Information for Clients
Licensed Counselor Disclosure Statement

You are requesting to enroll in a program or obtain services from Tom Wilson Counseling Center Incorporated, which is directed and managed by Thomas A. Wilson, M.A., a State Licensed Clinical Professional Counselor. The following information is provided in accordance with Idaho Code:

Name of Counselor: Thomas A. Wilson, M.A., L.C.P.C.

Business Address: 514 So. Orchard, Suite 101, Boise, ID 83705; Phone (208) 368-9909; Fax: (208) 388-1687

Degrees: B. A. Psychology, 1968; M.A. Psychology 1971- St. Mary’s University, San Antonio TX.

1. The Idaho Counselor’s Licensing Board, through the Idaho Bureau of Occupational Licenses is responsible for licensure of counselors within then State of Idaho. State Licensure does not imply or constitute an endorsement of that counselor nor guarantee effectiveness of treatment.

2. Confidentiality

a.  Information provided by and to a client during therapy session is legally confidential if the counselor is a licensed counselor, or reasonably believed by the client to be so, and the communication was not intend to be disclosed to a third persons, except persons present to further the interest of the client or participation under the direction of the counselor. If the information is legally confidential, the counselor cannot be forced to disclose the information without the client’s consent.

b.  Information disclosed to licensed professional counselor is a privileged communication and cannot be disclosed in any civil or criminal court proceeding in Idaho without the consent of the client. However, under Idaho Rules of Evidence 517 (d), there is no privilege for the following acts:

Civil action, case or proceeding by one of the parties to the confidential communication against the other.

Proceedings for guardianship, conservatorship or hospitalization as to communication relevant to an issue in proceedings for the appointment of a guardian or conservator for a client for mental illness or to hospitalize the client for mental illness.

Child related communications - In a criminal or civil action or proceeding as to a communication relevant to an issue concerning the physical, mental, or emotional condition, of or injury to a child, or concerning the welfare of a child including, but not limited to the abuse, abandonment or neglect of a child.

Licensing Board proceedings under Idaho Code 54-3404. Contemplation of a crime or harmful act. If the communication reveals the contemplation of a crime or harmful act.


3. FEES and REFUND Policy: You are financially responsible for all charges related to and for the counseling services provided. All fees paid for services are non-refundable whether paid by you or by a third party.


The following is a list of Fees I charge for Services:

Online Classes:

·  Online DUI Class: $150.00

·  Online Alcohol and Drug Class: $150.00

·  Online Relapse Prevention Class: $150.00

·  Online Anger Management Class: $150.00

·  Defensive Driving & Traffic Safety Class: $49.00

In-Person Classes

·  Anger Management Classes: $120/8 hours, $240/16 hours

·  Domestic Violence/ Batterer Treatment: $480/32 hours, $780/52 hours, $1560/104 hours

·  Alcohol/Drug/DUI Classes $10.00 per hour.

·  Makeup/Missed class fee: $25.00

·  Class Re-enrollment Fee: $75.00

Evaluations & Misc.

·  Alcohol/DUI Evaluations: $125.00

·  Drug/Substance Abuse Evaluations: $150.00

·  Domestic Battery Evaluations: $300.00

·  Risk to Child/Anger Evaluations: $300.00

·  Individual Face-to-Face or Phone Consultation: $150.00 per hour

·  Consultations and Court Appearances: $100.00 per hour

·  Expedite fee for Evaluations $50.00

·  Correspondence other than completion certificates $100.00 per hour.

·  Additional Copies of Reports, Certificates or Correspondence $5.00 per page

INSURANCE: I accept most insurance and will submit claims to your insurance company. You are responsible for providing proof of insurance enrollment, paying your co-pay and meeting your deductible. Insurance billing & payment services are handled by a contracted billing service.

4. Therapeutic Approach

a.  I use group and individual educational techniques to help clients make positive changes in behavior. You will be participating in a group setting where you are required to conform to group rules, and will be discharged if you do not comply with group rules. You have the right to discontinue treatment at any time, but you should be aware there may be legal or other consequences for not completing a course of treatment.

b.  I also offer Internet-based counseling and classes for individuals who are experienced in using the internet, have access to the internet, and understand the risks of using the internet. Internet classes have certain risks and benefits much different than face-to-face counseling. Please click this link to access "Information and Informed Consent for Internet-based Clients."

5. Counselors are required to adhere to the Professional Code of Ethics adopted by the Idaho Counselor Licensing Board.

Client Signature Date Counselor Date