Consent for treatment - therapist Leslie Marler

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Ephesians Professional Counseling

Leslie J. Marler, MS, NBCC, LCPC

State Licensed Clinical Professional Counselor, National Board Certified Counselor


Name of Client*


Complete Notice of Privacy Practices and Statement of Policy are available at

As a Board Certified, Maryland Licensed Clinical Professional Counselor holding the Master of Pastoral Counseling from Loyola University, Baltimore, Maryland, the Maryland State Department of Health requires that I maintain records, provide disclosure information to all clients, and that I make the following statement to clients:

As a paid counseling practitioner, I must maintain registration and/or certification with the Maryland State Department of Health for the protection of public health and safety. As a counseling client, you have the right to choose a counselor who best suits your needs and purposes. The first session is an opportunity for both client and counselor to evaluate whether or not this particular professional relationship is right for each party.


In therapy sessions I offer you two gifts: time uninterrupted by work or family or friends, and a compassionate, listening, empathic presence in a safe and hospitable space.

My counseling approach is primarily influenced by Cognitive Behavioral Therapy, Client Centered Therapy, Solution Focused Therapy, and Marriage and Family Therapy. I offer Pastoral Counseling to those who seek it. Therapy is relationship based, and during our sessions we will generate solutions that lead you to achieve your therapeutic goals. We do this through our initial intake process, questionnaires, homework, and open conversation between counselor and client. Establishing a positive and trusting relationship starts you on your journey toward enhanced emotional health and renewed social and family relationships.


All information shared in therapy is confidential. This means that I cannot release information about a client without that client’s written permission, except in the cases of imminent danger to self or others, suspected child/dependent abuse, court order, or where otherwise required by law. As needed, I may consult with a professional colleague within a professional setting about some aspect of understanding or treating your case. Only relevant information is shared, and your confidentiality is never compromised.


It is important to remember that therapy requires a commitment of weekly session and your personal reflection upon ways to make the change you want part of your daily life. Sometimes this involves homework, and I ask you to bring a notebook to your first session. Since change happens over time, it is best not to judge your therapy by the way you are feeling in any moment. Rather I encourage my clients to share with me their questions and observations. Therapy is not a miraculous phenomenon. It is a collaborative effort between the counselor and an active and motivated participant. Consistency in attending therapy sessions and being on time for each session is an essential part of your progress.

If a client does not come to a session or call to reschedule that session within one week, I reserve the right to remove that client from my weekly rotation.

Counseling may open up levels of awareness that could cause pain and anxiety. Therefore, it is your right to refuse to participate in certain therapeutic techniques. You may terminate therapy with two weeks’ notice. This allows you time to review your progress and to leave therapy with a clear recall of the skills you have been acquiring.


As a client, you have the right to request referrals for other therapy or psychiatric services. When requested by another health care provider, you may obtain a summary of your records. There is a fee for summary preparation. You will routinely be participating in reviewing your therapeutic goals and evaluating your progress toward meeting them. You may receive a copy of the code of ethics to which your counselor adheres, and you may contact the appropriate professional organization if you have doubts or questions about my work as a counselor.


INSURANCE and EAP. I accept many well-known insurances and EAP plans. Please call me to learn how to determine your deductible and copay. My work includes individual, couples, family and occasionally group therapy. EAP and HMO individual and some PPO individual sessions are 45 minutes in duration. Some PPO plans pay for a 55-60 minute individual session. I require 60 minutes to conduct couple, premarital, and family sessions; your insurance may or may not cover 60 minutes. Please call me to find out if yours does.

OUT OF POCKET FEES. For clients who do not have insurance or prefer not to use it, my standard out-of-pocket fee is $120 per 50 minute session. You may inquire about my sliding scale Fees. My fee for each person participating in group therapy is $50. I realize that not everyone can afford these out-of-pocket fees per session. Therefore, I accept most insurance plans. We will discuss fees and insurance approval during one of our earliest phone conversations.

Payment is expected at the beginning of each session. You may pay by check to Leslie J Marler, LCPC, through Venmo, or by cash.

Please understand that when you make an appointment, I am reserving that time for you. When you miss your appointment for any reason without 24 hour cancellation notice, it is my policy to charge the standard $65 late cancel/no show fee unless you are able to reschedule an appointment on my weekly calendar during the same week of your missed appointment. If you are late for your appointment, you will be charged for a full session. Please remember that cancellation within 24 hours is your responsibility.

Please inquire about teletherapy health sessions during times of illness.

If your check is returned to me from the bank, a $40 charge will be added to your fee, and the total must be paid in full prior to your next session.

For all life-threatening emergencies, please call 911. Then when you are safe, you may proceed to notify me at 301-466-2050. Please be aware that I may not be able to answer your call during therapy sessions or after 8:00 pm. In that event, please leave a message, and I will return your call as I am able.


This information is required by the Board of Professional Counselors and Therapists which regulates all certified and licensed counselors and therapists.

Board of Professional Counselors and Therapists. (410) 764-4732
4201 Patterson Ave. Baltimore, MD 21215.


Signature below indicates understanding and compliance with this document and obligates both client and clinician to abide by all rules and regulations as governed by the Maryland State Department of Health.

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