 106 Vacation/Leave of Absence Form....................................................................................................................... 107 PIMFT Case Notes Form ..................................................................................................................................... 108 Fee Agreement Form ............................................................................................................................................. 111 Authorization for Release of Client Records ...................................................................................................... 112 Case Termination Form ......................................................................................................................................... 114 Case Transfer Form ................................................................................................................................................ 115 Transfer Case Grid ................................................................................................................................................. 116 Monthly Clinical Service Report (MCSR) form ................................................................................................. 117 Case Assignment Suspension Form ..................................................................................................................... 118 Research Participant Consent Form .................................................................................................................... 119 Agreement to Live Contract ................................................................................................................................. 120 Violence Prevention Contract............................................................................................................................... 121 Scheduling Clients Using Outlook ....................................................................................................................... 122 PIMFT Client Handbook ...................................................................................................................................... 124 PIMFT Client Handbook ...................................................................................................................................... 126 Professional Fitness Evaluation............................................................................................................................ 127 Page 6

Servant Leadership ................................................................................................................................................. 128 Sample Letter to Client .......................................................................................................................................... 129 Case Review Form .................................................................................................................................................. 130 Case Assignment Form .......................................................................................................................................... 131 Risk and Safety Assessment Form ....................................................................................................................... 137 Suicide Assessment Flowchart .............................................................................................................................. 138 Therapist Intern Agreement Form ....................................................................................................................... 139 Permission to Treat Minors Form…………………………………………………………………….140

Page 7

Pfeiffer University Mission Reflecting its relationship with the Methodist Church, Pfeiffer University is a globally engaged, regional university distinctive for its transformational undergraduate experience and its leadership in professional and graduate programs that fill demonstrated needs. Vested in its history as a Univted Methodist-related university and propelled forward by an innovative faculty and staff, Pfeiffer prepares its students for a lifetime of achievement, scholarship, spirituality and service (see Mission Statement, Pfeiffer University Graduate Catalog, p. 3).

Educational Goals for the Graduate Program The graduate programs are designed to offer the depth of education and specialized skills necessary for graduate to practice and contribute to their professions. Graduates will be expected to have demonstrated abilities in analyzing, planning, and performing in relation to specific problems and issues. These skills are evaluated through the use of a designated capstone course within each graduate program (see Pfeiffer University Graduate Catalog 2014-2015, p. 4).

Vision We will be recognized as the model church-related institution preparing servant leaders for lifelong learning.

Purpose and Philosophy The Pfeiffer Institute for Marriage and Family Therapy (PIMFT) was established to provide training opportunities for Master’s level graduate students in the Marriage and Family Therapy (MFT) Program. The PIMFT student therapists provide direct services for individuals, couples, families, or groups and serve as servant leaders and community resources for other agencies in the Charlotte and the surrounding areas of Mecklenburg County. The focus of all services, direct and indirect, is on assessing and improving the way relational systems work – whether the system is a couple, family, group, classroom, or agency. The PIMFT adheres to the rules and regulations of the American Association for Marriage and Family Therapy (AAMFT) Code of Ethical Principles for Marriage and Family Therapists in the provision of direct and indirect services. In addition, the PIMFT adheres to the policy and procedures of the Pfeiffer University Marriage and Family Therapy Program Manual. The Pfeiffer Institute for Marriage and Family Therapy (PIMFT) serves as the primary clinical training facility for the MFT Graduate Program at Pfeiffer University, Charlotte. Each entering student therapist is required to obtain an adequate amount of their clinical training and the majority of their supervision in the PIMFT. Further description of obtaining and completing hours will be discussed in the Commission on Accreditation for Marriage and Family Therapy Education (COAMFTE) Requirements for Graduation section of this manual.

Page 8

Clinical training is obtained through an on-site practicum in the clinic, the student’s first experiential course (MMFT606 – Practicum - Therapeutic Alliance), participation in community outreach opportunities, and continuation through off-site internship (MMFT690). All entering students will spend a portion of their first year becoming acquainted with the program, specific clinical requirements, and protocol prior to serving clients. Most students will begin collecting client contact hours in the PIMFT during the second year. Students are encouraged (and at times, required) to observe other student therapists working with the clients in the PIMFT during their first year in order to become better acquainted with the PIMFT and its operating protocol. In addition to being a training facility for the MFT Program, the PIMFT is also a service facility for the community. The PIMFT operates much like any other mental health related business. The PIMFT serves residents of Mecklenburg County and surrounding counties, in addition to providing services to Pfeiffer University students, faculty, and staff. Since opening PIMFT in September 2008, the clinic is currently not 100% self-sustaining. In 2011, the PIMFT has been generating revenue from collected client fees to cover most operating costs. As a service facility, the student therapists and supporting staff of the PIMFT have an obligation to clients to conduct themselves in a professional manner including, but not limited to, the way one dresses, one’s attitude and behavior towards clients, and one’s focused attention to the details of how the business portion of the PIMFT is conducted. Regardless of how much a client may pay per session, each and every individual will be treated with respect and compassion.

Administrative Policies Internship MMFT690 To ensure that the potential student therapist is ready to begin PIMFT internship, the following steps will be taken: The student will review the material contained in the Pfeiffer MFT Student Handbook. All incoming students must attend an orientation led by the Clinic Director or Front Desk Administrative Staff for a further review of the contents of the Clinic Manual, the AAMFT Code of Ethics, confidentiality issues, and emergency procedures. The student will meet with the Clinic Director and/or Front Desk Administrative Staff to review PIMFT policies and procedures, to receive training on completing all required forms and documents correctly, and to learn efficient operation of all PIMFT digital recording equipment.

Procedures to Begin PIMFT Internship When the student completes required coursework and obtains approval from MFT faculty, the student will schedule an interview with the Clinic Director before the semester of MMFT690 begins. The student may contact the Clinic Director 8 weeks prior to the anticipated semester of MMFT690. At the time of the Page 9

interview the student will turn in documentation (see next section for details) to the Clinic Director to become a therapist intern in the PIMFT. The student must have taken and successfully completed MMFT606 within the previous 3 semesters upon entering MMFT690. Students may need to retake or postpone registering for MMFT606 if he/she is unable to register for MMFT690 within the following 3 semesters of successful completion of MMFT606.

Documentation Required Prior to Internship The following forms must be completed and signed by the student and applicable MFT faculty and/or Clinic Director:  Intern Checklist  MMFT690: Supervision Contract for Therapist Interns  Intern Acknowledgment of Confidentiality  Proof of Student Liability Insurance (free from CPH with AAMFT Student Membership; call 800875-1911)  Application for Internship Candidacy  Professional Fitness Evaluation completed by two former professors (not the Clinic Director)  Therapist Intern Agreement Form

All forms will be placed in the therapist’s MFT file. A copy of these forms, and all other forms referenced in the manual, are included in the Appendix. Once a student has submitted a completed application packet (i.e. all forms signed), she/he will schedule and successfully complete a mock intake session and attend the clinic orientation before his/her first live therapy session. It is the responsibility of each intern to renew his/her liability insurance and to give the Clinic Director the updated proof of coverage. If liability insurance expires and no renewal is on file, the intern will be required to immediately discontinue therapy and arrange an alternative treatment plan for cases (e.g., find another therapist/provider to continue treatment).

Early Entry to PIMFT Based on clinic needs, students who have successfully completed the procedures to enter into the clinic may be asked to enter the clinic early. Times exist when interns finishing their clinic experience need to transfer their sessions to continue and preserve the integrity of client care. In addition, existing interns may need to transition out of the current rotation (e.g., accepting new intakes) in preparation for taking on an additional external site. Thus, a need may be created in which incoming interns may be offered the opportunity to begin their clinic experience early to help with availability with new cases, transfer sessions, and/or desk duty. An intern will be eligible for early entry if the following conditions are met: a) a complete application has been received from the intern with liability insurance verification; b) the intern has conducted a mock intake session ; c) an acting supervisor is assigned for the interim period; and d) the intern will only participate in co-therapy sessions. The hours accrued during this interim period between semesters will be able to be counted if the above conditions are met. Although early entry may occur one semester, it is not a guarantee that the need or offer will exist every semester.

Page 10

MFT Competencies In 2004, AAMFT published a list of 128 distinct competencies. The MFT competencies describe what it means to practice as a marriage and family therapist. The therapist intern will be evaluated on the assigned MFT competencies in the MMFT690 course during the end of each semester (see MMFT690: MFT Competencies). Each intern will receive a final semester supervisory assessment over the assigned MFT Core Competencies for MMFT690. This assessment is designed to indicate the intern’s progress in professionalism, therapeutic skills and abilities, case management, and case conceptualization. The MFT Core Competencies will not be an academic score. The COAMFTE Core Competencies are outlined in each syllabus in every course each semester. During the semester, the professor is responsible for assessing the degree to which the competency has been developed at a minimal Performance Level of “3” on the 1-5 Assessment Rubric Rating Scale. If the student has not achieved each competency at the minimal level of success by the last day of the semester, the student will have (30) days after the final exam date to remediate the competency, and then report back to the professor to demonstrate how the competency has been met. If demonstration of the competency has not been satisfactorily completed at a minimal performance level of “3” after the 30 day period, the student will be referred to the Faculty Remediation Committee (FRC) who will meet with the student and provide corrective feedback through the use of a written Individual Remediation Plan (IRP) and timeline. The student will have until the end of the semester to demonstrate fulfillment of the minimal performance level. If the student does not address the student learning outcome prescribed or cannot meet a minimal performance level of “3,” the student will be dismissed from the program at the recommendation of the FRC Committee members.

Reflecting Team Interns may be given the opportunity to participate in a Reflecting Team. The Reflecting Team offers benefits to interns, who have the opportunity to collaborate on cases using the two-way mirror, and clients, who benefit from in-session feedback from multiple interns. Interns must be in good standing (e.g., maintain a B or A in MMFT690, not involved in an IRP) to participate in reflecting team.

Role of the Supervisor An important part of training in marriage and family therapy is the experience of being supervised by an experienced therapist and supervisor. In the PIMFT, MFT faculty and Clinic Director provide both live supervision of sessions, and review digitally recorded sessions and case records. Supervision will occur in a group format (eight students or fewer) and individually (one or two students) in accordance with the AAMFT Commission on Accreditation for Marriage and Family Therapy Education (COAMFTE). By policy, the internship supervisor is responsible for all cases seen by therapists under his/her supervision. Therefore, the therapist must ensure that the supervisor is aware of each case being seen and that the supervisor is involved in decisions regarding the course of

Page 11

therapy, including fee setting, contact with other agencies and professionals, decisions to transfer a case or to terminate a case, and interventions. The relationship between supervisor and student therapist is intended to be collegial, with each party contributing to the enhancement of therapy for the client. However, differences in experience between student therapists necessarily lead to differences in the degree of control that a supervisor must have in a particular case. Some student therapists will have considerable latitude in deciding on case matters; others will be expected to consult the internship supervisor on what may appear to be minor matters until the supervisor is convinced that the student can act alone. Disputes that may arise between the student therapist and the supervisor are best settled between the two parties. If a satisfactory resolution cannot be reached, grievance procedures are available to either party (see Grievance Policy).

Professional Fitness Evaluation As part of the Application for Internship Candidacy, the Professional Fitness Evaluation is completed by two current or former professors of the student therapist. The student should meet with each evaluator to discuss their scores; the student must earn at least a 3 (meets expectations in most respects) in order to register for MMFT 690. This evaluation serves as a confidential barometer of professional fitness and therapist readiness to enter internship. The purpose of this evaluation is to ensure that a student does not have non-academic personal and/or professional problems significant enough to limit his/her effectiveness as a professional therapist. This evaluation encourages students to nurture their roles as “servant leaders” and monitor their attitudes and attributes for therapist identity development and self-regulation. During the first semester of MMFT 690, the student intern’s professional fitness – as demonstrated at the PIMFT and field placement sites -- will be evaluated by the supervisor. Each supervisor will meet with the intern to provide feedback and review the evaluation. The student must earn at least a 4 (meets expectations in all respects); if the student is not evaluated as meeting expectations in all respects (less than 4) on any item, the supervisor will discuss ways with the student how he/she can improve. The supervisor will give the form to the Clinic Director, who will give it to the second semester supervisor so the student’s progress can be monitored and re-evaluated with a Professional Fitness Evaluation during the second semester of internship. If the student again does not have 4 for all items, an IRP may be necessary. The student may request a copy of the evaluation; the original will be kept in the student intern’s clinical file and an electronic copy will be stored in the student’s file on DropBox.

Live Observation Assessment Each time a student therapist is supervised live (i.e., while meeting with a client), the supervisor will complete a Live Observation Assessment and go over the feedback with the student therapist. The Live Observation Assessment uses the same categories and scoring system as the Clinical Performance Evaluation (see below) and can be used to track progress and areas of concern. The student is expected to “meets criteria consistently at this program level” (i.e., score of 2) on all items (Communication Skills and Abilities, Professional Responsibility, Case Management, Competence, Maturity, Integrity, Case Progression, and Integration of Feedback). For any items scored below 2, the supervisor provides written and verbal

Page 12

feedback to the student. The student therapist will receive a copy of the form to keep in the client’s file; the original form will be kept in the student’s file in the Clinic Director’s office.

Clinical Performance Evaluation During each semester of MMFT690, the student therapist will be evaluated by his/her internship clinic supervisor and externship on-site supervisor using the Clinical Performance Evaluation. Each supervisor will meet with the intern to provide feedback and review the evaluation. The student must be assessed at a minimal "performance level of 2" based upon the 0-2 scale. If the student is deficient (less than 2), the supervisor will discuss ways with the student how he/she can improve; however, if the student does not improve in that area by the next evaluation, the Pfeiffer University instructor/supervisor may initiate a FRC meeting and recommend the appropriate IRP for corrective feedback and remediation. The original copy of the evaluation will be stored in a locked filing cabinet in the office of the Clinic Director of the Pfeiffer Institute for Marriage and Family Therapy. If requested, a copy will be given to the student for his or her personal file. The purpose of the evaluation is to provide feedback and track the progress of the student therapist.

Servant Leadership Self-Assessment During the second semester of MMFT690, the student therapist will complete a Servant Leadership SelfAssessment. Servant Leadership is addressed in each course that the students take and a self-assessment is completed in MMFT 601, 606, and 621. In MMFT690, however, the emphasis becomes integrating servant leadership in the therapeutic role. Qualities addressed are integrity, humility, servanthood, caring for others, empowering others, developing others, visioning, goal setting, leading, modeling, team-building, and shared decision-making. The student therapist should submit the completed assessment to the Clinic Director to be scanned in the student’s program file on Dropbox; the assessment will be kept in the intern’s file.

Core Competency Completion Student therapists must successfully achieve all core competencies at the end of three semesters of MMFT690. Through the assessments listed above, student therapists are evaluated each semester as they move through their internship. If a student therapist has completed all core competencies at the end of three semesters yet still has client contact hours to accrue to reach the 500 hour requirement, then he/she is eligible to register for MMFT690A (see next section). However, if a student therapist has had 3 semesters of MMFT690 yet has not demonstrated an adequate level of competency (i.e., at least a 3 on the Assessment Rubric Rating Scale for all competencies associated with MMFT690), the student will continue to register for MMFT690 and complete all required assignments. Demonstration of core competencies is recorded on the Assessment Rubric Rating Scale by the Clinic Director based on feedback from clinic and field placement site supervisors; the student therapist must earn at least a 3 on each core competency associated with MMFT690.

Registration for MMFT 690A Student therapists are eligible to register for MMFT690A after they have completed three semesters of MMFT690 and met all of the Core Competencies in MMFT690. In MMFT690A, students continue to see clients at Reach and field placement site for the purpose of accruing client contact hours. Since the core competencies have already been met, student therapists are not required to complete the written assignments in MMFT690, yet they are required to participate in individual and group supervision throughout the semester (i.e., Page 13

even if hours requirement is reached during the semester). Reach and field placement supervisors will complete the Clinical Performance Evaluation to monitor progress, and students will complete the Office Performance Self-Evaluation to examine their participation in the “life” of the clinic each semester.

Clinical Assessment Timeline Semester 1st Semester of MMFT690 2nd Semester of MMFT690 3rd Semester of MMFT690 4th and 5th Semester (as needed) MMFT690A

Evaluation of Student Therapist by Supervisor(s) Professional Fitness Evaluation Clinical Performance Evaluation Servant Leadership Self-Assessment Clinical Performance Evaluation Completion of Core Competencies Clinical Performance Evaluation Clinical Performance Evaluation

Confidentiality Client information will be protected by the therapist, PIMFT staff, and internship supervisor. The PIMFT will abide by Health Insurance Portability and Accountability Act (HIPAA) in an effort to protect client confidentiality. All information about clients should be considered confidential – names, personal information (age, gender, occupation, relationship status, etc.), topics discussed in therapy, etc. Information regarding clients should only be discussed with other therapists in private or with the internship supervisor. All client information including case records and recordings must be secured at all times. Records, recordings, and phone calls to clients must remain within the confidential areas (e.g., locked filing cabinets, intern room) of the PIMFT administrative offices. If information is to be released or obtained from another agency or professional, a properly completed and signed Authorization for Release of Client Records must be obtained from the client. Procedures in protecting the confidentiality of the client involve the following:  

 

Refraining from discussing anything about a client anytime you are outside the clinic or field placement site that could possibly identify the client; If, while observing a session (live or during supervision), you recognize the client from some other aspect of the life of the therapist (e.g., a neighbor, a current student) you must excuse yourself from observing that particular session immediately; You must resist any behavior that might be in conflict with the AAMFT Code of Ethics regarding confidentiality; Only PIMFT staff, students, and faculty are allowed into the clinic, including the administrative offices and therapist work room. Do not bring friends, spouses, children, students, etc. into the facilities without first discussing the visit and obtaining prior approval from the Clinic Director;

Page 14

 

All clinical work (e.g., case notes, recordings) must stay in the clinic and cannot be uploaded to a personal computer. Interns may choose to view their Outlook calendar on a Smart phone or other device outside PIMFT premises. If so, all client information must be safeguarded (e.g. enter client initials rather than names) and the device must be password protected.

Instances may occur when another adult calls on behalf of an adult client. For instance, an adult client’s parent, spouse, etc. calls on behalf of the client, but is not a client here and is not part of the client’s session (e.g., signed a consent form). PIMFT cannot confirm nor deny that the person whom the caller is calling about is a client without written consent from the adult client. In the event of this situation, the front desk attendant will inform the caller that due to confidentiality regulations we cannot confirm nor deny that person is a client. In addition, the front desk can offer to take a message for the therapist the caller believes is working with the person he/she is calling about and if the therapist has a written release, the therapist will return the call. However, if there is no release or if that person is not a client here the caller may not get a returned call. The front desk attendant will inform the person to talk with his/her adult child, spouse, etc and during the next session if he/she (the client) wants the therapist to disclose information to the caller in the future he/she (client) must sign a release form. It is equally important to maintain professional boundaries and protect the confidentiality of PIMFT staff, students, and faculty. Procedures in protecting the confidentiality of PIMFT staff, students, or faculty involve the following:  

Refraining from disclosing personal email, contact number, or home or work address to clients or any person without rights to such privileged information. Refraining from accepting “friend” requests on Facebook or following on Twitter with clients.

Social Media Disclosure of any client personal identification outside of PIMFT is unethical; thus, there is also a fine line of respecting the privacy and professionalism of our practice. While there is not a specific code of ethics delineating the use of “therapy references or general client discussion” via social media, therapist interns will practice not disclosing any information, general or specific, about our practice/clients through a social media outlet. If an intern is curious about the appropriateness of a comment or status update, he/she is encouraged to review with his/her supervisor in advance of posting.

Co-therapy AAMFT COAMFTE regulations dictate what can be counted as co-therapy hours. To have a session count as co-therapy, it is necessary that each therapist be in the room with the client(s) for the majority of the session. Co-therapy can be especially useful in dealing with couples, families, and groups. Students are assigned a co-therapist during part of the PIMFT experience and are encouraged to engage in co-therapy when it is appropriate. To avoid confusion, while working as co-therapists, one therapist must be declared as the primary therapist; the other

Page 15

therapist is the co-therapist. The supervisor who supervises the primary therapist will provide supervision for the case. Times may exist when an existing case could benefit from an additional therapist’s involvement (e.g., conflictual couple, parents requesting therapy sessions for child). Therapists must consult with his/her supervisor prior to adding an additional therapist to the session. Therapist interns involved in co-therapy must commit to the following per co-therapy case: 1) Plan additional time to discuss the case on a weekly basis and 2) Work together until case terminates. No more than two therapists may work on the same case (e.g., couple, family).

Professional Dress Code All therapists are expected to ensure that their dress and grooming project a positive image of the PIMFT. Choice of dress should convey respect, competence, and caring to our clients and colleagues. In an effort to ensure professionalism, therapists are required to dress in appropriate attire that complies with the clinic dress code in effect even when entering the clinic back offices, seeing clients, or representing the clinic or program at professional meetings/engagements on campus and/or in the community that pertain specifically to clinic or field placement performance, issues, and/or concerns. These guidelines are in effect even if an intern does not have a client scheduled that day. For example, a therapist may request assistance from a reflecting team made up of all those observing the session, so all interns at that session must be dressed congruent with their role as professionals.

Dress Guidelines For clinic purposes, business or business casual dress is defined as the following:        

A dress shirt (button-down with collar)* Nice sweater or blouse* Slacks, chinos, or skirt (no jeans) Dress* Clean, nice shoes Belts and dress socks (for men) Neck tie (optional) Jackets (optional)* – sports jackets (men), layered jackets with

*minimum elbow-length sleeves (women)

Dress Code Requirements Dresses and/or skirts must be conservative in style and length, so that bare legs do not touch the seat when seated. Pants and/or slacks for men and women should be at least ankle length. Jewelry and other accessories must be conservative and not distract from the focus of the therapeutic relationship or professional presentation of self. Earrings are limited to two per ear and the top earring(s) must be a post

Page 16

(males may not wear earrings). Nail length should be conservative in length and nail designs and colors must be moderate and not distracting.

Grooming Guidelines Hairstyles, make-up, the grooming of beards and mustaches, and personal hygiene should be reasonable and in accordance with customary business practices. Extreme hairstyles and color are not acceptable. An employee’s personal grooming and hygiene should contribute to a clean, neat appearance and impression. Clothing should be clean, neat, well-fitted, and ironed in appearance at all times. The recognizable odor of tobacco smoke is not acceptable and colognes or perfumes should not be worn during therapy sessions.

Unacceptable attire and accessories Unacceptable attire includes, but is not limited to, the following:                     

Jeans or jean/denim material (of any color) Capri pants, cargo pants, culottes, drawstring and/or ruched pants, low rise or “hip-hugger” pants Knit/golf shirts Sundresses Muscle shirts, tank tops, halter tops, spaghetti strap tops, or shirts that reveal the midriff Stand alone camisoles Torn clothing, cutoffs, and beach attire Mini-skirts, mini-skorts, and other skirts/shorts Sheer or “see through” clothing or fabric that exposes bare skin Plunging necklines Spandex clothing and leggings Tee-shirts, sweatshirts, sweatpants, and other workout attire Slippers, casual sandals, tennis shoes, sneakers, or work boots Clothing that is offensive, revealing, distracting, provocative or excessively tight Evening attire or formal wear Hats or caps Open-toed, peep toe, or backless shoes Non-traditional accessories or outer wear, such as chains or fanny packs Visible body piercings (other than earrings), such as dental, tongue, lip, nose, or eyebrow jewelry Excessively long nails Exposed tattoos

Front Desk Staff The front desk staff must wear business casual attire at all times.

Page 17

Exceptions The Clinic Director may specify additional dress guidelines based on the PIMFT needs and field placement requirements. Examples of such needs are as follows: public presentations, workshops, health fairs. During times of professional presentations in the community, it will be necessary for students to be in traditional business attire, unless otherwise directed by Clinic Director.

Religion, Ethnicity, or Disability Reasonable accommodations for dress or grooming directly related to a student’s religion, ethnicity, or disability will be reviewed and accommodated accordingly. Note: The PIMFT Administrative Staff reserves the right to determine the professional appropriateness of dress/attire, accessories, and/or appearance of all staff and therapist interns. Students who do not follow the dress code are subject to a disciplinary counseling record being placed in their program file. In addition, if the dress code is not respected and violations occur either intentional or unintentional in the PIMFT or community setting the therapist intern may be asked to leave and change clothing.

Other products The employees and therapist interns of the PIMFT are not permitted the use of tobacco or tobacco products (e.g., cigars, pipe tobacco, chewing tobacco, snuff, electronic cigarettes), alcohol, or other illegal substances in the Pfeiffer Institute. In addition, the use of chewing gum is not permitted at any time in the presence of clients, visitors, or guests. Nicotine replacement products including gum, lozenges, nasal spray, and inhalers may be used during work hours, but usage should be discreet and in accordance with physician and product manufacturer directions.

Office Maintenance The PIMFT does not have a nightly janitorial staff to take care of cleaning responsibilities. The cleanliness and general maintenance of the PIMFT is the sole responsibility of the individuals who use the facility. Please do not leave any paper, food wrappers, food, etc. on the floors or desks of the clinic and work room. Return chairs to their usual place if you rearrange them during a session or group supervision. Clinic rooms and the waiting room should be picked up and prepared for the next client every evening. Please be aware that food odors may linger. Clean up after any consumption of food or beverages. Please be aware that talking, coughing, or laughing while you are observing a session from one clinic room to another can be seen and heard by clients. Please be respectful of the client(s) in the therapy session and refrain from rude or condescending comments made to another therapist, regardless of how the session may be impacting you and/or the therapist who is working with the client.

Recording Equipment The PIMFT is designed to accommodate the highest standard of training for student therapists and to provide high quality care for clients. The facility offers digital technology to record therapy sessions. All

Page 18

therapists will be instructed on how to use the technology for successful recording of each session. See Recording Therapy Sessions.

Intern Work Room The therapist work room is provided to therapists for clinic work (e.g., case management, phone calls to clients, and any other clinic related activity). Please be respectful of clinic properties and do not misuse equipment (e.g., multiple print outs of large documents, printing documents not related to direct clinic work).Use of the therapist work room is a privilege; misuse of clinic equipment or facility may result in a loss of privileges or fines. If equipment is found broken due to mishandling after properly trained, the student(s) responsible may be held liable in any costs associated with repair or replacement. The clinic lab fee is $125 per semester. The fee will go directly towards operating costs of the clinic for student use. Fee is subject to change at the beginning of the new academic year.

Computers Computers are available for therapist intern use for clinic purposes. Therapist interns may not download software (e.g., itunes, games). Each computer will have access to the clinic’s server. The server will hold a personal file for each therapist intern (the file will be the name of the therapist intern) to store his/her recorded session. Therapist interns may use any computer for clinic purposes. Therapist interns must adhere to confidentiality guidelines and not open other colleague files. If a therapist intern is found in another colleague’s file, he/she will meet with the PIMFT Clinic Director and disciplinary action will be taken. Therapist interns are to store recorded therapy sessions in personal file only and download immediately. Please see directions on how to download recorded sessions to file (manual is located on the desktop of each computer: Milestone PDF). Do not save any personal work, completed forms, case notes, or any other files on a personal computer. The Clinic Director reserves the right to delete any unnecessary or miss-saved files at any time, without notice to the file author. Therapy session recordings will be deleted from personal files at the completion of intern’s program experience. Any problems with the PIMFT clinic equipment (e.g., computers, monitors, printers, recording equipment) should be reported to the Clinic Director immediately.

Visitors Visitors of therapist interns (e.g., partners, children, friends) are not permitted to enter the therapy wing without prior consent from the PIMFT Clinic Director (see Confidentiality section). Therapist interns are not allowed to bring their children to the PIMFT clinic if they plan to do work (e.g., see clients, write case notes, make calls) and must arrange other forms of child-care. Children should not be left unattended.

Page 19

Grievance Policy In accordance to the MFT Program Manual, any appeal process will begin at the level of the individuals immediately involved. Grievances can involve, but are not limited to, a student (if an issue ensues between students), an associated instructor (if an individual course is at issue), the Director of the Marriage and Family Therapy (MFT) Program (if an MFT policy is involved), a clinical supervisor and/or Clinic Director (if a clinical matter is involved), or the Department Chair or Provost (if a departmental policy is involved). In the event that a therapist intern has a grievance with the Clinic Director and/or a clinical supervisor, he/she must submit a written and signed document discussing his/her concern directly to the administrative person(s) directly involved. The therapist intern will schedule an appointment to discuss his/her concerns with the Clinic Director and/or clinical supervisor. Where satisfactory resolution has not been achieved at one level (e.g., student with student), the appeal is taken to the next appropriate level of administrative authority. Thus, certain matters proceed from the PIMFT Clinic Director to the MFT Program Director and then to the Provost or Vice-President of Academic Affairs. At any of these levels, there is a specified and explicit procedure. The procedures outlined above have been developed in compliance with existing procedures documented in the Pfeiffer University Student Handbook and the MFT Program Manual. In addition, the university is in compliance with existing legislation such as Titles VI and VII of the Civil Rights Act of 1964, Title IX of the Education Amendments of 1972 (45 CFR 86), and Sections 503 and 504 of the Rehabilitation Act of 1973 (all requiring nondiscrimination on the basis of race, color, national origin, sexual orientation, religion, sex, or disability), plus the Age Discrimination in Employment Act of 1957. This is not an exhaustive list but each item encompasses a particular pattern of compliance with associate procedures for assuring accountability. In almost all cases, it is preferable to handle a grievance informally at the level at which the grievance has arisen. With specific regard to therapist interns in Internship, the individual with a grievance should attempt to resolve it directly with the other person(s) involved. If satisfactory resolution is not reached, the individual should bring the grievance to the Clinic Director who will attempt to help the parties involved reach a satisfactory resolution. If the issue still remains unresolved, the Clinic Director will sign off that the complaint has been forwarded to the next appropriate level (i.e., MFT Program Director). If the issue still remains unresolved at that point, the MFT Program Director will sign off that the complaint has been forwarded to the next appropriate level (i.e., Provost or Vice President of Academic Affairs) and the individual with the grievance should initiate a formal grievance process by writing a letter to the Provost or Vice President of Academic Affairs outlining the grievance, summarizing the previous attempts to reach a satisfactory resolution, and requesting the initiation of the formal grievance procedure. The appeal is on the basis of whether or not appropriate procedures were followed. The goal of the appeal process is not to resolve the issue, but rather to ensure that the therapist intern was treated fairly following established procedures.

Page 20

With both the informal and formal grievance process, it is crucial to proceed in a timely manner. Typically, the therapist intern with a grievance would initiate the resolution process as soon as possible after the incident or incidents in question occurred, within 60 days at the latest. In any grievance procedure, it is crucial that the individual bringing the grievance be protected from any negative consequence arising from the act of bringing a grievance. Fear of negative consequences is one of the reasons it is difficult to begin the grievance procedure at the level in which it must necessarily begin – with the person(s) involved. This is especially difficult when the person with the grievance is in a position of less power than the other individual. For example, a student with a grievance against a clinical supervisor or a faculty member has less power by nature of that relationship. However, a fair grievance procedure requires that difficult issues must be raised and all parties involved must be informed that the grievance exists. Every effort will be made to protect the rights of the person bringing the grievance against retaliation. The MFT Program faculty and staff are committed to insuring that the grievance procedure is a fair one and that procedures are in place for protection and appeal.

Sexual Harassment “Sexual harassment” is defined as the unwanted written, spoken, implied, unwanted sexual or romantic advances made by any person towards another. Sexual harassment, like harassment on the basis of color, race, religion, gender orientation, or national origin, has long been recognized as a violation of Section 703 of Title VII of the Civil Rights Act of 1964, as amended. Pfeiffer University will not tolerate sexual harassment and intimidation of its employees and/or students in the workplace (see Pfeiffer University Graduate Programs Catalog 2014-2015, p. 2; see also AAMFT Code of Ethics, 3.7; see MFT Student Handbook, p. 32): Harassment on the basis of sex exists when there are unwelcome sexual advances, requests for sexual favors, and other verbal or physical conduct of a sexual nature when:  Submission to such conduct is made either explicitly or implicitly as a term or condition of an individual's employment or student's grades.  Submission to or rejection of such conduct by an individual is used as the basis for employment decisions or grading status thus affecting such individual. Page 22 of 138  Such conduct has the purpose or effect of substantially interfering with an individual's work performance or creating an intimidating, hostile, or offensive working or learning environment. Pfeiffer Institute has adopted the stance that any report or witness of perceived sexual harassment will not be kept confidential. All incidences will be reported to the proper authorities of Pfeiffer University.

Therapist Intern Remediation In accordance with the MFT Program Handbook, times may exist when a therapist intern may need remediation. Remediation is the process of evaluating the therapist intern’s current below average

Page 21

performance, attitude, and academic and professional development and developing a plan to improve area(s) of concern for continuation in the MFT Program. The MFT Program Handbook specifies the circumstances under which students may be subject to the remediation process. In addition, the MFT faculty may probate, suspend, or dismiss from the program any student who does not fulfill the academic or clinical requirements specified in the MFT Program Handbook or Clinic Policies and Procedures Manual. In addition, any student whose work over a period of time shows a demonstrable lack of progress toward their degree may be put on probation, suspended, or dismissed from the MFT program. Usually the actions described above will be initiated by communicating in writing to the student, the MFT faculty members, the Clinic Director, and the MFT Program Director. A Faculty Remediation Committee (FRC) will be formed to discuss the circumstances of the remediation. The student may request a meeting with the MFT faculty to discuss the matter and/or may appeal to the Dean of Social and Behavioral Sciences. The levels of appeal follow those already stated in the Grievance section. Due to the clinical nature of the program, it may be necessary to dismiss a student from the MFT Program for other than academic reasons. One of the most difficult tasks facing a team of faculty occurs when a student’s behavior is deemed to be so inappropriate as to warrant major concern as to whether the person is emotionally, interpersonally, or ethically suited for entry into the profession of marriage and family therapy.

Gatekeeping “Gatekeeping refers to the responsibility of all counselors, including student counselors, to intervene with professional colleagues and supervisors who engage in behavior that could threaten the welfare of those receiving their services” (Foster & McAdams, 2009, p. 271). This responsibility is a personal obligation to the profession and is mandated in the ethical standards of the American Association for Marriage and Family Therapy (AAMFT) by instructing therapists to “seek appropriate professional assistance for issues that may impair work performance or clinical judgement ” (AAMFT Code of Ethics, 3.3).. More importantly, it is the responsibility of all students and faculty to uphold the competence and integrity of the Marriage and Family Therapy profession by protecting the profession from unethical behavior, through corrective feedback (peer colleagues and supervisors) and fair remediation assurance when necessary to assist impaired students and/or supervisors. Although reporting a colleague or supervisor may create overwhelming anxiety, it is the well-being of a classmate or supervisor, and subsequently the ultimate harm that may impact a present or future client, which must be addressed first and foremost. Failing to do so may jeopardize one’s professional standing (Hutchinson, p. 175). The role of the professional is a serious and sensitive one. Responsibility must be assumed by the MFT faculty and staff to assure that any individual who might pose serious risks to clients, the community, and to the standards of the profession (due to emotional instability or questionable ethical standards) is not allowed to enter the profession. The MFT faculty and staff have the right to refuse to endorse degree candidates to practice marriage and family therapy due to possible risks to clients (e.g., inability to regulate and modify appropriate behavior). Even though such measures are unpleasant, decisions are necessary in considering the welfare of everyone involved. Such issues may transcend effective adjustments via feedback provided in Page 22

day-to-day supervision and instruction. Accordingly, when such problems occur, the MFT faculty will meet and specify their concern(s) to the student in writing. In addition, an Individual Remediation Plan (IRP) will be developed. The IRP will define the particular behaviors in question, the desired changes and means to address them, and a timeline for re-evaluation of the concern. The IRP will accompany full verbal feedback to the student determined by the FRC, particularly from faculty or others with information from direct observations of the student. If the student feels the matter has been misrepresented, he/she will reply to these concerns and present his/her perspective on the matter. The matter may be settled at the level of the MFT Program level or the recommended measure invoked (e.g., suspension from the program, pending a student’s attempts to resolve the problem via personal therapy). At the end of the stated time or process the matter would be reviewed and, in the absence of sufficient change in the desired direction, measures would be taken to dismiss the student from the program. At any point in this process, the student has the right to appeal. Due to the sensitive nature of this process, students are reminded that they are not required to appeal and that the matter may be resolved without bringing it to the attention of the full graduate faculty and administration. If the student does wish to appeal a decision of this type, he/she may do so, in writing, to the Provost or Vice President of Academic Affairs. From that point, the appeal procedure follows that already stated. Usually students who would be dismissed under these circumstances would be dismissed from the graduate program. However, under some circumstances, a dismissal decision may specify that the student retains the right to apply for admission to other graduate programs within the university. In regards to taking extended time off during Internship, remediation may occur. It is important to anticipate long term absences such as personal, legal, or medical circumstances which might make it impossible to complete the requirements of the internship. If a pregnancy has progressed in time so that time off for the delivery and post-delivery make it impossible to complete the requirements of the internship, students will be discouraged from enrolling to avoid the costs of remediation due to absence If a student has been convicted with a felony prior to entering the MFT program, Pfeiffer University may not grant the student permission to enroll (see NC LMFT grounds for licensure denial, suspension, etc.). However, any felonies committed by the student while enrolled in the MFT program will be addressed by Pfeiffer University and may be ruled that the student must be automatically dismissed from the program. In addition, misdemeanor offenses committed by the student while enrolled in the MFT program will be evaluated by Pfeiffer University and may also be deemed grounds for automatic dismissal from the program, especially if such offenses require probation and/or incarceration . If students conceal such legal circumstances from Pfeiffer University, the concealment may become grounds for dismissal from the internship and the MFT program. The relationship with external internship sites is vital to the Pfeiffer University Marriage and Family Therapy Program. Therefore, students who jeopardize any external internship site relationships (through, but not limited to, cited impropriety, negative attitudes, disrespectful behavior, not fulfilling external site agreements, or excessive absences) will be evaluated through the IRP process. Page 23

The therapist intern will be consistently evaluated per semester by his/her clinic supervisor and his/her external internship site supervisor using the Clinical Performance Evaluation.

Internship Requirements The MFT Program Handbook outlines detailed requirements and expectations for completing internship. It is the responsibility of each student to be familiar with these requirements and expectations. In addition to seeing clients at the PIMFT, if a student desires a field placement (i.e. to see clients through a site in the community), he/she must discuss plans with the Clinic Director to elicit feedback on readiness to meet with clients outside the clinic. Leaving PIMFT is determined more on student readiness as determined by MFT faculty and Clinic Director, rather than a set number of hours and/or semesters spent in the clinic or in the program. Once the student has completed all of the requirements named above and has received permission to start a field placement site, he/she will apply to the site of his/her choice. See Field Placements below for details and requirements. At the final conclusion of internship, (over a minimum of 3 consecutive semesters,) the student therapist will have fulfilled PIMFT and internship agreements, completed required hours, and received passing evaluations from each supervisor. The final indication that all internship requirements have been met is the Final Report of Internship – Client Contact and Supervision Hours form and Intern Self-Evaluation. These final forms must be completed and submitted to the Clinic Director no later than the Monday before graduation day.

COAMFTE Requirements Client Contact Hours The accrediting body of the American Association for Marriage and Family Therapy (AAMFT), the Commission on Accreditation for Marriage and Family Therapy Education (COAMFTE), accredits Master’s degree, doctoral degree, and post-graduate degree clinical training programs in Marriage and Family Therapy throughout the United States and Canada. The Marriage and Family Therapy Program of Pfeiffer University at the Charlotte Campus is a fully accredited COAMFTE program. The Pfeiffer University MFT Program and the PIMFT will adhere to COAMFTE guidelines. All students must complete COAMFTE guidelines to graduate from the Pfeiffer University Marriage and Family Therapy Program. All students who graduate from the program will have the status of graduating from a COAMFTE accredited program. As required by COAMFTE, all students must complete 500 hours of direct client contact. Direct client contact is defined as face-to-face (therapist and client) therapy with individuals, couples, families, and/or groups from a relational perspective. In addition, students who start internship prior to January, 2016, must Page 24

earn at least 250 relational hours (e.g., couples or families present in the therapy room) of the required 500 hours of client contact. Students starting internship in January 2016, or later must earn at least 200 (40%) relational hours of the required 500 client contact hours. As long as a student is registered for Internship in MFT, s/he must maintain a caseload of at least one to three active cases at PIMFT at all times (i.e. client seen at least every other week). The number of minimum cases (one, two, or three) is a joint decision of the student, his/her clinical supervisor, and the Clinic Director.

Relational Hours For a session to count as a “relational hour,” interns must utilize a family systems approach to treatment that includes more than one member in the same session at the same time. These members must belong to an organized system with delineated boundaries while demonstrating a social and psychological interdependence and reciprocity. The members must also directly interrelate with repeated ongoing transactional patterns that impact and influence each other on a consistent basis to meet the needs of its members. Contact must be conducted via joining, assessing, diagnosing, or intervening. Additionally, “marriage and family therapy includes referrals to and collaboration with other health care professionals when appropriate” (Marriage and Family Therapy Licensure act – NC Statutes 90-270.47. Definitions. 3a).

Relational Group Hours For a session to count as a “relational group hour,” interns must utilize a family systems approach to treatment that includes more than one member of a group in the same session at the same time. These group members must belong to and live within an organized system with delineated boundaries while demonstrating a social and psychological interdependence and reciprocity for a period lasting no fewer than 10 days. The members must also directly interrelate with repeated ongoing transactional patterns that impact and influence each other and the group as a whole on a consistent basis to meet the needs of its members.

Supervision Hours Supervision of students is a requirement of COAMFTE. The PIMFT will ensure students are supervised at PIMFT by an AAMFT Approved Supervisor or a Supervisor Candidate. Individual supervision is defined as supervision of one or two individuals. Group supervision is required and will be 8 students or less per group. During group supervision, each student will participate in the group class for at least 1 hour and then may be observed live for one hour while seeing a client. To preserve the integrity of the program for accreditation, students must participate in at least one hour of class time and observe others to enhance the learning process. (This means that the intern will not see clients during all of group supervision.) Students will receive at least 100 hours of face-to-face supervision, which includes at least 30 hours of individual supervision and up to an additional 70 hours of group supervision. Of the 100 hours of required supervision, at least 50 must be conducted live (i.e., the supervisor viewing the case in live observation via two-way mirror or video monitor while the session is taking place). Under normal circumstances, students in the MFT Program will receive more hours of supervision than required.

Page 25

Field Placement After the therapist intern has become oriented to PIMFT, he/she may have the option of supplementing his/her required number of hours at an external internship site. The Field Placement is to provide the intern with a supervised, full-time experience of at least one semester duration, emphasizing relationally focused practice and/or research. The MFT Program defines “full-time” as 15-20 hours minimum per week on site (combination between PIMFT and Field Placement site. The therapist intern should consider whether the internship will provide sufficient hours of direct client contact (e.g., relational hours) and supervision to meet licensure and/or clinical membership requirements. Prior to the start of the Field Placement without a prior relationship with Pfeiffer University, the student must submit to the Clinic Director a written internship proposal specifying how the site meets the program requirements. The Faculty Regulatory Committee will have the final decision of whether to approve the Field Placement. (The Faculty Regulatory Committee is composed of all MFT Faculty and Clinic Directors.) The Field Placement must be located within a 60-mile radius of the PIMFT. Students interested in a field placement that is not in the Charlotte area should discuss the location with the Clinic Director prior to applying for the site.

The Purpose of a Field Placement The purpose of a Field Placement is to build on the therapist intern’s existing clinical and research skills. In addition, the Field Placement is to provide an intensive professional experience. A Field Placement may be taken in a variety of settings and may include various combinations of clinical and research activities, depending on the therapist intern’s interests, needs, and previous experience. One of the primary focuses of the Field Placement is training. The Field Placement will be established as collaboration between the student, Clinic Director, and Field Placement Site Supervisor.

The Procedures to Begin a Field Placement There are four main steps that must be completed before a therapist intern may begin working at a Field Placement: 1. First, the therapist intern must schedule an appointment with the Clinic Director to have a conversation about his/her interest in working at a Field Placement site. The purpose for the conversation will be to assess the therapist intern’s readiness, interests, and needs, to identify potential Field Placement sites, and to identify the requirements for completion of the Field Placement. 2. Second, the therapist intern must decide which potential Field Placement sites will meet the site and graduation requirements (see Field Placement Site Requirements). The therapist intern must discuss his/her choices for a Field Placement site with the Clinic Director. Upon approval from the Clinic Director, the therapist intern must contact the Field Placement site and apply to be an intern for that particular site. Once an agreement is reached with the site, the therapist intern will complete the Field Placement Site Supervision Agreement.

Page 26

3. After the Field Placement Site Supervision Agreement is approved, the Field Placement Supervisor Application must be completed by the site(s), and returned to the Clinic Director. 4. All paperwork will be filed in the therapist intern’s file. Note: Any change in the Field Placement Proposal or the Field Placement Site Agreement(s) must be approved by the Clinic Director. If a student wishes to have more than one field placement simultaneously, she/he should submit to the Clinic Director a written proposal describing the need for the second site after serving at the first site for at least one semester. The Faculty Regulatory Committee will have the final decision whether to allow a second site.

Who is Qualified to Begin a Field Placement The Field Placement is an opportunity for the therapist intern to obtain professional experiences and training outside of the PIMFT. Not all students may choose to pursue Field Placements in their first semester, but it is highly recommended. If a student does not pursue a Field Placement, he/she will be required to obtain 500 hours direct client contact (minimum) at the PIMFT. In addition, not all therapist interns may be qualified to have a Field Placement opportunity. The following are the minimum requirements to be qualified to begin a Field Placement: 1. The therapist intern must be in good standing in the MFT Program (individuals on academic, nonacademic, or clinical probation or on leave of absence cannot apply). 2. The therapist intern must be in good standing in the PIMFT. If he/she has taken a previous semester of MMFT690, he/she must have passed with a grade B or higher. 3. The therapist intern must have permission from current faculty supervisor and Clinic Director. 4. The therapist intern must be sufficiently advanced in the MFT program to maximally benefit from the Field Placement experience. This means that the Field Placement activities do not interfere with the completion of coursework and continued progress in the MFT program and vice versa.

Documentation Required before the Field Placement begins The following documents must be completed and signed by appropriate administration and filed in therapist intern’s file before the Field Placement begins:  

Field Placement Site Supervisor Application (required of each supervisor at each site) Field Placement Site Supervision Agreement from each site

Supervision and Supervisory Relationship of Field Placement The Field Placement must involve direct client contact and the therapist intern must continue to meet with an AAMFT Approved Supervisor (or equivalent) weekly in the clinic in compliance with COAMFTE guidelines for structured supervision. Each site must provide an administrative and/or site supervisor who is responsible for the efforts of the therapist intern and who provides supervision of cases at least one hour per week. The therapist intern will also receive supervision from an AAMFT Approved Supervisor (or equivalent; aka Clinic Supervisor) at the PIMFT during group supervision. Responsibilities of the Field Placement Site Supervisor include the following: Site supervisors must be full-time administrative or clinical staff who can provide sufficient oversight and accurate assessment and evaluation of intern’s progress. Note: there can be no dual relationship between the site supervisor and the intern per the AAMFT Code of Page 27

Ethics, Principle 4.1. More importantly, the intern cannot accrue clinical face-to-face hours for their customary employment responsibilities (i.e., clinical hours must be different from the intern’s customary employment responsibilities). The Site Supervisor for the intern’s field placement cannot be the same supervisor for their paid employment.

Documentation Required in the Field Placement Therapist interns must complete the following documentation for the Field Placement:   

The Monthly Clinical Service Report (MCSR) must be maintained and kept up-to-date by the therapist intern. Proof of Student Liability Insurance At the end of each semester, the field placement site supervisor must complete the Clinical Performance Evaluation about the therapist intern and review it with him/her. The therapist/intern will bring the CPE to his/her clinic supervisor for review and file with Clinic Director.

Completion of Field Placement The Field Placement requirements are deemed complete once all the following criteria have been met:   

The duration of the Field Placement experience has lasted a minimum of one full semester; and The concluding date as stipulated on each “Field Placement Site Supervision Agreement” form has been reached; and All required evaluation forms for each internship site have been filed with the Clinic Director.

At the completion of the Field Placement or upon leaving a Field Placement site, the Intern Self Evaluation (therapist intern), the Clinical Performance Evaluation (separately, AAMFT-Approved Supervisor (or equivalent) and the Field Placement Site Supervisor(s)), and the Field Placement Site Evaluation (therapist intern), must be submitted to the Clinic Director.

Procedures Case Assignment and Scheduling Case Assignment A rotation system will be used in the assignment of new cases. Error! Reference source not found. will be sed to assist in case assignment. The index card will include the Therapist Intern’s Name, Therapist ID code, contact number, Pfeiffer email address, interest, and have an area reserved for client type (I, C, F). The Client type area will be used as a way to tally which type of case constellation was assigned. When a new client calls the PIMFT to schedule an initial appointment (intake), they will be assigned to the next therapist in the rotation based on the match between therapist and client availability. Exceptions to the rotation schedule are: 1) the client requests a specific therapist or type of therapist (e.g., male/female, Page 28

religious orientation) and 2) a therapist indicates they are not accepting new clients. At times clients who initially call for an individual concern may evolve into a couple or family case. Students that entered the MFT Program after Fall 2007 and enrolled in Internship (MMFT690) will carry a minimal active caseload depending on number of new clients entering the clinic and whether or not they are providing services at an external internship site. It is ideal for a therapist intern to have a minimal active caseload of 10 to 12 clients per week, providing the clinic caseload is sufficient to do so. Note, it is the therapist intern’s responsibility to keep an adequate case load of individual and relational hours to complete required hours for graduation.

Scheduling New Clients All telephone intakes and case assignments for internship will be handled through the Front Desk Administrative Staff or Clinic GA, under the supervision of the Clinic Director. In addition, new intakes may be scheduled during desk duty. A professional relationship forms the moment the client makes contact with the PIMFT (e.g., initial phone call). From this perspective, the intake process is much more than a clerical activity and requires professionalism and sensitivity at all times. The intake process and follow-up calls play a crucial role in clients’ experience with the PIMFT. Most intake calls will be handled by the Front Desk Administrative Staff or Clinic GA (see Scheduling Clients Using Outlook). During the initial phone call, the Administrative Staff or Clinic GA will complete a Phone Intake Form to collect basic demographic information about the client and the nature of their concern. The Front Desk Administrative Staff/GA/Desk duty attendant will instruct the new client to arrive at least 20 minutes in advance of their initial scheduled appointment to fill out initial paperwork. Typically, clients will not be scheduled for the same day as the intake call unless it is determined by the Clinic Director that to do so is vital for client care. The therapist will be notified of any last minute or “emergency” scheduled appointments. In general, the PIMFT does not take cases that are assessed as a suicidal emergency at the onset during the initial call. Such cases are referred first to a local hospital emergency room or crisis assessment center. Once a case assignment and initial appointment is scheduled, a message will be sent to the therapist’s Pfeiffer email informing the therapist intern that a new case has been assigned. It is the responsibility of the therapist intern to reserve a clinic room for the intake. In addition, the therapist intern is required to contact the client to confirm the scheduled appointment, preferably 24-48 hours before the initial appointment, and to make sure the client has directions to the PIMFT. Any phone contact with the client prior to the first appointment should be noted on the Phone Intake Form. Once therapy has begun, the therapist intern must use the Phone Log Sheet. When a therapist calls to confirm the initial appointment, he/she should determine who will be receiving services. For example, the therapist must verify that if minors will be seen, they must be accompanied by adults who can provide consent (first appointment should be adults only; see below). In addition, the therapist intern must be able to give accurate directions to the PIMFT and remind the clients that the initial appointment will last 50 minutes. Sessions are usually 50 minutes in length (the PIMFT fee schedule assumes 50 minute sessions); however, it is possible to increase a session to 1.5 hours in length, if needed Page 29

and approved by Clinic Director. If a session is scheduled for 1 hour and 20 minutes, the therapist intern must discuss the additional session fee with the clients (add half of the 50 minute session price for the extra 30 minutes). The clients must agree to the increase in time and increase in session fee before scheduling the next session. It is the therapist intern’s responsibility to put the accurate amount due for the client’s session in their Outlook appointment slot.

Scheduling Returning Clients The therapist intern is responsible to reschedule their clients. During the end of the session in the therapy room, the therapist intern and client(s) should discuss future appointment times. Due to the limited space and possibilities of congestion at the front desk, clients are NOT to be rescheduled at the front desk or in the hallway. This procedure needs to be done in the therapy room at the completion of the session. It is the responsibility of the therapist to go to the Intern Work Room and use a computer to input next scheduled appointment in Outlook Calendar. The front desk staff should not be used to reschedule returning clients after a session. However, if the client calls to reschedule and the therapist the Front Desk Administrative Staff/GA may reschedule clients if the intern has available times indicated in his/her calendar. . See Scheduling Clients Using Outlook.

Scheduling New Constellation Appointments of Returning Clients Existing clients may request additional therapy services for other members of his/her family. For instance, a parent may be in therapy and request additional sessions for his/her child. Ideally, the current therapist would provide treatment for additional family members; however, situations may warrant a co-therapist. In an effort to continue providing systemic care, only one or two therapists (co-therapy) are authorized to be assigned to work on the same case (e.g., couple or family) at any given time. Before a new therapist is assigned and a new appointment is created, the intern must consult with his/her supervisor (see Co-therapy). However, there may be times when the client bypasses the intern he/she is working with and call the office directly. If the front desk receives a call to add an appointment, the front desk attendant must ask the caller if he/she is a current client and with whom he/she is already meeting. If the caller says that he/she is currently a client with “Intern X” and he/she requests another family member to be seen, the front desk attendant should reply, “I would be happy to help you. However, before scheduling a new session, I must inform Intern X that you have requested your family member to be seen. Before I can schedule this appointment, the intern will need to speak with you first. May I take a message and have Intern X call you?”

Scheduling Therapy Appointments for Minors Minors can benefit from therapy sessions. A minor is considered a person under the age of 18. The Pfeiffer Institute has a therapy room designated to provide treatment designed specific to the needs of children and youth. Each object in the play therapy room has a therapeutic intention. Children should not use the room unless it is a play therapy session (e.g., it is not a child’s waiting room). Before treatment can begin, the initial session must involve only the parent(s)/legal guardian. The front desk attendant must communicate this procedure during the phone intake. In addition, the front desk attendant Page 30

must screen whether the parents are married, separated, or divorced. The front desk attendant must instruct the parent/legal guardian what paperwork is necessary for them to bring to the initial session, if necessary (see below). If the parents of the child are married, obtaining consent from one parent is sufficient for treatment to begin. However, best practices suggest obtaining consent from both parents whenever possible. If the parents of the child are separated or divorced, the parent with legal custody (legal custody means having the right and the obligation to make decisions about the child’s upbringing, such as medical and mental health care) can sign the Permission to Treat Minors Form. The parent must bring the custody order, the intern must make a copy of the section of the document stating which parent has legal custody to make medical decisions for the child, and the copy of the document must be placed in the file before treatment of the child can begin. If the parents are separated, but no legal documentation is available (e.g., parents have not gone to court) both parents are required to sign the consent to treatment of their child before therapy can begin. If the parents are separated or divorced and both have documentation stating equal legal custody, both parents are required to sign the Permission to Treat Minors Form for their child before therapy can begin. If the other parent is incarcerated or lives out of state/country, the intern should make his/her best effort to obtain written consent from the absent parent. However, if it is not possible and/or it has been determined that the parent bringing in his/her child for treatment has legal custody, the intern must document the steps taken and may proceed with treatment; in addition, the intern must consult with his/her supervisor. During the initial session with the parent(s) the therapist intern will review the Permission to Treat Minors Form and obtain a thorough history of concerns, behaviors, etc. of the child and family system. If an intern is assigned a child’s case with separated or divorced parents, he/she must consult with his/her supervisor.

Greeting Incoming Calls The Front Desk Administrative Staff/GA/Desk duty attendant should answer the phones in a professional manner. The greeting should follow this format: “Good [morning, afternoon, evening], thank you for calling the Pfeiffer Institute. How may I help you?”

Scheduling Clinic Rooms for Therapy The therapist intern is fully responsible for reserving a therapy room in the PIMFT as soon as appointments are made with his/her client. Therapy rooms are available on a first-come, first-serve basis using the Room Reservation Binder located at the clinic front desk. If a therapist intern would like to schedule a client for live supervision, it is especially important that they make sure they reserve a room as soon as they plan for live supervision to ensure the availability of space. The therapist intern is fully responsible for deleting his/her name from the reservation binder if his/her appointment cancels or reschedules.

Page 31

Intake Calls and Scheduling by a Third Party When a caller wishes to schedule an appointment for a third party (e.g., a probation/parole officer, a social worker), the Administrative Staff/GA will ask the caller if he/she will accompany the other person(s) to the appointment. If the caller DOES NOT plan to attend the session, the Administrative Staff/GA must request that the client(s) call the clinic to schedule the appointment. (This procedure does not apply in the event that the initial caller is the parent/guardian for the minor who is the client.) In the event that a person calls to obtain information on a client (e.g., an agency mandating therapy) the PIMFT must abide by confidentiality rules and regulations. Due to the rules protecting confidentiality, PIMFT personnel may not give any information without an Authorization for Release of Client Records from the client. In addition, PIMFT cannot either confirm or deny any client is or has been seen at PIMFT without release form signed by the client. In addition, the PIMFT cannot either confirm or deny any client is or has been seen without this release form signed by the client. The release form can be completed during therapy sessions by client. In addition, it is required that the therapist intern thoroughly explain the confidentiality rules and procedures during the intake process. Upon receipt of the signed release form, the therapist intern may then call the identified person for whom release was granted. Only information granted by client identified on the Authorization for Release of Client Records can be disclosed. Client information from other agencies may never be copied and distributed to the client for his/her use. Original documents must be released directly from respective agencies, although the intern should still ask the client to complete an Authorization for Release of Client Records specifying what content may be discussed.

Referral Sources Clients may be referred to the PIMFT by agencies, other professionals, etc. It is essential that we maintain good communication between ourselves and our referral sources. If a client was referred by a particular agency or professional, please inform the Clinic Director. The Clinic Director may send a “thank you” card (without client names or identifying information) to show the appreciation of the PIMFT for the referral. Many referral sources have an investment in the clients they refer and may want to know if their referral has been worthwhile. Therapist interns who are aware of potential referral sources are encouraged to discuss these contacts with the Clinic Director.

General Information Hours of Operation Sessions may be scheduled with beginning times from 10am to 9pm Mondays through Thursdays or from 10am to 4pm on Fridays. Clients should be out of the clinic no later than 9pm Monday through Thursday, 4 pm on Friday, and 2 pm on Saturday to allow adequate time for the therapist interns to complete case paperwork and nightly maintenance of the PIMFT. Saturday appointments will be offered with beginning times from 9am to 1pm. Therapist interns are not allowed to meet with clients during times outside of normal operating hours. Many clients prefer evening appointments. The busiest times for the PIMFT are between the hours of 4pm and 7pm. Every attempt should be made by the therapist to schedule as many of Page 32

his/her clients’ appointments during group supervision as allowed to take advantage of the opportunity for live supervision by his/her supervisor.

Directions Clients may not know the directions to the clinic. When speaking with the new client, please ask if they have access to the internet to look up the address on mapquest or google maps. If the client does not have access to the internet, please ask if they are familiar with the Charlotte area. Depending on their response, please give the client the following directions: “The Pfeiffer Institute is located at 4805 Park Road, Suite 250 in the Myers Park area off of Park Road. The nearest main crossroads are Park Road and Woodlawn Road, just south of the Park Road Shopping Center.” From I-77 “Take Exit 6a, which is Woodlawn Road/Queens University of Charlotte exit. Turn right on Woodlawn Road from the ramp, Turn right on Park Road, and turn left on Seneca Place. Turn left into the McAlister’s Deli parking lot. We are located in Suite 250 on the second floor.” From I-85 “Take Exit 33, which is Billy Graham Parkway. Take Billy Graham Parkway away from the airport. Billy Graham Parkway eventually becomes Woodlawn Road. Stay straight on Woodlawn Road. Turn right on Park Road, turn left on Seneca Place, and turn left into the McAlister’s Deli parking lot. We are located in Suite 250 on the second floor.” If the client is using Charlotte Area Transit System (CATS), we are route 19 at the corner of Park Road and Seneca.

Operating Schedule The PIMFT functions as a mental health service provider in the community. Therefore, appointments are scheduled year-around. Semester breaks, summer sessions, and Pfeiffer holidays should have minimal effect on the operation of the PIMFT. Therapist interns and supervisors are expected to be available for new cases during semester breaks, unless prior arrangements have been made with Clinic Director. The PIMFT will be closed over the Thanksgiving holiday, Christmas holiday, New Year’s Day, Good Friday, Memorial Day, and Independence Day. Vacations for internship supervisors and therapist interns must be scheduled well in advance, and backup services for clients should be arranged. Therapist interns are expected to take ‘normal’ vacation periods (during holidays) and any extended vacation time must be discussed with and granted permission by the Clinic Director and clinic supervisor. A Vacation/Leave of Absence Form must be completed and approved BEFORE travel arrangements are made. Additionally, it is the responsibility of the therapist intern to inform their active clients of their leave and identify who will be covering for them during their time away from PIMFT.

Page 33

Children at PIMFT Children under the age of 12 are not allowed to be left unattended at PIMFT due to safety issues. This includes leaving a child in the waiting room or in a therapy room. If the therapist intern must separate a child under the age of 12 from their family for therapy purposes, it is his/her responsibility to get a colleague to watch the child for the brief period of time.

Fee Schedule and Collection Pfeiffer University provides partial underwriting of the costs of maintaining the PIMFT. Due to this agreement, PIMFT is able to provide services at a reduced cost to clients who cannot afford to pay the full fee of $30.00 per session. Fees for services from $10.00 - $30.00 per 50 minute session are negotiated between the therapist and the client during the first session, and are set based on the current PIMFT Fee Schedule . If a client discloses they are unable to pay the designated fee based on their income and number of dependents, the therapist must consult with the Clinic Director for further fee reductions. Upon final fee determination, the client must sign the Fee Agreement form. The fee for Pfeiffer University students is $10 per 50 minute session, including the initial session. The fee for any university student is $15 per 50 minute session, including the initial session. Clients will be informed that the initial session will be $30 (exception: university students); however, if they need the sliding scale, they can discuss an agreement during the initial session with their therapist. Clients must pay for services at the time of their appointment, using check or cash. No credit cards will be accepted. Checks are to be made payable to “Pfeiffer Institute.” A receipt will be written in carbon copy form by the Front Desk Administrative Staff/GA. The original (white) copy will be given to the client and the second (yellow) copy will be kept with form of payment for clinic financial records. Receipts should include client’s name, date, amount paid, balance, Intern's name, and type of appointment (Regular or Intake) and sign. If client cancels or reschedules, draw a slash through the receipt and write RS or CX. If a receipt is not able to be used (e.g., incorrect information written on receipt), write VOID across receipt. The therapist intern should discuss the fee and billing procedures with the client during the initial session. Clients must be told that missing an appointment without notifying the PIMFT 24 hours in advance may result in the session fee being charged for the missed appointment. The client must sign the bottom of the Fee Agreement form to indicate that he/she has been notified of this policy. It is under the discretion of the Clinic Director to waive the fee for a missed appointment. If a client does not pay for a session (e.g., forgot wallet, did not get paid), the missed fee must be collected by the next session. If a client fails to pay his or her fee for more than two sessions in a row, the therapist intern must discuss this issue with the clinic supervisor and/or Clinic Director. The PIMFT does not accept third-party payment from insurance companies for any services rendered in the clinic. In addition, PIMFT personnel will not assist clients in filing for insurance plan reimbursement for services rendered in the PIMFT.

Page 34

Case Management & Documentation All therapist interns will maintain and store active PIMFT client records in the secured storage space in the front office. When creating case file labels include the following information: Client’s Last name, First name, Case # (which consists of the specific Intern # and appropriate file number based upon what number that client is for the individual therapist; e.g., Thomas, April 007-004). Case records contain confidential information and care must be taken to ensure client privacy. The file cabinets will remain locked when not in use. Case records (including digital clips) are not permitted outside of the PIMFT except for training purposes on the Pfeiffer University, Charlotte campus. If files or client recordings will be released to the Pfeiffer University, Charlotte campus for training purposes, the supervisor must inform the Clinic Director. Files must be returned to the front office immediately after use. In the case of field placement clinical sites where the sessions are recorded with portable camcorders, the students must keep all recorded material in their possession at all times or in a secured location until she/he can return to the PIMFT facilities and securely store material. It is the student therapist’s responsibility to supply recording materials (e.g., camcorder, DVDs, tapes) if he/she chooses to work at an external internship site. Starting January 1, 2010, student therapists working at an external internship site will be required to record at least one hour of his or her client session per week and bring to MMFT690 supervision. Session recordings and client records are the property of PIMFT and are not to be removed from the secure area without permission from the Clinic Director. To protect client privacy, MFT faculty, therapist interns, and PIMFT staff must make every effort to keep file cabinets locked, to keep the front office, storage room, and Clinic Director’s office locked when not in use. In addition, all PIMFT personnel and MFT faculty must exercise extreme care when moving confidential material from one area to another. It is important to keep up-to-date and accurate information in case records. It is the responsibility of the assigned therapist intern to update client’s address, contact numbers, and other personal information whenever changes are reported. To obtain the greatest accuracy, progress notes should be completed immediately after each session; however, it is not always possible to complete progress notes directly after a session. The PIMFT expects progress notes to be completed within 72 hours after the therapy session. Progress notes should be typed on a PIMFT Progress Note Form and secured in the case record. The internship supervisor is responsible for monitoring records to ensure that information is timely and accurate. Therapist interns must be prepared to show any case to their clinic supervisor or Clinic Director at any time. It is not unusual for clients to return to services months or years after initial treatment. In addition, therapists who started a case may not always be present or available to reopen the case. It can be helpful to the new therapist to know prior treatment plans and client information. For this reason, the PIMFT will archive all case records for at least 6 years, except for minor clients (5 years after the age of consent was or would have been reached). In addition, the time of storage is in compliance with AAMFT standards of ethical practice and HIPAA. After this time frame, all documentation will be destroyed.

Page 35

Recording Therapy Sessions The PIMFT offers the latest technology for recording therapy sessions. Therapist interns are not permitted to alter the recording equipment. The recording equipment must stay on at all times and record both audio and visual material from the therapy rooms and group room. A sign will be displayed to alert all individuals on PIMFT premises that they may be audio and video recorded for training purposes. In compliance with the HIPAA privacy regulations, visual and recording devices will be used only in patient/client care areas (i.e., therapy rooms, group room). In addition, clients will document consent to treatment and recording during the initial session. Please note information noted below: 

Camera-equipped devices issued by Pfeiffer University are designated for therapist intern use for requirements of the MFT program.

Otherwise, recording is authorized only when:   

A therapist intern documents a hearing-impairment or physical challenge and who is unable to write or record information or data. Faculty member or staff gives permission for recording meetings or other investigatory hearings. The use of video or auditory recordings by students for lectures and/or classroom activities is granted permission by faculty member or staff.

Therapist interns will record each therapy session in its entirety for supervision purposes. Please see Recording Therapy Sessions for instructions. The video recording system holds recorded sessions for approximately 3 months (i.e. 90 days). However, therapist interns are encouraged to record and download therapy sessions he/she wants to present for final before they leave the clinic for the evening to ensure downloading and securing recorded video of therapy session. If a therapist intern provides therapy sessions outside of the PIMFT (i.e., field placement site), he/she is expected to video record therapy sessions in their entirety; however, not all therapy sessions at a field placement site must be recorded. The therapist intern must obtain permission from his/her off-site supervisor and off-site client(s) for permission to record session. Please see Field Placement Site Supervisor Agreement form. The PIMFT is not required to provide therapist interns with video equipment outside of PIMFT. It is the responsibility of the therapist intern to obtain video recording equipment and materials to record at a field placement site. If the field placement prohibits any type of recording, (e.g., audio recording, video recording focused on therapist), therapist must obtain special permission from clinic director and will be expected to increase the number of clients seen at the PIMFT. Session videos contain confidential information and the privacy will be protected using the same regulations as the case file (e.g. Authorization for Release of Client Recrods must be signed before anyone outside of the MFT program is allowed to view the video). Session videos are used for educational and supervision Page 36

purposes only (i.e. are not part of the clinic record), and are deleted after 60 days or when no longer useful for supervision or educational purposes.

Two-way mirrors The PIMFT has two-way mirrors in all therapy rooms. A two-way mirror is a mirror which is partially reflective and partially transparent. The purpose for using a two-way mirror is to allow the darkened side of the room to easily view the well-lit room. Blinds are provided on the windows to ensure privacy when the two-way mirrors are not being used. When the two-way mirrors are used, the clinic supervisor and/or Clinical Director must be informed. In addition, the therapist intern must inform his/her client(s) that the session will be viewed by therapists and/or supervisors from the adjoining room through the two-way mirror.

Obtaining and Releasing Client Information The communication between professionals and agencies is often an essential aspect of therapy services. Appropriate Authorization for Release of Client Records must be obtained by the therapist intern to give or receive ANY information about a client. If a therapist intern wants to share information about a client with another agency/professional, the Release of Information Form must be completed by the therapist intern and signed by the client (or parent/guardian if the client is a minor). If the therapist intern is collecting information from another agency/professional, the release should then be sent to the agency with a cover letter signed by the student and his/her supervisor. The therapist intern must be specific about the information being requested – diagnosis, medications, prior therapy history, etc. It is not necessary to request an entire case file. The therapist intern must keep a copy of the letter and completed forms in the client’s folder. Alternatively, the therapist/intern may call and speak directly with the professional specified on the Authorization for Release of Client Records. The therapist/intern should identify himself/herself and the mutual client, letting the professional know that we have a release to be able to speak about the case. If requested by the professional, the therapist/intern can offer to email a copy of the release (ask the front desk staff for help). If the information is communicated by phone call instead of letter, the phone call should be documented using the Other Provider Contact Note. If a client requests information to be sent to an outside agency/professional, the Authorization for Release of Client Records must be completed by the therapist intern (not the client) and signed by the client (or parent/guardian if the client is a minor). The therapist intern must be specific about what information will be sent to the other agency/professional – list of sessions attended, summary of treatment, etc. In general, PIMFT does not release the client’s entire case file; a summary letter is preferred, signed by both the therapist intern and the clinical supervisor. In the event that any information is requested from an outside agency/professional, the therapist intern must discuss with supervisor and /or Clinic Director. In addition, no information from other agencies may be released to the client or to third parties. As noted in the previous paragraph, the therapist/intern may call and speak directly with the professional specified on the Authorization for Release of Client Records. The therapist/intern should identify himself/herself and the mutual client, letting the professional know that we have a release to be able to speak about the case. If Page 37

requested by the professional, the therapist/intern can offer to email a copy of the release (ask the front desk staff for help). If the information is communicated by phone call instead of letter, the phone call should be documented using the Other Provider Contact Note. It is not uncommon for the ‘client’ to be a couple or family. In the event that information is requested and the therapist intern is working with a couple or family, he/she must obtain a Release of Information Form from EACH individual who is named in the record. All members of a couple or family must consent to release information regarding their system’s treatment. In the event an attorney or judge requests information from the PIMFT, NO INFORMATION IS TO BE RELEASED WITHOUT THE CONSENT OF THE SUPERVISOR AND IF NEEDED, A CONSULTATION WITH PFEIFFER UNIVERSITY ATTORNEYS.

Terminating a Case A case may be closed by either terminating the case (i.e., active therapy is discontinued) or by transferring the case to another therapist. In the case of termination, the Case Termination Form must be completed by the therapist and signed by the supervisor before being filed in the client record. The termination sheet must be placed on top of the case note section in the case file. The folder must be turned into the Front Desk Administrative Staff for proper archiving. Archived cases will be stored by the PIMFT for a minimum of six years with the exception of minor clients. In cases of minor clients, case files will be destroyed 5 years after the age of consent was or would have been reached. Please note: The supervisor must review any and all cases before deemed closed. If the therapist intern never sees the client (e.g., the client never comes in to receive services at PIMFT), attempts to contact the client must be reflected on the Phone Intake form or Phone Contact Record.

Transferring a Case to another Therapist The Case Transfer Form must be completed when a case is to remain open and is being transferred from one therapist intern in the PIMFT clinic to another. This sheet is to be signed by both sets of therapists and supervisors. The therapist number of the new therapist is added to the original case number (case 001-022 becomes 004-001-022). The original copy must be placed on top of the case note section in the case file. All subsequent case notes will be placed on top of the Transfer Sheet; the transfer sheet will act as a divider between the work of the different therapists. Therapist interns expected to graduate soon must submit a Transfer Case Grid to his/her supervisor and Clinic Director at least one month prior to the end of the graduating semester. The therapist intern will discuss with supervisor any available therapist intern for transfer sessions. The minimum number of transfer sessions is two (2). Transferring a case must be discussed with the supervisor and the number of transfer sessions must be monitored and negotiated with the supervisor. It is the responsibility of the therapist interns to work out their schedules to be able to see the client for transfer sessions. Therapist interns are encouraged to plan ahead, if possible, and be flexible during this time of transition for all involved.

Page 38

Managing Client ‘No show’ or ‘Cancellations’ Client absences (no shows or cancellations) are not uncommon in clinics. If a client has multiple ‘no shows’ and/or ‘cancellations,’ the therapist intern must discuss these events with their supervisor. The supervisor may create a general policy or choose to deal with client absences on a case by case basis. The therapist intern is responsible for informing their supervisor so that appropriate action can be taken. When a client fails to arrive for the initial session, the therapist should consult her/his supervisor. The therapist intern should make a reasonable attempt to contact the client to understand the circumstance of the missed appointment and to verify the level of engagement in the therapeutic process. All attempts to contact client(s) before the initial session must be documented on the Phone Intake Form. If a client fails to appear for an initial session, or otherwise indicates s/he is no longer interested in attending therapy, the Phone Intake Form should be returned to the Front Desk Staff in order for the therapist intern’s card to be placed at the top of the rotation. Established clients (i.e., three or more sessions) should be allowed to terminate therapy when they fail to make scheduled appointments. The therapist intern must make attempts to contact the client: 1) by phone, and 2) by letter stating that their file will be closed unless they contact the therapist intern or PIMFT (see Sample Letter to Client). All attempts to contact the client must be documented in the case file. Clients not seen for 60 days are considered inactive and should be terminated following the procedure outlined in the manual.

Documenting Client and Supervision Hours Students will document client contact hours and supervision hours using the Monthly Clinical Service Report (MCSR). Students must keep an up-to-date record of their hours to ensure that they get proper credit for their work. Interns will be provided a monthly cumulative report of their documented client contact and supervision hours. It is the intern’s responsibility to find and prove the discrepancy by the last day of the month the report was received (e.g., receive report April 15, have until April 30 to submit documentation correcting the error). No corrections to the report will be accepted after the last day of the month. Monthly Clinical Service Report (MCSR). Client contact hours and supervision hours are recorded on the MCSR. This form should list contact hours for each case, along with hours of supervision. A MCSR must be filed for each month, even if no cases were seen (which is on rare occasion). All cases must be listed on the MCSR, regardless of whether they were seen or not. This reminds the supervisor of the therapist’s caseload and can be an indication that cases need to be terminated. The therapist intern will bring this completed form to the weekly individual supervision meetings to review with the supervisor. After the supervisor reviews and signs the report, the student must make a copy of the report for him/herself, giving the original to the PIMFT Clinic Director for processing. The PIMFT Clinic Director will review and sign the form and forward it to the PIMFT Front Desk Administrative Staff/GA. The Front Desk Administrative Staff/GA will enter the hours into a computer database and file the original. Every site at which the therapist accumulates client contact and supervision hours MUST be documented via its own

Page 39

MCSR with all appropriate signatures in order for the hours to count toward program completion. Electronic copies of the MCSR are available. Due to the specific design of Pfeiffer University’s COAMFTE Accredited MFT Program, only individual and group supervision hours provided by the AAMFT Approved Supervisor (or equivalent) in MMFT690 (i.e., faculty or adjunct member officially employed by Pfeiffer University to assume the specific role of clinic supervisor) can be counted toward program requirements. Although interns may receive additional hours from an AAMFT Approved Supervisor at his/her external placement site, those hours are strictly part of the extern site agreement and will not be counted toward the intern’s supervision hours predegree/graduation. Note, COAMFTE Accreditation educational guidelines supersedes state licensure requirements and other guidelines for other contextual roles (e.g., AAMFT Approved Supervisor guidelines). Students are strongly encouraged to use the electronic form and personalize it with their name and the name of their current supervisor. Typing in as much information on the form saves time and prevents possible mistakes due to poor handwriting. The students must keep up-to-date with the MCSR’s. MCSR’s that are excessively late (more than three weeks) may be rejected at the discretion of the practicum supervisor and/or PIMFT Clinic Director, which means the hours will not be counted towards the program requirements for graduation. During the first semester, students will also complete a Monthly Documentation of Clinic Hours form each month. This form will be used to track each student’s scheduled client hours, as well as hours spent at desk duty. During the first semester, it is recommended that students schedule at least 3 client hours at the clinic. First semester interns are required to be present whether or not a client is scheduled or attends a session. The remaining client hours (to total at least 10) may be earned in a combination of time spent at the PIMFT and field placement, if applicable. First semester interns must spend at least 2 hours each week on desk duty. Each week, students should document at least 12 hours total across those categories.

Therapist Vacations and Absences from the Clinic Vacations, illnesses, attendance at professional meetings, and other absences from PIMFT duties should be handled in a professional manner to ensure that proper care is provided to clients. If possible, the therapist intern should notify his/her supervisor well in advance of any upcoming absence. In addition, it is the responsibility of the therapist intern to identify a backup therapist intern to respond to client’s need in the event of an emergency. Furthermore, the therapist intern must inform clients of their time away from the clinic and the name of the therapist intern who will be covering their calls during the absence. In the event of scheduled absences: 1. Obtain the supervisor’s approval for the time away in advance, preferably before finalizing travel plans. 2. Make arrangements for one of the other students to cover cases for the period of the absence, including checking your mailbox daily and responding to any messages. Provide the back-up therapist with a Phone Log Sheet to document any messages and how they were handled. 3. Complete the Vacation/Leave of Absence Form, have the supervisor sign, and return to the Clinic Director. The dates of the absence, the name of the therapist providing backup coverage, and

Page 40

telephone numbers where the therapist can be reached for emergency consultations must be included on the form. 4. Notify each active client of the expected absence, informing the client the name of the therapist providing backup coverage, and ensuring that each client has the PIMFT clinic phone number. 5. Before leaving, remind the backup therapist of the upcoming absence, making sure he/she also has emergency contact numbers, and making sure that he/she and the supervisor are aware of any clients who may call with emergencies.

Case Assignment Suspension Form In the event that a therapist intern has an active, consistent caseload and does not wish to receive new intakes, the Case Assignment Suspension Request must be completed and turned in to the PIMFT Clinic Director. The reason(s) for not accepting new intakes must be discussed and granted permission to be taken out of rotation by current supervisor and/or the Clinic Director.

Therapist Intern Mailbox The clinic mailboxes and e-mail are used as a way of communication between daily clinic operations and the therapist intern. The therapist interns will check their clinic mailbox and clinic e-mail on a daily basis. Due to the number of therapist interns and daily activity of the clinic, it is not the responsibility of the Front Desk Administrative Staff or GA to be a personal receptionist for the therapist interns. Therapist interns should not make a habit of calling the Front Desk Administrative Staff or GA to retrieve personal messages from their clinic mailbox. If a therapist intern neglects to check mailbox and message area regularly, the therapist intern will have conversation with PIMFT Clinic Director and may lose client-seeing privileges due to not showing responsible client care procedures. The clinic mailboxes and email are used as a way of communication between daily clinic operations and the therapist interns. In addition, the message area is a way to communicate information from clients to his/her therapist intern.

Case File Forms Forms Required to Open a Case Phone Intake Record The Phone Intake Record should be used to obtain information about a new client. Instructions on completing this form are reviewed in the section entitled Scheduling New Clients.

Client Handbook The clients will receive a PIMFT Client Handbook at their initial session. The handbook outlines the purpose and mission of the Institute and valuable information for the client about the therapeutic process and PIMFT privacy policies. Page 41

Initial Session Forms Informed Consent The Informed Consent Form should be the first form completed with the client. This form is used to obtain agreement from the client for treatment in the PIMFT. During this time, the therapist intern should review the limits of confidentiality and general policies of the PIMFT clinic, including all therapy sessions are recorded for training purposes. All participants in session must sign the informed consent in order to receive therapy services. A legal guardian or parent must sign for any minors.

Research Participant Consent Form As a training facility, part of the vision of the PIMFT is to further the program and the MFT field through research. In order to include a client’s information in research projects, they must sign the Research Participant Consent Form. The therapist must explain to the client that donating their information to the research database is voluntary, and that only non-identifying information will be included for study. The therapist intern must ensure clients that they will receive therapeutic services regardless of whether they decide to donate their information to the research archive. For any client who declines to participate, the therapist intern should write “decline” at the top of the Client Information Form.

Fee Agreement New clients will pay the full $30 for the intake session (exception: university students). However, the fee agreement should be negotiated during the initial session before treatment begins. The therapist intern will inform the client of the $30 fee per session. If a client requests the sliding fee scale, the therapist intern will negotiate a fee per session using the Fee Schedule. Fees in the PIMFT are based on a “sliding fee” scale, ranging from $10.00-$30.00 per session. Negotiations with clients for fees less than what is determined based on the fee schedule must be approved by the PIMFT Clinic Director before a new Fee Agreement form is signed. Usually fees negotiated below $10.00 are established for extreme circumstances and for a limited number of sessions after which an assessment of financial need is made by the therapist and the director. On occasion, the director may contract with certain parties to provide a limited number of sessions at no charge. If a case is contracted for no charge sessions, the therapist intern will be notified before the initial session. Fees will be collected by the Front Desk Administrative Staff/GA/Desk duty attendant at the front desk at time of client check-in. The Fee Agreement form also outlines the clinic cancellation policy. The therapist intern must be familiar with the policy and review the terms with the client. The therapist intern may use this time as an opportunity to discuss procedures for contacting the therapist intern (i.e., client should leave a message with front desk staff who will get a message to therapist; therapist will return call within 24-48 hours, what to do in case of emergency).

Assessment Packet For clinical purposes, clients are required to complete the Assessment Packet before the initial session. The packet requires approximately 20 minutes to complete. The packet contains several measures that can be

Page 42

useful in opening conversations with clients about their concerns and developing therapeutic goals. Once the clients are finished with the Assessment Packet, the therapist should make sure that all of the measures have been completed while also reviewing the client’s concerns and questions regarding harm to self or others. If a member of a couple or family indicates that physical violence is a concern, the therapist intern should interview the person individually to assess safety issues. If a client indicates having suicidal thoughts, the therapist should assess the lethality of the thoughts by asking the client if they have had prior suicide attempts, a plan, the means/tools to carry out their plan, feelings of hopelessness and despair, etc. A safety plan and emergency procedures should be reviewed with the client and documented in the session case note. If applicable, an Agreement to Live Contract should be completed, giving one copy to the client and the original under the casenote for that session in the case file. If a client is considered at risk, a Risk and Safety Assessment Form is completed and included with the casenote. If a client has difficulty reading, the therapist may verbally administer the assessment packet. The therapist interns must be sensitive to such issues. Having clients complete the Assessment Packet after the session or sending it home with them is strongly discouraged.

Client Feedback Collecting and implementing client feedback is important for therapeutic alliance and progress, as well as improving clinic function. The information is entered in a database by the Graduate Assistant, and the results are used by the Clinic Director and MFT Faculty to improve therapist training and clinic functioning. Pfeiffer Institute Reach obtains written feedback in several ways. Outcome Rating Scale In order to further build a culture of feedback, at the beginning of every session, the therapist will have each client complete an Outcome Rating Scale (ORS; child forms are also available). The client should be instructed to make a mark along each line indicating how the past week has been for them on four dimensions: Individually, Interpersonally, Socially, and Overall, with “low” to the left and “high” to the right. The client returns the form to the therapist, who scores it using a ruler (indicate number of centimeters to two decimal places; e.g., 5.25). The therapist will then add the four scores together and write the total at the bottom. Using the ORS/SRS graph, the therapist will circle the approximate area of the score in the column for the first session. The clinical cutoff is 25; scores below 25 are associated with being a client. The therapist can use the item or added score to start a conversation about the client’s life and problems. The ORS should be kept in the file under the respective Case Note for that session. Session Rating Scale At the end of each session, the therapist will ask each client to complete the Session Rating Scale (SRS; child forms are also available). Constructed much like the ORS, the SRS measures therapeutic alliance across four dimensions: Relationship, Goals and Topics, Approach or Method, and Overall. The therapist scores each item and adds them, making an “X” in the approximate area of the score in the column for the first session. The cutoff score is 36; any scores below 36 should be processed with the client. The SRS should be kept in the file under the respective Case Note for that session.

Page 43

For further information about the ORS and SRS, including how to introduce, interpret, and integrate the measures, therapists are strongly encouraged to read On Becoming a Better Therapist by Barry Duncan. In addition, therapists should discuss the ORS and SRS for each case with their Clinical Supervisor. Client Satisfaction Survey At the end of the first session, therapists should enter the identifying information at the top and give each adult client the Client Satisfaction Survey Part I to complete in the waiting room. This brief survey assesses client’s initial communication with the clinic and their responses to the clinic environment. At the end of the first, fifth, tenth, and last sessions, therapists should enter the identifying information at the top and give each adult client the Client Satisfaction Survey Part II to complete in the waiting room. This brief survey assesses clients’ responses to the clinic environment and therapy process. If a client provides narrative feedback and indicates that the feedback can be shared with the therapist, the Clinic Director will do so.

Forms to be Completed after Each Session Progress Note Template PIMFT Case Notes Form should preferably be completed immediately following a session; however, the form must be completed within 72 hours of the session. Any progress notes for Saturday sessions should be completed before leaving the clinic for the weekend. A well-written case note allows the therapist to quickly review previous sessions, keep track of treatment goals, and check up on tasks assigned to clients. Progress notes must be written legibly. Accurate, complete, and up-to-date case notes are absolutely essential to protect the liability of PIMFT in the case of legal involvement. The template of this form may be found on the MFT Server in the “Manuals and Forms” folder. Progress notes must be recorded using the PIMFT case note template for continuity of record keeping and to adhere to best practice standards. Additionally, the following guidelines should be used when composing progress notes: 1. Case notes should be typed. Other documentation, such as records of phone contact, can be neatly written in ink on the appropriate form. 2. Document the date and session number on the top of each case note. 3. Always sign case notes and include your credentials, date, and time. 4. Complete case notes within 72 hours after the therapy session; case notes from Saturday sessions must be completed before leaving the PIMFT for the weekend. 5. Place all case notes on the right hand side of the client’s file with the most recent case note on the top. 6. Do not keep loose papers and post-it notes in the file; remove such items before turning in case for termination. Copy pertinent information onto appropriate forms for archive purposes. 7. Use the form provided (Progress Note 2.1, on shared drive under Clinic Forms), complete all necessary boxes. You may save your own copy in your folder. 8. Print the progress note and sign in blue or black ink.

Page 44

9. Do not use client names within the progress note. You can refer to client using confidential format (A = Adult, C = Child, M = Male, F = Female, include age as needed. Alternatively, you could refer to your client as “client,” and anyone else by their relationship to the client (e.g., girlfriend, mother). 10. Give enough information such that another therapist could pick up the case and basically know what had been done in therapy, but only content is significant. 11. Note any major changes since last session. 12. Note any change in mood or affect during session. 13. If there is a crisis situation (e.g., suicidal ideation), document the evidence in the Progress note and put a check in the appropriate section. In order to thoroughly document how a crisis situation was managed (e.g., asked client if s/he had a plan, contacted supervisor), interns should complete a Risk and Safety Assessment Form. This form is to be completed in addition to the Progress Note for a session, and should be kept immediately beneath the progress note.

Forms Needed to Close a Case Case Termination Form The Case Termination Form is to be completed when the therapist and supervisor are in agreement about closing a case. A case may be closed due to multiple reasons: 1) therapeutic goals are complete, 2) the client has “dropped out” of treatment, 3) the client was referred out to another provider, or 4) the client completed mandated number of sessions. If a client “drops out” of treatment, the therapist must make several attempts to re-engage the client in therapy. The attempts must be documented in the case file (i.e., phone contact record). Once the termination form has been complete, it must be submitted with the case file to the individual supervisor. The supervisor will review the case and sign the form if all paperwork is complete. The signed, completed form should be placed on top of the case note section on the right hand side of the case folder. Terminated cases should be turned in to the Front Desk Administrative Staff.

Case Transfer Form In the event a case is transferred from one therapist intern to another, the Case Transfer Form is to be completed. The signature of the current supervisor, current therapist intern, new supervisor and new therapist intern are mandatory.

Additional Case Record Forms Case Review Form The case review is to be completed each time the case is reviewed (e.g., live observation, recording, case discussion). Therapist intern will write a brief summary of what was discussed in supervision and present it to the supervisor for signing the Case Review Form. The Case Review form should be kept behind all case notes on the right hand side of the case folder.

Page 45

Phone Log Sheet The Phone Log Sheet documents any contact via telephone between therapist intern and client. In addition, the form should be used to document any contact with agencies and other professionals on behalf of the client to review case (after Authorization for Release of Client Records has been signed). Telephone contact of a lengthy manner (more than 15 minutes) or significant content discussed requires a case note to be completed to document the necessary details of the telephone conversation. Additionally, responses to emergency calls should be recorded on a case note. Telephone conversations with a client over 20 minutes in duration is discouraged and a face-to-face session should be scheduled. Phone therapy is not an option due to complication regarding supervision and fee collection. The Phone Log sheet should be kept on the bottom of the left side of the file.

Crisis Intervention and Emergency Procedures Acute Crisis Over-the-Phone Potential clients who call while experiencing a crisis (actively suicidal with a plan, or homicidal), should be referred to a hospital emergency room or law enforcement should be notified (i.e., police). It is unwise to attempt to provide more than a brief telephone assessment, and the therapist intern should refer potential client to a service that is equipped to deal with such an acute crisis. If an established client calls the PIMFT requesting immediate services, the client should be advised that the PIMFT will attempt to reach the client’s therapist intern immediately and have the therapist intern call the client. Therapist interns must keep their contact information up-to-date with the clinic and should identify a back-up person if they are out of town. If the therapist intern is not available to handle the crisis, the PIMFT Clinic Director and/or supervisor will be notified and he/she will respond to the client. The Clinic Director and/or supervisor will assess the situation, and he/she will take the necessary appropriate action. Any client who calls and is assessed in acute crisis, the person who answered the phone call must obtain caller’s name, current location, and current contact number in the event that the call is dropped and/or if law enforcement must be notified. If there is any indication that a client might harm himself/herself or others, or if the situation presents possible ethical/legal concerns, a supervisor is to be contacted immediately. At no time should a therapist intern go to a client’s home, meet a client at the hospital or other location, or transport a client.

Clinical Emergencies If a crisis develops in the course of a therapy session, the therapist intern should contact their supervisor, if available, or the PIMFT Clinic Director. If there is a concern for the physical safety of the therapist, the

Page 46

client, or others, law enforcement should be called (911) at once. All therapists should be familiar with the emergency procedures outlined in the manual. Certain clinical situations require immediate attention and action from the clinician. The therapist intern must be prepared to deal with these situations should they arise in the PIMFT. The therapist intern must act immediately if he/she has reasonable grounds to suspect or conclude that the following conditions exist:      

Current or ongoing sexual or physical abuse of a child, an elderly person, or a disabled person Current or ongoing relational violence between partners Current intoxication of a client in therapy room Suicidal threats or gestures Client in acute need of psychiatric hospitalization (due to hallucinations, suicidal intent, etc.) Homicidal intentions or threats of physical violence towards others

If a therapist intern suspects or concludes that any of the above listed exist, there are two general rules to remember: 1. Act to protect any actual or potential victims, including the client and yourself. 2. Involve another person at once – this means, a. Supervisor in the building b. Another supervisor in the building c. The PIMFT Clinic Director d. Law enforcement (911 – emergency, 704.336.8398 - non-emergency)

Safety Risk to Therapist The therapist intern must determine if there is an immediate risk of violence or of the client(s) leaving. If there is concern about intimate partner violence, separate the clients into separate rooms, or take one with you if necessary and if no risk to therapist. Involve another therapist or staff member – by interrupting another session, opening the door to the therapy room, contacting the PIMFT Clinic Director and informing him/her there is an emergency, etc. Identify options and develop a plan to handle the situation; remain calm. If the therapist intern has been threatened or feels threatened, he/she should not go back into the therapy room by him/herself; rather he/she should wait for help.

Current or Recent Sexual or Physical Abuse Marriage and Family Therapists have an ethical and legal obligation to report physical or sexual abuse of minors. If the therapist intern questions whether or not an incident is reportable, engage supervisor at once to help make the determination. Always contact your supervisor before making any report to an outside agency. According to North Carolina General Statute (N.C.G.S.) 7B-302(b), “Any person or institution who has cause to suspect that any juvenile is abused, neglected, or dependent, as defined by N.C.G.S. 7B-301, or has

Page 47

died as the result of maltreatment, shall report the case of that juvenile to the director of the department of social services in the county where the juvenile resides or is found.” If the therapist intern and their supervisor decides that a report must be filed, the following guidelines must be completed: 1. Explain to the client(s) that a report about the abuse or suspected abuse of a minor must be made, as required by law and ethical guidelines. 2. Ask the client(s) if they would like to make a report first; self-reporting empowers the client. Let the client know that a report will be made to the proper authorities regardless of their decision to report. 3. Inform the client(s) of the reporting process. 4. The therapist intern may make the report of child abuse by calling, writing, or visiting the county Department of Social Services, Child Protective Services (CPS) Division by calling (919.733.4622) or finding further information online at http://www.dhhs.state.nc.us/dss/local/index.htm. If it is after-hours, contact the local police department’s non-emergency number (704.336.8398). 5. If the therapist intern has reason to believe the abuse is happening “at this moment,” call 911 or the local police department’s non-emergency number (704.336.8398) to report the abuse immediately. The therapist intern is not required to report child abuse in North Carolina to CPS after contacting the police; law enforcement will get in contact with CPS after answering the call, if they deem it necessary. 6. The therapist intern must document any instructions given by CPS/local law enforcement in the case notes. In addition, document any CPS or local law enforcement case number in case note. 7. The therapist intern should be prepared to deal with possible anger and distress from family. Therapist intern should explain likely procedures after making a report. In addition, the therapist intern should help family prepare for any investigation that may occur.

Intimate Partner Violence Therapy is ineffective if one or both clients are being physically hurt or being threatened or intimidated with harm. The therapist intern must give attention to the “Current Concerns Checklist” items that involve physical violence and watch for nonverbal cues that may suggest physical violence. If the therapist intern suspects physical violence in the relationship: 1. Separate couple and talk with each one about alternatives (e.g., Women’s Protective Services, temporary separation (where one partner can go for cooling off period – parent, sibling, friend, motel, shelter). 2. Find out if other individuals/groups might be at risk (parents, siblings, children, others). 3. Have client(s) sign a No Violence Contract (person who is perpetrating the abuse) or Violence Prevention Contract (mutual contract). 4. Develop a Safety Plan with target of violence. 5. If therapist intern brings a couple back together after assessment, he/she may or may not review #1-#4 above. Decision should be guided by personal judgment of risk of violence and feedback from supervisor. Do not increase the risk of further violence by revealing too much to an angry, unrepentant partner. Page 48

6. If there is a threat of domestic violence, follow the guidelines for Expressions of Homicidal Intent. 7. Call law enforcement (911) if threat is immediate or if any physical violence occurs.

Intoxication Similar to intimate partner violence, it is unethical and not helpful to conduct a therapy session if the client is under the influence of a substance. If the therapist intern suspects a client is under the influence of a substance, he/she must refer to the portion of the Informed Consent form that outlines the PIMFT policy on such issues and: 1. State that you can see the client is intoxicated, drunk, or high (i.e., address concern and do not ignore) and that you cannot proceed with therapy unless everyone in the therapy room is sober. 2. State that the intoxicated client cannot drive him/herself home (i.e., client must be driven home by someone else – someone in session, cab). 3. Offer to help find someone to pick up intoxicated person, such as a partner, relative, friend, taxi cab, or the police. 4. If a client threatens to leave without proper escort, explain that you must call the police. 5. If client does leave, call the police (911). Explain who you are, what you have observed, and give any information you have: Name, address, condition, car description, license number (if available), and likely destination. 6. If the client becomes threatening or belligerent, call police (911). 7. Carefully document interaction with client and the steps that were taken to ensure everyone’s safety.

Suicidal Ideation Suicidal ideation is a common symptom of depression, but the lethality of the ideation should always be assessed. Consider all expressions of “wanting it all to end,” “wanting to never come back,” “not wanting to wake up,” etc. as carrying the potential for suicide. Check the appropriate Assessment Packet items regarding suicidal ideation (e.g. item #8 on the OQ) and ask follow-up questions such as the following to further assess the lethality of the suicidal ideation: 1. “Have you been thinking about hurting yourself or attempting suicide?” 2. “On a scale from 1 to 10, how likely are you to hurt yourself?” (Anything over a 5 suggests a formal evaluation is necessary.) 3. “Do you think about ways to hurt yourself or commit suicide?” 4. “Have you tried to end your life before?” 5. “Do you have a plan?” 6. “When would this happen?” 7. “What would happen then?” 8. “Do you have a gun (or pills) in the house?” (or other tools to carry out the plan) If the client has been thinking seriously about suicide, has a plan, does not have a plan but has the means to harm themselves, or if there is a timetable, then the situation should be considered an emergency. Use the Agreement to Live Contract with the client and identify at least two people besides the therapist intern to call for help when suicidal ideation occurs. Develop a safety plan and, if warranted, involve the Page 49

friend/family member listed on the contract in the current session or call them to verify willingness to be a part of the safety plan (with Authorization for Release of Client Records). For severe suicidal ideation or other acute psychiatric concerns, have the client go for an evaluation for inpatient treatment. If the client agrees to go to an emergency room: 1. Have a friend or relative drive the person. Obtain a Release of Information Form so that you can confirm the client’s arrival. If a friend or relative is not available, call law enforcement (911) and explain that you have a client who needs to be transported to an emergency room. Send a PIMFT business card with your contact information with the client, to facilitate communication between yourself and the other care providers. 2. Contact the PIMFT Clinic Director and advise her/him of the situation. Do not go with the client to the hospital, do not meet the client at the hospital, and do not transport the client in your own vehicle. 3. Explain to any waiting clients, and/or have the Front Desk Administrative Staff/GA or a colleague call all clients scheduled with you for that day, that an emergency is forcing you to cancel their appointment and that you will contact them to re-schedule. 4. Make it clear with the client that you expect either the client or other care provider to follow up by phone to discuss the outcome of the evaluation and any additional safety plans. If the client refuses all other forms of assistance and will not go to the emergency room voluntarily: 1. Call law enforcement (911), explain who you are and what you have observed. The police will only get involved if the client is a danger to him/herself or others. 2. Only discuss facts and request that a police officer be sent to help transfer the client. Stay with the client until the police arrive; tell the officer what you know and the risk to the client. 3. When the officer arrives, have the officer explain to you and the client what will happen when they leave the building. 4. Contact the PIMFT Clinic Director to advise her/him of the situation. 5. Explain to any waiting clients, and/or have the Front Desk Administrative Staff/GA or a colleague call all clients scheduled with you for that day, that an emergency is forcing you to cancel their appointment and that you will contact them to re-schedule. If the client leaves before the police arrive, provide a description of the person (e.g., height, weight, hair color, and clothing). If possible, get a license plate number and a description of their vehicle (e.g., color, make, model, etc.). Call law enforcement immediately; tell them who you are and what has happened.

Acute Psychiatric Concerns Hospitalization is a possibility if a client seems very confused, reports hallucinations, is extremely panicky, reports being intensely and acutely depressed, suicidal (see above), or delusional. The basic rule to consider is the client’s safety and well-being. (Is the client safe on the streets or at home?) If you know the client well and see a drastic change in behavior or emotions, think about acute decompensation requiring hospitalization. Use the following questions as a general guide: Page 50

1. 2. 3. 4. 5. 6. 7. 8.

“Have you been thinking about hurting yourself or attempting suicide?” “Have you been seeing or hearing things that other people may not see or hear?” “Are you afraid that someone or something may hurt you?” “Is there something going on that is hard to talk about?” “Is someone else worried about you or are you worried about yourself?” “Do you feel safe in here?” “When did you last have a good night of rest?” “Are you currently on any medication or substance?”

If your questions lead you to conclude that the client needs hospitalization, follow the emergency procedures outlined above addressing suicidal ideation.

Expression of Homicidal Intent If a client expresses a sincere desire to hurt another person, you must assess the level of danger. Explore whether or not the client has a plan, an intended target, means, or time-table for carrying out their plan (similar to exploring the lethality of a suicide threat). If the client is willing to talk with you, focus on alternative actions, likely consequences, effect of the action on friends or family, effect of action on the client him/herself; in brief, try to deflect the client’s anger into other channels. Develop future plans of action. The therapist intern must discuss his/her responsibility with such threats. Discuss the Informed Consent (especially the section on disclosing confidential information due to harm to self or others) and show the client where he/she signed. Tell the client you must act to protect the intended target. You are their supporter, you hear their anger, but they must not injure another person. Help them identify healthy options. If a client threatens to harm another person and the therapist intern assesses that the threat is serious and imminent, he/she must contact his/her supervisor and/or PIMFT Clinic Director immediately. Tarasoff ruling for North Carolina: Tarasoff in North Carolina does NOT require a duty to warn; however, the clinician may still do so. The clinician has permission to warn, but may not be fully protected if he/she breaks client confidentiality. Guidelines that need to be met before warning intended target: 1. 2. 3. 4. 5.

The therapist must have a professional relationship with the client making the threat. The threat must be made in the presence of the mental health professional. The threat must be toward an identified or identifiable person. The threat must pose a serious and imminent threat of physical harm to the person. The therapist must assess the client for potential dangerousness to that person (see guideline #4).

How to warn:

Page 51

1. Contact clinical supervisor and clinical director and inform them of the situation. Based on their feedback, do #2 and/or #3 as follows. 2. Contact law enforcement (911). Inform law enforcement of who you are and what you heard from the client. Identify the intended target and plan. Only discuss facts and make it brief. 3. Contact intended target. Inform target of who you are and what you heard from the client. Only discuss facts and make it brief. 4. Document discussion with supervisor, PIMFT Clinic Director, law enforcement, and/or intended target. 5. Document the facts that helped you determine the threat was serious and imminent (see guidelines above). 6. Document how you gave warning and to whom you gave the warning (e.g., time, by phone)

Other Safety Measures for PIMFT Staff and Therapist Interns In the evening, there must always be at least two people in the PIMFT clinic. Even though a therapist intern may not have any more clients on a given evening, he/she should remain until the other therapist intern has finished seeing clients for the evening. If therapist intern has reason to believe that a client or a member of the client’s family may become violent, he/she should communicate that possibility to his/her supervisor and the Clinic Director before next appointment with client. In addition, if a client is assessed as a safety issue future appointments must be made during the day and the clinic must be well staffed. The therapist intern should notify the front desk when they leave the office; if leaving the building after dark, therapists are encouraged not to leave alone.

Page 52

Appendices

Page 53

Intern Checklist Pfeiffer Institute for Marriage and Family Therapy Intern Checklist Intern Name: _______________________________________________________________ (Last) (First) (Middle/Maiden) Phone Number: ________________________ Email: _______________________________

Form

Date Completed/Received

Intern Application for Candidacy Meeting with Clinic Director Proof of Student Liability Insurance Expiration Date: Acknowledgement of Confidentiality Supervisory Contract Acknowledgement of Clinic Policies and Procedures Manual Read Co-therapy articles

Observation (3 hours of sessions)

New Intern Orientation/Desk Duty

Mock-therapy with Dr. Haines

Page 54

Initials

Application for Clinical Internship Candidacy

Page 55

Page 56

Page 57

MMFT 690: Supervision Contract for Therapist Interns 1. The therapist intern will be responsible for attendance at all individual and group supervision sessions and all structured therapy hours. Additional supervision hours may be negotiated by mutual agreement of the supervisor and therapist intern. 2. Each intern is required to complete a minimum of 12 hours weekly of intern service during each semester of internship or field placement, not including individual and group supervision hours weekly. Each intern must maintain 1-3 active cases at the PIMFT each semester, and all interns are responsible for helping keep the PIMFT clean and neat at all times. 3. Supervision will be provided by an assigned clinic supervisor for MMFT 690. The supervisor will cover therapy and outreach provided by the therapist intern at both the Pfeiffer Institute and in his/her clinical field placement. Individual supervision will be scheduled for (1) hour weekly. Group supervision will be scheduled weekly for (2) hours and will include readings and assignments. A lab fee of $125.00 will be charged each semester in addition to the respective tuition for MMFT 690. 4. Supervision is not psychotherapy. The therapist intern is strongly encouraged to seek therapy, peer support, and/or consultation if personal issues come up that cannot be resolved within the professional relationship of supervision. Remember that a total of (10) hours of personal growth/counseling is required during each academic year during regular semesters. 5. The supervisor and the therapist intern are bound by and expected to conduct themselves in a manner required by the laws and ethical standards of the State of North Carolina and the AAMFT Code of Ethics, Pfeiffer University, and any other relevant professional bodies. Failure to adhere to these legal and ethical standards will result in immediate termination of this contract and immediate dismissal of the therapist intern from the Marriage and Family Therapy Program. Therapist interns must notify the clinic supervisor, who should then notify the clinic director and the program director, if he or she is grieved, sanctioned, sued, or judged liable or guilty in a judge or jury trial. 6. The therapist intern will personally purchase a minimum $1 million/$3 million professional liability student insurance policy and deliver such copy of policy verification on the first day of the semester. No student will conduct therapy without the evidence of the proper policy (CPH & Associates). 7. The therapist intern will comply with all designated rules, policies, procedures, including the PIMFT dress code. The therapist intern will abide by the dress code in any situation in which s/he is representing the PIMFT or the Pfeiffer University Marriage and Family Therapy Program (e.g., staffing a booth at a community fairs, meeting with a field placement supervisor, interviewing prospective students). 8. This contract is based on mutual agreement of the supervisor and the therapist intern. Either party may terminate this contract, without cause, with 24 hours prior notice. Notice may be verbal, written, or both. Other supervision arrangements must be made to continue in the program. This

Page 58

contract includes and supersedes any previous contract between the supervisor/PIMFT and the therapist intern. 9. The therapist intern agrees to the release of relevant client information, including recordings of confidential information for professional review by the clinic supervisor, the supervisory staff at the Institute, and other Pfeiffer MFT program faculty with an interest in the therapist intern’s academic progress, professional behavior, ethical conduct, development, and performance. Therapist interns also agree to allow such discussions between Pfeiffer MFT faculty and field placement site supervisors to monitor experiential progress throughout the semester. All clinical supervisors will be AAMFT Approved Supervisors or Supervisors in Mentoring. All field placement site supervisors will be committed to the daily supervision of therapist interns and maintain regular communication and collaboration with Pfeiffer faculty supervisors. End of the semester evaluations will be required for each student. 10. The therapist intern is required by North Carolina law to: a) protect the confidentiality of each and every client, b) report suspicion and direct knowledge of child abuse and/or child neglect, c) inform clients that he/she is a therapist intern in training and is not licensed, d) inform clients of the name of his/her clinic supervisor, e) not practice therapy in areas beyond his/her competence, training, education, or experience, f) review his/her disclosure statement with clients during the initial session and keep it on record, g) abide by and comply with the AAMFT Code of Ethics, h) implement ethical decision making and consult with the clinic supervisor when in doubt, i) report the intent of a client to harm himself/herself (suicide) or other (homicide) to the clinic supervisor, and immediately warn the (foreseeable or identifiable) intended victim, and j) contact the clinic supervisor for all legal and/or ethical dilemmas. 11. The therapist intern will participate in the PIMFT clinic operations (e.g., desk duty) as part of the initial semester of MMFT 690. Hours can be counted toward the minimum 12 hours/week of service at the PIMFT It is the responsibility of the therapist intern to switch desk duty hours or find a replacement for desk duty if he/she is unable to carry out his/her responsibility. By signing below, the therapist intern affirms that he/she has read and understands this supervision contract/disclosure statement and agrees to all the terms described.

_______________________________________

___________________________________

Therapist Intern

Clinic Director

Date

Page 59

Date

Intern Acknowledgment of Confidentiality Pfeiffer Institute of Marriage and Family Therapy Intern Acknowledgement of Confidentiality One of the principle requirements of working in the Pfeiffer Institute for Marriage and Family Therapy (PIMFT) is that confidentiality be strictly maintained. Any and all information concerning clients serviced in and/or by this office is strictly confidential. This includes, but is not limited to, any acknowledgement that a client was seen in this clinic. We can neither confirm nor deny any individual received therapy services at PIMFT without his/her written consent and release of information. No identifying information acquired as a result of placement in counseling services involving any client may be discussed with anyone outside of the clinic. If a case is discussed within the MFT program (e.g., class training), caution and discretion will be used in discussing the case and no identifying information about the client/client system will be discussed. My signature below indicates that I understand and accept all of the above conditions of placement in the Pfeiffer Institute (MMFT 690). I will respect the privacy of all clients all the time, maintain the conduct expected of a mental health professional in compliance with the AAMFT Code of Ethics and North Carolina statutes, and adhere to PIMFT clinic policy and procedure manual.

_________________________________________ Therapist Intern

Date

_________________________________________ Clinic Director

Date

Page 60

MFT690: MFT Competencies Students will become knowledgeable of the COAMFTE Core Competencies and their application to the practice of therapy: 1.3.1 (Executive) Gather and review intake information, giving balanced attention to individual, family, community, cultural, and contextual factors. 1.3.4 (Executive) Explain practice setting rules, fees, rights, and responsibilities of each party, including privacy, confidentiality policies, and duty to care to client or legal guardian. 1.3.6 (Executive) Establish and maintain appropriate and productive therapeutic alliances with the clients. 1.3.7 (Executive) Solicit and use client feedback throughout the therapeutic process. 1.3.9 (Executive) Manage session interactions with individuals, couples, families, and groups. 1.4.1 (Evaluative) Evaluate case for appropriateness for treatment within professional scope of practice and competence. 2.3.1 (Executive) Diagnose and assess client behavioral and relational health problems systemically and contextually. 2.3.6 (Executive) Assess family history and dynamics using a genogram or other assessment instruments. 2.3.8 (Executive) Identify clients’ strengths, resilience, and resources. 2.5.1 (Professional) Utilize consultation and supervision effectively. 3.2.1 (Perceptual) Integrate client feedback, assessment, contextual information, and diagnosis with treatment goals and plan. 3.3.5 (Executive) Manage progression of therapy toward treatment goals. 3.5.3 (Professional) Write plans and complete other case documentation in accordance with practice setting policies, professional standards, and state/provincial laws. 4.3.1 (Executive) Match treatment modalities and techniques to clients’ needs, goals, and values. 4.3.2 (Executive) Deliver interventions in a way that is sensitive to special needs of clients (e.g., gender, age, socioeconomic status, culture/race/ethnicity, sexual orientation, disability, personal history, larger systems issues of the client). 4.3.11 (Executive) Move to constructive termination when treatment goals have been accomplished. 4.4.1 (Evaluative) Evaluate interventions for consistency, congruency with model of therapy and theory of change, cultural and contextual relevance, and goals of the treatment plan. 4.4.4 (Evaluative) Evaluate clients’ reactions or responses to interventions. 4.5.1 (Professional) Respect multiple perspectives (e.g., clients, team, supervisor, practitioners from other disciplines who are involved in the case). 4.5.2 (Professional) Set appropriate boundaries, manage issues of triangulation, and develop collaborative working relationships. 4.5.3 (Professional) Articulate rationales for interventions related to treatment goals and plan, assessment information, and systemic understanding of clients’ context and dynamics. 5.3.5 (Executive) Take appropriate action when ethical and legal dilemmas emerge. 5.4.2 (Evaluative) Monitor attitudes, personal well-being, personal issues, and personal problems to insure they do not impact the therapy process adversely or create vulnerability for misconduct.

Page 61

Live Observation Assessment Live Observation Assessment Please print: Student Observed: Course: MMFT690

Date: Time:

Rating Scale: N = No opportunity to observe 0 = Does not meet criteria

1 = Meets criteria minimally or inconsistently for program level 2 = Meets criteria consistently at this program level

Communication Skills & Abilities

Comments :

N / 0 / 1 / 2 Professional Responsibility

Comments :

N / 0 / 1 / 2

Case Management

Comments :

N / 0 / 1 / 2

Competence

Comments :

N / 0 / 1 / 2

Maturity

Comments :

N / 0 / 1 / 2

Page 62

Integrity

Comments :

N / 0 / 1 / 2

Case Progression

Comments :

N / 0 / 1 / 2

Integration of Feedback

Comments :

N / 0 / 1 / 2 Supervisor Feedback:

Supervisor Signature

Student Signature (See back for additional comments)

Additional Comments Communication Skills & Abilities:

Professional Responsibility:

Page 63

Case Management:

Competence:

Maturity:

Integrity:

Case Progression:

Integration of Feedback:

Supervisor Signature

Student Signature

Page 64

Clinical Performance Evaluation Please Print Student: _____________________________________________ Date: ___________________________ Course: ______________________________________________ Supervisor: ______________________ Rating Scale: N = No opportunity to observe O = Does not meet criteria COMMENTS:

1= Meets criteria minimally or inconsistently for program level 2= Meets criteria consistently at this program level

Communication Skills and Abilities 1. The student demonstrates the ability to establish relationships in such a manner that a working alliance can be created. 2. The student demonstrates effective communication skills including: a. Creating appropriate structure – setting the boundaries of the helping frame and maintaining boundaries throughout the work such as setting parameters for meeting time and place, maintaining the time limits, etc. b. Understanding content – understanding the primary elements of the client’s story. c. Understanding context – understanding the uniqueness of the story elements and their underlying meanings. d. Responding to feelings – identifying affect and addressing those feelings in a therapeutic manner. e. Congruence – genuineness; external behavior consistent with internal affect. f. Establishing and communicating empathy – taking the perspective of the individual without over identifying, and communicating this experience to the individual. g. Non-verbal communication – demonstrates effective use of head, eyes, hands, feet, posture, voice, attire, etc. h. Immediacy – communicating by staying in the here and now. i. Timing – responding at the optimal moment. j. Intentionality – responding with a clear understanding of the therapist’s therapeutic intention. k. Self-disclosure – skillful and carefully – considered for a specific strategic purpose. 3. The student demonstrates awareness of power differences in therapeutic relationship and manages these differences effectively. 4. Respects multiple perspectives (e.g., clients, team, supervisor, practicioners from other disciplines who are involved in the case). 5. The student creates a safe environment. 6. The student demonstrates analysis and resolution of ethical dilemmas.

N 0

1

2

N 0

1

2

N 0 N 0

1 1

2 2

N 0 N 0 N 0

1 1 1

2 2 2

N 0

1

2

N N N N N

0 0 0 0 0

1 1 1 1 1

2 2 2 2 2

N 0

1

2

N 0 N 0

1 1

2 2

N 0 N 0 N 0

1 1 1

2 2 2

N 0

1

2

N 0 N 0 N 0

1 1 1

2 2 2

Professional Responsibility 7. The student conducts self in an ethical manner so as to promote confidence in the counseling profession. 8. The student relates to peers, professor, and others in a manner consistent with stated professional standards. 9. The student demonstrates sensitivity to real and ascribed differences in power between themselves and others, and does not exploit or mislead other people during or after professional relationships. 10. The student demonstrates application of legal requirements relevant to counseling training and practice.

Case Management 11. Completes case documentation in a timely manner and in accordance with relevant laws and policies. 12. Develop, establish, and maintain policies for fees, payment, record keeping, and confidentiality. 13. Maintain client records with timely and accurate notes.

Page 65

Rating Scale: N = No opportunity to observe O = Does not meet criteria

1= Meets criteria minimally or inconsistently for program level 2= Meets criteria consistently at this program level

Competence 14. The student demonstrates cultural sensitivity (e.g., gender, age, race, ability, sexual orientation) in the therapy room and adapts therapeutic process to meet the cultural needs of client system.

N 0

1

2

15. The student recognizes the boundaries of her/his particular competencies and the limitations of her/his expertise

N 0

1

2

16. The student takes responsibility for compensating for her/his deficiencies.

N 0

1

2

17. The student takes responsibility for assuring other’s welfare when encountering the boundaries of her/his expertise.

N 0

1

2

18. The student provides only those services and applies only those techniques for which she/he is qualified by education, training and experience.

N 0

1

2

19. The student demonstrates basic cognitive, affective, sensory, and motor capacities to respond to others.

N 0

1

2

20. The student demonstrates appropriate self-control (such as anger control, impulse control) in interpersonal relationships with faculty, peers, and others.

N 0

1

2

21. The student demonstrates honesty, fairness, and respect for others.

N 0

1

2

22. The student demonstrates an awareness of his/her own belief systems, values, needs and limitations and the effect of these on his/her work.

N 0

1

2

23. The student demonstrates the ability to receive, integrate and utilize feedback from peers, teachers and supervisors.

N 0

1

2

24. The student exhibits appropriate levels of self-assurance, confidence, and trust in own ability.

N 0

1

2

25. The student follows professionally recognized conflict resolution processes, seeking to informally address the issue first with the individual(s) with whom the conflict exists.

N 0

1

2

27. The student avoids improper and potentially harmful dual relationships.

N 0 N 0

1 1

2 2

28. The student respects the fundamental rights, dignity, and worth of all people.

N 0

1

2

29. The student respects the rights of individuals to privacy, confidentiality, and choices regarding selfdetermination and autonomy.

N 0

1

2

30. The student respects cultural, individual, and role differences, including those due to age, gender, race, ethnicity, national origin, religion, sexual orientation, disability, language, and socioeconomic status.

N 0

1

2

31. The student moves to constructive termination when treatment goals have been accomplished.

N 0

1

2

32. The student collaborates with an individual to establish clear therapeutic goals.

N 0

1

2

33. The student facilitates movement toward the individual’s goals.

N 0

1

2

Maturity

Integrity 26. The student refrains from making statements which are false, misleading, or deceptive.

Case Progression

Page 66

34. The student demonstrates the capacity to match appropriate interventions to the presenting problem in a consistent manner.

N 0

1

2

a. Integrates client feedback.

N 0

1

2

b. Responsiveness to client feedback.

N 0

1

2

36. Utilize consultation and supervision effectively.

N 0

1

2

37. Integrate supervisor/team communications into treatment.

N 0

1

2

38. Evaluate client’s reactions or responses to interventions.

N 0

1

2

39. Modify interventions that are not working to better fit treatment goals.

N 0

1

2

40. Evaluate client’s outcomes for the need to continue, refer, or terminate therapy.

N 0

1

2

41. Consult with peers and/or supervisors if personal issues, attitudes, or beliefs threaten to adversely impact clinical work.

N 0

1

2

Integration of Feedback 35. Solicit and use client feedback throughout the therapeutic process.

COMMENTS:

2 Rating Scale: N = No opportunity to observe O = Does not meet criteria COMMENTS:

1= Meets criteria minimally or inconsistently for program level 2= Meets criteria consistently at this program level

___________________________________ Student Signature

Date

___________________________________

______________________________________

Pfeiffer Institute Supervisor Signature

Field Placement Site Supervisor Signature

Date

Date

Adapted and edited by the Marriage and Family Therapy Program, Pfeiffer University from the Professional Counseling Program of the Department of Educational Administration and Psychological Services, Texas State University-San Marcos. Rev 5/07/09

Page 67

Field Placement Site Requirements 

     



  

The MFT Program and Pfeiffer Institute for Marriage and Family Therapy will maintain clear relationships with all Field Placement site(s), which will be specified in a written document. Activities of each therapist intern will be documented at the Field Placement site(s). These records will be made available to the MFT Program. The institution sponsoring the Field Placement site(s) will have been in operation for at least two years. Field Placement site(s) will provide adequate facilities and equipment for the therapist intern to carry out designated responsibilities. Mechanisms for therapist intern evaluation of Field Placement site(s) and supervision, and site evaluation of the therapist intern’s performance will be demonstrated. Documentation of liability insurance for therapist intern will be confirmed. Liability insurance will be purchased by the therapist intern. Field Placement site(s) will publish and adhere to policies prohibiting discrimination on the basis of age, culture, ethnicity, gender, physical ability, race, religion, sexual orientation, and socioeconomic status. An AAMFT Approved Supervisor or the equivalent will supervise the therapist intern’s clinical work; however, not required at the Field Placement site. An administrative supervisor is required at a Field Placement site to provide structured supervision or case staffing. The Field Placement supervisor will be available to the therapist intern and will be an active participant in his/her training. The Field Placement supervisor will be clearly senior in experience to the intern. The Field Placement site(s) will have opportunities for the therapist intern to obtain relational hours.

Page 68

Field Placement Site Supervision Agreement Intern: ________________

Field Placement Site Supervision Agreement I. Requirements of Field Placement Site 1. Orient the intern to the mission, goals, and objectives of the field placement site. 2. The field placement site supervisor agrees to provide site orientation to the intern, including applicable policies and procedures, and to provide clarification of the intern’s relevant roles, functions, and relationships. 3. Provide the appropriate permanent designated confidential space, equipment, resources and supplies determined necessary and reasonable by both parties for clinical learning experiences. 4. The field placement site agrees to provide direct client contact hours consistent with the published COAMFTE Education Requirement as stated in the following: “Direct client contact is defined as face-to-face (therapist and client) therapy with individuals, couples, families, and/or groups from a relational perspective. Assessments [client intakes] (sic) may be counted as direct client contact if they are face-to-face processes that are more than clerical in nature and focus. Psychoeducation may be counted as direct client contact.” (Section 201.01, adopted on November 11, 2005.) 5. The field placement site will provide direct client contact of which approximately 50% of the direct client contact must be relational (e.g., couple, family, relational group, medical family therapy). 

The field placement site must provide a structured schedule of approximately ________ clinical hours beginning on _________ and concluding on __________. Continued placement of the intern is contingent upon satisfactorily meeting mutual goals and expectations of the clinical field placement and Pfeiffer University’s Marriage and Family Therapy program.

6. The field placement site agrees to provide relevant unique and specialized information and training to the intern, which is necessary for competent delivery of services to the field placement site’s clientele. 7. The field placement site supervisor will make appropriate experiences available for the intern’s professional growth. 8. Permit video recordings of marriage and family therapy sessions to be reviewed by the Pfeiffer Institute clinical supervisor who will be evaluating the intern’s progress. Interns are not required to Page 69

record all sessions. Therefore, clients are free to decline permission for recording. Interns will obtain consent from all clients to permit recording. Each field placement site may have its own form for obtaining such consent or the Pfeiffer Institute’s form will be used. Recordings will not include identifying information about the client and will be erased or destroyed following their use for clinical supervision. 9. Confidentiality of records will be maintained in accordance with field placement regulations. During clinical supervision, case content must be disclosed while protecting client identity. 10. Permit clinical supervisor/program faculty to observe interns at the field placement site. 11. The field placement site supervisor agrees to contact the intern’s clinical supervisor (information provided below) if concerns arise about an intern’s performance, skills preparation, level of progress, ethical behavior, and/or attitudes.

II. Responsibilities of the internship field placement site supervisor. 1. Field placement site supervisors must be full-time administrative or clinical staff who can provide sufficient oversight and accurate assessment and evaluation of intern’s progress. (Note: there can be no dual relationship between the site supervisor and the intern.) 2. The field placement site supervisor must be on site whenever the intern is conducting therapy unless a designated alternative supervisor, who meets the standards of item #1 above, is clearly identified to the intern and contact information made available to both the intern and Pfeiffer Institute. 3. The field placement site supervisor will provide an assessment mid semester and at the semester end using Pfeiffer Institute’s Assessment Form, and mutually review it with the intern. Both parties must sign the assessment and return it to the Clinic Director to be placed in the student’s academic file. 4. Field placement site supervisor must verify the intern’s regularly scheduled hours including intern’s client contact hours and field placement site supervision hours. 5. Ensure that the intern receives at least one hour per week of scheduled one-on-one confidential supervision by the field placement site supervisor, exclusive of case staffing. 6. The field placement site supervisor agrees to contact the intern’s clinical supervisor should concerns arise concerning an intern’s performance, skill preparation, level of progress, ethical stance, behavior, or attitudes.

Page 70

III. Responsibilities of the Intern 1. Present Field Placement Site Agreement outlining collaborative goals/objectives. 2. Become aware of and comply with the policies and procedures of the field placement site. This may include, but is not limited to, immunizations, background checks and specialized training. 3. Attend all orientation programs at the field placement. 4. Comply with operational time and schedule as prescribed by the field placement site. The intern must remain at the field placement site for the designated hours even when clients are not scheduled. 5. Maintain an appropriate professional appearance as prescribed by the field placement site. However, the minimum standard will be the Pfeiffer Institute’s Dress code. 6. Keep the field placement site supervisor fully informed about client activities. 7. Complete COAMFTE Form C as specified in the Pfeiffer Institute Internship Manual. 8. Meet weekly with the designated Pfeiffer Institute clinical supervisor and participate in the weekly group supervision class. 9. Abide by the ethical standards and confidentiality laws as established by North Carolina and the American Association for Marriage and Family Therapy. Additionally, the intern must avoid the appearance of fostering unprofessional relationships within the site. 10. Obtain and hold current professional liability insurance. 11. At the conclusion of the experience/semester complete a field placement experience summary and field placement site evaluation.

Page 71

Signatures and Date

____________________________________ Field Placement Site Supervisor Signature

____________________________ __________ Intern Signature Date

_____________________________________ Field Placement Site Supervisor Name

____________________________________ Intern Name

_____________________________________ Name of Field Placement Site _____________________________________ Number Street Ste ______________________________________________ City State Phone Number Pfeiffer Institute Approval: _____________________________________ Clinic Director’s Signature

Page 72

Field Placement Site Supervisor Application Pfeiffer University Marriage and Family Therapy Program FIELD PLACEMENT SITE SUPERVISOR APPLICATION Please provide the following information: Date: __________________ Supervisor Name: _________________________

Therapist Intern Name:________________

Name of Agency: _______________________________________________________________ Agency Address: _______________________________________________________________ Agency Phone Number: ____________________

Agency Fax Number: __________________

If supervision is to be provided in a location separate from the above listed agency, please indicate the location (agency name, private office, etc.) where supervision will be conducted. _____________________________________________________________________________ Intended start date for supervision: ___________________________ Supervisor Background: I. Highest Degree Attained (please check):  B.A.  B.S.  M.A.  M.S.

 MMFT  PhD

 PsyD

 Other: _____

Area: ______________________________ Year Degree Awarded: ______________________ Granting Institution: ____________________________________________________________ II. Licensure (Please attach a copy of your current license(s) to this application.) 1. Do you hold a current license in marriage and family therapy?  Yes  No If yes, in what state(s)? __________________________________________________________ License number: ______________ Year received license: __________

Expiration: ________

2. Do you hold a license in any other area of clinical practice?  Yes  No Please list other license(s) held: _____________________________________________________ License number: ______________ Year received license: __________ Page 73

Expiration: ________

3. Has your license ever been revoked or suspended?  Yes  No If yes, please explain: _____________________________________________________________ 4. Are any complaints currently pending against you before your state’s licensing board?  Yes  No If yes, please explain: _____________________________________________________________ III. MFT Clinical Experience 5. Please indicate the number of years you have been practicing marriage and family therapy: _____ 6. Please indicate the approximate number of direct client contact hours or number of years that you have completed in each of the following areas: Individual Adult Counseling/Therapy Individual Child Counseling/Therapy Couple Counseling/Therapy Family Counseling/Therapy Group Counseling/Therapy Other (please specify): ______________

_____ _____ _____ _____ _____ _____

 Direct client contact hours  Direct client contact hours  Direct client contact hours  Direct client contact hours  Direct client contact hours  Direct client contact hours

IV. American Association for Marriage and Family Therapy (AAMFT) Membership 7. Are you currently a Clinical Fellow of AAMFT?  Yes  No If yes, in what year did you initially become a member? _________ 8. Are you currently recognized as an Approved Supervisor by AAMFT?  Yes  No If yes, for how many years have you been an approved supervisor? ________ 9. Are you currently recognized as a Supervisor Candidate by AAMFT?  Yes  No If yes, for how many years have you been an approved supervisor candidate? ________ V. Training in MFT Supervision 10. Please indicate which of the following training activities you have completed:  AAMFT approved seminar/workshop in MFT supervision  Graduate MFT supervision course through an accredited program  Seminars or coursework in general (not specific to MFT) supervision  Supervision of your supervision of others  Other training, study, or preparation for supervision: ____________________ VI. MFT Supervision Experience Page 74

 Years  Years  Years  Years  Years  Years

11. For how many years have you been supervising MFT interns? _______ 12. Please indicate the total number of supervision hours you have completed in each of the following: _____ Individual MFT Supervision _____ Group (3 or more supervisees) MFT Supervision _____ Individual (Non MFT) Supervision _____ Group (Non MFT) Supervision 13. How many interns do you currently supervise? _____ 14. Please indicate the percentage of supervision you devote to each of the following (total should = 100%) _____ Live supervision _____ Videotape review _____ Audiotape review _____ Case discussion (without video or audio review) _____ Other (please specify): _________________________________ Thank you for your cooperation in providing the requested information. Please feel free to contact the Clinic Director of the Pfeiffer Institute Reach should you have any concerns or questions in regards to these matters. All inquiries can be directed to: Dr. Jenny Haines, PhD, LMFT Clinic Director, Pfeiffer Institute for Marriage and Family Therapy 4805 Park Road, Suite 250 Charlotte, NC 28209 704.945.7324

Page 75

Field Placement Site Evaluation Field Placement Site Evaluation MMFT 690 Pfeiffer University Marriage and Family Program

Please complete after your field placement experience and submit to the Clinic Director. This information is confidential in that it will not be shared with the externship site.

Site Name:

On Site Supervisor:

Your job/title/role at the field placement:

Number of semesters at the field placement:

Approximately how many hours per week did you spend at your field placement?

Please make general comments as to the strengths and weaknesses of this site on the following areas: Page 76

General climate of the site:

Professional opportunities available at the site:

Supervision quantity and quality

In the following section, please rate the site in the following areas: 1 = Poor 2 = Marginal 3 = Adequate 4 = Good 5 = Outstanding

Page 77

1 2. Attitude of administration toward having an intern 3. Attitude of teachers/staff toward having an intern 4. Attitude of clients toward having an intern 5. Degree you felt that you were accepted as a valued member of the staff 6. Degree that your comments/observations/ideas regarding clients, program, etc. were solicited and/or valued 7. Space availability for intern (e.g., private, etc.) 8. Orientation to site and counseling expectations 9. Availability of clients for individual counseling 10. Availability of clients for relational counseling 11. Availability of clients for group counseling 12. Attitude toward audio/video taping 13. Availability of clients (guardians) willing to allow taping 14. Opportunity for a variety of job related experiences 15. Availability of other support personnel 16. Amount of feedback given to intern about intern’s performance 17. Overall rating for this site

Please use this space to expand on any of the above items:

Page 78

2

3

4

5

N/ A

If the site were to be graded, what grade would you give?

A

B (Excellent)

C (Very Good)

D

(Good, Adequate)

F (Poor)

(Very Poor)

If the site supervisor were to be graded according to the supervision, what grade would you give?

A

B (Excellent)

C (Very Good)

D

(Good, Adequate)

Page 79

F (Poor)

(Very Poor)

Intern Evaluation of Field Placement Supervision In the following section, please rate your on-site supervisor: Rating Scale: 4 = Exceeds expectations 3 = Meets Expectations 2 = Needs Improvement 1 = Not applicable 4 Demonstrates knowledge and expertise in counseling Clear in communicating expectations Supports intern’s creativity Gives feedback in a supportive manner Effectively models professionalism in the workplace Respectful of intern’s ideas and input Consistently available and approachable for consultation Mentors effectively Has positive regard for the counseling profession Functions in an ethical manner Structures appointed supervision hour weekly Provides case staffing opportunity in group process Fosters an environment of intern growth and progress Encourages increasing intern independence Ability to communicate feedback to intern Amount of time supervisor spent in observing and supervising intern Page 80

3

2

1

N/A

NOTE: Please provide written explanation of your evaluation scores. Written Evaluation (attach additional sheet if necessary)

Please indicate the level of effort that your site supervisor displayed in providing a quality field placement experience (please circle) (e.g., provided referrals, invited participation in other job related duties, shared office space, facilitated problem-solving, etc.)

1. 2. 3. 4. 5.

= Little effort (Intern carried responsibility to create opportunities) = Marginal effort (Supervisor was helpful in some ways and not in others) = Adequate effort (Supervisor was directive in suggestions for intern’s activities) = Good effort (Supervisor was active in working to facilitate a quality experience overall) = Outstanding effort (Supervisor was active, helped the intern develop own problem solving, case conceptualization, and organization skills)

Page 81

In your opinion, what would make this a strong(er) site for our interns?

Do you feel that your field placement experience will be of help to you in pursuing professional opportunities after graduation? In what ways was it, or was it not, helpful?

What did you learn through this field placement that you particularity value? How did you learn that?

Have you met your initial expectations for this field placement? Why or why not?

Would you recommend this site to other therapist interns?

Yes _____

No_____

Does it appear that after-graduation this site may be interested in hiring you for a permanent paid position? Yes _____ No_____ Does not apply ____

Page 82

After all identifying information has been removed, would you be willing to have this evaluation of your field placement experience made available to other students? Yes No *The Intern Self-Evaluation will not be included.

May we list your name as a contact for other students who may be interested in signing with the same field placement organization? Yes No

If so, please list your email address:

Please include any additional comments:

THANK YOU FOR YOUR TIME! Please submit to Clinic Director

Page 83

Recording Therapy Sessions Locate the Milestone XProtect Smart Client 5.0: User’s Manual – Adobe Reader on the desktop of each clinic computer for recording, playback, and downloading instructions.

Page 84

Final Report of Internship – Client & Supervision

Page 85

Intern Self Evaluation Intern Self-Evaluation Please print

Therapist Intern: _____________________________________________ Date: _______________ Field Placement Site:_________________________ Supervisor:______________________ Does not meet criteria 1 = Needs improvement 2 = Meets criteria Communication Skills and Abilities 1. The therapist intern demonstrates the ability to establish relationships in such a manner that a working alliance can be created. 2. The intern demonstrates effective communication skills including: a. Creating appropriate structure – setting the boundaries of the helping frame and maintaining boundaries throughout the work such as setting parameters for meeting time and place, maintaining the time limits, etc. b. Understanding content – understanding the primary elements of the client’s story. c. Understanding context – understanding the uniqueness of the story elements and their underlying meanings. d. Responding to feelings – identifying affect and addressing those feelings in a therapeutic manner. e. Congruence – genuineness; external behavior consistent with internal affect. f. Establishing and communicating empathy – taking the perspective of the individual without over identifying, and communicating this experience to the individual. g. Non-verbal communication – demonstrates effective use of head, eyes, hands, feet, posture, voice, attire etc. h. Immediacy – communicating by staying in the here and now. i. Timing – responding at the optimal moment. j. Intentionality – responding with a clear understanding of the therapist’s therapeutic intention. k. Self-disclosure – skillful and carefully – considered for a specific strategic purpose. 3. The student demonstrates awareness of power differences in therapeutic relationship and manages these differences effectively. 4. Respects multiple perspectives (e.g., clients, team, supervisor, practitioners from other disciplines who are involved in the case). 5. The intern creates a safe environment. 6. The intern demonstrates analysis and resolution of ethical dilemmas.

N 0

1

2

N 0

1

2

N 0 N 0

1 1

2 2

N 0 N 0 N 0

1 1 1

2 2 2

N 0

1

2

N N N N N

0 0 0 0 0

1 1 1 1 1

2 2 2 2 2

N 0

1

2

N 0 N 0

1 1

2 2

N 0 N 0 N 0

1 1 1

2 2 2

N 0

1

2

N 0 N 0 N 0

1 1 1

2 2 2

Professional Responsibility 1. The intern conducts self in an ethical manner so as to promote confidence in the counseling profession. 2. The intern relates to peers, professor, and others in a manner consistent with stated professional standards. 3. The intern demonstrates sensitivity to real and ascribed differences in power between themselves and others, and does not exploit or mislead other people during or after professional relationships. 4. The intern demonstrates application of legal requirements relevant to counseling training and practice.

Case Management 1. Completes case documentation in a timely manner and in accordance with relevant laws and policies. 2. Develops, establishes, and maintains policies for fees, payment, record keeping, and confidentiality. 3. Maintains client records with timely and accurate notes.

Page 86

Maturity 1. The intern demonstrates appropriate self-control (such as anger control, impulse control) in interpersonal relationships with faculty, peers, and others. 2. The intern demonstrates honesty, fairness, and respect for others. 3. The intern demonstrates an awareness of his/her own belief systems, values, needs and limitations and the effect of these on his/her work. 4. The intern demonstrates the ability to receive, integrate and utilize feedback from peers, teachers and supervisors. 5. The intern exhibits appropriate levels of self-assurance, confidence, and trust in own ability. 6. The intern follows professionally recognized conflict resolution processes, seeking to informally address the issue first with the individual(s) with whom the conflict exists.

N 0

1

2

N 0 N 0

1 1

2 2

N 0

1

2

N 0 N 0

1 1

2 2

N N N N

0 0 0 0

1 1 1 1

2 2 2 2

N 0

1

2

N 0 N 0 N 0

1 1 1

2 2 2

N 0

1

2

N N N N N N N N

1 1 1 1 1 1 1 1

2 2 2 2 2 2 2 2

Integrity 1. The intern refrains from making statements which are false, misleading, or deceptive. 2. The intern avoids improper and potentially harmful dual relationships. 3. The intern respects the fundamental rights, dignity, and worth of all people. 4. The intern respects the rights of individuals to privacy, confidentiality, and choices regarding selfdetermina tion and autonomy. 5. The intern respects cultural, individual, and role differences, including those due to age, gender, race, ethnicity, national origin, religion, sexual orientation, disability, language, and socioeconomic status.

Case Progression 1. The intern moves to constructive termination when treatment goals have been accomplished. 2. The intern collaborates with an individual to establish clear therapeutic goals. 3. The intern facilitates movement toward the individual’s goals. 4. The intern demonstrates the capacity to match appropriate interventions to the presenting problem in a consistent manner.

Integration of Feedback 1. Solicit and use client feedback throughout the therapeutic process. a. Integrates client feedback. b. Responsiveness to client feedback. 2. Utilize consultation and supervision effectively. 3. Integrate supervisor/team communications into treatment. 4. Evaluate client’s reactions or responses to interventions. 5. Modify interventions that are not working to better fit treatment goals. 6. Evaluate client’s outcomes for the need to continue, refer, or terminate therapy. 7. Consult with peers and/or supervisors if personal issues, attitudes, or beliefs threaten to adversely impact clinical work.

0 0 0 0 0 0 0 0

Adapted and edited by the Marriage and Family Therapy Program, Pfeiffer University from the Professional Counseling Program of the Department of Educational Administration and Psychological Services, Texas State University-San Marcos. Rev 10/14/09

Please reflect on your field placement experience and respond according to each question. 1. What experiences in this field placement were the most helpful to you in your preparation for the MFT field?

Page 87

2. As a therapist, what are your strengths?

3. As a therapist, what therapeutic skills do you believe you still need to improve?

4. What have you learned about yourself in this field placement experience? What areas of your life have your discovered that may need special attention?

5. Has this field placement experience confirmed your desire to the MFT field? Why or why not?

6. Are there other areas in the MFT field that you would like more experience or exposure to? (e.g., children, adolescents, addiction, etc.)

7. In what ways have your professional goals changed? Why?

______________________________________ Student Signature

Date

Page 88

Index Cards Student name

Therapist ID Code

Contact # Pfeiffer Email address Interest: Client type:

I

C

F

Page 89

Phone Log Sheet Pfeiffer Institute for Marriage and Family Therapy 4805 Park Road, Suite 250 Charlotte, NC 28209

PHONE LOG SHEET Date

Time

Person Contacted

Content

Page 90

Informed Consent Form Pfeiffer Institute for Marriage and Family Therapy Informed Consent for Therapy Services Consent to treatment I voluntarily consent to receive therapy services and/or to have my child receive services provided at the Pfeiffer Institute for Marriage and Family Therapy. I understand that services will be provided by marriage and family therapists in training under the supervision of program or clinical faculty and staff. I further understand that Pfeiffer University is a teaching program. I understand that if I miss, reschedule, or cancel appointments to the point of not being seen for 60 days or longer, my case will be considered inactive and will be terminated. I understand that I may resume therapy by calling 704.945.7324. I understand the purpose and potential benefit of questionnaires, videotaping, live observation, and supervision of my therapy services, and I voluntarily consent and agree to their use. I understand that the Pfeiffer Institute will retain the ownership rights to these digital recordings, which will be used for supervision and educational purposes only. I understand that these images will be stored in a secure manner that will protect my privacy and that they will be kept for the time period outlined in the Pfeiffer Institute’s policy. Images that identify me will be released and/or used outside the institution only upon written authorization from me or my legal representative. I understand that this consent to services will be valid and remain in effect as long as I attend the Pfeiffer Institute for Marriage and Family Therapy unless revoked by me in writing, with written notice provided to the Institute. I understand that the Pfeiffer Institute may not be used to formally document grievances against Pfeiffer University campus personnel; neither will the Pfeiffer Institute be used as a vehicle to substantiate client testimony in a court of law. No clinical student intern is qualified to testify in a court of law – it is beyond their scope of training. In addition, I agree not to ask the student intern at the Pfeiffer Institute to testify in court, nor will I obtain a subpoena because I understand that by doing so it may harm our professional and therapeutic relationship. I understand that all communications with the Pfeiffer Institute are confidential and that no information about my sessions will be released without my written authorization and the written authorization of each member in the client system. I understand that the therapist intern may work with multiple members of my family (e.g., partner, children). In relational cases, the intern may need to share information learned in an individual session (or a session with only a portion of the treatment unit being present) with the entire treatment unit – that is, the family or the couple, to effectively serve the unit being treated. This “no secrets” policy is intended to allow the intern to continue to treat the couple or family by preventing, to the extent possible, a conflict of interest to arise where an individual’s interests may not be consistent with the interests of the unit being treated. I certify that the handbook, including statements on the limits of confidentiality, has been fully explained to me, that I have read it or had it read to me*, and that I understand its contents. I understand that there are certain occasions when federal and/or North Carolina law or ethical considerations allow or require the disclosure of confidential information to others. Such considerations for disclosure are: 1. North Carolina law and ethical practice requires clinic personnel or PIMFT personnel to notify appropriate state agencies if we suspect or know of a child abuse situation or have cause to believe that an elderly or disabled person is being abused. 2. Pfeiffer Institute may be called upon to give case information when state or federal law requires it or when a court of law orders the release of information. 3. If there is a threat to harm yourself or another person and the threat is determined to be serious, the therapist may take whatever actions are necessary to protect the person at risk, even if it involves disclosing confidential

Page 91

4. 5.

information. If the therapist assesses that the client has made a serious threat, the therapist may disclose information to law enforcement and/or the intended target of the threat. If I become a civil litigant and use my mental health for a legal claim or defense, the content of my communication may not be protected under these conditions. If I am involved in a serious medical emergency, appropriate information may be given to medical personnel.

I understand that if I make an allegation against the student intern/Pfeiffer Institute, the Pfeiffer Institute has the right to disclose my records in their own defense to the appropriate legal and ethical boards involved. I understand that upon graduation and passage of the national licensure exam, students are provisionally licensed (for details, see www.nclmft.org). I understand that if I choose to continue therapy with this therapist intern after his/her graduation, s/he will no longer be under the supervision or responsibility of Pfeiffer Institute. If I have any questions or concerns now or in the future, I understand that I should consult with my therapist or the Clinic Director (704.945.7324). I understand that I certify that I have legal authority to give consent for the treatment of all minor children that are included in therapy. I have asked my therapist for any needed clarification of the procedures and conditions mentioned in this consent statement. I am satisfied with the explanations, and agree to abide by the conditions in of this consent form.  I have read or have had this form read* to me and I AGREE to receive counseling services.  I have read or have had this form read* to me and I DECLINE to receive counseling services.

____________________ Date _____________________________ Print Client Name/Legally Authorized Person

____________________ Signature

__________________ Relationship to Client

_____________________________ Print Client Name/Legally Authorized Person

____________________ Signature

__________________ Relationship to Client

_____________________________ Print Client Name/Legally Authorized Person

____________________ Signature

__________________ Relationship to Client

_____________________________ Print Client Name/Legally Authorized Person

____________________ Signature

__________________ Relationship to Client

_________________________ Print Witness/Translator* Name

____________________ Signature

Page 92

Phone Intake Form Pfeiffer Institute for Marriage and Family Therapy Phone Intake Record Today’s Date: ___________________

Case # ____________

Intake taken by: _________________________

IP First Name: ______________________

Last Name: ________________________

M/F

Age: ___

Spouse / Partner: First Name: ________________________

Last Name: ________________________

M / F Age: ___

*IF caller is not client, Relationship: ______________ First/Last Name: ___________________________ Others who will attend therapy: First Name: ________________________

Last Name: ________________________

M / F Age: ___

First Name: ________________________

Last Name: ________________________

M / F Age: ___

First Name: ________________________

Last Name: ________________________

M / F Age: ___

Contact Info: Phone: __________________________ ( Home / Work / Cell ) OK to leave message: Yes / No Phone: __________________________ ( Home / Work / Cell ) OK to leave message: Yes / No Pfeiffer University Student? Yes / No How did he/she hear about us? Ad/Flyer, Google Search/Website, Friend/Coworker, Physician, _________________ Therapy Constellation: Individual / Couple / Family Availability Days/Times: ____________________ Presenting Issue / Goals to Focus on / Comments or Special Requests: ___________________________ ______________________________________________________________________________________ Appointment Date: ________________

Appointment Time: ______________ *Please Arrive 20-30 min early *

Intern Assigned: ________________

Date Assigned: ________________ *Contact 48-24 hours prior*

Intern: Attempts to contact client: ________________________________________________________ Notes: * Client is seen by an intern working towards MFT licensure; Supervised by a licensed MFT and AAMFT approved supervisor * Sessions are recorded but remain confidential and are only utilized for supervision purposes. * Please arrive 20-30 minutes early. First session is $30, Cash/Check Only (several ATMs at Park Road Shopping plaza) * We are NOT at the school, we are located next door, at the corner of Park Rd & Seneca Place. We are in the same building as MacAlister’s Deli: Come through the double glass doors in center of building and we are upstairs at the end of the hall on the right. We are located at: 4805 Park Road, Suite 250 – 704.945.7324

Page 93

Assessment Packet THERAPIST #________ CASE #________ PFEIFFER INSTITUTE (PIMFT) CLIENT INFORMATION

Name: _____________________________________

Today’s Date:

______________________________ Address: ___________________________________

City: ________________ State: ___ Zip: _______

Phone: ___________________________ ( Home  Work  Cell) OK to leave message?

 Yes  No Alternate Phone: ___________________ ( Home  Work  Cell) OK to leave message?

 Yes  No Recognizing that electronic communication may not always be secure, will you allow Pfeiffer Institute to email you regarding scheduling and referral information?  Yes  No If yes, please provide your preferred email address: _________________________________ Current Concerns: What brings you to the Pfeiffer Institute? For each problem you identify, please list when the problem began and how distressed you have been by that problem. Problem

Distress Level

When it began A little

Moderate

Quite a bit

Extreme

1

2

3

4

1

2

3

4

1

2

3

4

Please list all medications you are taking, including over-the-counter or herbal medications: Medication Dosage Prescribing Date Started Reason Taking Doctor

Page 94

Please list everyone who currently lives in your in household: Name: _________________________  Male  Female Age: ______ Relationship to you: _____________ Name: _________________________  Male  Female Age: ______ Relationship to you: _____________ Name: _________________________  Male  Female Age: ______ Relationship to you: _____________ Name: _________________________  Male  Female Age: ______ Relationship to you: _____________ Name: _________________________  Male  Female Age: ______ Relationship to you: _____________ Please provide the following information about yourself by checking the boxes that apply:

Date of Birth: mm/dd/yyyy ______________ Current age: _______ What is your gender?  1. Male  2. Female  3. Other What is your sexual orientation?  1. Heterosexual  2. Gay / Lesbian  3. Bisexual  4. Other: ______________________

What language do you prefer to speak in therapy?  1. English  2. Spanish  3. Other: ______________________ What is your racial or ethnic origin?  1. American Indian or Alaska Native  2. Asian or Pacific Islander  3. African-American / Black  4. Caucasian / White  5. Latino/a  6. Biracial or Multiracial: _______________  7. Other: ____________________________

Page 95

What is your religious preference?  1. Catholic  2. Protestant (Baptist, Methodist, etc.)  3. Latter-Day Saint (Mormon)  4. Jewish  5. Muslim  6. Other (specify): __________________  7. None Do you have any children?  1. No  2. Yes How many? ____________

What is the highest level of education that you have completed?  1. Grade school  2. High school (or GED)  3. Some college  4. Bachelor’s degree  5. Graduate Student  6. Master’s degree  7. Doctorate degree What is your employment status?  1. Employed full-time Occupation: ___________________ 2. Employed part-time Occupation: ___________________  3. Unemployed  4. Homemaker  5. Retired  6. Student What is your current annual income?  1. Less than $10,000  2. $10,000 – $19,999  3. $20,000 – $29,999  4. $30,000 – $39,999  5. $40,000 – $49,999  6. $50,000 – $59,999  7. $60,000 – $69,999  8. $70,000 or above What is your current relationship status?  1. Single, never married, not dating  2. Single, divorced or separated  3. Single, widowed  4. Dating  5. Living together  6. Engaged to be married  7. Married, first marriage  8. Married, second or third marriage How long have you been in this current relationship? __________________________________________

Page 96

On the following checklist, please indicate problems that are a concern to you about YOURSELF:  1. chronic illness/pain  2. depression  3. anxiety/worries  4. stress  5. sexual abuse / rape  6. eating disorder  7. relationship problem  8. physical problem  9. excessive alcohol/drugs  10. family relationships  11. sexual problems  12. parenting  13. self-esteem  14. lack of assertiveness  15. suicidal thoughts  16. anger  17. grief  18. self-injury / self-mutilation  19. sexual addiction  20. emotional abuse in childhood  21. physical abuse in childhood  22. sexual abuse in childhood  23. other (please specify) _______________

Problems that are a concern to you about YOUR PARTNER:  1. chronic illness/pain  2. depression  3. anxiety/worries  4. stress  5. sexual abuse / rape  6. eating disorder  7. relationship problem  8. physical problem  9. excessive alcohol/drugs  10. family relationships  11. sexual problems  12. parenting  13. self-esteem  14. lack of assertiveness  15. suicidal thoughts  16. anger  17. grief  18. self-injury / self-mutilation  19. sexual addiction  20. emotional abuse in childhood

Page 97

 21. physical abuse in childhood  22. sexual abuse in childhood  23. other (please specify) _______________

Problems that are a concern to you about YOUR RELATIONSHIP:  1. poor communication.  2. argue about finances.  3. not enough time together.  4. fighting/arguing.  5. physical violence.  6. excessive alcohol/drugs.  7. refuses sex too often.  8. demands sex too often.  9. physical sexual problems (impotence, painful intercourse, etc.).  10. parenting differences.  11. partner too controlling.  12. different values.  13. emotional abuse.  14. difficulties with in-laws/extended family  15. other (please specify): __________

 2. fire setting  3. truancy  4. fighting  5. drugs/alcohol  6. adolescent pregnancy  7. sexual abuse (victim)  8. sexual abuser  9. disobedience  10. divorce adjustment  11. death in family  12. anger  13. peer relationships  14. poor self-esteem  15. bed-wetting/soiling  16. destructiveness  17. issues with stepchildren/stepparenting  18. eating disorder  19. self-injury / self-mutilation  20. other (please specify) ________________

Problems that are a concern to you about your CHILDREN/FAMILY:  1. stealing  10. other (please specify) _______________ Problems that occurred IN THE HOUSEHOLD(S) IN WHICH YOU WERE RAISED BEFORE AGE 18:  1. alcohol/drug addiction  2. physical abuse  3. emotional/verbal abuse  4. unwanted touching  5. financial problems  6. sexual abuse  7. divorce  8. lived in foster home  9. emotional distance  10. other (please specify) _______________

Problems that occurred TO YOU BEFORE AGE 18:  1. alcohol/drug addiction  2. physical abuse  3. emotional/verbal abuse  4. unwanted touching  5. financial problems  6. sexual abuse  7. divorce  8. lived in foster home  9. emotional distance

Page 98

Do you have any concerns about your weight?  Yes  No If yes, please describe ____________________________________________ Have you struggled with an eating disorder?  Yes  No If yes, which one(s)?  1. Anorexia  2. Bulimia  3. Binge Eating  4. Obesity How long (length of time)? _____________________

Has anyone objected to your tobacco use?  Yes  No

In general, how often do you drink alcohol?  1. Never  2. Less than once a month  3. About once a week  4. 2 to 3 days per week  5. 4 to 6 days per week  6. Daily Do you drink more now than you used to?  Yes  No Has anyone objected to your drinking?  Yes  No In general, how often do you use recreational or illicit drugs?  1. Never  2. Less than once a month  3. About once a week  4. 2 to 3 days per week  5. 4 to 6 days per week  6. Daily What drugs do you use? _______________________ Do you use drugs more often than you used to?  Yes  No Has anyone objected to your drug use?  Yes  No When was the last time you drank alcohol or used drugs?

_____________________________________________

In general, how often do you use tobacco products?  1. Never  2. Less than once a month  3. About once a week  4. 2 to 3 days per week  5. 4 to 6 days per week  6. Daily Do you use tobacco products more often than you used to?  Yes  No

Page 99

INSTRUCTIONS: Looking back over the last week, including today, help us understand how you have been feeling. Read each item carefully and put a check under the category which best describes your current situation. For this questionnaire, work is defined as employment, school, housework, volunteer work, and so forth. Almost always

Outcome Questionnaire (OQ – 45.2)

1. I get along well with others 2. I tire quickly. 3. I feel no interest in things 4. I feel stressed at work/school. 5. I blame myself for things. 6. I feel irritated. 7. I feel unhappy in my marriage/significant relationship. 8. I have thought of ending my life. 9. I feel weak. 10. I feel fearful. 11. After heavy drinking, I need a drink the next morning to get going. (If you do not drink, mark “never”) 12. I find my work/school satisfying. 13. I am a happy person. 14. I work/study too much. 15. I feel worthless. 16. I am concerned about family troubles 17. I have an unfulfilling sex life. 18. I feel lonely. 19. I have frequent arguments. 20. I feel loved and wanted. 21. I enjoy my spare time. 22. I have difficulty concentrating. 23. I feel hopeless about the future. 24. I like myself.

Page 100

Frequently

Sometimes

Rarely

Never

25. Disturbing thoughts come into my mind that I cannot get rid of. 26. I feel annoyed by people who criticize my drinking (or drug use). 27. I have an upset stomach. Almost always

Outcome Questionnaire (OQ – 45.2)

Frequently

Sometimes

Rarely

Never

28. I am not working/studying as well as I used to. 29. My heart pounds too much. 30. I have trouble getting along with friends and close acquaintances. 31. I am satisfied with my life. 32. I have trouble at work/school because of drinking or drug use. (If not applicable, mark “never”) 33. I feel that something bad is going to happen. 34. I have sore muscles. 35. I feel afraid of open spaces, of driving, or being on buses, subways and so forth. 36. I feel nervous. 37. I feel my love relationships are full and complete. 38. I feel that I am not doing well at work/school. 39. I have too many disagreements at work/school. 40. I feel something is wrong with my mind. 41. I have trouble falling asleep or staying asleep. 42. I feel blue. 43. I am satisfied with my relationships with others. 44. I feel angry enough at work/school to do something I might regret. 45. I have headaches. Complete the following questionnaire if you are in a relationship with a significant other (e.g., spouse, partner, boyfriend, and girlfriend)

Most persons have disagreements in their relationships. Please indicate the degree of agreement or disagreement between you and your partner for each item on the following list. Almost Almost Always Occasionally Frequently Always always always DAS-R agree disagree disagree disagree agree disagree 1. Religious matters

Page 101

2. Demonstrations of affection 3. Making major decisions 4. Sex relations 5. Conventionality (correct or proper behavior) 6. Career decisions More All the Most of often than Occasionally Rarely time the time not

Never

7. How often do you discuss or have you considered divorce, separation, or terminating your relationship? 8. How often do you and your partner quarrel? 9. Do you ever regret that you married (or lived together)? 10. How often do you and your partner “get on each other’s nerves”? Every Day 11. How often do you and your partner engage in outside interests together? More How often would you say the following than events occur between you and your once a partner? day 12. Have a stimulating exchange of ideas? 13. Work together on a project? 14. Calmly discuss something?

Once a day

Almost Occasionally Rarely Every Day

Never

Less than once a month

Never

Once or twice a week

Once or twice a month

Thank you for taking the time to accurately complete this intake information packet!

Page 102

Outcome Rating Scale Outcome Rating Scale (ORS) Name ________________________Age (Yrs):____ Gender_____________ Session # ____ Date: ________________________ Who is filling out this form? Please check one: Self_______ Other_______ If other, what is your relationship to this person? ____________________________ Looking back over the last week, including today, help us understand how you have been feeling by rating how well you have been doing in the following areas of your life, where marks to the left represent low levels and marks to the right indicate high levels. If you are filling out this form for another person, please fill out according to how you think he or she is doing.

Individually (Personal well-being) I----------------------------------------------------------------------I

Interpersonally (Family, close relationships) I----------------------------------------------------------------------I

Socially (Work, school, friendships) I----------------------------------------------------------------------I

Overall (General sense of well-being) I----------------------------------------------------------------------I

International Center for Clinical Excellence _______________________________________ www.scottdmiller.com © 2000, Scott D. Miller and Barry L. Duncan

Page 103

SRS/ORS Graph © 2000, Scott D. Miller and Barry L. Duncan 40 35

SRS Cutoff

30

Discuss

25 ORS Cutoff 20 15 10 5 0 Session Number

1

2

3

4

5

6

Page 104

7

8

9

10

Session Rating Scale Session Rating Scale (SRS V.3.0)

Name ________________________Age (Yrs):____ ID# _________________________ Gender:_______ Session # ____ Date: ________________________ Please rate today’s session by placing a mark on the line nearest to the description that best fits your experience.

Relationship I did not feel heard, understood, and respected.

I----------------------------------------------------------------------I

I felt heard, understood, and respected.

Goals and Topics We did not work on or talk about what I wanted to work on and talk about.

I----------------------------------------------------------------------I

We worked on and talked about what I wanted to work on and talk about.

Approach or Method The therapist’s approach is not a good fit for me.

I----------------------------------------------------------------------I

The therapist’s approach is a good fit for me.

Overall There was something missing in the session today.

I----------------------------------------------------------------------I

International Center for Clinical Excellence _______________________________________ www.scottdmiller.com © 2002, Scott D. Miller, Barry L. Duncan, & Lynn Johnson

Page 105

Overall, today’s session was right for me.

Room Reservation Binder

Page 106

Vacation/Leave of Absence Form Pfeiffer Institute for Marriage and Family Therapy Vacation/Leave of Absence Form Therapist Name: ______________________________ Clinic Phone Extension: _________ Dates of Absence: _________________ through ______________ (date you will return to duty)

Itinerary and Contact Information During Absence: Location: ___________________________ Phone Number: _______________________ Location: ___________________________ Phone Number: _______________________ Location: ___________________________ Phone Number: _______________________

Coverage will be provided by: Therapist Name: ______________________________

Clinic Phone Extension: __________

Cell Phone: _________________________________

Home Phone: __________________

Additional Information for Clinic Staff and Covering Therapist: __________________________ ______________________________________________________________________________ ______________________________________________________________________________ _________________________________________ ___________ Supervisor’s Signature

Date

_________________________________________ ___________ Clinic Director Signature

Date

Notes/Messages for Therapist upon their Return: __________________________

Page 107

PIMFT Case Notes Form

Page 108

Page 109

Pfeiffer Institute for Marriage and Family Therapy Fee Schedule ANNUAL/UP TO:

TOTAL GROSS MONTHLY INCOME NUMBER IN FAMILY 1 2 3+ $833 OR LESS

$12.00

$11.00

$10.00

$834 - $1,660

$15.00

$13.00

$12.00

$1,661 - $2,500

$20.00

$17.00

$15.00

$2,501 - $3,334

$25.00

$25.00

$20.00

$3,335 OR MORE

$30.00

$30.00

$30.00

0 -$10,000 $10,001 - $20,000 $20,001 - $30,000 $30,001 - $40,000 $40,001 +

  

Clients will be expected to pay for all missed sessions that have not been cancelled 24 hours in advance. For the first appointment the client will pay the full fee of $30. If the client is unemployed, or cannot pay reduced fees, an agreed upon fee will be determined between Therapist Intern and client for the next session. The Therapist Intern will discuss a further reduction in the fee with the Clinic Director for all other future sessions.

Therapist intern will set fee at the beginning of 1st Session

Page 110

Fee Agreement Form Pfeiffer Institute for Marriage and Family Therapy Fee Agreement Form The Pfeiffer Institute of Marriage and Family Therapy operates as a part of the Marriage and Family Therapy Program. Our standard fee for therapeutic services is $30.00 per session. However, in order to offer our services to clients of varying financial circumstances, we are able to offer a “sliding scale” client fee for those clients needing financial assistance for therapy. Your calculated fee is based on your gross income level and the number of dependents living in your home. The difference in this calculated fee and our standard fee of $30.00 is underwritten by Pfeiffer University Marriage and Family Therapy Program. Gross Income = $________________ per � year � month 1. Standard charge per session: $ 30.00 2. Client fee obligation to be paid each session, based on sliding scale fee schedule: $__________ I understand the above fee policy and certify that the income information contained on this form is true and correct. __________________________________________ Signature of Client or Parent/Guardian

____________________ Date

____________________________________________ Signature of Witness

____________________ Date

CANCELLATION POLICY Clients who wish to cancel an appointment must do so within 24 hours of the visit. Otherwise the usual session fee will be charged for any missed appointment. I understand that I am responsible for payment of missed sessions unless I give 24 hours notice of cancellation. X________________________________________ Signature of Client or Parent/Guardian

Page 111

_____________________ Date

Authorization for Release of Client Records Pfeiffer Institute for Marriage and Family Therapy 4805 Park Road, Suite 250 Charlotte, NC 28209

Client Name: ____________________ DOB: __________________________

AUTHORIZATION FOR RELEASE OF CLIENT RECORDSCase #: ________________________ I request and authorize the Pfeiffer Institute for Marriage and Family Therapy to: Release the following information to: Receive the following information from: Name of Facility/Person: ____________________________________________________________ Address: __________________________________________________ Phone: ________________

RELEASE IS FOR THE PURPOSE OF:

INFORMATION TO BE DISCLOSED IF REQUESTED:

Continued care by the other provider Attorney Disability School Personal review Other (specify): _____________________

Service dates Session constellation Session participants Clinical assessments Summary of treatment Other (specify): _____________________

I understand that the information I am authorizing to be released may include mental health information and any therapy constellation (individual, couple, family, group) in which I have participated.

I further understand that this Authorization is voluntary and I may refuse to sign this Authorization. I further understand that my treatment will not be affected if I do not sign this form (45 C.F.R. 164.508 (c)(2)).

I further understand that I may revoke

I further understand that the person(s) I am authorizing to use or disclose my information may receive compensation (either directly or indirectly) for doing so.

RELEASE FROM LIABILITY I release and agree to hold harmless

Page 112

TO THE RECEIVING PARTY OF THIS INFORMATION:

This information has been disclosed to you for the sole purpose(s) stated in this Authorization. Any other use of this information without the express written consent of the client is prohibited. These

this Authorization at any time by notifying the Pfeiffer Institute Reach (or the releasing facility) in writing, except to the extent that action has been taken in reliance on it. Unless earlier revoked, this Authorization expires automatically 90 days from the day signed or 90 days after the last Reach visit (45 C.F.R. 164.508 (c)(2)).

Pfeiffer Institute Reach (or other releasing facility) and its agents, representatives, and employees from any and all liability associated with the release of confidential client information in accord with this Authorization

records may be protected by federal regulation (42 C.F.R. Part 2).

I understand that Pfeiffer Institute Reach (or the releasing facility) cannot be responsible for use or redisclosure of information to third parties (45 C.F.R. 164.508

(c)(2)).

I certify that this form has been fully explained to me, that I have read it or have had it read to me*, and that I understand its contents. _________________________ _______________________ ______________ Print Client Name/Legally Authorized Person

Signature

Date

_________________________

_______________________

______________

Print Witness/Translator* Name

Signature

Page 113

Date

Case Termination Form Pfeiffer Institute for Marriage and Family Therapy Case Termination Form Client Name(s): Case Number:

Date of Last Session: Individual

Number of Sessions by Constellation

Couple Family �1. Completed therapeutic goals �2. Dropped out of therapy (notes should reflect attempts to contact

Reason for Termination:

AXIS V

client)

�3. Referred to another provider �4. Completed contracted/required sessions �5. Other: ___________________________ GAF (Current): _______ GAF (at Intake): ______

Problems Discussed/Diagnosis

Progress During Treatment

�1. Poor �2. Fair �3. Average �4. Good �5. Unable to assess

Contact Attempts

�1. Letter sent Date: ____________ �2. Contact via telephone �3. Letter not sent; not needed

Additional Notes: _________________________________ Current Therapist Name __________________________________ Current Supervisor Name

__________________________________ ______________ Signature Date _________________________________ ______________ Signature Date

Page 114

Case Transfer Form Pfeiffer Institute for Marriage and Family Therapy Case Transfer Form Client Name(s): Case Number:

Date of Last Session: Individual

Number of Sessions by Constellation

Couple Family

Reason for Transfer:

Problems Discussed/Diagnosis

Progress During Treatment

� 1. Poor � 2. Fair � 3. Average � 4. Good � 5. Unable to assess

Additional Notes: _________________________________

__________________________________ ______________

Current Therapist Name

Signature

__________________________________

_________________________________

Current Supervisor Name

Signature

Date

__________________________________

_________________________________

______________

New Therapist Name

Signature

Date

__________________________________

_________________________________

New Supervisor Name

Signature

Page 115

Date ______________

______________ Date

Transfer Case Grid

Page 116

Monthly Clinical Service Report (MCSR) form Pfeiffer University Marriage and Family Therapy Program Monthly Clinical Service Report Month of:

YEAR

MONTH

MMFT 690 INTERNSHIP NAME OF BUSINESS

Site:

Supervision Date

Client #

Supervisor

TOTAL

Ind

Couple

0

0

Fam

Ind Live

0

0

Ind Vid

0

Student:

R=

Cumulative Internship Hours: I=

Ind CN

0

Group Therapy

Grp Live

0

Grp Vid

0

Grp CN

0

Ind Grp

0 Date:

Print

Signature

Print

Signature

Print

Signature

Print

Signature

External-Site Supervisor:

Date:

Clinical Supervisor:

Date:

Clinic Director:

Date:

Page 117

Cpl Grp

0

Fam Grp

0

Case Assignment Suspension Form Pfeiffer Institute for Marriage and Family Therapy Case Assignment Suspension Request Please remove me from the rotation of new client assignments from ____________ (starting date) to ____________ (ending date). I understand that I will remain out of the rotation until the expiration date or until I contact the Front Desk Administrative Staff (whichever comes first), and that it may be several days after such until I receive a new client. Additional Comments: ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ __________________________________________ Therapist Name (Print)

__________ Date

___________________________________________ Current Supervisor

__________ Date

___________________________________________ Clinic Director

__________ Date

Page 118

Research Participant Consent Form PFEIFFER INSTITUTE FOR MARRIAGE AND FAMILY THERAPY RESEARCH PARTICIPANT CONSENT FORM We invite you to participate in research in the Pfeiffer Institute for Marriage and Family Therapy. The research is about individuals, couples, and families. The research will be conducted by graduate students and faculty in the Marriage and Family Therapy Program. The research will help Marriage and Family Therapists as they work with individuals, couples, and families similar to yours. Other mental health professionals may benefit as well. In the end, the research can benefit individuals, couples, and families. If you agree, the information on the intake survey, case records, and recordings of your sessions will become part of a research database. The intake survey asks questions about your current relationship, present concerns, and general well-being. The intake information is put into the computer without your name. No one, other than MFT clinic personnel, will see your answers. No information will be tied back to you. Any other information will be kept strictly confidential. Completed surveys, case records, and video tapes are stored in locked cabinets. Only graduate students and faculty in the MFT program will have access to your data. No risks or harm to you is anticipated. Your participation is voluntary. You will not be paid for your participation. It should take no more than 20-30 minutes of your time to complete the survey. You are free to withdraw your information from the database at any time. Contact the Clinic Director, Dr. Jenny Haines, to remove your information from the database. You may have questions regarding current research projects. If so, contact Dr. Susan Wilkie, Program Director, or Dr. Jenny Haines, PIMFT Clinic Director, at (704) 945-7324. By signing my name below, I certify that I have read this form and that all of my questions have been answered. I have received a copy of this form. I understand that participation in any research is voluntary and that I may end my participation at any time. ________________________________________________ _________________ Signature of Client Date ________________________________________________ _________________ Signature of Client Date ________________________________________________ _________________ Signature of Client Date ________________________________________________ _________________ Signature of Client Date

Page 119

Agreement to Live Contract Pfeiffer Institute

for Marriage and Family Therapy 4805 Park Road, Suite 250 Charlotte, NC 28209

AGREEMENT TO LIVE CONTRACT

I, _______________________________, enter into this AGREEMENT TO LIVE CONTRACT of my own free will, and with the full understanding of its meaning. I hereby agree to follow the plan below in the event I ever begin having suicidal ideations, feelings of wanting to attempt suicide, or harming myself in any physical manner. 1. I agree to contact _____________________________ at ___________________. Name of contact

Phone number

2. I agree to follow any directives provided by my Pfeiffer Institute Therapist Intern to ensure my safety and the safety of others around me, including immediate hospitalization. 3. In the event that I have completed the first two steps and I am still intent on wanting to attempt suicide or physically harm myself, I will go to, or have someone take me to, the nearest hospital emergency room. 4. If I am unable to take myself to the emergency room, or if my contact or other person is unable to take me to the emergency room, I will call 911. At this time, I AM IN NO DANGER OF HARMING MYSELF OR ANYONE ELSE. _____________________________

_____________

__________

Signature of client

Date

Time

_____________________________

_____________

__________

Signature of Pfeiffer Therapist Intern

Date

Time

Page 120

Violence Prevention Contract Pfeiffer Institute

for Marriage and Family Therapy 4805 Park Road, Suite 250 Charlotte, NC 28209

Contract of Violence Prevention Names: _____________________________ and _____________________________ (partner 1) (partner 2) I will not hit, slap, push, kick, throw objects, or be violent towards my partner in any way. Also, I will not prevent or block my partner from leaving the room, house, or car if he or she feels the need to do so in order to stay safe. When my anger starts to feel out of control, I will leave immediately and will go to: _____________________________________ or _____________________________. I will use the following strategies to calm myself down: 1. _________________________________________________________________ 2. _________________________________________________________________ 3. _________________________________________________________________ I understand that my partner will call the police if I do not follow the strategies listed above to calm myself appropriately and/or try to prevent my partner from leaving. _______________________________________ Signature of Client _______________________________________ Signature of Client ______________________________________ Signature of Therapist

________________ Date ________________ Date

Page 121

Scheduling Clients Using Outlook Instructions for New Clients:   

  

Open client slots will be identified by a “CT” on the therapist’s calendar. Indicate that the client is new by putting a (N) in front of the client’s name in the appointment slot in calendar. In the appointment slot, type in this information: o The names of everyone who will be attending the session o A daytime contact number o The fee the client will pay (the initial session is $30) Ask the client to arrive 20-30 minutes early to complete the intake paperwork. Ask the client if they need directions to the clinic. Fill out an intake sheet and put it in the therapist’s mailbox.

To schedule an appointment for established clients:   

All open client slots will have a CT in the appointment slot. When you find the appointment time you need, double click on the CT. A window will open for the appointment slot. Make sure your cursor is by the CT (click in the section containing the CT to get it there). o For all appointments, type in the client(s) name, contact phone number(s), and fee next to the “CT”. o Convert the “CATEGORY” to reflect RED. All scheduled appointments are identified as RED. o When all the information has been entered, click Save and Close (on the top left of the toolbar). The window will close, and the client information should now appear in the appropriate slot on the calendar.

If a client calls to cancel:     

Ask client if he/she would like to reschedule appointment. Open the appointment on the calendar by double-clicking the appointment slot. Right-click to “Copy” the client information. If client would like to reschedule, try to find slot in therapist’s calendar to reschedule and “paste” client information, if possible. If client would not like to reschedule or front desk staff is unable to find an available future appointment in therapist intern’s calendar, write down client information (e.g., name, contact number), and leave hard copy of information in therapist intern’s box.

Page 122

    

Create new email message (to Pfeiffer email address) and inform therapist intern that their client has canceled, has been rescheduled, or there is a message in their clinic box and they need to reschedule with client as soon as possible. If same day cancellation, mark ***CX*** in therapist’s calendar. If it is NOT the same day, delete the client information from appointment slot and replace it with the letters “CT” so that another client can take that appointment if needed. Change the slot to a BLANK or NON-COLOR. Save and close appointment box.

If possible, reschedule the client. Or, inform the client that you will give the therapist a message to return their call because a new appointment time cannot be easily identified. If a client calls to cancel within a couple hours of appointment, please call the therapist to inform of the cancellation (as long as the front desk is well staffed and has the ability to do so). A courtesy call to the therapist intern is not a requirement. Color coding for calendar:     

Clear: Available appointment slot Red: Client is scheduled Blue: Individual and group supervision Orange: Desk duty Purple: Class and external site time

Page 123

PIMFT Client Handbook

Page 124

Page 125

PIMFT Client Handbook

Page 126

Professional Fitness Evaluation Professional Fitness Evaluation Pfeiffer University -- Marriage and Family Therapy Program Student: _____________________________________ Faculty: __________________ Course #: ___________________ Date: ____________________ The purpose of this evaluation is to ensure that a student does not have non-academic personal and/or professional problems significant enough to limit his/her effectiveness as a professional therapist. This evaluation encourages students to nurture their roles as “servant leaders” and monitor their attitudes and attributes for therapist identity development and self-regulation throughout specific milestones in the Marriage and Family Therapy Program. This evaluation will serve as a confidential barometer of personal fitness and therapist readiness throughout the program. Assessment Timeline: Professors will complete this form at mid-term during (MMFT 601). As part of the application to internship (MMFT 690), students must submit Professional Fitness Evaluations from two former professors (not the Clinic Director). A minimum score of “3” (meets expectations in most respects) across all categories is required for application approval. A minimum score of “4” (meets expectations in all respects) across all categories is required during the internship experience prior to graduation. Clinical supervisors complete this evaluation before graduation. Not applicable

Meets expectations in few or no respects Meets expectations in some respects Meets expectations in most respects Meets expectations in all respects Exceeds expectations in all respects

Demonstrates interpersonal skills necessary to effectively interact with 5

4

3

2

1

N/A

5

4

3

2

1

N/A

5

4

3

2

1

N/A

Shows concern for the impact of personal words and actions on others

5

4

3

2

1

N/A

Demonstrates acceptance of perspectives other than own

5

4

3

2

1

N/A

Demonstrates the ability to receive and use constructive feedback

5

4

3

2

1

N/A

Makes effort to understand & accept necessary changes in policy/protocol

5

4

3

2

1

N/A

Responds to faculty, staff and others in a respectful manner

5

4

3

2

1

N/A

Respects cultural, individual, and role differences (e.g., age, gender)

5

4

3

2

1

N/A

Embraces MMFT learning opportunities with interest and enthusiasm

5

4

3

2

1

N/A

Promotes positive student community within the MMFT Program

5

4

3

2

1

N/A

5

4

3

2

1

N/A

Respectfully responds to emails within 48 hours

5

4

3

2

1

N/A

Demonstrates leadership in MMFT Program special events/committees

5

4

3

2

1

N/A

faculty and staff Consults with faculty when personal issues/conflicts threaten to adversely impact academic/clinical work Demonstrates warmth, personability, and engagement through accurate and congruent facial expressions and body language

Demonstrates application of program and professional standards as stated in the MFT Student Handbook, AAMFT Code of Ethics, etc.

Page 127

Servant Leadership Student Signature DATE Faculty Signature

Servant Leadership Definition “The servant leader is servant first…it begins with the natural feeling that one wants to serve, to serve first. Then conscious choice brings one to aspire to lead. He is sharply different from the person who is leader first, perhaps because of the need to assuage an unusual power drive or acquire material possessions. For such it will be a later choice to serve—after leadership is established. The leader first and the servant first are two extreme types. Between them there are shadings and blends that are a part of the infinite variety of human nature.” Robert K. Greenleaf (1970)

Best Test “The best test, and difficult to administer, is: Do those served grow as persons? Do they, while being served, become healthier, wiser, freer, more autonomous, more likely themselves to become servants? And, what is the effect on the least privileged in society? Will they benefit or at least not be furthered deprived?” Robert K. Greenleaf (1970)

Page 128

Sample Letter to Client Date Client Name Client Address City, State Zip RE: Follow-Up Dear Mr. or Mrs./Ms./Miss Last name, Hello! Your last appointment was on (date). Since I have not heard from you in a while, I wanted to follow up with you. The last time we met, we discussed (brief couple words and not too specific). If you would like to continue working on this issue or if you would rather discuss something else, please call for an appointment. However, if you feel that our work is done or if I do not hear from you within the next two weeks, I will go ahead and close your case. If your file is closed, it can be reopened at any time. It was a pleasure working with you and I hope to hear back from you. If I, or another therapist intern, can be of further service to you, please feel free to call the Pfeiffer Institute at 704.945.7324. Sincerely,

Name, Credentials Therapist Intern Pfeiffer Institute for Marriage and Family Therapy

Page 129

Case Review Form CASE REVIEW FORM Client Name: _______________________ Case Number: _______ Supervisor: _______________________ Therapist: ___________________________ Co-therapist: ______________________________ Date

Supervisor’s Comments / Suggestions / Directives

Supervisor’s Signature

1. ________

________________________________________

________________________

________________________________________

Circle: Live, Video, Case

________________________________________ 2. ________

________________________________________

________________________

________________________________________

Circle: Live, Video, Case

________________________________________ 3. ________

________________________________________

________________________

________________________________________

Circle: Live, Video, Case

________________________________________ 4. ________

________________________________________

________________________

________________________________________

Circle: Live, Video, Case

________________________________________ 5. ________

________________________________________

________________________

________________________________________

Circle: Live, Video, Case

________________________________________ 6. ________

________________________________________

________________________

________________________________________

Circle: Live, Video, Case

Page 130

Case Assignment Form

Intern Name Intern Number

Client Number

Client Last Name

Page 131

Client First Name

Client Satisfaction Survey: Part I, The Clinic Thank you for allowing us to serve you. Please take the next couple of minutes to provide us feedback on your experiences at Pfeiffer Institute (PIMFT). Please read each question carefully and mark the appropriate answer. Your identifying information will not be revealed to your therapist

Gender:

 Male  Female

Which type of session did you attend? (Check all that apply)  Individual

 Couple

 Family

 Group

How did you learn about Pfeiffer Institute?  1. I am a former client  2. Friend / Family Member  3. Employer Name: ______________________________________ May we contact him/her?  Yes  No

 4. Physician Name: ______________________________________ May we contact him/her?  Yes  No

 5. Another Professional Name: ______________________________________ May we contact him/her?  Yes  No

 6. Website  7. Other: __________________________ How did you first make contact with Pfeiffer Institute?

Page 132

 Phone

 Email

 Face-to-face

 Someone else contacted PIMFT on my behalf

 Other ___________________________________________________

For the following statements, please indicate to what degree you agree or disagree. 1 = Strongly disagree

2 = Disagree

3 = Neutral

4 = Agree

5 = Strongly agree

______________________________________________________________________________ __ Initial contact with Pfeiffer Institute was easy.  1 = Strongly disagree  2 = Disagree  3 = Neutral agree

 4 = Agree  5 = Strongly

I was able to be seen by a therapist in a timely manner.  1 = Strongly disagree  2 = Disagree  3 = Neutral agree

 4 = Agree  5 = Strongly

The waiting room was warm and inviting.  1 = Strongly disagree  2 = Disagree  3 = Neutral agree

 4 = Agree  5 = Strongly

The physical environment of the waiting room was comfortable.  1 = Strongly disagree  2 = Disagree  3 = Neutral agree

 4 = Agree  5 = Strongly

Office distractions were minimal.  1 = Strongly disagree  2 = Disagree  3 = Neutral agree

 4 = Agree  5 = Strongly

The front desk staff was friendly.  1 = Strongly disagree  2 = Disagree  3 = Neutral agree

 4 = Agree  5 = Strongly

The front desk staff was helpful.  1 = Strongly disagree  2 = Disagree  3 = Neutral agree

 4 = Agree  5 = Strongly

The physical environment of the therapy room was comfortable. Page 133

 1 = Strongly disagree  2 = Disagree  3 = Neutral agree

 4 = Agree  5 = Strongly

Were you made aware that a sliding scale fee is available when or if needed?  Yes

 No

Thank you!! Please return this survey to the front desk or mail to our office: Attn: Dr. Jenny Haines * Pfeiffer Institute * 4805 Park Rd., Suite #250 * Charlotte, NC * 28209

Client Satisfaction Survey, Part II: The Therapist

The following questions examine your experience with the Therapist Intern(s). Please answer honestly, as these confidential responses will be used to help your Therapist Intern continue to improve his/her skills. I would like the therapist to have access to my responses:

Gender:

 Male

 Yes

 No

 Female

Which type of sessions did you attend? (Check all that apply)  Individual

 Couple

 Family

 Group

1. The therapist appears knowledgeable and resourceful.  1 = Strongly disagree  2 = Disagree  3 = Neutral agree

 4 = Agree  5 = Strongly

2. The therapist shows respect for me and my concerns.  1 = Strongly disagree  2 = Disagree  3 = Neutral agree

 4 = Agree  5 = Strongly

3. The therapist appears to be a thoughtful listener.  1 = Strongly disagree  2 = Disagree  3 = Neutral agree

 4 = Agree  5 = Strongly

4. The therapy experience appears to be safe and confidential. Page 134

 1 = Strongly disagree  2 = Disagree  3 = Neutral agree

 4 = Agree  5 = Strongly

5. The therapist is aware and sensitive to contextual issues, including gender, age, race, ability, and sexual orientation in the therapy room.  1 = Strongly disagree  2 = Disagree  3 = Neutral agree

 4 = Agree  5 = Strongly

6. The therapist demonstrates professional and ethical behavior.  1 = Strongly disagree  2 = Disagree  3 = Neutral agree

 4 = Agree  5 = Strongly

7. I am benefitting from the therapy experience.  1 = Strongly disagree  2 = Disagree  3 = Neutral agree

 4 = Agree  5 = Strongly

8. I feel like the therapist is working hard to help me accomplish my goals.

 1 = Strongly disagree  2 = Disagree  3 = Neutral agree

 4 = Agree  5 = Strongly

9. I think therapy is a valuable option for me.  1 = Strongly disagree  2 = Disagree  3 = Neutral agree

 4 = Agree  5 = Strongly

10. If there was a need beyond which Pfeiffer Institute (PIMFT) could help (for example, legal or medical question), were you referred to another source?  Yes  No  Not applicable 11. My therapist appears confident and professional.  1 = Strongly disagree  2 = Disagree  3 = Neutral agree

 4 = Agree  5 = Strongly

12. I would recommend my therapist to others.  1 = Strongly disagree  2 = Disagree  3 = Neutral agree

 4 = Agree  5 = Strongly

13. Overall, I believe my therapist and I worked well together.  1 = Strongly disagree  2 = Disagree  3 = Neutral  4 = Agree  5 = Strongly agree

Page 135

Is there anything else about your experience at Pfeiffer Institute that you would like for us to know? ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ _____________________________________________________________________________ ______________________________________________________________________________ Thank you for completing this satisfaction survey. Your responses will help us continue to serve you better.

Page 136

Risk and Safety Assessment Form RISK AND SAFETY ASSESSMENT FORM FOR CLIENT # NAME (S) Date: Present:

Time: : am/ Adult Male Adult Female

pm Session # Child Male Child Female

Other:

Suicidality Homicidality Alcohol Abuse No indication/Denies No indication/Denies No indication/denies Active ideation Active ideation Past abuse Passive ideation Passive ideation Current; Freq/Amt: Intent without plan Intent without means Drug Use/Abuse Intent with means Intent with means No indication/denies Ideation in past year Ideation in past year Past use Attempt in past year Violence past year Current drugs: Family or peer history of completed History of assaulting others Freq/Amt: suicide Cruelty to animals Family/sig.other use Sexual & Physical Abuse and Other Risk Factors Childhood abuse history: Sexual Physical Emotional Neglect Adult with abuse/assault in adulthood: Sexual Physical Current History of perpetrating abuse: Sexual Physical Emotional Elder/dependent adult abuse/neglect History of or current issues with restrictive eating, binging, and/or purging Cutting or other self harm: Current Past: Method: Criminal/legal history: Other trauma history: None reported Indicators of Safety NA Willingness to reduce contact with people who make situation At least one outside support person worse Able to cite specific reasons to live or not harm Willing to implement safety plan, safety interventions Hopeful Developing set of alternatives to self/other harm Willing to dispose of dangerous items Sustained period of safety: Has future goals Other: Elements of Safety Plan NA Plan for contacting friends/support persons during crisis Verbal no harm contract Specific plan of where to go during crisis Written no harm contract Specific self-calming tasks to reduce risk before reach crisis level Emergency contact card (e.g., journaling, exercising, etc.) Emergency therapist/agency number Specific daily/weekly activities to reduce stressors Medication management Other: Actions Taken Contacted Clinical Supervisor Contacted Clinic Director Contacted Other Professional Describe Actions and Outcome: Legal/Ethical Action Taken:

NA

______________________ Clinician’s Printed Name ______________________ Supervisor’s Printed Name

Action:

_______________________, _MFT Intern Clinician’s Signature License/Intern _______________________, ___________ Supervisor’s Signature License

Page 137

________ Date ________ Date

Suicide Assessment Flowchart Below are some general guidelines provided by Schwartz and Rogers (2004) that may be helpful in determining the lethality of a client who acknowledges suicidal ideation:  Low lethality—suicidal ideation is present but intent is denied, client does not have a concrete plan and has never attempted suicide in the past.  Moderate lethality—more than one general risk factor for suicide is present; suicidal ideation and intent are present, but a clear plan is denied; and the client is motivated to improve his/her psychological state if possible.  High lethality—several general risk factors for suicide are present, client has verbalized suicidal ideation and intent, client has a coherent plan to harm him or herself, and client reports access to resources needed to complete the plan.  Very high lethality—client verbalizes suicidal ideation and intent, he or she has communicated a well thought out plan with immediate access to resources needed to complete the plan, client demonstrates cognitive rigidity and hopelessness for the future, he or she denies any available social support, and he or she has made previous suicide attempts in the past. Schwartz, R. C., & Rogers, J. R. (2004). Suicide assessment and evaluation strategies: A primer for counseling psychologists. Counseling Psychology Quarterly, 17(1), 89-97.

More lethality → More need to contact Supervisor and involve others.

Page 138

Therapist Intern Agreement Form I have read the Pfeiffer Institute for Marriage and Family Therapy’s Clinic Policy and Procedure Manual in its entirety. I understand that by signing my name to this document, I am fully responsible for abiding by the Clinic Policies and Procedures. I understand that if I do not abide by the PIMFT Clinic Policy and Procedure Manual, I will be held accountable and may be put into a remediation process as outlined in the manual.

________________________________ Therapist Intern

_____________________ Date

________________________________ Clinic Director

_____________________ Date

*After this is signed, please give to Clinic Director and the original will be placed in the therapist intern file.

Page 139

Permission to Treat Minors Pfeiffer Institute for Marriage & Family Therapy List names of children to be treated in counseling:

Definitions 1.

1.__________________________________ 2.

2.__________________________________ 3.__________________________________

3. 4.

4.__________________________________ 5.__________________________________

Joint physical custody: Children split their time between parents, spending a substantial amount of time with each parent. Joint legal custody: Parents share in decision-making regarding medical, educational, and religious issues involving the children. Joint legal and physical custody: Parents share both time and decision-making responsibilities. Primary (sole) custody: One parent is designated the primary physical and legal custodian of the child or children, and the other parent is granted visitation rights.

List names of individual(s) with custody rights for the above named children and list type of custody each possesses (print only): Name_______________________________________ Address:______________________________________________________________________ Type of Custody:______________________________ Name_______________________________________ Address:______________________________________________________________________ Type of Custody:______________________________ If one parent is not consistently involved in the care of the above named child(ren), please write a statement attesting to this fact: ______________________________________________________________________________ Sign below to verify that all information provided here is true and accurate. If both individuals share joint legal custody (definition 2 or 3) both must sign below giving permission for the above named children to be treated in counseling. Parents, please attach a copy of the settlement agreement. ___________________________________________

________________________

(Signature of person authorized by law)

(Date)

___________________________________________

________________________

(Signature of person authorized by law)

(Date)

Page 140

Page 141