This document is designed to inform you about my background and to insure that you understand our professional relationship.
Counseling and Psychotherapy
A counseling relationship between a counselor and client is a professional relationship in which the counselor assists the client in exploring and resolving difficult life issues. I believe that as people gain a greater understanding and become more accepting of themselves, they are more capable of finding happiness and contentment in their lives. Self-awareness and self-acceptance are goals that sometimes take a long time to achieve. I encourage you as my client to share your concerns, curiosities, and input regarding our sessions and their projected course. It is not only your right, but my desire that you have a complete understanding of the ways and means of our sessions together, as well as agreed upon goals.
Therapist Background and Licensure
I have a Master’s of Education in Clinical Counseling from Vanderbilt University. I have worked in multiple settings as a therapist in the Portland area. I am a Licensed Professional Counselor with the State of Oregon (C3578) and a Certified Alcohol and Drug Counselor with The Addiction Counselor Certification Board of Oregon (12-12-46).
Risks and Benefits of treatment
The counseling and change process in general can involve new perspectives, emotional experiences and changes in behaviors, and even though the intent is client growth, the process itself can be challenging. An option for no treatment can be an alternative to counseling and might bring with it risks by doing nothing to address or accelerate an opportunity to change.
Alternatives to treatment
These might include a medical evaluation, counseling from a different theoretical perspective, talking with trusted family and friends, participating in self-help groups, utilizing body based therapies, exercise and nutrition.
Competence and Lack of Coercion
All clients included in the therapy dynamic have a right to clearly understand informed consent, and be competent to make a decision free from undue coercion to agree to therapy.
Right to Refuse or Discontinue
Any client has a right to refuse or discontinue treatment at anytime without penalty. If needed a referral will be provided.
Confidentiality and Limits to Confidentiality
These following conditions are defined by Oregon Law:
Reporting suspected child abuse
Reporting Elder abuse
Reporting imminent danger to self or others
Reporting information required in court proceedings
As requested by client’s insurance company
Providing general information for therapist case consultation or supervision
Defending claims brought by client against therapist
Privacy of Client information
All client counseling records and notes have coded identification and are kept in hard copy only in a locked file cabinet in my locked residence or the counselor’s office. Client information is minimally represented on a personally owned business computer, which sometimes contains e-mails between client/counselor. No client information is sent electronically to insurance companies for the purposes of insurance billing. Written client permission is necessary for electronic transmission, which includes a release of information. As my client, you are within your rights to request, and be given, access to these records.
If therapy progresses to areas that fall outside the my area of expertise which cannot be fulfilled through consultation or supervision I will discuss with you the need for a possible referral to a clinician who specializes in that area.
Office Hours & Contact Information
I am able to offer appointments in person and via telephone or Internet videoconference. Please phone 503-984-7620, leave a message and I will return your call as quickly as possible, or email me at firstname.lastname@example.org
I am available to return calls Monday through Friday 8:00 a.m. to 6:00 p.m. related to needs like rescheduling, cancellations, questions or general information and if you leave a message I will return your call as quickly as possible. If you have an emergency outside my office hours or I can’t be immediately reached, please call Multnomah County Triage Center/Crisis Line - 503-988-4888, your local emergency room or call 911.
I will make every attempt to return emails within 24 hours Monday-Friday. You can email me in reference to scheduling appointments, insurance and general information. However my email is NOT confidential or encrypted, please communicate confidential information in person.
Fee Structure and Payment
In return for a fee of $110 per session I agree to provide counseling services for you. This fee can be adjusted on a sliding scale depending upon an individual’s finances. I trust the client’s discretion regarding the fee that best suits their situation. Sessions are 50 minutes in duration. It is impossible to guarantee any specific results regarding your counseling goals, however, I assure you that my services will be rendered in a professional manner consistent with accepted ethical standards.
The fee for each session will be due and must be paid each session. Cash, personal checks or credit cards are acceptable forms for payment. If requested, I will provide you with a monthly receipt for all fees paid.
In the event you will not be able to keep an appointment, you must notify me 24 hours in advance. If I do not receive such advance notice, you will be responsible for paying for the session you missed.
I am currently credentialed with several insurance companies and this information can be found on the services and fees page. Before making an appointment please contact your insurance company to determine if you require a referral to a therapist and also what your co-pay is if you have one.
Most health insurance companies that do reimburse usually require that a standard amount be paid by you before reimbursement is allowed and usually only a percentage of my fee is reimbursable. You should contact a company representative to determine whether your insurance company will reimburse you and the schedule of reimbursement that is used.
Health insurance companies usually require that I diagnose your mental condition and indicate that you have an illness before they will agree to reimburse you. In the event a diagnosis is required, I will consult with you regarding the diagnosis I plan to render before I submit it to the health insurance company.
I follow the ethical guidelines set out by Oregon State licensing board, the American Counselors Association and National Board of Certified Counselors.
As a client of an Oregon licensee you have the following rights:
To expect that a licensee has met the minimal qualifications of training and experience required by state law:
To examine public records maintained by the Board and to have the Board confirm credentials of a licensee;
To obtain a copy of the Code of Ethics;
To report complaints to the Board;
To be informed of the cost of professional services before receiving the services;
To be assured of privacy and confidentiality while receiving services as defined by rule and law, including the following exceptions: 1) Reporting suspected child abuse; 2) Reporting imminent danger to client or others; 3) Reporting information required in court proceedings or by client’s insurance company, or other relevant agencies; 4) Providing information concerning licensee case consultation or supervision; and 5) Defending claims brought by client against licensee;
To be free from discrimination because of age, color, culture, disability, ethnicity, national origin, gender, race, religion, sexual orientation, marital status, or socioeconomic status.
Disputes and Complaints
If possible, please bring concerns to my attention for discussion and resolution before taking further action. If you have any concerns or questions regarding this contract, my services, licensure status, or state regulations regarding professional counseling service in the state of Oregon, please contact the State of Oregon Board of Licensed Professional Counselors and Therapists at:
3218 Pringle Rd. SE, Suite 250 Salem, OR 97302-6312