Disclosure Statement

Thank you for considering my therapy services. In order to help you make an informed decision, I have prepared this statement for you to read. Please review this statement in its entirety and sign it in the space provided. If you have any questions or concerns, I would be happy to discuss them with you.

Philosophy and Approach

I believe that individuals, couples, and families have the inner resources to enhance their emotional, mental, and behavioral well being, but often get stuck in unproductive stories and/or cycles or patterns of behavior. My task, therefore, is to help them discover their resources and to identify and develop alternative stories or patterns of behavior. I employ an integrated family therapy approach based in theory and research. My approach includes elements of systemic, structural, and contextual family therapies, as well as narrative and solution-focused approaches. In couples therapy, I employ Gottman Method Couples Therapy, an integrative approach based on the research and work of Dr. John Gottman.

Education and Training

I hold a Master of Science in Counseling in Marriage, Family, and Child Therapy from the University of Phoenix and a Master of Divinity in Theology from the Washington Theological Union. My major coursework in Marriage, Family, and Child Therapy included lifespan and family development, family systems theory, child therapy, family interventions, advanced marriage and family therapy, and human sexuality and sex therapy. I am a Certified Gottman Therapist, Couples Workshop Leader, and Clinical Trainer.

As a licensee of the State of Florida Board of Clinical Social Work, Marriage and Family Therapy and Mental Health Counseling and a Clinical Fellow of the American Association for Marriage and Family Therapy…,

I will abide by Rule 64B4 of the Florida Administrative Code and all Florida Statutes pertaining to the practice of Marriage and Family Therapy, as well as the Code of Ethics of the American Association for Marriage and Family Therapy. To maintain my license I am required to participate in annual continuing education.

Fees

Services are to be paid prior to or at the time of service and by cash, check, or credit/debit card only. If you need a statement for insurance reimbursement, I will be happy to provide that for you. If you do not show for an or appointment and fail to cancel it at least 48 hours ahead of time, the full fee will be charged to the credit/debit card of record.

As a client, you have the following rights:

• To expect that a licensee has met the minimal qualifications of training and experience required by state law;

• To examine public records maintained by the Board and to have the Board confirm credentials of a licensee;

• To report complaints to the Board;

• To be informed of the cost of professional services before receiving the services;

• To be assured of privacy and confidentiality while receiving services as defined by rule and law, including the following exceptions: 1) Reporting suspected child abuse; 2) Reporting imminent danger to client or others; 3) Reporting information required in court proceedings or by client’s insurance company, or other relevant agencies; 4) Providing information concerning licensee case consultation or supervision; and 5) Defending claims brought by client against licensee;

• To be free from discrimination because of age, color, culture, disability, ethnicity, national origin, gender, race, religion, sexual orientation, marital status, or socioeconomic status.

If you feel that I have violated your rights at any time, you can file a complaint via the Florida HealthCare Complaint Portal at https://www.flhealthcomplaint.com or by calling 850-245-7339.

If you should have questions or concerns, please do not hesitate to bring them up. My goal is to have therapy be a positive, productive part of my clients’ lives. I will give my utmost effort to help accomplish this goal.

I have read this disclosure statement and understand its content. I also acknowledge receiving a copy of this statement. I have been provided with a fee agreement stating the agreed cost of counseling sessions and policies regarding payments.

Consent Regarding SMS and Electronic Communication

  • (Responsible Party if client is a minor)
    I consent to receive electronic communication from Michael Brown, MSC, LMFT, regarding appointments and billing (please initial).
  • I consent to receiving electronic communication from Happy Couples Healthy Communities regarding workshops, groups, and marriage and family therapy (please initial).

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