1820 Glynwood Drive, Suite B

Prattville, Alabama 36066




WELCOME!  I look forward to working with you.


I believe that a clear and open relationship is an important part of the therapeutic process.  Therefore, I encourage you to bring to my attention anything that you do not understand or that feels uncomfortable to you in any way.


The sessions are completely confidential EXCEPT when

a.      I have reason to believe that you intend to harm yourself or another person

b.      A minor has been abused or neglected.

(This does not apply to adults working on abuse/neglect that occurred in their childhood.)

c. I am informed that you have a communicable disease that is affecting another party without his/her knowledge.

d. I am court ordered to testify or submit files and records by a judge.

e. I am required to submit information to insurance providers.


I would like to also inform you of pertinent ethical standards established by the American Counseling Association Code of Ethics.    The Code states the following:


Multiple Clients

When a counselor agrees to provide counseling services to two or more persons who have a relationship, the persons who have a relationship, the counselor clarifies at the outset which person or persons are clients and the nature of the relationships the counselor will have with each involved person.  If it becomes apparent that the counselor may be called upon to perform potentially conflicting roles, the counselor will clarify, adjust, or withdraw from the roles appropriately.  (A.7)


Role Changes in the Professional Relationship

When a counselor changes a role from the original or most recent contracted relationship, he or she obtains informed consent from the client and explains the right of the client to refuse services related to the change.  Examples of role changes include

1.      changing from individual to relationship or family counseling, or vice versa;

2.      changing from a nonforensic evaluative role to a therapeutic role, or vice versa;

3.      changing from a counselor to a researcher role;

4.      changing from a  counselor to a mediator role, or vice versa.

Clients must be fully informed of any anticipated consequences (financial, legal, personal, or therapeutic) of counselor role changes.  (A.5.e.)


Couples and Family Counseling

In couples and family counseling, counselors clearly define who is considered “the client” and discuss expectations and limitations of confidentiality.  Counselors seek agreement and document in writing such agreement among all involved parties having capacity to give consent concerning each individual’s right to confidentiality and any obligation to preserve the confidentiality of information known.(B4b)


In any case, I will take appropriate action to protect all clients’ privacy and safety.


Fees for counseling services


Due to difficulties experienced in receiving payments from insurance companies, please clarify in advance that your insurance will cover services provided by a Martha B. Ellis, Licensed Professional Counselor, and that there is no required preferred provider list from which you must choose.  Fees for services are as follows:


50 minute session                                $80.00

30 minute session                                $50.00

Preparation for court per hour         $125.00

Court appearances per hour              $125.00

Missed appointments                          $50.00

Cancellation of appointments must be received a minimum of 24 hours in advance to prevent being charged for the cancellation or missed appointment.


Client records are maintained for seven (7) years and destroyed after that time frame. 


I understand the above mentioned ethical guidelines, understand that I am responsible for all fees associated with counseling services including unpaid insurance claims, and understand that


_________________________________________is/are the clients to be served.


__________________                        ____________________________________

Date                                                    Signature of Client


__________________                        ____________________________________

Date                                                    Signature of Client


__________________                        ____________________________________

Date                                                    Signature of Client


__________________                        ____________________________________

Date                                                    Witness                                                    May 2010