This is the text of the current Professional Disclosure Statement for Kristen B. Beck, MS, LPC and Counseling Services Agreement for 2020. You will need to log into the client portal and sign this document online after your initial phone consultation and before your first session. (Do not print out or send in this page. It is for reference only.)
Gresham Counseling and Therapy LLC
Practice location: 4316 SE 182nd Ave., Gresham, OR 97030 | Mailing address: PO Box 865, Gresham, OR 97030
Phone: 503-766-9083 | email@example.com | GreshamCounseling.com
Purpose of this Document
This document (also referred to as “this agreement”) pertains to counseling services provided by me, Kristen B. Beck, MS, LPC (the counselor) at Gresham Counseling and Therapy LLC (this practice), to you (the client), and will inform you of my background as a counselor, help you understand our professional relationship and policies, and provide you with your rights as a client.
You must agree to the terms of this document, sign it, and submit it to me to enter into a counselor-client relationship with me and receive counseling services. The counselor-client relationship is established only when all of the following are completed: 1) I explicitly agree to provide counseling services to you, 2) this signed document is submitted to me, 3) any other required intake documents are completed and submitted to me, and 4) you provide verbal informed consent at the start of the first session. Please ask me any questions you have about the counselor-client relationship, counseling services, or this document before signing.
My Philosophy and Approach
I work collaboratively with clients to help them develop understanding of circumstances and patterns and develop skills to make informed choices to move toward valued directions. I strive to build therapeutic relationships that are safe and egalitarian while respecting professional boundaries. My approach to counseling is integrative and based on the biopsychosocial model, in which the physical, mental, and social factors are seen as equally influential in a client’s personal development. I use a combination of methods drawn from a variety of evidence-based counseling theories, primarily including Interpersonal Neurobiology (IPNB), Psychophysiology, Cognitive Behavioral Therapy (CBT), Acceptance and Commitment Therapy (ACT), Narrative Therapy (NT), Positive Psychology, Compassion Focused Therapy (CFT), Feminist Therapy, Somatic Psychotherapy, Family Systems, Humanistic Psychology, and Existential Therapy.
Sessions may be conducted via in-person or telehealth. In sessions, we may explore your personal story, social dynamics, activities, values, goals, thinking and behavioral patterns, emotional experiences, and perceptions. We may use therapeutic tools (e.g. props, worksheets, drawings, etc.), physical movements, or discussions with other persons with your permission. I may offer educational information, hypothetical narratives, and clinically appropriate self-disclosure for psychoeducation; encourage you to complete tasks between sessions; and consult with other professionals about your case as appropriate. I will usually allow you to choose the frequency of your sessions, but I may set limits to your session frequency, require increased frequency, or limit your treatment duration at my discretion.
Formal Education and Training
I hold a Master of Science (MS) degree in Mental Health Counseling from Capella University in Minnesota. The degree program is accredited by the Council for Accreditation of Counseling and Related Education Programs (CACREP). Major coursework included curriculum in human growth and development, personality development, marriage and family counseling, child and adolescent counseling, group counseling, crisis counseling, psychotherapy, assessment and diagnosis, ethics, multicultural awareness, mental disorders, addictions, sexuality, life planning, career development, personal growth, research methodology, and clinical skills training. I also hold a Bachelor of Arts (BA) degree in Natural Science from San Jose State University in California and an Associate of Arts (AA) degree in Liberal Arts from College of the Desert, in California. I have completed additional coursework from multiple professional continuing education providers focused on topics related to counseling.
Licensure as an LPC with the OBLPCT
As a Licensee of the Oregon Board of Licensed Professional Counselors and Therapists (OBLPCT), I abide by its Code of Ethics set forth in OAR Chapter 833, Division 100. To maintain my license I am required to participate in continuing education, taking classes dealing with subjects relevant to this profession
Client Bill of Rights: As a client/consumer of counseling or therapy services offered by an Oregon Licensee, you have the right:
- To expect that a licensee or person granted a temporary practice authorization has met the minimum 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 or person granted a temporary practice authorization;
- To obtain a copy of the Code of Ethics (Oregon Administrative Rules 833-100);
- 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 or law, with the following exceptions: 1) Reporting suspected child abuse; 2) Reporting imminent danger to you or others; 3) Reporting information required in court proceedings or by your insurance company, or other relevant agencies; 4) Providing information concerning licensee case consultation or supervision; and 5) Defending claims brought by you against me;
- To be free from discrimination on any basis listed in the Code of Ethics while receiving services (e.g. age, color, culture, disability, ethnicity, national origin, gender, race, religion, sexual orientation, marital status, or socioeconomic status).
Board Information: You may contact the Oregon Board of Licensed Professional Counselors and Therapists at
- Address: 3218 Pringle Rd SE, #120, Salem, OR 97302-6312
- Telephone: (503) 378-5499
- Email: firstname.lastname@example.org
Additional information about this counselor or therapist is available on the Board’s website: www.oregon.gov/oblpct
As required by the Board, I have designated a custodian of records and filed their information with the Board. In the event that I am incapacitated due to death or disability, my custodian of records will retain my client files for the legally required amount of time and can provide copies of your files to you upon request.
Fees and Related Policies
Fee Payment: The client or client’s guardian is fully responsible for the payment of all fees. All fees must be paid in full at the beginning of each session using cash (exact amount in USA currency only delivered in-person), checks (made to Gresham Counseling and mailed by USPS to my PO box or delivered in-person), or select credit/debit cards (paid at the time of service or online via email invoice). Invoices for overdue balances are sent via email or USPS.
Information on checks, invoices, statements, receipts, credit/debit card transactions, and other hard-copy and electronic records of transactions may be viewed by anyone who has access to your financial accounts, documents, or electronic communications. If you are concerned about protecting your information regarding financial transactions for counseling, you agree to pay using cash only and avoid overdue balances.
Insurance and Employee Assistance Programs (EAP): I DO NOT accept or bill any client insurance claims or EAP claims, and I am NOT a contracted provider with any client’s insurance or EAP organization or plan. I can provide you with a Super Bill to submit to your benefits plan administrator for out-of-network reimbursement, but reimbursement is not guaranteed and may be a fraction of the total fee. Your benefits plan may require receipt of your clinical documents. I will not modify clinical documents or diagnoses to satisfy benefit plan requirements. You agree to pay all fees in full even if your benefits plan does not provide reimbursement.
Standard Session Fee: The Standard Session Fee is $80 for each 50-minute session or fraction thereof.
Sliding-Scale Session Fee: Upon request, a Sliding-Scale Session Fee may be charged instead of the Standard Session Fee if you are facing financial hardship and have an annual household income that is less than or equal to 200% of the United States Federal Poverty Level (FPL) in effect for the current calendar year.
The current and previous years guidelines can be viewed at the US Department Health and Human Services website https://aspe.hhs.gov/poverty-guidelines and are based on both household size (i.e. number of persons in a residence filing on a single tax return) and gross annual income (i.e. all income earned or received from any source in the calendar year, regardless of whether it is taxable under state or federal law, including interest, child support payments, alimony, disability income, unemployment assistance, sales of stocks and other property even if sold at a loss, dividends, Social Security income, business income, wages, and salary).
The FPL effective on 15 January 2020 for each household size follows:
1 person = $12,760; 2 persons = $17,240; 3 persons = $21,720; 4 persons = $26,200; 5 persons = $30,680;
6 persons = $35,160; 7 persons = $39,640; 8 persons =$44,120; for each additional person, add $4,480.
Your FPL percentage will be calculated by dividing your gross income by the FPL for your household size and multiplying by 100 (Gross Income / FPL for household size X 100 = FPL%).
The Sliding-Scale Session Fees are as follow (percentages are rounded to the nearest whole percent):
At or below 100% of the FPL = $40;
Between 101% and 140% of the FPL = $50;
Between 141% and 170% of the FPL = $60;
Between 171% and 200% of the FPL = $70;
Over 200% of the FPL = the full Standard Session Fee.
Clients using a Sliding-Scale Session Fee may pay higher fees, up to the Standard Session Fee, if they choose.
To calculate your FPL percentage, legal proof of income and number of dependents may be required and may include documents such as tax returns, payroll stubs, or benefits forms. Sliding-Scale Session Fees must be mutually agreed to in writing prior to the start of the session and updated at least annually.
Cancellations and Fees: Please provide at least 24 hours notice when cancelling an appointment. You will be charged a Late Cancellation Fee of $30 for every appointment canceled with less than 24 hours notice. If you cancel 2 sessions in a row and have a regular appointment time (e.g. the same appointment time each week), your future regular appointment times may be canceled.
Missed Appointments and Fees: You will be charged a Missed Appointment Fee equal to your usual session fee for every appointment you do not attend and do not cancel prior to the appointment time. No fee will be charged in cases of dangerous weather conditions, emergency office closures, and cancelations by the counselor. If you miss 2 sessions in a row without cancelling, all future appointments may be canceled.
Phone Call Fees: There is no fee for initial consultations via phone. For all other phone calls, you will be charged a Telephone Services Fee of $40 for calls longer than 15 minutes.
Record Copy Fees: You may request 1 free copy of your counseling records sent to you 1 time per year via electronic transmission or USPS. For additional requests, you will be charged a Records Copy Fee of $10 for each fulfilled request. There is no charge for records sent to other healthcare providers for continuity of care.
Declined Payment Fees: If any financial institution declines your payment by check, you will be charged a Declined Payment Fee of $30 for each declined payment.
Counselor’s Legal Tasks Fees: If I am subpoenaed or receive a court order to provide testimony or documentation for any legal case or proceeding in which you are involved, you will be charged a Counselor’s Legal Tasks Fee of $300 for every hour or fraction thereof that I spend in activities related to your case (e.g. testimony, records prep, etc.) plus the cost of any attorney fees, document processing fees, shipping and handling fees, or court fees I incur in such activities.
Counselor’s Travel Fees: If I am required to travel for any of your court or legal issues, you will be charged a Counselor’s Travel Fee of $300 for every hour or fraction thereof that I spend in travel time, including waiting time or overnight stays, plus any commercial or public transportation costs, vehicle fuel costs, lodging costs, insurance costs, tolls, taxes, parking, or other required fees I incur in such travel.
No Additional Fees: No additional fees will be added to the above set fees, and you will not be charged such additional fees.
Unpaid Balances: If you have an unpaid balance, the entire amount of the balance must be paid at the start of your next scheduled session. Otherwise, additional sessions will not be scheduled until the balance is paid. This is to avoid financial conflicts that can interfere with the egalitarian professional relationship and to model healthy boundaries in relationships. Exceptions may be made for emergencies or at my discretion. If you cannot afford to continue paying for sessions, I can refer you to lower cost counseling services.
Future Changes to Fees: Fees for services may increase or decrease in the future. In the event of any fee increases while you are actively receiving counseling services, you will be given at least 90 days notice prior to the fee change and will be required to sign an updated Professional Disclosure Statement and Counseling Services Agreement document or similar documents prior to continuing counseling services and being charged the increased fee. If you choose not to sign such documents and pay the new fees, your services may be terminated. Discounts on fees to allow for continued care may be granted temporarily at my discretion.
No Guarantees, Warranties, or Refunds: Receiving counseling services does not guarantee the alleviation of any disorder, symptom, or problem or guarantee any outcomes. No refunds shall be issued for any reason.
Referrals and Recommendations: If I provide you with referrals to other providers or recommend a product, you are responsible for acquiring and paying for any such products and/or services. There is no guarantee that other providers will provide services or products to you.
Other Policies and Information
Treatment of Clients under the Care of Legal Guardians: To ensure that a person is the legal guardian of a client, I may require legal documents to prove guardianship and to identify other guardians and custodians; such documents may include but are not limited to birth certificate, custody agreement, and court orders. To ensure that the client is able to discuss topics confidentially, I discourage guardians from requesting the client’s counseling information, including records, without the client’s consent. Clients under guardianship may refuse to participate in counseling even if the guardian wants the client to attend.
Maintenance of the Professional Relationship: To maintain a professional relationship, I establish and maintain professional boundaries with clients and do not knowingly engage in friendships, sexual or romantic relationships, social media relationships, or non-counseling business relationships with clients or their known immediate relatives. I do not attend client’s events (e.g. birthdays, weddings), accept gifts from clients, provide “favors” for clients, or accept favors from clients.
Communication Outside of Sessions: If I encounter you in public, I will typically attempt to avoid communication to protect your privacy unless doing so would be problematic, in which case I will attempt to limit communication to minimal amounts required in the interaction.
Email and text messages are not secure methods of communication and will only be used to discuss administrative issues, such as scheduling and payment issues or providing information to access your secure client portal. These messages may include, but are not limited to, my professional and business information, your name and contact information, appointment information, financial information, portal passwords, and links. You agree to secure access to the account of any email address you provide using appropriate security methods. When I make a phone call to the phone number that you provide, I may identify myself and my business and ask for you by name, and I may leave a message for you requesting a return call; if the call is answered by voicemail, I may, with your permission, leave a message and state information about my services.
Any issues of a clinical nature must be conducted via phone (including voicemail), a secured telehealth service, the secure messaging service in the client portal, or in-person. Secure messaging is for short text-based messages only and is not to be used for ongoing discussion or crises. Topics mentioned in secure messaging may receive only a minimal response and may be discussed in future sessions.
Appointment Availability: I offer a variety of appointment scheduling options during regular business hours, but appointment times available may not match your desired session frequency or schedule. If you are unable to attend sessions during the available appointment times or require a session frequency that is not available,you may be better served by a provider who can meet your scheduling needs.
Response Times: I typically respond to clients messages (e.g. voicemails, texts, secured messages, emails) within 2 business days (Monday-Thursday), but in some cases it may take longer. I may take multi-week vacations, get sick or injured, or have technical issues that cause me to be unreachable for extended periods of time. If you require responses sooner, you may be better served by a provider who can meet your response requirements. I do not provide crisis response or emergency services.
Emergencies and Crises: If you experience an emergency, you agree to call 911 or go to the nearest hospital emergency room. If you require urgent mental health services, you agree to call the Multnomah County Crisis Line at 503-988-4888, the Clackamas County Crisis Line at 503-655-6585, or the crisis line for your area or go to the nearest hospital emergency room. To promote your safety, if I receive a call from a healthcare provider, emergency responder, or an emergency contact person stating that you are experiencing a crisis or emergency related to your mental health, or if I contact your emergency contact person because you are in an emergency or crisis situation, I may provide the minimal confidential information required to to assist them in providing appropriate emergency/crisis care, and by signing this form, you consent to the release of such information.
Right to Refusal and Termination: You may refuse to participate in any intervention and may terminate services at any time. I may refuse to provide services to you and terminate the counselor-client relationship for reasons that may include, but are not limited to, if you require services I am not qualified to provide, request services I believe will not provide a significant benefit to you, miss or cancel multiple scheduled sessions, have unpaid fees, refuse to sign required documents, have not attended a counseling session in at least 6 months, harass or threaten me or persons I interact with personally or professionally, or have difficulty respecting the boundaries of our professional relationship. In some cases, reasons for termination may not be disclosed to you. I will attempt to provide you with referrals to other providers if you request them. I will attempt to notify you of termination via voice (e.g. phone) and/or written communication via email using the email address on file, secured client portal, or USPS to the mailing address on file unless you have not authorized or have requested not to receive such communications.
Services Not Provided: I do not provide services for court-mandated counseling, services required by civil agreements, sex-offender treatment, services for insurance or legal requirements, or letters for emotional support animals. If you require such services, you will need to seek services from a professional who provides them.
Legal or Court Issues: I do not wish to participate in any activities related to your court or legal issues. If I am required to testify or provide depositions or documents, the information I provide may not be in your favor and/or may be harmful to the therapeutic relationship. I will not modify testimony or documents to support any side of any legal argument. To promote confidentiality and protect the therapeutic relationship, you agree to not involve me in legal or court proceedings or attempt to obtain records for legal or court proceedings, including but not limited to issues such as divorce, custody, civil litigation, and criminal defense. You must notify me as soon as possible if you become involved or anticipate being involved in any legal or court proceedings.
Potential Consequences of Participation in Counseling: Change is often a difficult process with unforeseen outcomes. In the counseling process you may experience uncomfortable emotions and feelings, new symptoms, exacerbated or aggravated symptoms, or no change to symptoms and changes in relationships, career and academics, values and goals, beliefs, activities, and behaviors. There is no way to know with certainty how counseling will affect you and your unique circumstances. If you have concerns about the risks of counseling, please discuss these with me prior to consenting to counseling.
Potential Incompatibility with Counselor and Services Provided: Each professional counseling relationship is unique, and the effectiveness of the professional relationship depends on a combination of compatible personalities and treatment approaches. There is no guarantee that my approaches or personality will match your expectations or needs. If you feel uncomfortable working with me for any reason, you are encouraged to end counseling services with me and seek services from another provider who may have a personality or approach that is more compatible with your needs.
Other Treatment Options: Counseling is one of multiple methods for treating a problem, diagnosis, or symptom and promoting personal growth. You may require other services provided by other qualified professionals to achieve your desired outcome.
Other Documents Required: You may be required to complete other documents prior to or during your counseling services or to obtain records after termination of counseling services. Such documents include, but are not limited to Fee Agreements, payment authorizations, Authorizations for the Disclosure/Use of Personal Health Information, demographic information, biopsychosocial history forms, questionnaires about symptoms and experiences, Wellness and Safety Plans, Records Requests, and additional policy agreements.
Records Retention: Your counseling records will be retained for the minimum retention period required by law and will be destroyed after the required retention period.
Superseding Other Agreements: This document supersedes all prior written or oral agreements with respect to the content of this document.
Term of Agreement: This agreement shall remain in effect until you sign a new Professional Disclosure Statement and Counseling Services Agreement or similar agreement with me. If our counselor-client relationship is terminated, you will be required to sign a new Professional Disclosure Statement and Counseling Services Agreement to resume services. If provisions in this document are updated in a new Professional Disclosure Statement and Counseling Services Agreement or similar agreements, you will be required to sign such documents to continue receiving counseling services from me; otherwise, our counselor-client relationship will be terminated after a period of 90 days.
Severability: If any provision of this document should be determined to be void or unenforceable, the validity and effectiveness of the remaining provisions shall not be affected.
Verification and Consent to Treatment
For the remainder of this document, the words “I” and “my” refers to the person signing this document, and the “counselor” refers to Kristen B. Beck, MS, LPC.
My signature verifies that I have read, understood, reviewed, and agreed to the complete content of this document; have received a copy of this document either in print or digital format; have asked appropriate persons (e.g. the counselor, my insurance organization representative, my case worker, etc.) any questions I have about the information contained in this document; have been assisted by the counselor if I requested such assistance to ensure my understanding of the content of this document; have the legal authority to consent to treatment of the client; and am giving my informed consent for treatment of the client.
If this document is completed and signed in an electronic format, I consent and agree to the use of my electronic signature in lieu of paper signatures to electronically sign paperless documents required by Gresham Counseling and Therapy LLC, including this document, and will be bound to any documents electronically signed the same as if I had received a paper copy of the document and signed it by hand with an ink pen. I also consent to the collection of the IP address and any other identifying information of the device used in the signing of this document.