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Informed Consent

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					                             Susan J. Bramlette, LMFT                                       1/1/09

Cascade Crest Professional Center                  Flanders Medical Building
108 SE 124th Ave                                   2250 NW Flanders St. #310
Vancouver, WA 98684                                Portland, OR 97210
(503) 956-5144                                      (503) 956-5144
FAX: 360.254.3926                                  Fax: 503.229.0176

                    A. Professional Disclosure Statement and Policies

Welcome…thank you for choosing us to help address your healthcare needs today. An intake
appointment may require 60 –75 minutes, as needed, while later appointments are generally 50
minutes in length. Beginning therapy is a major decision and you may have many questions.
Please feel free to ask and we will do our best to give you information on practice policies, state
and insurance law, and your private healthcare information rights.

          We honor your time and Thank You for your patience when waiting.


   Appointments can run up to ten minutes after when a prior emergency mandates.
    50-minute Sessions beginning at ten minutes after will complete on the Hour.


     Sessions beginning on the Hour will Complete at ten minutes ‘til to allow for
              Appointment-setting, co-pay receipt, and smooth transition.


                     Preparation of your copay is greatly appreciated.

Susan Bramlette earned a masters degree in Marriage and Family Therapy at the University of
Oregon and Northwest Christian College, Eugene, OR. She is licensed by the States of Oregon,
Washington, and Idaho and treats adolescents, adults, and families using individual and family
therapy resources. She is a clinical member of the American Association of Marriage and Family
Therapists (AAMFT.org) and a member of Psi Chi, the American Psychological Association
Honor Society.

As an LMFT of the Oregon State Board of Licensed Professional Counselors & Therapists and
the Washington Department of Health Service Professionals, I abide by the Code of Ethics of:

                                   Oregon Board of Licensed Professional
                                        Counselors and Therapists
                                      3218 Pringle Road SE Suite 250
                                         Salem, OR 97302-6312
                                            (503) 378-5499

and the Washington Department of Health Service Professionals (www.doh.wa.gov/)

Client Name:________________________and Contact Preferences
May we contact you at home yes/ no? (circle one) At work yes/ no? (circle one)
By cell phone yes/ no? (circle one) Via email___________________ yes/ no? (circle one)
Best contact method/place/time? _____________________________________________

B. Communication: An Open Therapeutic Approach

Your counselor practices systemic, Bowenian Intergenerational and cognitive-behavioral
therapy for most presenting problems, while eclectic treatment approaches are also resourced
when needed. Between-session assignments help speed progress toward reaching your goals.
Treatment practices, philosophy, or limitations and risks of therapy may be discussed in early
sessions. Feel free to communicate your preferences and comfort level to Susan at any time.

Business matters may be attended to before or after session. Finding the correct “fit” with a
healthcare provider is always the first step, so it’s important to address questions early on and
also feel free to discuss your changing needs at any time throughout the therapeutic season.

C. Confidentiality, Notice of Privacy Practices, and Client Rights

Your verbal communication and clinical records are held in strict confidence, except when: a)
information (date of service, etc.) is shared with our staff to expedite your insurance billings, b)
information is shared with your insurance provider in order to process your claim, c)
information provided by you and/or you child/elder discloses physical or sexual abuse, which by
Oregon, Washington, and Idaho State Law I am required to report to the Department of Children
and Family Services, d) you sign a release of information requesting to have health care
information shared with physicians, disability insurers, specific others, or, e) you provide
information that informs me you are in danger of harming yourself or another, f) information
necessary for case supervision or consultation and/ or, h) when disclosure is required by law.
Records are retained for seven years. Request for access to stored records in transitional situations
may be made through Dr. James Boyer, P.C., LMFT, at 503.224.3522.

______I/we have read and understand this Notice of Privacy Practices and Client Rights.

D. Emergency Situations

In an emergency situation where the client or his/her guardian deems that immediate attention is
necessary, contact the emergency services in the community (911) immediately. Susan Bramlette
will follow up these emergency services with counseling and support to the client and/or your
family in a timely manner, as you request. Please advise us as soon as possible at 503-956-5144
after obtaining emergency care.

Emergency Contact:__________________________________Telephone:__________________
_______(initial)Permission is given to contact the above individual to discuss treatment needs
deemed emergency in nature. Client preferences:_______________________________________

E. Coordination of Treatment/ Prescribing Physician
If you would like to authorize permission to communicate with your primary care physician
and/or psychiatrist, please indicate below. Your consent is valid for one year or until such time
as consent is revoked in writing.
____You may notify my physician(s) ____I decline notification of my physician at this time.
Current Medications:___________________________________________________________
Prescribing Physician’s Name/Specialty:___________________________________________
Clinic/City:________________________Telephone or FAX:___________________________

F. Financial/Insurance Information

            Insurance providers with whom we have current contract agreements are:

MHN Managed Health Network               EAP Consultants                ODS
NEAS EAP                                 Definity                       Deer Oaks
Cigna Behavioral Health                  APS EAP                       PBH (Providence)
MBH Magellan (single case)               Value Options/ GreatWest/Nike
Tricare/Triwest                          NDBH New Directions            HumanaCare
UBH United Behavioral Health             The Holman Company BH
EAP Preferred                            Pacificare     Health Corp. Services/Adidas

Please ask concerning other insurances as single-case agreements are sometimes available.
For more information on insurance or financial matters, feel free to consult with your therapist.

Insured clients please call the number for Behavioral/Mental Health or EAP Services listed
on your insurance card for instructions, providing the following information:

    1. Client and Insured’s identification/Group/Authorization information.
    2. Insurance Company, type (EAP or Mental Health benefit), Date of Authorization Start,
       Deductible/Deductible satisfied? Please bring your card to the first session.
    3. Information given by your insurance company about number of sessions now
       authorized, authorization number, co-payment requirements, as well as the specific
       billing address and telephone number.

If you have not met your deductible, insurance rate fee is due at each session until the deductible
is satisfied. My deductible is $_____________________. It is not satisfied/satisfied (circle one).

My copay is: __________________________. My payment today is:____________________.

   Please advise immediately of any changes to your insurance plan or benefits. Thanks.

G. Fee Schedule for Services

 As a courtesy we will bill your insurance or third-party payor for you, then advise of denied
claims. We ask that you pay your copay or non-insurance session fee at the start of each visit.

Individual Appointment (90806, 50 minutes):                       $ 90.
Intake Appointment (90801, 90 minutes):                           $125.
Couples, Family Therapy (90847, 50/70 minutes):                   $125./165.
Group Therapy (90853, 90 minutes)                                 $ 30.
Calls/Letters/Forms Requested by Client                           $50.
Missed Appointment Fee (billed via Paypal)                        $20.
Prepaid Block/ Ten Sessions                                       $750.

Payment/checks should be made and/or mailed to Susan Bramlette, LMFT, 2250 NW
Flanders St. #310, Portland, OR 97210. Thank you.

WE ACCEPT PAYPAL VISA OR DEBIT PAYMENTS, invoiced via Email
(convenient for HSA accounts) Preferred email:__________________.

Your fees can be paid by Visa or Debit card at: http://www.susanbramlette.com.

________(initialed) Client Agreement: If my insurance company denies payment of my claim
for any reason, I accept responsibility to forward balance due at the time of statement or phone to
make arrangements for payments. After 60 days an unpaid balance on my account I will be
charged 2% invoicing fee a month on remaining fees due. I am responsible for any fee charged to
our office by an outside agency to collect the payment owed.

_______(initialed) I understand my anticipated fees for therapy and/or I will contact my provider
with any questions about fees. (Please initial. Thanks!)

H. LATE CANCELLATION POLICY
_______(initialed) If I need to cancel or reschedule an appointment, I will give 24 hours
advance notice at: 503.956.5144 or pay the missed appointment fee of $20. via email request on
Paypal.

                 We sincerely appreciate your collaboration with these policies.

    Please discuss any questions you may have regarding the information in this disclosure
    statement with Susan directly in session, or call during business hours at the number above.

I understand this statement. I give permission to begin treatment with Susan Bramlette, LMFT.

Signature__________________________________________Date________________

Signature__________________________________________Date________________

Client Questions:
______________________________________________________________________________
______________________________________________________________________________
Consent for Treatment of Child/ Adolescent:
 I/We consent that _____________________________________ may be treated as a client of
Susan Bramlette, LMFT. At times it maybe necessary to schedule appointments during school
hours. We ask for your cooperation to provide timely treatment for you and your children.
[Please note: both parents should consent to treatment where possible and have the right to be
informed of treatment outcomes and the welfare of the child except as a court rules otherwise.]

Signature_________________________________________Mother / Date________________
Telephone/best time:)_______________________
Signature__________________________________________Father / Date________________
Telephone/best time:________________________
Signature_______________________________________Guardian / Date________________

				
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