New Client Forms for Insurance Carrier

Please correct the errors described below.

Client Information Form

Therapist: Douglas K. Lormand, M.S., M.Ed., LPC, CST


Please fill out a complete set of forms for each person.


If referral is a physician:




This agreement contains important information about professional services and business policies for the office of Douglas K. Lormand, LPC (herein referred to as “Counselor”, I, We, or Us). It also contains summary information about the Health Insurance Portability and Accountability Act (HIPAA), a federal law that provides privacy protections and client rights with regard to the use and disclosure of your Protected Health Information (PHI) used for the purpose of treatment, payment, and health care operations.

Although these documents are long and sometimes complex, IT IS VERY IMPORTANT THAT YOU READ EACH DOCUMENT FULLY AND CAREFULLY PRIOR TO SIGNING. We can discuss any questions you have about the procedures. When you sign this document, it will also represent an agreement between us. You may revoke your consent at any time and as described more fully below. Revocation of consent will be binding from the point of revocation forward but will not apply to the extent we have taken action in reliance on this agreement. Note that failure to satisfy financial obligations under this agreement may impact your rights, including your right to revoke consent for certain types of disclosure.


Psychotherapy is not easily described in general statements. It varies depending on the particular problems you are experiencing, the therapeutic methods used, and the personalities of the counselor and client. There are many different methods counselors may use to deal with the problems that you hope to address. Psychotherapy is not like a medical doctor visit. Instead, it calls for a very active effort on your part. In order for the therapy to be most successful, you will have to work on things that are discussed both during your sessions and on your own.

As with all types of therapy, Psychotherapy has both benefits and risks. Since therapy often involves discussing unpleasant aspects of your life, you may experience uncomfortable feelings like sadness, guilt, anger, shame, frustration, loneliness, and helplessness. The changes you make in therapy may also affect your relationships in unexpected ways. Psychotherapy has also been shown to have many benefits. Therapy often leads to better relationships, solutions to specific problems, and significant reductions in feelings of distress. It is an individual experience, and because of this there are no guarantees of what you will experience or of the outcome.

Your first appointment (or more, in some cases) will involve an assessment of your needs. By the end of the assessment your counselor will be able to offer you some first impressions of what your work may include and recommendations. One of the recommendations may be psychotherapy. If so, I may or may not be able to provide you with psychotherapy, depending on your overall needs. If psychotherapy or any other suggested recommendations include things that I cannot provide, you may be given suggestions of where you might receive those services. Wherever you choose to obtain treatment, you should evaluate the information from your initial assessment along with your own opinions of what sort of treatment you are willing to do and whether you feel comfortable working with the treating clinician.

Therapy involves a large commitment of time, energy, and often money, so you should be very careful about the therapist you select. If you have questions about the procedures used or conclusions made, please discuss them whenever they arise. If your doubts persist, I will be happy to help you with referrals to secure another mental health professional for a second opinion.


You have received a payment schedule describing fees for Douglas K. Lormand, a Licensed Professional Counselor. Cancellation with less than 24 hours’ notice will result in a fee equal to the total amount of the missed session that will be collected with your payment information on file. After two no-shows/late cancellations, client will pre-pay before services are rendered. Clients who have pre-paid agree to have the entire fee deducted from their pre-payment in cases of no-shows and late cancellations. Counselor may choose to waive certain fees in extenuating circumstances, but such waivers are at the sole discretion of Counselor and any such waiver shall not be deemed a waiver of Counselor’s right to charge such fees in the future in accordance with the policy set forth herein.

Other services that may incur fees or charges include phone calls over five minutes, generating reports, consulting with other agencies and professionals at your request, paperwork and depositions resulting from a subpoena, and the time spent performing any other services you may request. These services will be charged as they occur. Please note that Douglas K. Lormand, LPC does not testify in court cases unless under subpoena (Duces Tecum) to do so.

You (not your insurance company) are responsible for full payment of fees, regardless of whether you choose to file claims for reimbursement from your insurance company and regardless of the outcome of any such claim. Counselor does not file insurance claims on behalf of his clients – such claims are the sole responsibility of the client.

Acknowledgement: I have received a copy of the Price List and Payment Schedule, understand the implications of leaving my credit card information on file, and fully consent to abide and honor the payments terms as set forth herein.

DISCLAIMER: By typing your name below, you are signing this application electronically. You agree that your electronic signature is the legal equivalent of your manual signature on this application.


The initial assessment will last from one to two sessions. During this time, we can both decide what the best course of treatment is based on your needs. Part of this process will include determining if I, as a clinician, am compatible with you as a client. If psychotherapy is pursued, you and your counselor will typically schedule one meeting per week at a mutually agreeable time, but this may change based on your needs, treatment plans, and the schedules of all necessary parties. Once an appointment is scheduled, you will be expected to attend unless you provide advance notice of cancellation. If you need to cancel an appointment, it is your responsibility to contact the main office number to cancel in accordance with the cancellation policy detailed below.

1958 W. Gray St.

Houston, TX 77019



Counselor will make every effort to return messages within 24 hours but return calls after 24 hours in special circumstances. IF THERE IS AN EMERGENCY, CONTACT EMERGENCY PERSONNEL FIRST AS APPROPRIATE. You may have your Counselor’s cell phone number in order to coordinate administrative tasks (defined as appointment arrival, appointment time, and directions). Email and text messaging are not secure mediums in terms of privacy and confidentiality so our policy regarding electronic communication and cell phone use includes the following:

  • Therapy is not provided via email or text messaging.
  • Text messaging and email will be used for administrative tasks or as needed to support the therapeutic alliance.
  • Counselor will acknowledge or return emails or text messages that are administrative or critical to the therapeutic frame. This includes emergency texts and emails.
  • Telephone, and web conferencing for counseling are allowed if you are within the state/s of Louisiana/Texas/Colorado and there is completed intake paperwork on file.
  • If your Counselor leaves for an extended period of time you will be given the information for another licensed professional counselor with whom you may schedule if you need an appointment during your Counselor’s absence.
  • If you have an emergency do not contact your Counselor’s cell phone, email, or the office main number. Instead go to the emergency room nearest you or call 911.


The law protects the privacy of all communications between a client and a counselor. In most situations, Douglas K. Lormand, LPC can only release information about your treatment to others if you sign a written Authorization Form that meets certain legal requirements imposed by HIPAA (included with this intake packet). There are other situations that require only that you provide written, advance consent which is provided by signing this document. Your signature on this Agreement provides consent for the following activities:

In providing, coordinating, or managing your treatment and other services related to your counseling care, Douglas K. Lormand, LPC sometimes interacts with other professionals concerning your well-being. An example of this would be where Counselor consults with another health care provider, such as a physician. A release of information may be required to keep on file if such coordination is necessary.

  • If you are involved in a court proceeding and a request is made for information concerning your diagnosis and treatment, Douglas K. Lormand, LPC cannot provide any information without a) your (or your legal representative’s) written authorization, or b) a court order/subpoena. If you are involved in or contemplating litigation, you should consult with your attorney to determine whether a court would be likely to order Douglas K. Lormand, LPC to disclose information.
  • If a client files a complaint or lawsuit against Douglas K. Lormand, LPC, Counselor may disclose relevant information regarding that client in order to address the complaint or lawsuit.
  • If Counselor has reasonable cause to suspect that a child has been or may be subjected to abuse or neglect or observe a child being subjected to conditions or circumstances that would reasonably result in abuse or neglect, the law requires that Douglas K. Lormand, LPC file a report with the respective state Department of Child Protective Services. Once such a report is filed, Counselor may be legally required to provide additional information.
  • If Counselor believes that it is necessary to disclose information to protect against a risk of serious harm being inflicted by you upon yourself, another person, or to the community, Counselor may be required to take protective action. Depending on the situation, these actions may include initiating hospitalization and/or contacting the police. If such a situation arises, Counselor will make every effort to fully discuss it with you before taking any action and will limit any disclosure to what is necessary and appropriate under the circumstances.
  • If you disclose past sexual abuse by a mental health provider, Counselor is obligated to report this to the proper authorities and licensing entities.

While this written summary of exceptions to confidentiality should prove helpful in informing you about potential problems, it is important that you discuss any questions or concerns that you may have now or in the future with your Counselor. The laws governing confidentiality can be quite complex. In situations where specific advice is required, formal legal advice may be needed.


The laws and standards of the mental health profession require that Counselor keep Protected Health Information about you in the Clinical Record during the ordinary course of business. Your Clinical Record may include information about your reasons for seeking therapy, a description of the ways in which your problem impacts on your life, your diagnosis, the goals for treatment, your progress towards those goals, your medical and social history, your treatment history, any past treatment records that Counselor receives from other providers, reports of any professional consultations, and any reports that may have been sent to anyone.

Except in the unusual circumstance where disclosure is reasonably likely to endanger you and/or others or when another individual (other than another health care provider) is referenced and Counselor believes disclosing that information puts the other person at risk of substantial harm, you may examine and/or receive a copy of your Clinical Record, if you request it in writing. Because these are professional records, they can be misinterpreted by and/or be upsetting to untrained readers. For this reason, it is recommended that you have them forwarded to another mental health professional so you can discuss the contents more fully with a professional. In most circumstances, Douglas K. Lormand, LPC is permitted, and may choose to, to charge a copying fee of $25.


Clients under 18 years of age and their parents should be aware that the law may allow parents to examine their child’s treatment records. Because privacy in psychotherapy is often crucial to successful progress, particularly with teenagers, it is sometimes my policy to request an agreement from parents that they consent to give up their access to their child’s records. If they agree, during treatment, I would provide them (if requested) only with general information about the progress of your treatment, and your attendance at scheduled sessions. If requested, I could also provide parents with a summary of your treatment when it is complete. Any other communication to your parents will require your Authorization, unless I feel that you are in danger or are a danger to someone else, in which case, I will notify the parents of my concern. Before giving parents any information, I will discuss the matter with you, if possible, and do my best to handle any objections you may have. In cases of divorce, a copy of the divorce decree indicating parental rights to view records and participate in treatment will be required.


HIPAA requires that Douglas K. Lormand, LPC share with you a Notice of Privacy Practices for use and disclosure of Personal Health Information for treatment, payment, and health care operations. The Notice explains HIPAA and its application to your personal health information in greater detail. The law requires that I obtain your signature acknowledging this information has been provided to you.

HIPAA provides you with several new or expanded rights with regard to your Clinical Records and disclosures of protected health information. These rights include requesting that your counselor amend your record; requesting restrictions on what information from your Clinical Records is disclosed to others; requesting an accounting of most disclosures of protected health information that you have neither consented to nor authorized; determining the location to which protected information disclosures are sent; having any complaints you make about Douglas K. Lormand, LPC policies and procedures recorded in your records; and the right to a paper copy of my privacy policies and procedures. You have the right to a paper copy of this Services Agreement. You also have the right to keep a paper copy of the Privacy Notice.

I may provide you with paperwork so you may submit for insurance reimbursement. I will not, however, file that paperwork for you. You should be aware that in the process of filing for a third party payment, your contract with your health insurance company requires that your counselor provide additional clinical information such as treatment plans or summaries, a diagnosis, or copies of your entire Clinical Record. This information will become part of the insurance company files and will probably be stored in a computer. Though all insurance companies claim to keep such information confidential, counselors have no control over what the insurance companies do with it once it is in their hands. In such situations, your counselor will make every effort to release only the minimum information about you that is necessary for the purpose requested. If you will be filing with your insurance company for reimbursement of fees, please indicate your consent for me to release your PHI by signing below.


DISCLAIMER: By typing your name below, you are signing this application electronically. You agree that your electronic signature is the legal equivalent of your manual signature on this application.

An individual who wishes to file a complaint against a Licensed Professional Counselor may write to:

Colorado Department of Regulatory Agencies, Division of Professions and Occupations

1560 Broadway, Suite 1350, Denver, CO 80202 or call 303-894-7800

Texas State Board of Examiners of Professional Counselors

P.O. Box 141369, Austin, TX 78714 or call 1-800-942-5540

Louisiana Licensed Professional Counselors Board of Examiners

11410 Lake Sherwood Ave. North Suite A, Baton Rouge, LA 70816 or call 225-295-8444



Licensed mental health professionals are required by their licensing boards to provide you, the client, with certain basic information. You have already received and signed the basic Declaration of Practices and Procedures from Satisfying Relationships and Douglas Lormand, LPC. This Teletherapy Policy & Procedure document describes certain important aspects of therapy unique to Teletherapy. I am providing you this information for your review and agreement. Please read it carefully and discuss any questions you have before signing below.

By signing this form, you are not making a commitment to continue teletherapy therapy as a permanent modality, but you will continue to have that option should you and Douglas Lormand, LPC bothagree that it is in your best interest.


I have completed the requirements of live telehealth care training in addition to my professional qualifications as a clinician. This training covered the Law and Ethics and Clinical Skills specifically related to telehealth care. I will continue to receive at least three hours of continuing education in the area of telemental health every two years. All teletherapy sessions will be conducted through approved teletherapy platforms.

Scheduling and Structure of Teletherapy:

Counseling sessions will be scheduled in 50 minute increments, unless you and Douglas Lormand, LPC agree on a different time schedule. The next session will scheduled at the end of the current session, unless otherwise agreed upon. The structure of sessions will be dependent on the treatment plan and interventions being used.

Ethical and Legal Rights Related to Teletherapy:

Douglas Lormand, LPC is licensed and can conduct Teletherapy in Louisiana, Texas and Colorado and cannot conduct therapy in any other state unless he specifically seeks and obtains licensure in the other state. It is important for you, as a client, to realize if you should relocate to another state, Douglas Lormand’s ability to continue to conduct teletherapy would be dependent on his decision whether or not to seek licensure in the state to which you are relocated.


All clients should:

  • Be appropriately dressed during sessions.
  • Avoid using alcohol, drugs, or other mind-altering substances prior to session.
  • Be located in a safe and private area appropriate for a teletherapy sessions.
  • Make every attempt to be in a location with stable internet capability.

Clients should NOT

  • Record sessions unless first obtaining Douglas Lormand’s permission.
  • Have anyone else in the room unless you first discuss it with Douglas Lormand.
  • Conduct other activities while in session (such as texting, driving, etc.).

* If the client is a minor, a parent or guardian must be present at the location/building of the teletherapy session (unless otherwise agreed upon with the therapist).


When using technology to communicate on any level, there are some important risk factors of which to be aware. It is possible that information might be intercepted, forwarded, stored, sent out, or even changed from its original state. It is also possible that the security of the device used may be compromised. Best practice efforts are made to protect the security and overall privacy of all electronic communications with you. However, complete security of this information is not possible. Using methods of electronic communication with us outside of our recommendations creates a reasonable possibility that a third party may be able to intercept that communication. It is your responsibility to review the privacy sections and agreement forms of any application and technology you use. Please remember that depending on the device being used, others within your circle (i.e. family, friends, employers, & co-workers) and those not in your circle (i.e. criminals, scam artists) may have access to your device. Reviewing the privacy sections for your devices is essential. Please contact me with any questions that you may have on privacy measures.


Teletherapy is an alternate form of counseling and should not be viewed as a substitution for taking medication that has previously been prescribed by a medical doctor. It has possible benefits and limitations. By signing this document, you agree that you understand that:

  • Teletherapy may not be appropriate if you are having a crisis, acute psychosis, or suicidal/homicidal thoughts.
  • Misunderstandings may occur due to a lack of visual and/or audio cues.
  • Disruptions in the service and quality of the technology used may occur.
  • While I do not file insurance claims, I can make an invoice available to you to file with your insurance company.

Please check with them ahead of time to be sure your policy covers telemental health counseling.


The following items are important and necessary for your safety. The clinician will need this information in order to get you help in the case of an emergency. By signing this consent to treatment form you are acknowledging that you have read, understand, and agree to the following:

  • The client will inform Douglas Lormand, LPC of the physical location where he/she is, and will utilize consistently while participating in sessions and will inform Douglas Lormand, LPC if this location changes.
  • In the first teletherapy session, you will provide the name of a person Douglas Lormand, LPC is allowed to contact in the case she believes you are at risk. You will be asked to sign a release of information for this contact.
  • In the first teletherapy session, you will provide information about the make, model, color, and License plate of your automobile.
  • In each session you will provide information about the nearest emergency room or emergency services (such as fire station, police station, if there is not an emergency room nearby.)
  • Depending on the assessment of risk and in the event of an emergency, you or Douglas Lormand, may be required to verify that the emergency contact person is able and willing to go to the client’s location and, if that person deems necessary, call 911 and/or transport the client to a hospital. In addition to this, Douglas Lormand may assess, and therefore require that you, the client create a safe environment at your location during the entire time of treatment. If an assessment is made for the need of a “safe environment” a plan for this safe environment will be developed at the time of need and made clear by Douglas Lormand.
  • In the case of a need to speak to me between sessions, please call, or text, and leave a message. I do not provide emergency services on a 24-hour basis. If your emergency is after hours, please contact your nearest emergency room. Typically contact between sessions is limited to arranging for appointments.
  • If you are in need of the services of other professionals, I am happy to consult and coordinate with them. Clients should not routinely be meeting with more than one counselor, unless the two counselors have agreed to coordinate your care.


A phone is the most reliable backup option in case of technological failure. It is, therefore, highly recommended that you always have a phone at your disposal and that I know your phone number. If disconnection from a video conference occurs, end the session and I will attempt to restart the session. If reconnection does not occur within five minutes, call me at the contact number I have provided. If, within 5 minutes, I do not hear from you, you agree (unless otherwise requested) that I can call the provided phone number.


I have read this Declaration of Telehealth Policies and Procedures and my signature below indicates my full informed consent to services provided by Douglas Lormand, LPC via teletherapy treatment.

DISCLAIMER: By typing your name below, you are signing this application electronically. You agree that your electronic signature is the legal equivalent of your manual signature on this application.

Colorado Only – Mandatory Disclosure Statement

My name is Douglas Lormand, and I am a Licensed Professional Counselor. My business address is 1958 W. Gray St. Houston, TX 77019. My business phone number is 832-364-4444.

As a mental health professional practicing in Colorado, I am required to give you an explanation of the different types of mental health professionals regulated under Colorado's Mental Health Practice Act; the differences between licensure, registration, and certification; and the educational, experience, and training requirements applicable to the particular level of regulation.

A Registered Psychotherapist is a psychotherapist listed in the State's database and is authorized by law to practice psychotherapy in Colorado, but is not licensed by the state and is not required to satisfy any standardized educational or testing requirements to obtain a registration from the state.

A Licensed Addiction Counselor must pass the Master Addiction Counselor examination or an equivalent examination, meet the requirements for Certified Addiction Specialist, and complete at least 3,000 hours of clinically supervised work in the addiction field with a minimum of 2,000 direct clinical hours.

A Certified Addiction Technician must be a high school graduate or equivalent, accrue a minimum of 1,000 of supervised clinical experience hours over a minimum of six months, which includes hours accrued prior to the application for certification, pass a jurisprudence exam, and pass the National Certification Addiction Counselor Level I examination or an equivalent.

A Certified Addiction Specialist must have a Bachelors degree in a behavioral health concentration, have accrued a minimum of 2,000 hours of supervised clinical work hours over a minimum of twelve months, which may include the hours required for certification as a CAS, pass a jurisprudence exam, and pass the National Certification Addiction Counselor Level II Exam or an equivalent.

A Licensed Social Worker must hold a master's degree from a graduate school of social work and pass an examination in social work.

A Licensed Clinical Social Worker must hold a master's or doctorate degree from a graduate school of social work, practiced as a social worker for at least two years, and pass an examination in social work.

A Psychologist Candidate, a Marriage and Family Therapist Candidate, and a Marriage and Family Therapist Candidate must hold the necessary licensing degree and be in the process of completing the required supervision for licensure.

A Licensed Marriage and Family Therapist must hold a master's or doctoral degree in marriage and family counseling, have at least two years post-master's or one-year post- doctoral practice, and pass an exam in marriage and family therapy.

A Licensed Professional Counselor must hold a master's or doctoral degree in professional counseling, have at least two years post-master's or one-year postdoctoral practice, and pass an exam in professional counseling.

A Licensed Psychologist must hold a doctorate degree in psychology, have one year of post-doctoral supervision and pass an examination in psychology.

I hold the following degrees, credentials, certifications, registrations, and/or licenses:

  • Master of Education in Counseling
  • Master of Science in Human Resource Development
  • Licensed Professional Counselor in Colorado, Texas and Louisiana
  • AASECT Certified Sex Therapist
  • I have obtained the education and training required for this credential, as outlined above.

Regulating Division and Board

The practice of licensed or registered persons in the field of psychotherapy is regulated by the Mental Health Licensing Section of the Division of Professions and Occupations. You can reach the Division, or the board regulating my profession, at 1560 Broadway, Suite 1350, Denver, Colorado 80202, (303) 894-7800.

Right to Be Informed

You are entitled to receive information about the methods of therapy, the techniques used, the duration of therapy, if known, and the fee structure. At any time, you may seek a second opinion from another therapist or may terminate therapy.

Appropriateness of Professional Relationship

In a professional relationship, such as the client/therapist relationship, sexual intimacy is never appropriate and should be reported to the above-mentioned Division or Board.


The information you provide during our therapy sessions is legally confidential. However, there may be certain legal exceptions to this confidentiality, which I will identify should any such situation arise during therapy. You have received our Notice of Privacy Practices, which addresses our confidentiality and record-keeping practices.

DISCLAIMER: By typing your name below, you are signing this application electronically. You agree that your electronic signature is the legal equivalent of your manual signature on this application.

Colorado Only – Surprise/Balance Billing Disclosure Form

Surprise Billing - Know Your Rights

Beginning January 1, 2020, Colorado state law protects you* from "surprise billing", also known as "balance billing". These protections apply when:

You receive covered emergency services, other than ambulance services, from an out-of-network provider in Colorado, and/or

You unintentionally receive covered services from an out-of-network provider at an in-network facility in Colorado

What is surprise/balance billing, and when does it happen?

If you are seen by a health care provider or use services in a facility or agency that is not in your health insurance plan's provider network, sometimes referred to as "out-of- network", you may receive a bill for additional costs associated with that care. Out-of- network health care providers often bill you for the difference between what your insurer decides is the eligible charge and what the out-of-network provider bills as the total charge. This is called "surprise" or "balance" billing.

When you CANNOT be balance-billed:

Emergency Services

If you are receiving emergency services, the most you can be billed for is your plan's in-network cost-sharing amounts, which are copayments, deductibles, and/or coinsurance. You cannot be balance-billed for any other amount. This includes both the emergency facility where you receive emergency services and any providers that see you for emergency care.

Nonemergency Services at an In-Network or Out-of-Network Health Care Provider

The health care provider must tell you if you are at an out-of-network location or at an in-network location that is using out-of-network providers. They must also tell you what types of services that you will be using may be provided by any out-of-network provider.

You have the right to request that in-network providers perform all covered medical services. However, you may have to receive medical services from an out-of-network provider if an in-network provider is not available. In this case, the most you can be billed for covered services is your in-network cost-sharing amount, which are copayments, deductibles, and/or coinsurance. These providers cannot balance bill you for additional costs.

Additional Protections

Your insurer will pay out-of-network providers and facilities directly.

Your insurer must count any amount you pay for emergency services or certain out-of-network services (described above) toward your in-network deductible and out-of-pocket limit.

Your provider, facility, hospital, or agency must refund any amount you overpay within sixty days of being notified.

No one, including a provider, hospital, or insurer can ask you to limit or give up these rights.

If you receive services from an out-of-network provider or facility or agency, you may still be balance billed, or you may be responsible for the entire bill. If you intentionally receive nonemergency services from an out-of-network provider or facility, you may also be balance billed.

If you want to file a complaint against your health care provider, you can submit an online complaint by visiting this website:

If you think you have received a bill for amounts other than your copayments, deductible, and/or coinsurance, please contact the billing department, or the Colorado Division of Insurance at 303-894-7490 or 1-800-930-3745.

*This law does NOT apply to ALL Colorado health plans. It only applies if you have a "CO-DOI" on your health insurance ID card.

Please contact your health insurance plan at the number on your health insurance ID card or the Colorado Division of Insurance with questions.

Your information will be encrypted.