* * * * * STATEMENT OF UNDERSTANDING FOR ANGER ASSESSMENT * * * * *
The words “your counselor” in this document mean John DeMarco M.Ed., LPC.
The purpose of an anger assessment is to determine the degree to which your anger response is maladaptive. Your anger response may in fact be normal. The assessment process involves your counselor interviewing you using assessment questions, symptoms checklists, and other self-
In the assessment process you have the following rights:
Limits of Confidentiality—Your counselor will keep your assessment records and everything discuss strictly confidential, except for matters pertaining to:
Authorization to Release Information—Your assessment records and discussions are strictly confidential. With very few exceptions (as required by law), if there is ever a need for your counselor to communicate with people outside of your client/counselor relationship, you will need to sign an authorization for release of information form.
Request for a Letter or Documentation—The preparation of a letter or document by your counselor disclosing any of your consultation information must be made a minimum of two weeks in advance of when you want it and you must: (1) furnish the accurate name and address of the letter’s recipient and (2) sign an authorization for a release of information form.
Your Assessment File—A written record of your assessment will be maintained by your counselor. Your counselor will retain your file for a period of seven years following the date of your last session with your counselor. After that seven-
Copy of Your File—Any request by you for a copy of your assessment file, in whole or in part, must be made in writing with your signature and dated; and must contain an explanation of the intended use of the copy. Any information in your file pertaining to an identified individual or individuals other than yourself will be edited out of the copy. A service fee of $3 per page will be charged.
Length of Sessions—An assessment session is one ninety (90) minute period of time. One hour for conducting the assessment and one half hour for preparing documentation. Depending on the nature of your needs the assessment may necessitate more than one session.
Payment Procedure—Payment for an anger assessment is required at the beginning of the session and payable in cash only.
I have read and understand this policy statement or my counselor has explained it to me. I understand and acknowledge that there is a possibility that the assessment may conclude that I in fact do have a problem with anger. I also certify that I am voluntarily seeking an anger assessment from John DeMarco M.Ed., LPC.