MaryJane Wilt, LPC, MAC, CSAT, MA Ed.                       Whole Heart Counseling Services
212 NE 80th Ave., Portland, OR, 97213                                     971.242.9322 (tel)
 
Informed Consent

Qualifications:

Training and Degrees:

Experience:

                                                                                                                                     

Counseling Orientation: I view the counseling process as forming an alliance with you to explore the nature of your problem(s). Although we’ll spend much time exploring the specific problem(s) that brought you into counseling today, we’ll also look at the nature of your relationships across your lifespan. According to my theoretical orientation, many of the forces and dynamics that influence the complexity and intensity of our problem(s) are rooted in relational issues. I believe that we were designed to relate in a satisfying and self-giving manner, which is the source of our greatest joy when relationships work well but also of our deepest pain when they don’t. When this occurs, we usually develop a self-protective relational style that we take into all of our relationships, so we’ll explore how your relational style interferes with the enjoyment for which you are made. This is meant to give you hope, in that by not only dealing with the problem(s) that brought you in today, we’ll aim at the source of the problem(s). I believe that certain problems can have a physical component as well, and in such cases, I will advise medical consultation.

Billing and Insurance Information: The billable rate for the Initial 50-minute Intake Session is $150. Subsequent Individual 50-minute Sessions are $130. For self-paying clients, Initial Intake Sessions are $150, and subsequent Individual Sessions will be charged on a discount fee schedule of $95-130, depending on your gross income and the number of dependents for whom you are responsible.  Payments are to be made with cash, check or money order at the beginning of each session; I do not take credit cards. You will be charged for a missed appointment if you have failed to notify me within 24 hours of our scheduled time (illness and emergencies excepted). Fees may increase periodically, and thus the fees are subject to change with two weeks prior notification.  The fee for group therapy sessions will vary depending on the length and nature of the group.

I do not file insurance claims for you. If your insurance provider will be covering the cost of your counseling then you need to make arrangements with them to reimburse you directly. You are responsible for obtaining and filling out any appropriate paperwork and submitting it to the insurance company. I will be glad to fill out any part of the form that is necessary.

Choosing a Counselor: You have the right to choose a counselor who best suits your needs and purposes. You may seek a second opinion from another mental health practitioner or may terminate therapy at any time.

Confidentiality: There is a legal privilege in this state protecting the confidentiality of the information that you share with me. As a professional, I can assure you that I strive to maintain the strictest ethical standards of confidentiality.

There are legal exceptions to confidentiality. The following situations are those in which the information you have shared with me may be shared with others.

When it is possible, we will discuss any exceptions to confidentiality as they arise.

Consultations: I consult regularly with other therapeutic professionals which allows me to gain other perspectives and ideas as to how to best help you reach your goals. These consultations are obtained in such a way that confidentiality is maintained.

Continuing Education: Licensed Professional Counselors practicing in the state of Oregon are required to participate in 40 hours of continuing education every two years.

Scheduling Appointments: Appointments are generally made on a regular, weekly basis. Appointment times are not automatically held open for you from week to week. It is your responsibility to reschedule at the end of a session.

Unprofessional Conduct: In the state of Oregon, the website of the Oregon Board of Licensed Professional Counselors and Therapists (http://www.oblpct.state.or.us/) lists ways in which counselors may work in an unprofessional manner (http://www.oregon.gov/OBLPCT/web-coe.shtml).  It also describes the nature of a complaint and how to file one. If you suspect that my conduct has been unprofessional in any way, please contact the Oregon Board of Licensed Professional Counselors and Therapists at the following address and phone number:

Oregon Board of Licensed Professional Counselors and Therapists

3218 Pringle Rd SE, Ste #250

Salem, OR  97302-6312

(503) 378-5499

Client Bill of Rights: As a client of an Oregon licensee, you have the following rights:

Contacting Me by Phone: You may leave me a message at 971.242.9322. I will check these messages on a regular basis. Please limit your phone conversation needs to appointment scheduling and emergencies.

Emergencies: If you are in an emergency and cannot reach me, please call one of the following numbers for help: General Emergencies 911; Crisis Clinic 800.716.9769 or 503.988.4888 or 360-696-9560.

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I have read and understand the information presented in this form.

 

Client Signature / Date                                                                                       Client Signature / Date

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Parent/Guardian Signature / Date                                                    Parent/Guardian Signature / Date                             

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Therapist Signature / Date

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