And the day came when the risk to remain tight in a bud was more painful than the risk it took to blossom.

 Max Wilson, LPC intern

PO Box · (503) 555-5555   

·maxwilsoncounseling@gmail.com

Professional Disclosure & Informed Consent Form

Approach to Therapy

I believe in the power of finding ways to rewrite our stories, align with our core self, and allow space for the wisdom we carry within us to be heard. Therapy can be a collaborative space to seek change, reconnect with ourselves, and forage for the core authentic self that is held within each of us. I believe we all have the ability to heal and grow from our sources of pain. I draw from theories such as Mindfulness, Internal Family Systems, Narrative, and Emotionally Focused philosophies.  I seek to bring myself into the counseling room, and in doing so I am culturally curious and aware.

I work from the belief that therapy can give us insight and meaning into our world in a way that helps foster growth and change as we let go of false assumptions and move towards a more authentic and holistic view of ourselves and the landscape that makes up our inner world. As a direct and engaged therapist I view therapy as a place to live in our present experience, show up as we are, and find awareness, choice, and growth in the life that awaits each of us.

Formal Education and Training

I hold a Masters Degree in Counseling from Portland State University.  The focus of my studies was on Marital, Couple, and Family therapy, and included specific course work in counseling theories, families and couples counseling, career and lifestyle planning, diagnosis and treatment, multi-cultural counseling, counseling youth, human development, foundations of substance abuse, and professional ethics. I have also completed the M.E.T.A/Hakomi training, an Applied Suicide Intervention Skills training, and an EFT core skills training focusing on couples/relationships.

I received my B.A. from Sarah Lawrence College with a focus on Art and Writing. Additionally, I received my M.F.A. in Poetry from the School of the Art Institute of Chicago. I use my background as an artist and poet to inform the way I view healing and the mind-body-spirit integration work that I feel can be an important route to healing.

Supervision

I am currently a registered LPC intern in private practice. As an intern, I am required to have supervised clinical hours. I am under clinical supervision of Pilar Hernandez-Wolfe, PhD, LPC, LMFT.

Code of Ethics

As a Counseling Intern, I will abide by Oregon Licensing Board’s Code of Ethics set forth in OAR Chapter 833, Division 60 and the Hakomi Institute Code of Professional Conduct and Ethics.

Client Bill of Rights

As a client of an Oregon Registered Intern or a Graduate Student Intern, you have the following rights:

·       To expect that an intern has met the minimal qualification of training and experience required by state law.

·       To examine public records maintained by the Board and to have the Board confirm credential of a licensee or intern.

·       To obtain a copy of applicable Codes of Ethics.

·       To report complaints to the Board.

·       To be informed of the cost of professional services before receiving the services.

·       To be free from being the object of discrimination on the basis of race, age, religion, marital status, gender, sexual orientation, gender identification or other unlawful category while receiving services.

·       To be assured of privacy and confidentiality while receiving services, as defined by rule and law.

If you want to contact the licensing board related to your experience of a client, their contact information is below:

Oregon Board of Licensed Professional Counselors and Therapists

3218 Pringle Road SE, #250, Salem, Oregon 97302-6312

Phone: (503) 378-5499

Email: lpc.lmft@state.or.us

Website: www.oregon.gov/OBLPCT

Confidentiality

Our work together is confidential. What you choose to discuss with me is private and protected by federal and state laws. Except under unusual circumstances, discussed below, I will not share anything we talk about with others unless I have your written permission to do so. Similarly, if it is helpful to exchange information with others, such as your physician, school or work personnel, or family members, I will explain the rationale and discuss which information I believe should be shared. If you agree that I can share this information, then I will ask you to sign a release of information form.

You may direct me to share information with whomever you chose, and you can change your mind and revoke that permission at any time. I will always act to protect your privacy, even if you give me permission in writing to share information about you.

Most information and records regarding you and your counseling are collected and stored in a secure, cloud based electronic health record system. It is password protected and meets HIPPA requirements for security and privacy.  Any written documents related to you or your counseling with us will be stored in a locked file cabinet temporarily, scanned and uploaded to your electronic chart, and then shredded. Only my supervisors and I have access to your file.

To provide the best possible support, it’s important for me to learn about your motivations for seeking therapy, your past experiences with therapy, your past and current relationships, and your future aspirations. Your honest answers will help create a partnership between us, oriented towards the specifics of your circumstances and what you would like to address. This process is central to the quality of our working towards your goals. I will welcome your continued feedback, questions or concerns throughout this process.

Exceptions to Privacy

It is important for you to know that some things, by law, cannot be kept private. They include the following:

·       If I firmly believe that you intend to harm yourself, I am required by law to inform other people who can help you to protect yourself.

·       If I am court ordered to testify in court, I may have to give information about you without your permission. If I am subpoenaed or receive a court order, I will make every effort to contact you. If you oppose release of information, a court may nevertheless order me to disclose information about you.

·       A non-custodial parent who wants to learn about their child’s counseling may have the right to review their child’s treatment record and to discuss their child’s care with me.

·       If you were to bring suit against me or the clinic, I may need to break confidentiality in a legal defense.

·       As a mandated reporter, if I learn that you have harmed a child or vulnerable adult, I am required by law to report this to authorities. I may inform family members, other health care providers or the police.

·       Oregon law does not require me to report your intention to hurt another person, but Oregon law allows me to tell the appropriate authorities if I believe this person is in clear and immediate danger.

·       These exceptions seldom occur, but it is nonetheless important for you to be aware of them. I encourage you to talk to me about any concerns related to privacy at any time in our work.

Fees

My fee is currently for 50-minute session individual session is $90 and for a 60 minute relationship session $120. Please be prepared to pay your fee at the beginning of each session. Since I am an intern I cannot accept insurance. I will provide a receipt upon request.

Cancellation Policy

 If you need to cancel or reschedule an appointment, please provide at least 24 hours’ notice. You may be charged the full appointment fee if you cancel less than 24 hours in advance.

What to Expect

It is important for us to find the type of relationship in working together that feels good for you. In doing so, it is important for me to learn about your past experiences, both with therapy in other relationships, and in your life. I will also

 I will invite you to work with a special kind of consciousness called “mindfulness.” This is a way of paying attention to yourself with curiosity, openness, and acceptance. It often means closing your eyes to focus your attention on your actual experiences in the moment. I may also offer suggestions for experiments to help you study what is and is not working in your life, create related emotionally corrective experiences, or explore ways to intentionally shift from disempowered, painful, limiting states of being into empowered, alive, preferred states of being.

Risk in Counseling

Counseling is not without risk. Some people experience an increase in feelings of stress, especially during the early stages of counseling. Some problems may seem to get worse before they get better. Exploring longstanding, deeply seated issues can sometimes initially seem to aggravate rather than help the issue, especially in couples and family counseling. Some people find themselves feeling emotions and having insights that are new and uncomfortable, sometimes leading to feelings of discouragement and thoughts of quitting counseling. Some people are surprised by how others in their lives respond as counseling progresses. These dynamics are natural and to be expected. You may also experience other unique consequences of counseling. I encourage you to talk with me about them as and if they occur.

Ending Counseling

I will do my best to provide effective therapy that meets your needs. However, if we determine that I cannot adequately help you, I will assist you in finding an alternative counselor. If at any time you have doubts about our work together, please talk to me about your concerns. You may terminate counseling at any time. Typically, termination occurs when your goals have been met, a conflict of interest arises, policies have been broken, or it becomes evident that you should be referred to another practitioner. I encourage you to talk to me about your inclination to discontinue before acting, however, so that we may explore the issues, implications of terminating, and bring closure to our work together.

Emergencies, Immediate Response Needs

Since we are not a crisis counseling service, in the event of a mental health emergency please call the Multnomah County Crisis Line at 503-988-4888, or call 911, or go to the emergency room of the hospital nearest you. If you feel that you might hurt yourself, go to the nearest hospital emergency room. In the event of a difficulty related to our counseling work that you need immediate support with, you may call the Clinic voice mail (503) 450-9999 and leave a confidential message. Please identify that you need a call back from me and leave a call back number. I will return your call within 24 hours.

Inclement Weather

We follow the Portland Public School inclement weather policies. If the weather or travel restrictions in your area make it dangerous or impossible to attend your counseling session, you will not be charged if you do not attend. Please call or email to let us know you cannot make it.

Contacting Me

You can reach me at 503-450-9999 x [127]. I will respond to you in as timely a manner as I can, and certainly within 48 hours. If you do not hear from me within 48 hours, please contact me again. Do not send text messages as I am not able to receive them.

For scheduling purposes only, you may email me at maxwilsoncounseling@gmail.com. Please do not share sensitive information via email with me, as I cannot guarantee confidentiality with email communication.

Though we may occasionally communicate by phone in support of your therapeutic process, the most effective way for us to work together is in person during your scheduled sessions.

Consent to Treatment

I have read and initialed and I understand the above information. I consent to participate in treatment and/or evaluation. I understand that I may refuse services at any time. In the development of my treatment plan, I will be informed of the risks and benefits, the availability of alternatives, and the consequences of withdrawing before treatment is complete.

Client Name (Printed)                                                                             

Client Signature                                                                           Date    

Client Name (Printed)                                                                             

Client Signature                                                                          Date     

Max Wilson                                                                                 Date