Gail Hardman-Woung, LCSW
3939 NE Hancock Suite 210 Portland, OR 97212
Phone: 503-314-8591 Email:
Please keep a copy of the document for your records
This form has been prepared to help clarify some important issues. Please read the following information carefully and feel free to ask any questions prior to signing.
PSYCHOLOGICAL SERVICES
Psychotherapy can have benefits and risks, as it often involves discussing unpleasant aspects of your life. You may experience uncomfortable feelings such as sadness, guilt, anger, frustration, loneliness, or helplessness. However, therapy has been shown to have many benefits including better relationships, solutions to specific problems, and significant reductions in feelings of distress.
I have a strong commitment to be useful to you as a therapist. I appreciate all feedback about how the process is going for you and what would enhance it. Your active and responsible participation in the therapeutic process is essential for maximum progress.
APPOINTMENTS AND CANCELLATIONS:
An appointment reserves a specific time for you. Please notify me at least 24 hours in advance if you need to cancel or reschedule your appointment. Otherwise, you will be billed for the missed appointment and responsible for the full fee; except in cases of illness or other unforeseeable circumstances.
TELEPHONE AND CRISIS CONTACTS:
If you need to reach me by phone please call me at 503-314-8591. Phone consultations of less than 10 minutes duration are generally at no cost, unless there is a need for frequent calls. Regular phone sessions are billed at the rate of $180.00 an hour. I do not have receptionist coverage so you will likely need to leave a message on my voice mail. I attempt to return all calls as soon as possible. In a mental health emergency when you cannot reach me, you should call the Multnomah County Crisis Line at 503-988-4888 or the Clackamas County Crisis Line at 503-655-8555.
FEES AND INSURANCE COVERAGE:
The fee for an intake interview is $250.00. This session is 60 minutes in length. Individual sessions 60 minutes in length cost $180.00. Family sessions are 45 minutes in length and cost $150.00. I am accepted by most insurance companies and bill them as a courtesy. However, the ultimate responsibility for payment is yours. Please check your benefits prior to our appointment.
I am only able to bill one insurance company. If you have coverage from two companies, payment is expected at the time of your initial claim. I am happy to provide a receipt for submission to a second company for reimbursement.
Overdue balances will accrue a late fee at the rate of 20% per 60 days past due. The fee for a returned check is $25.00. There is a $50.00 fee if your account must be sent to collections. If you have any questions or concerns about my fee, please discuss these with me. Efforts will be made to provide a workable payment schedule.
PROFESSIONAL CONSULTATION:
To enhance my services, I regularly participate in consultation with colleagues or specialists. These consultants are bound by the rules of confidentiality. To further ensure privacy, client’s identities are never disclosed. If you have any concerns about such consultations, please discuss them with me.
CONFIDENTIALITY:
Apart from the exceptions listed below, the information you share with me in therapy will be kept private and will not be released to other parties without your written permission.
Under these certain circumstances, I am mandated by law to break confidentiality:
· When information is shared indicating acts of child or elder abuse.
· When statements indicate suicidal or homicidal intentions.
· When subpoenaed to testify in court.
· When information would assist in a medical emergency.
If exceptions to confidentiality arise, it is my policy, whenever possible, to first inform you of the necessity to disclose information and to do this in a way that is maximally responsive to your needs and concerns. In cases of family therapy, expectations between family members should be discussed and negotiated on an individual basis. It is my policy to release files and or information regarding minor children, upon receiving the signatures of both parents.
For more information, see the document titled: Notices of Privacy Practices
I have read the above statement and understand my rights and responsibilities. I understand that there can be no absolute guarantee of cure in the practice of therapy. I understand my rights to confidentiality as well as the limitations.
I have received a copy of the Notice of Privacy Practice.
I consent to the electronic and paper submission of treatment plans, Mental Health Assessments, and Treatment Notes, if they become required by my insurance company. The electronic submission may be in the form of email, fax, or online submission through the insurance company’s site.
Client name: ____________________________________ DOB: ________________________.
Client’s signature: ______________________________________
Guardian’s’ signature: _____________________________________________________.