Tia Harms LLC
M.A. Counseling Psychology 280 Court St. NE, Suite 215, Salem, OR 97301 503.559.2233 or email@example.com
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 licensee has met the minimal qualifications and experience required by state law; 2) examine public records maintained by the Board and to have the Board confirm credentials of a licensee; 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 race, religion, gender, or other unlawful category while receiving services; and 7) be assured of privacy and confidentiality while receiving services as defined by rule and law, including the following exceptions: a) reporting suspected child abuse; b) reporting imminent danger to client or others; c) reporting information required in court proceedings or by client’s insurance company, or other relevant agencies; d) providing information concerning licensee case consultant or supervision; and e) defending claims brought by client against licensee Qualifications/Education 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 habits.
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. Payment 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 check or cash. 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 firstname.lastname@example.org. 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, or the Crisis Line at (503) 585.5535, 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 or write to 3218 Pringle Rd. SE #250, Salem, OR 97302-6312. 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 _______________________________ Client Printed Name ____________ Date _______________________________ _______________________________ Address _______________________ Home Phone _______________________ Work/Other Phone