new client intake form
Policies and Privacy Practices
Please read these over these policies and information regarding our therapeutic relationship and ask any questions you may have. It is important that you understand them because when you sign this document it will represent an agreement between us. We can discuss any questions you have before you sign or at any time in the future.
Policies
My fee with you is $90-$150 per 60 minute session. You are responsible for paying at the time of your session unless prior arrangements have been made. Payment must be made by check, cash or another agreed upon method; I do not process credit cards as payment. Any checks returned to me are subject to an additional fee of up to $25.00 to cover the bank fee that I incur.
Because I organize my schedule and livelihood around our appointments, I charge $60 for hour-long appointments cancelled with less than 24 hours notice, and I charge the full session fee for no show appointments (you do not notify me to cancel). If possible, more notice than this is very helpful so that I am able to offer the opening to someone else if needed. Illness or emergencies that impact cancellations can be discussed at the time.
I seek clinical consultation from other mental health professionals on a regular basis to ensure the best possible outcomes for your therapeutic process. This means it is possible that I will be discussing your case with other professionals. This will be done in a discreet manner without revealing any identifying information about you. I adhere to laws of confidentiality, which dictate that I not reveal identifying information about my clientele. Exceptions to this are if you are at high risk of being a danger to yourself (suicidal) or to others (homicidal). I am also mandated to report any incidents of abuse or neglect to the elderly and to minors under the age of 18.
Licensure Status
I practice as an alternative, non-licensed therapist under Oregon Regulatory Statute 675.825(4). I do not have the legal right to diagnose or provide treatment for a diagnosis out of the DSM. If you are seeking treatment for a DSM diagnosis, I recommend seeking a licensed practitioner that can legally offer this kind of support. Though I have chosen to practice unlicensed, I receive monthly supervision from long time practitioners as well as monthly consultation support from a cohort of fellow practitioners, and I also engage in regular continuing education opportunities. Remaining skillful, ethical, and up to date on research in the field is of upmost importance to me.
Additional Info
If you are unhappy with what is happening in therapy, I hope you will talk with me so that I can respond to your concerns. Your comments will be taken seriously and handled with care and respect. You may also request that I refer you to another therapist and are free to end therapy at any time. If you decide to end treatment abruptly, I would appreciate it if you would schedule at least one additional meeting to discuss this and to review the work we have done together and how it can inform your future.
You have the right to considerate, safe and respectful care, without discrimination as to race, ethnicity, color, gender, sexual orientation, age, religion, or national origin. You have the right to ask questions about any aspects of therapy.
In signing this document I agree that I have read and will comply with the aforementioned policies.