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Terms and Policy

Informed Consent (rev. June 2019)

Informed Consent


I hold a Master of Arts Degree in Counseling from George Fox University.  I also hold a Bachelor of Arts Degree in Philosophy from George Fox University.  I am registered with the State of Oregon as a licensed professional counselor.  I seek to understand experience from a systemic perspective, recognizing the power of family and community to affect individuals. 


The goal of counseling is to improve.  We will work together to understand what improvements you would like to make.  My job is to help you make sense of your experience in a way that leads to a better and happier life.  We will work together to identify goals for our sessions and evaluate what steps can be taken to reach those goals.  At times I may encourage you to try new ways of interacting with your circumstances.  We may discuss topics such as family, relationships, career, drug and alcohol use, sexuality, communication, spirituality, or anything else that is important to you. 


Appointments can be made by calling 503-489-9817 Monday through Friday between the hours of 9:00 A.M. and 5:00 P.M.  If you must cancel or reschedule please contact me at least 24 hours in advance.  With limited exceptions, there is a $50 charge fee for a missed session if sufficient notice has not been provided. 

Length and Number of Sessions

The first session usually lasts 60 minutes, the following sessions last 50 minutes.  Generally we will meet once per week.  In some cases we may decide to meet more or less frequently than once per week.  We will decide together the number of sessions that would be beneficial.  The number of sessions varies, and depends on many factors which will be discussed in our meetings. 

Religious and Cultural Issues

I seek to treat religious, cultural and gender issues with sensitivity and respect, acknowledging that these factors significantly impact our sense of who we are.


The relationship between client and counselor is meant to be professional and therapeutic.  Personal and/or business relationships can compromise the effectiveness of the therapeutic relationship.  Accordingly, these types of relationships are avoided.  I am not in a position to engage in a social or personal relationship with you.  Gifts, bartering, and trading services are not appropriate within the therapeutic relationship.  Should we unexpectedly see one another in public I will not acknowledge you out of respect for your privacy. If you wish to say hello to me I will certainly say hello to you as well.   

Social Media Policy

I do not accept friend or contact requests from current or former clients on any networking site (Facebook, LinkedIn, Instagram, Twitter etc).  I believe that adding clients as friends or contacts on these sites can compromise your confidentiality and our respective privacy. It may also blur the boundaries of our therapeutic relationship. 

Goals, Purposes, and Techniques of Counseling

Counseling is one of a variety of different options for growth and wellness.  We will work together to find the option that best suits your needs.  Another counseling center or format may be beneficial, if so I will provide you with resources.  In some cases medical treatment may be suitable.  As counseling progresses we will decide together the best way of accomplishing the goals we set.   


The fee for 50 minutes of counseling is $120.  The fee for our initial appointment is $150.  If you are unable to afford the full fee I will try to help you find a suitable alternative counseling option.  There are a limited number of reduced fee sessions that may be available if you are unable to afford the full fee.  Payment is due by cash, check, or major credit card at the end of each session.  I am an in network provider with Regence Blue Cross Blue Shield, Pacific Source, First Choice Health Network, Moda, Optum (Providence, United Behavioral Health) and Kaiser. 

Confidentiality and Duty to Warn

Discussion between a counselor and a client is confidential.  I will not release your information without your consent unless mandated by law.  There are some circumstances in which I must disclose confidential information.  Possible circumstances include but are not limited to the following situations: child abuse; abuse of the elderly or disabled; reporting imminent danger to client or others; reporting information required in court proceedings or by client's insurance company, or other relevant agencies; providing information concerning licensee case consultation or supervision; and defending claims brought by you against me.  Even if you are an adult, should you disclose abuse suffered as a child, I am required to make a report to the authorities to ensure the safety of other vulnerable individuals. 

Contact Information

In the event I must contact you for purposes such as appointment cancellations or reminders, or to give/receive other information, efforts are made to preserve confidentiality. We will discuss during our initial session how you would like phone calls, emails and other communication to be handled. 

Risks of Counseling

The content and process of counseling can be sensitive.  It is possible that symptoms may not improve, or become worse.  It is possible that at times during the counseling process you will feel anxiety, anger, depression, or experience relationship difficulties.  These experiences may be part of the change and growth process.  You may begin to view relationships in new and challenging ways.          

After-Hours Emergencies

If you are experiencing a mental health emergency please call the Multnomah County mental health crisis number at (503) 988-4888 or the Clackamas County mental health crisis number 503-655-8585.  They have trained professionals available to assist you 24 hours per day, seven days per week.  You may also call 911 if you are experiencing an emergency.    

Counselor's Death/Incapacity

In the event that I die or am incapacitated, my colleague, Alan Wheatley LPC, would take possession of your file and records.  He can be reached at 971-231-4611 or by email at He would assist you in finding suitable counseling options.   

Consent to Treatment

By signing below you are indicating the following:

         You have received a copy of the Privacy Policy, Professional Disclosure Statement and Informed Consent document. 

         You agree to receive counseling assessment, care, treatment, or services and authorize me to provide such care, treatment and services as are considered necessary and advisable. 

         You understand and agree that you will participate in the planning of your care, treatment, or services and that you may stop such care, treatment, or services at any time. 

         You have read and understood all the terms and information contained herein and have been provided the opportunity to ask questions and gain clarification.

         You agree to pay the fees described above. 

( Type Full Name )
Professional Disclosure Statement (Rev June 2019)
Professional Disclosure Statement

Philosophy and Approach: My top priority is listening well and doing everything I can to understand and respond compassionately and intelligently to whatever people want to discuss.  I believe that growth occurs not because of specific techniques but through the trust and openness developed in the counseling relationship.  I believe that all people should be treated with respect and compassion.  As much as I can, I try to be myself and be genuine during our meetings.  Humor and laughter are welcome.  Sharing personal issues and trusting another is a risky endeavor and I respect the courage it takes to be yourself.

Formal Education and Training: I hold a Master of Arts Degree in Counseling and a Bachelor of Arts Degree in Philosophy, both from George Fox University.  Some of my coursework included: Human Growth and Development, Group Theory and Therapy, Spirituality and Clinical Praxis, Human Sexuality, and Lifestyle and Career Development.  As a Licensee of the Oregon Board of Licensed Professional Counselors and Therapists, I abide by its Code of Ethics. To maintain my license I am required to participate in continuing education, taking classes dealing with subjects relevant to this profession.

Fees:  The fee for counseling is $150 for a 60 minute initial session and $120 for standard 50 minute sessions.  If there is a financial hardship, please communicate this to me and we can discuss alternative payment options. All fees will be payable at the end of each session via check, cash or major credit card.  I must receive cancellation notification 24 hours before your scheduled appointment.  If you do not cancel an appointment by this time and yet are unable to make it, you will be billed $50. If you do not show for an appointment and you have not called to cancel prior to the session, you will be billed $50. If your payment by check is returned due to non-sufficient funds, you will be charged for any NSF and bank penalty fees. A prorated hourly fee will be charged for phone calls made by the counselor at the client's request. I am an in network provider with Regence Blue Cross Blue Shield, Pacific Source, First Choice Health Network, Moda, Optum (Providence, United Behavioral Health) and Kaiser.  

As a client of an Oregon licensee [or Registered Intern] 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 being the object of discrimination on the basis of race, religion, gender, or other unlawful category while receiving services.

Board of Counselors and Therapists

3218 Pringle Rd SE #120, 

Salem, OR 97302-6312

(503) 378-5499

Email: Website:

( Type Full Name )

The Health Insurance Portability and Accountability Act Privacy Rule is a law intended to assure that individuals’ health information is properly protected while allowing the flow of health information needed to provide and promote high quality health care and to protect the public's health and well-being. I am required by law to maintain the privacy of your protected health information (PHI). I am required to abide by the terms of this notice with respect to your PHI.

State and federal laws require that I keep your medical records private. Such laws require that I provide you with this notice informing you of my privacy of information policies, your rights, and my duties. I am re-quired to abide by these policies until replaced or revised. I have the right to revise my privacy policies for all medical records, including records kept before policy changes were made. Any changes in this notice will be made available upon request before changes take place.

The contents of material disclosed to me in an evaluation, intake, or counseling session are covered by the law as private information. I respect the privacy of the information you provide me, and I abide by ethical and legal requirements of confidentiality and privacy of records.

Information about you may be used for diagnosis, treatment planning, treatment, and continuity of care. I may disclose it to health care providers who provide you with treatment, such as doctors, nurses, mental health professionals, and mental health students and mental health professionals or business associates affiliated with this clinic, such as billing, quality enhancement, training, audits, and accreditation.

Both verbal information and written records about a client cannot be shared with another party without the written consent of the client or the client’s legal guardian or personal representative. It is my policy to not release any information about a client without a signed release of information except in certain emergency situations or exceptions in which client information can be disclosed to others without written consent. Some of these situations are noted below, and there may be other provisions provided by legal requirements.

When a client discloses intentions or a plan to harm another person or persons, the health care professional is required to warn the intended victim and report this information to legal authorities. In cases in which the client discloses or implies a plan for suicide, the health care professional is required to notify legal authorities and make reasonable attempts to notify the family of the client.

Health records may be released for the public interest and safety for public health activities, judicial and ad-ministrative proceedings, law enforcement purposes, serious threats to public safety, essential government functions, military, and when complying with worker’s compensation laws.

If a client states or suggests that he or she is abusing a child or vulnerable adult, or has recently abused a child or vulnerable adult, or a child (or vulnerable adult) is in danger of abuse, the health care professional is re-quired to report this information to the appropriate social service and/or legal authorities. If a client is the victim of abuse, neglect, violence, or a crime victim, and his or her safety appears to be at risk, I may share this information with law enforcement officials to protect the client.

Health care professionals may be required to report admitted prenatal exposure to controlled substances that are potentially harmful.

In the event of a client’s death, the spouse or parents of a deceased client have a right to access their child’s or spouse’s records.

Professional misconduct by a health care professional must be reported by other health care professionals. In cases in which a professional or legal disciplinary meeting is being held regarding the health care profession-al’s actions, related records may be released in order to substantiate disciplinary concerns.

Health care professionals are required to release records of clients when a court order has been issued.

Parents or legal guardians of non-emancipated minor clients have the right to access the client’s records.

When payment for services are the responsibility of the client, or a person who has agreed to providing pay-ment, and payment has not been made in a timely manner, collection agencies may be utilized in collecting unpaid debts. The specific content of the services (e.g., diagnosis, treatment plan, progress notes, testing) is not disclosed. If a debt remains unpaid, it may be reported to credit agencies, and the client’s credit report may state the amount owed, the time frame, and the name of the clinic or collection source.

Insurance companies, managed care, and other third-party payers are given information that they request re-garding services to the client. Information that may be requested includes type of services, dates/times of ser-vices, diagnosis, treatment plan, description of impairment, progress of therapy, and summaries.

Information about clients may be disclosed in consultations with other professionals in order to provide the best possible treatment. In such cases the name of the client, or any identifying information, is not disclosed.
In the event I must contact you for purposes such as appointment cancellations or reminders, or to give/receive other information, efforts are made to preserve confidentiality. We will discuss during out initial session how you would like phone calls, emails and other communication to be handled.

You have the right to request to review or receive your medical files. The procedures for obtaining a copy of your medical information is as follows. You may request a copy of your records in writing with an original (not photocopied) signature. If your request is denied, you will receive a written explanation of the denial. Records for nonemancipated minors must be requested by their custodial parents or legal guardians.

• You have the right to cancel a release of information by providing us a written notice. If you desire to have your information sent to a location different than our address on file, you must provide this information in writing.
• You have the right to restrict what information might be disclosed to others. However, if I do not agree with these restrictions, I am not bound to abide by them.
• You have the right to request that information about you be communicated by other means or to an-other location. This request must be made in writing.
• You have the right to disagree with the medical records in your file. You may request that this information be changed. Although I might refuse to change the record, you have the right to make a statement of disagreement, which will be placed in your file.
• You have the right to know what information in your record has been provided to whom.
• You have a right to a copy of this privacy policy.
• You have a right to file a complaint.

If you have any complaints or questions regarding these procedures, please let me know. I will get back to you in a timely manner. You may also submit a complaint to the U.S. Dept. of Health and Human Services and/or the Oregon Board of Licensed Professional Counselors and Therapists. If you file a complaint, I will not retaliate in any way.

I understand the limits of confidentiality, privacy policies, my rights, and their meanings and ramifications.
( Type Full Name )