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Informed Consent and Risk Managment


Clinet's Right to Informed Consent

Informed consent:

  • involves the right of clients to be informed about their therapy and to make autonomous decisions pertaining to it
  • a shared decision-making process
  • a powerful clinical, legal, and ethical tool
  • requires that the client understands the information presented, gives consent voluntarily, and is competent to give consent to treatment
  • a process that continues for the duration of the professional relationship as issues and questions arise

Content of Informed Consent

When educating clients about informed consent, the following information should be provided in writing and discussed:

  1. The therapeutic process
  2. Background of therapist
  3. Costs involved in therapy
  4. The length of therapy and termination
  5. Consultation with colleagues
  6. Interruptions in therapy
  7. Clients’ right of access to their files
  8. Rights pertaining to diagnostic labeling
  9. The nature and purpose of confidentiality
  10. Benefits and risks of treatment
  11. Alternatives to traditional therapy
  12. Tape-recording or videotaping sessions
The AMHCA 2010 Code of Ethics: Relevant Codes on Informed Consent

B. Counseling Process

2. Informed Consent

Clients have the right to know and understand what is expected, how the information divulged will be used, and the freedom to choose whether, and with whom, they will enter into a counseling relationship.

a) Mental health counselors provide information that allows clients to make an informed choice when selecting a provider. Such information includes but is not limited to: counselor credentials, issues of confidentiality, the use of tests and inventories, diagnosis, reports, billing, and therapeutic process. Restrictions that limit clients' autonomy are fully explained.

b) Informed Consent includes the mental health counselor's professional disclosure statement and client bill of rights.

c) When a client is a minor or is unable to give informed consent mental health counselors act in the client's best interest. Parents and legal guardians are informed about the confidential nature of the counseling relationship. Mental health counselors embrace the diversity of the family system and the inherent rights and responsibilities parents/guardians have for the welfare of their children. Mental health counselors therefore strive to establish collaborative relationships with parents/guardians to best serve their minor clients.

d) Informed consent is ongoing and needs to be reassessed throughout the counseling relationship.

e) Mental health counselors inform the client of specific limitations, potential risks, and/or potential benefits relevant to the client's anticipated use of on-line counseling services.

The ACA 2014 Code of Ethics: Relevant Codes on Informed Consent

A.2. Informed Consent in the Counseling Relationship

A.2.a. Informed Consent

Clients have the freedom to choose whether to enter into or remain in a counseling relationship and need adequate information about the counseling process and the counselor.

Counselors have an obligation to review in writing and verbally with clients the rights and responsibilities of both counselors and clients. Informed consent is an ongoing part of the counseling process, and counselors appropriately document discussions of informed consent throughout the counseling relationship.

A.2.b. Types of Information

Needed

Counselors explicitly explain to clients the nature of all services provided. They inform clients about issues such as, but not limited to, the following: the purposes, goals, techniques, procedures, limitations, potential risks, and benefits of services; the counselor’s qualifications, credentials, relevant experience, and approach to counseling; continuation of services upon the incapacitation or death of the counselor; the role of technology; and other pertinent information.

Counselors take steps to ensure that clients understand the implications of diagnosis and the intended use of tests and reports. Additionally, counselors inform clients about fees and billing arrangements, including procedures for nonpayment of fees. Clients have the right to confidentiality and to be provided with an explanation of its limits (including how supervisors and/or treatment or interdisciplinary team professionals are involved), to obtain clear information about their records, to participate in the ongoing counseling plans, and to refuse any services or modality changes and to be advised of the consequences of such refusal.

A.2.c. Developmental and Cultural Sensitivity

Counselors communicate information in ways that are both developmentally and culturally appropriate. Counselors use clear and understandable language when discussing issues related to informed consent. When clients have difficulty understanding the language that counselors use, counselors provide necessary services (e.g., arranging for a qualified interpreter or translator) to ensure comprehension by clients. In collaboration with clients, counselors consider cultural implications of informed consent procedures and, where possible, counselors adjust their practices accordingly

Aspirational Ethics Model of An Informed Consent with Clients


Client Informed Consent Form

 

The following are the policies and procedures of my counseling practice:

 

1. My Behaviors to Insure Ethical Counseling with you my client

  1. The Informed consent: This informed consent agreement, which you signed and I witnessed and dated, lasts throughout the life of our work together.
  1. Establish the “Why Now”: You and I will establish the “Why Now” for which you are seeking counseling services and we will do everything to address all the symptoms and issues involved in this “Why Now.”
  2. Clinical History: You and I will spend some time initially to garner as complete a personal history as possible to better understand the dynamics which might explain why you are experiencing your “Why Now” issues.
  3. Treatment Plan: The treatment goals, objectives and interventions which are developed during our work together are consistent with the best practices and counseling models which meet or exceed the standards established in my profession as evidenced based practices. We will strive together to determine your level of motivation to change the ways you think, feel and act concerning your “why now issues” as we proceed with our mutually agreed upon treatment plan. At the point of intake, the number of sessions to address your “why now issues” is set which complies both with your own level of motivation and the allowances of your third party payor.
  4. Counseling Sessions: We will schedule sessions initially on a weekly basis. We will move to less frequent sessions once intensity of symptoms have lessened and you feel self-empowered to face them independently. If you need to cancel an appointment you need to do so at least 24 hours in advance or you will be expected to pay for any missed appointments.
  5. Homework: The work we do together entails your participating in the counseling process outside of our sessions by doing homework assigned to you. If you consistently do not do your homework, it will be a clear indication that the progress desired in our counseling sessions is threatened and this might require us to terminate our counseling services.
  6. Termination of services: Our goal is to address your “Why Now” issues as thoroughly as possible in as short a time as possible. After such time that you and I agree that you are sufficiently educated and ready to move on your own, we will terminate our active working together. This is done with the full understanding that you are a client of mine for life. So if in the future any new issues arise for which you would desire counseling services you would feel free to reconnect with me so as to address them. If I find that I am not able to assist with your “why now issues” due to your reticence to change, I will cease providing counseling at that time until you are ready to change. I may also refer you to another therapist with whom you might feel more compatibility, in addressing these issues.

 

2. My Values in the Counseling Relationship

  1. I strive to be clear about my values with you throughout the counseling process so that you have a clear understanding of my approach in working with you.
  2. All people regardless of their spiritual beliefs and practices or those who have no spiritual affiliation at all are welcome and can expect their values and beliefs to be respected when they are working with me.
  3. I have a religious affiliation but my clinical practice functions independently of my religious practices and beliefs.

Basic Moral Principles which guide my decision making with you as a client are:

  1. Autonomy: to promote self-determination
  2. Beneficence: to do good for others and promote the well-being of clients
  3. Non-maleficence: to avoid doing harm
  4. Justice: to be fair by working equally hard with each client through equal effort of time and counsel
  5. Fidelity: to make realistic commitments and keep promises
  6. Veracity: to be truthful and deal honestly with clients

 

3. Dealing with Clients with Multicultural or Diversity Perspectives

  1. I strive to make my setting a safe haven for all, so that gender, creed, race, ethnicity, sexual orientation, disability, socioeconomic status etc. are not barriers in getting services with me.
  2. I strive to the best of my abilities to be sensitive to the cultural issues and values which you bring to the counseling setting.
  3. I believe that the best way to learn about your own cultural perspective is by you feeling free to inform me so that I can be better focused on your needs with in your personal cultural perspective.

 

4. Guaranteeing Clients’ Rights

Insurance companies require that I submit documentation to them for reimbursement for services. You are required to sign an authorization for me to submit such information with the understanding that:

  1. I maintain our office totally in compliance with HIPAA policies and procedures
  2. I provide all my clients with the HIPAA Privacy Statement for their signature
  3. I work hard for my clients and I to show you utmost respect in all aspects of our work together while here in the office and when on the phone with you
  4. You have the right to terminate counseling at any time as long as you come into the session and explain your rationale and your understanding of the consequences of this decision
  5. I keep brief records of our work together in counseling and at any time you have a right to review or get a copy of these records by just requesting them of me

 

5.  Insuring Client Confidentiality

My goal is to provide complete confidentiality of the work you and I do together and you can rest assured that I will never breach confidentiality unless I have the duty to inform.

Here are specific reasons why I have the “duty to warn” which requires me to breach confidentiality:

  1. When you have signed a written consent to release such information
  2. When you talk of harming self or others
  3. When you talk of participating in or committing child or elder/disabled  abuse
  4. When you talk about plans to commit a crime
  5. If you have revealed that you or someone else you know has been or is a victim or a perpetrator of sexual abuse
  6. When I am court ordered to release information on you to the courts

Note to Members of Groups: If you participate in group therapy you must realize that there is limited confidentiality of what is said or done in group since it depends on all group members committing to maintain this confidentiality and awe cannot insure that this will always be the case

Note for Marriage and Family Clients: Once you are seen as a couple or family I do not see individual members outside of such sessions

 

6. Maintaining Healthy Boundaries with Clients

  1. Once you become my client, I consider you a client of mine for life so that at any time in the future if you were to contact me I would immediately assume you are calling me as a client and respond to you in that manner.
  2. I respect my clients a great deal and yes we spend a great deal of time together but I cannot be of help to you if our relationship evolves into a friendship which will not allow for me to be as objective as I need to be in working with you
  3. Where different cultures may include gestures of touch such as hugs and embraces to connect with one another. In my counseling practice I do not use these forms of physical contact.

 

7. Maintaining Professional Counseling Competence

  1. I am committed to working hard to keep up with the latest research available in the field to insure that my work with you complies with the most recent empirically validated strategies and procedures which are known as evidenced based practices
  2. I maintain consultation with seasoned professional mentors to provide ongoing support, supervision and consultation to insure I am on target with my clients
  3. I participate in continuing education programs so as to stay current with the latest findings on evidenced based practices in the field
  4. I will for the life of my clinical practice maintain my membership in professional organizations whose codes of ethics I follow in my professional counseling practice. They are: American Mental Health Counselors Association Code of Ethics (AMHCA, 2010); American Counseling Association Code of Ethics (ACA, 2014) and National Board for Certified Counselors Code of Ethics (NBCC, 2013).

 

______________________                       ___________________

Signature of Client                                      Date

 

______________________                       ____________________

Signature of Client                                      Date

 


References on Informed Consent

Croackin, P., Berg, J. & Spira, J. (2003). Informed consent for psychotherapy: A look at therapists’ understanding, opinions and practices. Amercian Journal of Psychotherapy, 57(3), 384-400.

 

Fisher, C.B. & Oransky, M. (2008). Informed consent to psychotherapy: Protecting the dignity and respecting the autonomy of patients. Journal of Clinical Psychology, 64(5), 576-588. DOI: 10.1002/jclp.20472.

 

Goddard, A., Murray, C.D. & Simpson, J. (2008). Informed consent and psychotherapy: An interpretative phenomenological analysis of therapists’ views. Psychology & Psychotherapy: Theory, Research & Practice, 81(2), 177-191. DOI: 10.1348/147608307X266587.

 

Haslam, D.R. & Harris, S.M. (2004). Informed consent documents of marriage and family therapists in private practice: A qualitative analysis. The American Journal of Family Therapy, 32(4), 359-374.  DOI: 10.1080/01926180490455231.

 

Hudgins, C., Rose, S., Fifield, P.Y. & Arnault, S. (2013). Navigating the legal and ethical foundations of informed consent and confidentiality in integrated primary care. Families, Systems & Health: The Journal of Collaborative Family HealthCare, 31(1), 9-19.  DOI: 10.1037/a0031974.

 

Jensen, P.S., Josephson, A.M. & Frey III, J. (1989). Informed consent as a framework for treatment: Ethical and therapeutic considerations. American Journal of Psychotherapy, 43(3), 378-386.

 

McGuire, J.M., Graves, S. & Blau, B. (1985). Depth of self-disclosure as a function of assured confidentiality and videotape recording. Journal of Counseling & Development, 64(4), 259-263.

 

Meisel, A. (1983). Making mental health care decisions: Informed consent and involuntary civil commitment. Behavioral Sciences & the Law, 1(4), 73-88.

 

Pomerantz, A.M. & Handelsman, M.M. (2004). Informed consent revisited: An updated written question format. Professional Psychology: Research & Practice, 35(2), 201-205.  DOI: 10.1037/0735-7028.35.2.201.

 

Pomerantz, A.M. (2005). Increasingly informed consent: Discussing distinct aspects of psychotherapy at different points in time. Ethics & Behavior, 15(4), 351-360.

 

Recupero, P.R. & Rainey, S.E. (2005). Informed consent to e-therapy. American Journal of Psychotherapy, 59(4), 319-331.

 

Varnhagen, C.K., Gushta, M., Daniels, J., Peters, T.C., Parmar, N., Law, D., Hirsch, R., Takach, B.S. & Johnson, T. (2005). How informed is online informed consent? Ethics & Behavior, 15(1), 37-48. DOI: 10.1207/s15327019eb1501_3.



Risk Managment
What is risk managment for a clinical mental health counselor? It is conscientious committment to assess oneself on at least an annual basis as to how well, the counselor is working under our recommended "Aspirational Ethical Model" of Clinical Mental Health Counselor Practice. We recommend Aspirational rather than the Mandatory Ethical Model, because it in sures a more conservative approach to clinical practice and hopefully it assists the counselors to avoid ever having a claim pressed against them.

What needs to be included in Client's Records?
Client Records Must Include:
  • Identifying data
  • Fees and billing information
  • Documentation of informed consent
  • Documentation of waivers of confidentiality
  • Presenting complaint and diagnosis
  • Plan for services
  • Client reactions to professional interventions
  • Current risk factors pertaining to danger to self or others
  • Plans for future interventions
  • Assessment or summary information
  • Consultations with or referrals to other professionals
  • Relevant cultural and sociopolitical factors

Malpractice Claims -  What's Involved?

To succeed in a malpractice claim, these four elements must be present:

  1. a professional relationship between the therapist and the client must have existed
  2. the therapist must have acted in a negligent or improper manner, or have deviated from the “standard of care” by not providing services that are considered “standard practice in the community”
  3. the client must have suffered harm or injury, which must be verified
  4. there must be a legally demonstrated causal relationship between the practitioner’s negligence or breach of duty and the damage or injury claimed by the client 

Typical Reasons for Malpractice Suits
  1. Failure to obtain or document informed consent
  2. Client abandonment or premature termination
  3. Marked departures from established therapeutic practices
  4. Practicing beyond the scope of competency
  5. Misdiagnosis
  6. Mismanagement of a crisis intervention situation

In a recent report 2014 called " Understanding Counselor Liability Risk" from Healthcare Providers Service Organization (HPSO) and CNA pointed ouit that between January 1, 2003 and December 31, 2012 over that ten year period:
  • 50.8% of counselors experieincing liability claims worked in an office based setting
  • 66.7% of professional liability claims involved face to face counseling of an individual client
  • 92.1% of the claims involved adult clients and 7.9% involved children clients through age 17
  • The identified reasons for seeking services by clients for whom claims were brought were: 31.7% marital discord; 9.4% family discord; 7.9% depression; 7.9% alcohol abuse/addiction
  • The MOST FREQUENT of the allegations was 39,7% for inappropriate sexual/romantic relationship with the client; a client's spouse/partner or famlly member 
  • 10.1% of license protection closed claims were for counselors who acted outside their state-defined scope of practice

Read the Documents provided by the HPSO
2014 Understanding Counselor Liability: Click here to download document

2013 Qualitative Counselor Work Profile Survey: Click here to download document

2014 HPSO's Counselor Risk Control Self-Assessment Checklist: Click here to download document

Aspirational Ethical Clinical Mental Health Counselor’s Self-Assessment


Working within my Current Professional Competencies as a CMHC

_____Yes _____No (1) I have a clear understanding of my competencies and recognize the knowledge, skills and abilities which are needed to help each of the people whom I have accepted as my clinical clients.

_____Yes _____ No (2) I understand and can describe the full range of risks involved in working with clients for whom I am fully competent to treat for their mental health needs

_____Yes _____No (3) I recognize the risk of working with a client whose needs exceed my current level of clinical competence.

_____Yes _____No (4) I will not even contact a referral, who is assigned to me, until I have a better understanding of what this person’s needs are so that I can determine if I am fully competent to provide appropriate services to this client, given that once I contact this referred person from that point on the person is considered a “client” of mine even if I end up not working with this person. I prefer to assess my limitations in working with such a person prior to my contacting the person.

_____Yes _____No (5) I only provide services which are consistent with my State License, level of education, and specialized training and/or certifications.

_____Yes _____No (6) I make it a point to obtain continuing education and training to update and upgrade my current competencies as a CMHC and to increase my competencies to work with populations for whom I have not had prior training.

_____Yes _____No (7) I make it a point to seek out a complete orientation and copy of the policies and procedures manuals of any agency or organization in which I am involved with to provide clinical services.

 

Maintaining my Professional Competencies

_____Yes _____No (1) I am faithful in obtaining the Continuing Education Credits required by the State Licensing Board for my Professional Licensure Renewal by attending continuing education and/training sessions..

_____Yes _____No (2) I make it a point to stay current in the latest research into Evidenced Based Treatment Practices for treating clients in my clinical specialty.

_____Yes _____No (3) I consistently seek out consultation and/or collaboration with fellow CMHC’s, my supervisors, or other Mental Health Professionals so that I can insure that I offer my clients as optimal mental health therapeutic care as possible.

_____Yes _____No (4) I voluntarily participate in at least a monthly support session with fellow mental health professionals ,either in my agency or in the private practice community, in which we review cases with one another so as to insure we are maintaining our clinical and ethical competence.

 

Working within the Scope of Practice for CMHC’s

_____Yes _____No (1) I review on an annual basis the state’s understanding of the scope of practice of CMHC’s in my state so that I both understand and comply with the legal scope of practice of my profession in my state.

_____Yes _____No (2) I decline to work with clients if the services they need are outside of my legal scope of practice.

_____Yes _____No (3) I am licensed and/or certified in each state in which I provide cyber /distance counseling, and I am fully knowledgeable about each state’s scope of practice regulations when providing this service.

_____Yes _____No (4) Prior to working with a client, go over in person with the client a thorough “Informed Consent” form which we openly discuss and clarify before we both sign and date it and put in the client’s clinical file.

_____Yes _____No (5) If the client is uninsured or unable to afford necessary counseling services, I refer the client to get financial assistance or if this is not possible then I provide the services pro bono.

 

Assessment

For every client I work with, I complete and document in the client’s file, a thorough Clinical Assessment which involves:

_____Yes _____No (1) Establish the Why Now: which fully clarifies the client’s rationale for seeking out mental health services so as to best address the symptoms and issues involved in the “why now” issues.

_____Yes _____No (2) Review of Client’s Mental Health History: which identifies previous treatment for mental health problems, if had prior psychiatric hospitalizations, was involved in family therapy as a child or received previous treatments for substance abuse issues

_____Yes _____No (3) Determine if Client is on any psychotropic medications: which helps identify which medications are currently being prescribed, by whom, at what level of prescription and for what issues the medications are prescribed.

_____Yes _____No (4) Review Client’s relevant medical history: which reveals current overall physical health of the client, when the client last had a physical and if there is any comorbidity of physical health problems and the current mental health issues.

_____Yes _____No (5) Review of Client’s family history: to determine what are the psychosocial stressors within the family which could account for the current mental health distress and what is the history in the family of previous mental health and/or substance abuse treatment.

_____Yes _____No (6) Review of Client’s social history: including school history as to academic success and/or failure and highest academic level achieved, as well as community history in terms of level of social networks, peer group activities and other measures of social functioning

_____Yes _____No (7) Review of Client’s vocational history: including current level of employment, prior employment history and level of satisfaction with current employment

_____Yes _____No (8) Review of Client’s strengths brought into therapy

_____Yes _____No (9) Review of Client’s liabilities brought into therapy

_____Yes _____No (10) Rating of the Client on the Adverse Childhood Experience Scale

 

Diagnosis and Treatment Planning

After completing a thorough Initial Clinical Assessment I then am ready to delineate the diagnosis which is most appropriate for each client I assess. This includes:

_____Yes _____No (1) Using evidence-based objective clinical standards of care to determine diagnosis which address the client’s current expressed concerns

_____Yes _____No (2) Utilizing all existing past records in the Client’s file including previous clinical assessments, psychosocial histories, psychological testing and records from previous psychotherapeutic interventions

_____Yes _____No (3) Utilize and document current assessment measures which quantify the client’s emotional state and concerns

_____Yes _____No (4) Utilize consultation with previous or current medical and/or psychiatric providers to help clarify and identify relevant diagnostic factors to better serve the client

_____Yes _____No (5) Documenting the client’s diagnosis within the Initial Clinical Assessment Document

Tentative Diagnosis

After completing the Tentative Diagnosis of the client, I then develop a tentative treatment plan based on established evidenced based treatments specific to the client’s diagnosed needs which includes:

_____Yes _____No (6) A minimum of three long term goals to help the client achieve reduction of the “why now” symptoms which were the reasons for the request for mental health services

_____Yes _____No (7) For each long term goal, I identify three short term objectives which are measurable and verifiable

_____Yes _____No (8) For each of the short term objectives, I identify an intervention to be used with the client to reach each of the short term objectives so that the long terms goals are achieved through our mutual clinical interaction

Review with Client

Once the Clinical Assessment, Tentative Diagnosis and Treatment Plan is completed I then:

_____Yes _____No (9) Review the findings, assessment results, and proposed treatment plan which includes reasonable expectations for a desired outcome with the client and secure the client’s understanding of this care plan and how we each have responsible roles to plan to effect a successful treatment outcome. This dialogue is then documented and kept in the client’s clinical file.

_____Yes _____No (10) In the dialogue concerning the treatment plan, I counsel the client about the risks of not complying with the treatment plan. I point out if noncompliance with the treatment plan is potentially affecting the client’s safety and the current counseling has been ineffective, then it would be incumbent on me to consider discharging the client from my clinical practice.

 

Insuring Quality Client Treatment and Care

_____Yes _____No (1) I conscientiously follow the course of treatment outlined for the clients and get their ongoing feedback as to their assessment if the treatment goals, objectives and interventions are working well or not for them and document this ongoing client observation as we proceed through our treatment regimen

_____Yes _____No (2) I facilitate emergency medical and or mental health treatment in the event of an emergency or crisis

_____Yes _____No (3) I remind clients of regular appointments and document these reminders

_____Yes _____No (4) I contact clients after missed appointments for rescheduling and document these contacts

_____Yes _____No (5) I explain to clients that if they are noncompliant to the point of self-endangerment or creating a liability risk, I may be forced to withdraw my care. I document this interaction.

_____Yes _____No (6) I counsel noncompliant clients about the risks and possible consequences of such behaviors

_____Yes _____No (7) I terminate from treatment persistently noncompliant clients, and I assist in transitioning them to another healthcare provider, and document actions taken and support provided

_____Yes _____No (8) All my formal clinical records and notes are electronically recorded, duplicated and saved in at least two safe repositories.

 

Maintaining an Ethical Relationship and Healthy Boundaries with Clients

_____Yes _____No (1) From the first moment I speak with a prospective client either in person or by phone, that person is a “client” to me from that point on.

_____Yes _____No (2) From the moment a person becomes a “client” with me I consider that person as a “client” for life, even if that person has been referred out to another professional or has successfully completed the therapy for the original issues for which our counseling relationship was initiated. I am committed to the belief of “Once a Client always a Client.”

_____Yes _____No (3) I hold to the belief of “Never Hug a Client” and I also practice “Tissue Therapy” with boxes of tissues available to allow clients to feel free to expose their emotions in my office as a “safe setting” with no fear of being put in a  compromising position with me when they are feeling extremely vulnerable..

_____Yes _____No (4) I make it a point to never allow myself to give any conscious thought to being attracted to a client and make every effort to never act upon such attitudes or feelings.

_____Yes _____No (5) I would never allow myself to engage in a sexual relationship with a client (or a client’s family member) while in active counseling or after our counseling process has been terminated-in others words: I will never have any sexual or romantic relationship with anyone who has entered my professional life that was considered a “client” of mine.

_____Yes _____No (6) If clients find that they cannot afford to pay me for their clinical services, even after I have made adjustments for these fees, then I am committed to serve such clients “pro bono” with no expectation of being compensated in the future for the actual fees that would have been incurred.

_____Yes _____No (7) If clients find that they cannot afford to pay me for their clinical services, even after I have made adjustments for these fees, I would never barter for my services and rather provide the services “pro bono.”

_____Yes _____No (8) I never solicit gifts from clients but if a client gives me a gift unsolicited, I only accept the gift, which must not be worth more than $25, so as to be culturally sensitive to my clients’ offering such gifts because it is a culturally expected and accepted practice for these clients.

 

Remedial Actions I must take:

Given my responses on the above questions, for all of the “no” answers I gave I will commit to doing the following remedial actions so that within one year I will be able to answer all the above questions with a “yes” since I desire to follow a consistent Aspirational Ethical style of clinical practice in my professional life.