Professional Disclosure Statement - PDF

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					                                        Tia Harms LLC
                                  M.A. Counseling Psychology
                          280 Court St. NE, Suite 215, Salem, OR 97301
                             503.559.2233 or

                            Counselor Disclosure Information

Disclosure Statement
This is a statement of your rights and responsibilities for our therapeutic relationship. The ORS
675.580 and 675.755 require counselors to provide disclosure of the following information to
their clients. Please read this statement thoroughly and then sign the consent for treatment on the
second page. If you have any questions or concerns, please tell me and I will be happy to discuss
them with you.

Client’s Rights and Responsibilities
As a counseling client, you have the right to:
1) expect that a registered intern has met the minimal qualifications of training and experience
   required by state law;
2) examine public records maintained by the Board and to have the Board confirm credentials of
   a registered intern;
3) obtain a copy of the Code of Ethics;
4) report complaints to the Board;
5) be informed of the cost of professional services before receiving the services;
6) be free from being the object of discrimination on the basis of age, color, culture, disability,
   ethnicity, national origin, race, religion, sexual orientation, gender, marital or socioeconomic
   status, or other unlawful category while receiving services; and
7) be assured of privacy and confidentiality while receiving services as defined by rule and law,
   except under the following circumstances:
       a) reporting suspected child abuse;
       b) reporting imminent danger to client or others;
       c) reporting information required in court proceedings, by client’s insurance company, or
            other relevant agencies;
       d) providing information concerning intern case consultant or supervision; and
       e) defending claims brought by client against registered intern

M.A. in Counseling Psychology from Mars Hill Graduate School
Counseling Intern at Pathways for Women, Lynnwood, Washington
Supervision by a licensed professional in the field performed by Janet Taylor, MS, LMFT

Philosophy and Approach to Counseling
My counseling style is founded in relational and interpersonal therapy, which focuses on the
relationship between the client and therapist, as well as other significant relationships in the
client’s life. My commitment is to assist clients in personal exploration and empowerment,
provide insight around personal issues, and to work with them toward achieving a more fulfilling
style of engaging the world and those around them. Furthermore, I have a commitment to adhere
to the Code of Ethics for Counselor and Therapists adopted by the Oregon Board. The overall
goals of therapy include improvement of personal and social relationships as well as increasing
successful use of life skills, spiritual well being, decision-making skills, and healthy relational
Regarding Court Requirements
It is my policy not to provide clinical evaluations or assessments of the quality of client
participation when clients are accessing counseling to fulfill court requirements or for other legal
purposes. If documentation is needed for such a situation the client and therapist will work out
such details when they are necessary.

File Closure Notification
If at any point during the course of therapy you decide that you would like to discontinue your
work with me, I am happy to conclude our time with a termination session. If we do not have the
opportunity to have a closing session, I will automatically close your file after I have not heard
from you for 90 days. Returning to counseling after a file closure is simple, and you can feel
assured that my door is open to you anytime you would like to return for more sessions.

Counseling fees are based on a sliding fee scale and will be determined by your counselor based
on various factors. Fees are due at the beginning of each session either by cash, check, credit or
debit. Please be aware that I charge clients for missed sessions unless the client gives 24 hours
notice to my cell phone. (503) 559.2233.

I can be reached at (503) 559.2233 or via email at On days that I am in
the office, I check my messages frequently and I will return your call as soon as possible.

If you are experiencing an emergency situation, please call 911, the Crisis Center at (503)
585.4949, or go to the nearest hospital emergency room. If you need to contact the Board of
Professional Counselors and Therapists, you can call (503) 378.5499, write to 3218 Pringle Rd.
SE, Suite 250, Salem, OR 97302-6312, or visit

Consent for Treatment
With my signature, I acknowledge that I have read and understand this disclosure. I consent to
therapy with Tia Harms, according to the terms described here.

_______________________________                     _______________________________
Client Signature                                     Counselor

Client Printed Name




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