169o

Any individual, or employer or such an individual, who is licensed under this chapter may not charge a client or receive remuneration for professional services unless, before the performance of those services, the client is furnished a copy of a Professional Disclosure Statement. The Professional Disclosure Statement shall be displayed in a conspicuous location at the place where the services are performed and a copy of the statement shall be provided to the client on request. The Professional Disclosure Statement shall contain:\n(1) the name, title, business address, and business telephone number of the psychology professional licensed performing the services;\n(2) the formal professional education of the licensed person including the institutions attended and the degrees received;\n(3) the professional person's theoretical orientation, areas of specialization, and the services provided;\n(4) in the case of a person licensed under this chapter, a person who is engaged in a private individual practice, partnership, or group practice, the person's fee schedule listed by type of service or hourly rate;\n(5) the following words shall appear at the bottom of the first page of the

e individual practice, partnership, or group practice, the person's fee schedule listed by type of service or hourly rate;\n(5) the following words shall appear at the bottom of the first page of the disclosure statement 'This information is required by the Board of Psychology Examiners which regulates all licensed psychologists, associate psychologists, and psychological associates;\n(6) the name, address, and telephone numbers of the board shall appear immediately beneath the statement required by item (5) of this subsection; and\n(7) in the case of a licensed psychological associate, the name, title, business address, and business telephone number of the supervisor shall also appear on the Professional Disclosure Statement.