Clinical Forms
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For your convenience, you can download and print the following forms.
INFORMED CONSENT & AGREEMENT FOR PSYCHOTHERAPY SERVICES
Introduction:
This document is intended to provide important information to you regarding your treatment. Please read the entire document carefully and be sure to ask me any questions that you may have regarding its contents before signing it. You may have questions about me, my qualifications, therapy, or anything not addressed here. It is your right to have a complete explanation for any questions you may have, now or in the future. Please feel free to ask questions or share any concerns that may arise. Although I know this may be uncomfortable at times, your openness and honesty will allow me to better serve you.
Risks and Benefits of Therapy:
Psychotherapy has both benefits and risks. Risks may include experiencing uncomfortable feelings such as anxiety, guilt, sadness, anger, frustration, loneliness, helplessness, etc. because in the process of psychotherapy often requires discussing the unpleasant aspects of your life. There may be times in which I will challenge your perceptions and assumptions, and offer different perspectives. The issues presented by you may result in unintended outcomes, including changes in personal relationships. Sometimes a decision that is positive for one family member is viewed quite differently by another. You should be aware that any decision on the status of your personal relationships is your sole responsibility. However, participating in therapy may also result in a number of benefits to you, including, but not limited to, reduced stress and anxiety, a decrease in negative thoughts and self-sabotaging behaviors, improved interpersonal relationships, increased comfort in social, work, and family settings, increased capacity for intimacy, and increased self-confidence. Such benefits may require a substantial effort on your part, including an active participation in the therapeutic process, honesty, and a willingness to change feelings, thoughts and behaviors.
During the therapeutic process, some people find that they feel worse before they feel better. This is generally a normal course of events. Personal growth and change may be easy and swift at times, but may also be slow and frustrating as well. Due to the varying nature and severity of problems and the individuality of each patient, I am unable to predict the length of your therapy or to guarantee a specific outcome or result. Nor is there a guarantee that therapy will yield any or all of the benefits listed above. My hope is that you will always be willing to discuss with me any concerns you may have regarding your progress in therapy.
Discussion of Treatment Plan:
I believe that therapists and patients are partners in the therapeutic process. It is my intention to provide services that will assist you in reaching your goals within a reasonable period of time after the initiation of treatment. At Salem Counseling Place I take a holistic approach to therapy and will work with you in understanding the problem, treatment plan, and therapeutic objectives in order for you to reach your goals.
Termination of Therapy:
The length of your treatment and the timing of the eventual termination of your treatment depend on the specifics of your treatment plan and the progress you achieve. It is a good idea for us to collaborate together about your termination of treatment. I will discuss a plan for termination with you as you approach the completion of your treatment goals. You may discontinue therapy at any time. If you or I determine that you are not benefiting from treatment, either of us may elect to initiate a discussion of your treatment alternatives. Treatment alternatives may include, among other possibilities, referral, changing your treatment plan, or terminating your therapy. It is best to discuss this in a planned termination session if at all possible.
Professional Consultation:
Professional consultation is an important component of a healthy psychotherapy practice. As such, I regularly participate in clinical, ethical, and legal consultation with appropriate professionals. During such consultations, I will not reveal any personally identifying information regarding you or your situation.
Collaboration with Other Professionals:
In order to provide quality services, I at times need to collaborate with other professionals, such as your physician, psychiatrist, past therapists, and/or other mental health professionals. If we decide together that this would be helpful, you will be asked to complete a release of information authorizing these exchanges.
Records and Record Keeping:
I may take notes during session, and will also produce other notes and records regarding your treatment. These notes constitute my clinical and business records, which by law, I am required to maintain. Such records are the sole property of the therapist. Should you request a copy of my records, such a request must be made in writing. I reserve the right, under Oregon law, to provide you with a treatment summary in lieu of actual records. I also reserve the right to refuse to produce a copy of the record under certain circumstances, but may, as requested, provide a copy of the record to another treating health care provider. I typically maintain records for seven years following termination of therapy. After seven years, your records will be destroyed in a manner that preserves your confidentiality.
Confidentiality:
The information disclosed by you is generally confidential and will not be released to any third party without written authorization from you, except where required or permitted by law. Exceptions to confidentiality
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When there is risk of imminent danger to yourself or to another person, the clinician is ethically bound to take necessary steps to prevent such danger.
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When there is suspicion that a child or elder is being sexually or physically abused or is at risk of such abuse, the clinician is legally required to take steps to protect the child or elder, and to inform the proper authorities.
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When a valid court order is issued for medical records, the clinician and the agency are bound by law to comply with such requests.
If you participate in marital or family therapy, I will not disclose confidential information about your treatment unless all person(s) who participated in the treatment with you provide their written authorization to release such information. However, it is important that you know that I utilize a “no secrets” policy when conducting family or marital/couples therapy. This means that I do not keep secret information gathered in individual conversations (whether on the phone or in an individual session) if the information revealed in some way violates the integrity of the couples/family therapy (such as revealing an affair, substance problem, or intent to leave the relationship). Such information will need to be revealed to the other partner for therapy to effectively continue. Please feel free to ask me about my “no secrets” policy and how it may apply to you.
Patient Litigation:
I will not voluntarily participate in any litigation or custody dispute in which you and another individual, or entity, are parties. I have a policy of not communicating with patients’ attorneys and will generally not write or sign letters, reports, declarations, or affidavits to be used in any patient’s legal matter. I will generally not provide records or testimony unless compelled to do so. Should I be subpoenaed, or ordered by a court of law, to appear as a witness in an action involving you, you (not your insurance company) agree to reimburse me for any time spent for preparation, travel, or other time in which I have made myself available for such an appearance at my customary hourly rate for such services of $325.
Email and Phone/Text Messaging Communication:
Some patients prefer to communicate about appointment times or other administrative issues via email or phone. Although information stored on my computer is encrypted, email or text messages transmitted through regular services are not encrypted. This means that a third party may be able to access information in an email or through text messaging and read it, since it is transmitted over the Internet or phone. In addition, once the email or text messages are received by you, someone may be able to access your email account or cell phone and read it. This may include your employer if you use a work-related email address.
Therapist Availability / Emergencies:
You may leave a message for me at any time on my confidential voicemail at 503-510-3127. If you wish me to return your call, please be sure to leave your name and phone number(s), along with a brief message concerning the nature of your call. Non-urgent phone calls are generally returned within 24 hours during normal workdays (Monday through Friday).
Please understand that as a small practice I do not provide continuous 24-hour crisis services. In the event of a medical emergency or an emergency involving a threat to your safety or the safety of others, please call 911 to request emergency assistance, or go to the nearest emergency room, or contact other resources as listed:
Psychiatric Crisis Center - 503-585-4949; National Child Abuse Hotline - 1-800-4-A-Child; National Domestic Violence Hotline – 1-800-799-SAFE OR TTY 1-800-787-3224; National Sexual Assault Hotline (RAINN) - 1-800-656-HOPE; National Suicide Prevention Lifeline - 1-800-273-TALK OR TTY 1-800-799-4TTY; and Teen Line Online - www.teenlineonline.org, 1-800-852-5336.
RATES AND INSURANCE:
Therapy Fees:
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$250 Initial appointment 60minutes
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$200 Therapy session 60 minutes
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$175 Therapy session 45 minutes
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Uninsured or self-pay good faith estimate for one month weekly sessions $480-$700
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Please inquire if you need additional help in regards to payment.
Forms of Payment:
Cash, Checks, PayPal, or Credit Cards are accepted, and payment is due at time of service. Any returned checks are subject to an additional $35 bank fee, which I reserve the right to change as bank fees change.
Insurance:
Salem Counseling Place is contracted with some insurance agencies except Medicare. Clients are expected to pay at the time of service. Clients can be supplied with appropriate receipts and coding (coding will come from diagnoses out of the DSM – 5) so that you may seek reimbursement from your insurance company. Please inform me if you wish to utilize health insurance to pay for services. Although I am happy to assist your efforts to seek insurance reimbursement, I am unable to guarantee whether your insurance will provide payment for the services provided to you, the amount of reimbursement, and the amount of any co-payments or deductible depends on the requirements of your specific insurance plan. You should be aware that insurance plans generally limit coverage to certain diagnosable mental conditions, which then become part of your medical record. While insurance companies claim to keep such information confidential I have no control over what they do with your information once they have it. You are responsible for obtaining prior authorization for treatment from your insurance carrier. Please discuss any questions or concerns that you may have about this with me. If for some reason you find that you are unable to continue paying for your therapy, please inform me. I will help you to consider any other options that may be available to you.
Cancellation Policy:
If you do not show up for your scheduled therapy appointment, and you have not notified me at least 24 hours in advance, you will be required to pay $50 for the missed appointment. Exceptions will be made for illness or emergencies.
if an appointment can be rescheduled within the same week, you will not be charged for the missed appointment.
Delinquent Accounts:
You understand that you are responsible for all charges incurred and that services must be paid in full at the time of each visit, unless other arrangements have been made in advance. Should your account become delinquent, you agree to pay a late fee of $10 per month, and if it becomes necessary for the account to be referred for collection action, you agree to pay the actual balance due plus any collection expenses of 30-50% of any balances owing, and any attorney’s fees
After reading this Informed Consent:
Signing acknowledgements form is accepting you have read, understood, asked any questions that you may have regarding this document, and have been offered a copy of this form for your own records. The ACKNOWLEGEMENTS PAGE is to be printed and brought to your first appointment.
Financial Policy
Payment is required at the beginning of each session and payable by cash or check.
Current Rates:
Intake appointment (50-60 minutes) $250
Individual/Couple/Family therapy session (60-minutes) $200
Individual/Couple therapy session (45-minutes) $175
Please ask me if you wish to discuss a written agreement that specifies any alternative payment procedure.
Cancellations:
If you need to cancel or reschedule an appointment, please notify me no later than 5:00 p.m. on the day BEFORE your appointment. If you fail to cancel a scheduled appointment, I cannot use this time for another client, and you will be billed/charged $50 for the cost of your missed session. Special consideration is given for emergencies and must be negotiated.
Insurance:
I accept some private insurance except Medicare. If out of network all fees are due in full at time of service.
Other fees:
A fee of $35 will be assessed for all returned checks. In addition to session rates listed above, I charge $85/hr for other professional services you may need, though I will break down the hourly cost into 15-minute segments if I work for periods of less than one hour. Other services include report writing, telephone conversations lasting longer than 15 minutes, attendance at meetings with other professionals you have authorized, preparation of records or treatment summaries, and the time spent performing any other service you may request of me. If you become involved in legal proceedings that require my participation, you will be expected to pay for my professional time. Because of the difficulty of legal involvement, I charge $325 per hour for preparation and attendance at any legal proceeding.
I have read and understood the above information. I agree to submit payment at the beginning of each session as outlined by the current rates listed above. I agree to provide notification of a cancellation no later than 5:00 p.m. on the day before my appointment, and if I fail to do so, I agree to pay $50 for the missed session. Signing for this document acknowledging you have read, understood, and asked any questions that you may have is found on the ACKNOWLEDGEMENTS PAGE.
NOTICE OF PRIVACY PRACTICES
THIS NOTICE DESCRIBES HOW INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION.
PLEASE REVIEW IT CAREFULLY.
If you have any questions about this notice, please contact administrative offices at:
Salem Counseling Place
Barbara A. Norton, MS., LPC
3482 Liberty Rd. S. Salem, OR 97302
503-510-3127
WHO WILL FOLLOW THIS NOTICE
This notice describes the privacy practices followed by the practitioner, administrator and office personnel at the practice listed above.
YOUR HEALTH INFORMATION
This notice applies to the information and records we have about your health, health status, and the counseling and care services you have received through Barbara Norton, MS., LPC. Your health information may include information created and received by your therapist. This information may be in the form of written or electronic records or spoken words, and may include information about your health history, health status, symptoms, counseling, evaluations, test results, prescriptions, diagnoses, treatments, procedures and related billing activity and/or similar types of health-related information.
I am required by law to give you this notice. It will tell you about ways in which I may use and disclose health information about you and describes your rights and my obligations regarding the use and disclosure of that information.
HOW I MAY USE AND DISCLOSE HEALTH INFORMATION ABOUT YOU
I may use and disclose health information for the following purposes:
For treatment.
With your written consent, I may release information to your primary care physician and/or other treating physicians, therapists, counselors, care givers, office staff or other personnel who are involved in taking care of you and your health.
For example, your therapist may be treating you for a condition and may need to know if you have medical issues or problems that may complicate your treatment. The clinician may use this information to decide what treatment is best for you. I may need to confer with your doctor or another clinician in the field of practice to assist us in a choice of treatment that would be best for you.
Different personnel may share information about you and disclose information to people who do not work in your therapist’s office in order to coordinate your care, such as scheduling appointments and tests. Family members and other health care providers may be part of your medical care and may require information about you that I have.
For payment.
I may use and disclose health information about you so that the treatment and services you receive may be billed to and payment may be collected from you, an insurance company or a third party.
For example, I may need to give your health plan information about a service you received so your health plan will pay us or reimburse you for service. We may also tell your health plan about a treatment you are going to receive to obtain prior approval, or to determine whether your plan will pay for the treatment.
For health care operations.
I may use and disclose health information about you in order to make sure that you and our other clients receive quality health care. For example: I may use your health information to evaluate the performance of the office personnel who are caring for you. I may also use health information about all or many of my clients to help decide what additional services I should offer, how I can be more efficient, or whether certain new treatments are effective.
I may also disclose your health information to health plans that provide you insurance coverage and other health care providers that care for you. My disclosures of your health information to plans and other providers may be for the purpose of helping these plans and providers provide or improve care, reduce cost, coordinate and manage health care and services, train staff and comply with the law.
Appointment reminders.
l will text an appointment reminder 1 day prior to your appointment for counseling. Please specify on the intake form what phone numbers may be used to remind you of appointments. Please notify me if you do not wish to be contacted for appointment reminders.
Treatment alternatives.
I may tell you about or recommend possible treatment options or alternatives that may be of interest to you.
Health-related products and services.
I may tell you about health related products or services that may be of interest to you.
SPECIAL SITUATIONS:
I may use or disclose health information about you for the following purposes, subject to all applicable legal requirements and limitations:
To avert a serious threat to health or safety.
I may use and disclose health information about you when necessary to prevent a serious threat to your health and safety or the health and safety of the public or another person.
Required by law.
I will disclose health information about you when required to do so by federal, state or local law.
Military, veterans, national security and intelligence.
If you are or were a member of the armed forces, or part of the national security or intelligence communities, I may be required by military command or other government authorities to release health information about you. I may also release information about foreign military personnel to the appropriate foreign military authority.
Worker’s compensation.
I may release health information about you for worker’s compensation or similar programs. These programs provide benefits for work-related injuries or illness.
Public health risks.
I may disclose health information about you for public health reasons in order to prevent or control disease, injury or disability; or report births, deaths, suspected abuse or neglect, non-accidental physical injuries, reactions to medications or problems with products.
Health oversight activities.
I may disclose health information to a health oversight agency for audits, investigations, inspections, or licensing purposes. These disclosures may be necessary for certain state and federal agencies to monitor the health care system, government programs, and compliance with civil rights laws.
Lawsuits and disputes.
If you are involved in a lawsuit or a dispute, we may disclose health information about you in response to a court or administrative order. Subject to all applicable legal requirements, I may also disclose health information about you in response to a subpoena.
Law enforcement.
I may release health information if asked to do so by a law enforcement official in response to a court order, subpoena, warrant, summons or similar process, subject to all applicable legal requirements.
Coroners, Medical Examiners, and Funeral Directors.
I may release health information to a coroner or medical examiner. This may be necessary, for example, to identify a deceased person or determine cause of death.
Information not personally identifiable.
I may use or disclose health information about you in a way that does not personally identify you or reveal who you are.
Family and friends.
I may disclose health information about you to your family members or friends if we obtain your verbal agreement along with your written authorization to do so. We will give you an opportunity to object to such a disclosure and request you state this in writing. I may also disclose information to your family and friends if I can infer from circumstances, based on my professional judgment that you would not object. For example, I may assume you agreed to limited disclosure of information to your spouse when you bring your spouse with you to a counseling session and have not requested in writing that any form of disclosures cannot be made.
In situations where you are not capable of giving consent (because you are not present or due to your incapacity or medical emergency), I may, using my professional judgment, determine that a disclosure to your family member or friend is in your best interest. In that situation, I will disclose only the health information relevant to the person’s involvement in your care. For example: I may inform the person who accompanied you to the emergency room that you may have attempted suicide and provide updates and prognosis. I may also use my professional judgment and experience to make reasonable inferences that are in your best interest to allow another person to act on your behalf.
OTHER USES AND DISCLOSURES OF HEALTH INFORMATION
I will not use or disclose your health information for any purpose other than those identified in the previous sections without your specific, written authorization. If you give us authorization to use or disclose health information about you, you may revoke that authorization, in writing, at any time. If you revoke your authorization, we will no longer be able to use or disclose information about you for the reasons covered by your written authorization, but we cannot take back any uses or disclosures already made with your permission.
I will need specific, written authorization from you in order to disclose certain types of specially protected information such as HIV, substance abuse, mental health, and genetic testing information.
YOUR RIGHTS REGARDING HEALTH INFORMATION ABOUT YOU
You have the following rights regarding health information we maintain about you:
Right to inspect and copy.
You have the right to inspect and copy your health information, such as medical and billing records, that I keep and use to make decisions about your care. You must submit a written request to your therapist or our administrative office in order to set up an appointment to inspect and/or copy records of your health information. If you request a copy of the information, I may charge a fee for the costs of copying, mailing or other associated supplies.
I may deny your request to inspect and/or copy records in certain limited circumstances. If you are denied copies or access to information that I keep about you, you may ask that our denial be reviewed. If the law gives you a right to have our denial reviewed, I will select a licensed health care professional to review your request and my denial. The person conducting the review will not be the person who denied your request, and I will comply with the outcome of the review.
Right to amend.
If you believe health information I have about you is incorrect or incomplete, you may ask to amend the information. You have the right to request and amendment as long as your therapist keeps the information.
To request an amendment, complete and submit an amendment/corrections request to your therapist at 3482 Liberty Rd. S. Salem, OR 97302
We may deny your request for an amendment if your request in not in writing or does not include a reason to support the request. In addition, we may deny your request if you ask us to amend information that:
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Your therapist did not create, unless the person or entity that created the information is not longer available to make the amendment,
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Is not part of the information that I keep,
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You would not be permitted to inspect and copy,
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Is accurate and complete.
Right to an accounting of disclosures.
You have the right to request an “accounting of disclosures.” This is a list of the disclosures we have made of information about you for purposes other than treatment, payment, health care operations, and a limited number of special circumstances involving national security, correctional institutions and law enforcement. The list will also exclude any disclosures I have made based on your written authorization.
To obtain this list, you must submit your request in writing to your therapist at 3482 Liberty Rd. S. Salem, OR 97302.
It must state a time period, which may be no longer than six years subsequent to the date of signature. Your request should indicate in what form you want the list (for example, on paper or electronically). The first list you request within a twelve month period will be free. For additional lists, I may charge you for the costs of providing the list. I will notify you of the cost involved and you may choose to withdraw or modify your request at that time before any costs are incurred.
Right to request restrictions.
You have the right to request a restriction or limitation on the health information we use or disclose about you for treatment, payment or health care operations. You also have the right to request a limit on the information we disclose about you to someone who is involved in your care or the payment for it, like a family member or friend. For example, you could ask that I not use or disclose information about a hospitalization you had.
We are not required to agree with your request.
If we do agree, I will comply with your request unless the information is needed to provide you emergency treatment or I am required by law to use or disclose the information.
To request restrictions, you can complete a request for restriction on use/disclosure of medical information to your therapist at 3482 Liberty Rd. S. Salem, OR 97302. I will not ask you the reason for your request. I will accommodate all reasonable requests. Your request may specify how or where you wish to be contacted.
Right to a paper copy of this notice.
You have the right to a paper copy of this notice. You may ask your therapist or our office personnel to give you a copy of this notice at any time.
CHANGES TO THIS NOTICE
I reserve the right to change this notice, and to make the revised or changed notice effective from information we already have about you as well as any information I receive in the future. I will post the current notice in our office with the effective date in the top, right hand corner. You are entitled to a copy of the current notice in effect.
COMPLAINTS
If you believe your privacy rights have been violated, you may file a complaint with the Secretary of the Department of Health and Human Services. To file a complaint with my office, please contact Barbara Norton, MS.,LPC Salem Counseling Place at 3482 Liberty Road. S. Salem, OR 97302.
After reading HIPPA form: The signing for this document acknowledging you have read, understood, asked any questions that you may have regarding this document, and have been offered a copy of this form for your own records is found on the ACNOWLEGEMENT PAGE, which you are to print and bring a copy at your first appointment.
NOTICE OF PRIVACY PRACTICES
Philosophy and Approach:
I believe everyone can improve their level of functioning and reach an optimum level of health when adequate community supports are in
place to meet their financial, medical, educational, and social needs. Because everyone is unique with the issues they present; I employ an eclectic approach with a strong emphasis on cognitive-behavioral strategies. I find this approach allows people to fully understand their destructive thinking patterns and subsequent emotions that often lead to maladaptive choices in behavior which impacts functioning on multiple levels. People presenting with grief, anxiety, adjustments, and depression can reach an optimum level of functioning using cognitive behavioral techniques as I have witnessed in my years of practice.
Formal Education and Training:
I hold a Masters Degree in Guidance & Counseling from Texas A & M University. Major coursework included human growth and development with an emphasis on early childhood and adolescent development, assessment, family and group dynamics. I also hold a Post Masters Certificate in Clinical Community Counseling from Johns Hopkins University. Major coursework included advanced application of individual, group, marriage, DSM, psychological assessments, alcohol and drug counseling. I have 7 years assessment and crisis response counseling in hospital and community settings. 27 years’ experience providing individual, family therapy in school, home, and clinic-based settings.
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:
1) My fee in private practice will be $120 per 30min, $175 per 45min, $200 per 50-60min.
2) Sliding scale of fees are $120-$150 per hour.
As a client of an Oregon licensee, you have the following rights:
∗To expect that a licensee has met the 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, with 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.
You may contact the Board of Licensed Professional Counselors and Therapists at 3218
Pringle Rd SE, Suite 120, Salem, OR 97302-6312 Telephone: (503) 378-5499
Email: lpct.board@state.or.us Website: www.oregon.gov/OBLPCT