What is this? / Tweet this?

Professional Disclosure Statement & informed Consent

Icahn Saelao, Registered LPC Intern
1312 E. Burnside
Portland, OR 97214
(971) 303-8470
isaelao@icloud.com
Professional Disclosure Statement
Philosophy and Approach: I believe that true realization of self is derived from the
moment one realizes the whole is other than the sum of the parts. My approach
to counseling involves empathy, loyalty, and insight. I believe in feeling things
deeply and responding to them through inner knowing and curiosity. I use
evidence-based practices in order to evoke thoughts and feelings previously
disavowed or rejected.
Formal Education and Training: I hold a Master’s of Science in Counseling,
Marriage and Family Therapy option from California State University of Fresno. I
also hold a Bachelors of Arts in Psychology with Certification in Applied Behavior
Analysis. Major course work included an emphasis on family systems theory,
group therapy, and Adlerian Therapy.
As an Intern registered with the Oregon Board of Licensed Professional
Counselors and Therapists, I abide by its Code of Ethics . As an intern, I am
supervised by Karen Hixson, a Licensed Professional Counselor, which I will be
happy to explain.
Fees & Cancellations: My fee for an minute initial consultation session is $50.00,
every 50 minute session thereafter will be $85.00. For people undergoing
financial hardship, the flat rate will be $50.00 per session, however I would prefer
more. Sessions last 50 minutes. At this time I am unable to bill insurance, however
would be glad to provide documentation & receipts if your insurance offers
reimbursement for counseling. At this time I only am able to accept out-of-pocket
pay in the forms of checks and cash. I am willing to enter into payment plans
without interest as long as the payments are made on time. If you miss a session
without canceling, or cancel with less than twenty-four hours notice, you must
pay for that session at our next regularly scheduled meeting. Two late cancels or
no shows within a 3-month period will result in termination of counseling and a
referral to another provider, or suspended until the matter that prevents
attendance is resolved. Insurance will not pay for missed appointments. I am
away from the office several times in the year for extended vacations or to attend
professional meetings. I will tell you well in advance of any anticipated lengthy
absences. If you are experiencing an emergency when I am out of town, or
outside of my regular office hours, please call the Crisis Clinic at 503-988-5464. If
you believe that you cannot keep yourself safe, please call 911, or go to the
nearest hospital emergency room for assistance.
As a client of an Oregon registered intern, you have the following rights:
Page 1 of 6
Icahn Saelao, Registered LPC Intern
1312 E. Burnside
Portland, OR 97214
(971) 303-8470
isaelao@icloud.com
∗ To expect that a licensee has met the 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;
∗ 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 because of age, color, culture, disability,
ethnicity, national origin, gender, race, religion, sexual orientation, marital status,
or socioeconomic status.
You may contact the Board of Licensed Professional Counselors and Therapists
at
3218 Pringle Rd SE, #250, Salem, OR 97302-6312 Telephone: (503) 378-5499
Email: lpct.board@state.or.us Website : www.oregon.gov/OBLPCT
For additional information about this counselor or therapist, consult the Board’s
website.
Page 2 of 6
Icahn Saelao, Registered LPC Intern
1312 E. Burnside
Portland, OR 97214
(971) 303-8470
isaelao@icloud.com
Informed Consent and Confidentiality Agreement
Medical Concerns: I cannot recognize or diagnose medical conditions. It is
recommended that you obtain a medical examination to determine any medical
origins for your psychological problems, neurological disorders, endocrinological
disorders, side effects of medication etc. Not being a medical doctor, I cannot
prescribe medication but will refer you for psychiatric consultation if this appears
to be indicated. ____________initial
Assessment: Counselors and therapists must conduct both an initial and ongoing
assessment to understand your psychological needs. It is essential that you
cooperate by completing all forms requested. Please be completely open and
honest about your symptoms. I can only help you with your problems to the
extent of the information you provide. ____________initial
Confidential Therapy
The content of your sessions will be held confidential. I cannot release any
information or confirm or deny that you are in counseling without your written
consent. Confidentiality from Third Parties Counseling and therapy is confidential
from parties with important exceptions:
1) Information may be released to designated parties by written authorization of
clients or legal guardians.
2) When you seek reimbursement for therapy/counseling from insurance
companies or other third parties, information, including psychological diagnosis,
and in many cases, explanations of symptoms and treatment plans, and in rare
cases, entire client records, must be provided to the third party. If health
coverage is provided, employers could possibly have access to such information.
Insurance companies usually claim to keep psychological diagnosis confidential,
but may enter this information into national information data banks where it may
be accessed by employers, other insurance companies etc. It may limit your
future access to disability insurance, life insurance, jobs, etc. I can provide you
with copies of reports submitted to insurance companies at your request. They
are required by law to adhere to HIPPAA regulations of confidentiality.
____________initial
3) I am required to release information obtained from collateral sources, other
individuals involved in your counseling/therapy to which such disclosure may
help to advert danger to any psychotherapy client or others. This can include
imminent risk of suicide, homicide, abuse of a child or a disabled or elderly
Page 3 of 6
Icahn Saelao, Registered LPC Intern
1312 E. Burnside
Portland, OR 97214
(971) 303-8470
isaelao@icloud.com
person, and destruction of property that could endanger others. Counselors and
therapists are required to report when you are at imminent risk of a life
threatening danger. This includes suicidal or homicidal intent or action,
suspected past or present abuse or neglect of children, adults and elders, and
children being exposed to domestic violence. I am required to report to the
authorities including DHS and law enforcement based on information provided
by you and/or collateral sources. ____________initial
If you are required to undergo counseling as a result of a court order or mandate
from DHS or probation departments, I may be required to provide all notes of
your therapy and contact with collateral sources in response to a court order or
legitimate subpoena. I do not provide any recommendations for child custody,
settlement cases or other legal issues. ____________initial
As a counselor and counselor educator, I often consult with other professionals
on cases and teach about the psychotherapy process. I disguise identifying
information when doing so. Please indicate if you wish to place restrictions on
consultation or teaching related to your case. ____________initial
Professional Records : The Oregon Board of Counselor and Therapists requires
that I keep treatment records. I am required to keep your records for 7 years. At
the completion of 7 years, I have your records destroyed via a confidential
recycling facility. Your documents are shredded. I am present and witness this
event. I have notified the Oregon Board of Counselors of my contact person in the
event of my death or an illness that prevents me from managing my affairs.
Professional records can be misinterpreted and/or upsetting to untrained
readers. You are entitled to receive a copy of your records. I charge copying
costs of $2.00 per sheet for professional time spent responding to information
requests. Your records will be provided within 30 days of your documented
request. Your record includes a copy of the signed informed consent form,
acknowledgment of receipt of privacy policies and practice, progress notes, and
any release of protected health information and copies of your bill. Paper records
are kept in a locked file cabinet in a locked office. ____________initial
Emergencies: I am on call 24 hours a day and seven days a week. I am not
always immediately available by phone. It is imperative that you always leave a
message on my voice mail with a phone number I can reach you at. Please call
(503) 588-2113. If it is a life or death situation or you or another person is in a
severe mental health crisis, CALL 911 or go to the nearest hospital emergency
room. If you are a Salem resident, you may also call the Psychiatric Crisis Center
Hotline at 503-585-4949 24 hours a day to speak with a Crisis Counselor. Lake
Oswego and Clackamas clients may call the Clackamas Crisis Line at
Page 4 of 6
Icahn Saelao, Registered LPC Intern
1312 E. Burnside
Portland, OR 97214
(971) 303-8470
isaelao@icloud.com
503-655-8585 24 hours a day to speak with a Crisis Counselor. In the event that I
am ill, on vacation, or at a location where telephone access is unavailable, I will
provide you with backup numbers of alternative counselors or therapist you may
call. ____________initial
Counseling and Therapy Contract : I have read the above information, have
asked questions as needed and understand the issues related to risks and
benefits of therapy and counseling, medical concerns, assessment,
confidentiality, collateral contacts with others, professional records,
confidentiality form third parties, alternative treatments, lengthy of therapy, fee
for therapy emergencies and cancellations.____________initial
Length of Counseling or Therapy: Some problems can be alleviated in just a few
sessions. Other problems require longer treatment. It is often difficult to predict
the length of therapy needed. The decision to terminate therapy belongs to you
or at the therapist’s recommendation. If termination occurs before adequate
treatment has been achieved, I will provide you with referrals to other providers
upon your request or you may choose to find your own therapist.
____________initial
Social Media, Email, Texting : I do allow clients to contact me through email at
isaelao@icoud.com. It is not, however, a forum for discussing very serious issues
or counseling. Therefore, you can expect brief responses from me until we can
talk on the phone or at your next session. I do allow you to text me, however, I will
not use texting as a means to discuss counseling issues. Texting should be
reserved for appointment issues or minimal communication. You will need to
identify on your intake form if I can contact you by email or texting and accept
and understand the confidentiality limitations in doing so. I do not Friend or add
any clients to LinkedIn accounts, Facebook, etc. ____________initial
Contact Outside of the Office: As your counselor, I am obligated to do my best at
keeping our relationship professional and confidential. Therefore, I will not accept
invitations to weddings, birthdays, etc. Additionally, if we run into each other in
the community, I typically will not acknowledge you because of confidentiality
reasons. I do not accept gifts from clients as I do not want you to feel obligated in
anyway. I appreciate the kindness and generous thoughtfulness, but a verbal or
written “thank you” is more than enough and means a great deal to me. Page 4 of
5 Termination of Counseling You may terminate counseling at anytime. Primarily,
termination of therapy is usually a collaborative agreement. As your counselor, I
may choose to terminate counseling with you as a result of lack of attendance, or
if I have reason to believe you should be referred to another professional, if I am
finding that your needs are out of my scope of service or for other ethical reasons
Page 5 of 6
Icahn Saelao, Registered LPC Intern
1312 E. Burnside
Portland, OR 97214
(971) 303-8470
isaelao@icloud.com
set forth by my licensing board. I will provide you with a list of 3 names or
agencies you may contact to transfer care or you may contact your insurance
company or find other providers of your own choosing. If you are absent from
counseling for over 30 days and wish to return, it may require a new intake
assessment. ____________initial
Counseling and Therapy Contract: I have read the above information, have
asked questions as needed and understand the issues related to risks and
benefits of therapy and counseling, medical concerns, assessment,
confidentiality, collateral contacts with others, professional records,
confidentiality form third parties, alternative treatments, lengthy of therapy, fee
for therapy emergencies and cancellations.____________initial
I agree to treatment based on my informed wish to proceed.
________________________________
__________________
Client Signature Date
________________________________
__________________
Icahn Saelao, LPC Intern Date
Page 6 of 6