Download Treatment Disclosure - Celeste Doneen, LCSW, CADCIII

Treatment Disclosure
PAYMENT:
Payment/co payment is due at the end of every session unless other arrangements are made.
Insurance:
Clients are responsible for knowing their insurance benefits, specifically co pay and deductibles. I
will submit a bill to a client’s insurance company for payment, however if a claim is denied for any
reason the client is responsible for my hourly fee which is a $100.00 an hr.
Cancellation:
Please inform me of a cancellation notice at least 24 hours in advance to avoid being charged for
the missed session.
Confidentiality:
All information disclosed within sessions, including that of minors is confidential and may not be
revealed to anyone without written permission except where disclosure is permitted or required by
law. Disclosure may be required in the following circumstances:
1.
When there is a reasonable suspicion or report of child or elder abuse.
2.
When the client communicates a threat of bodily injury to self or others.
3.
When a client is suicidal.
4.
Physical injury due to violence.
5.
When disclosure is required pursuant to a legal proceeding.
*I receive regular consultation with a licensed practitioner and/or colleagues. In such cases your
name is not revealed and specific details that could reveal your identity are limited.
EMERGENCY PROCEDURES:
I am not available after hours for clients. If an emergency should arise, you can access a 24 hour
clinician at the Multnomah County Crisis Line 503.988.4888.
• Please initial that you understand I am not available after hours for mental health
emergencies _______________
COMMUNICATION PROCEDURES: There are many convenient ways to communicate.
I
am open to text message and emailing for scheduling purposes. These methods are not confidential
and the content of the message is not securely protected. Please initial the following statements if
you agree to the following statements:
1. ___OK TO SEND INVOICES, STATEMENTS, FINANCIAL INFORMATION BY EMAIL
2. ___OK TO USE TEXT MESSAGE TO SCHEDULE/CANCEL APPOINTMENTS
3. ___OK TO COMMUNICATE VIA EMAIL email address________________________________
CONSENT FOR TREATMENT:
I, _____________________________, authorize and request that Celeste Doneen LCSW, CADC III,
provide assessment, treatment, and/or diagnostic procedures during the course of my care. The
frequency and type of treatment will be decided between Celeste Doneen and me.
• I understand that the purpose of these procedures will be explained to me and subject to my
verbal agreement.
• I understand that there is an expectation that I will benefit from psychotherapy but there is
no guarantee that this will occur.
• I understand that maximum benefit will occur with consistent attendance and that at times I
may feel conflicted about my therapy as the process can sometimes by uncomfortable.
• I understand that If a minor child is the client receiving therapy, the responsible party
signing this consent to treatment form has to be a custodial parent or legal guardian.
• I understand that if both parents of a minor child have joint custody, only one signature of
the said minor child is required to consent for treatment.
• I have read and fully understand the above statements. By signing below, I am giving my
consent for treatment outlined in this disclosure:
Client Signature:__________________________________ Date:_______________________
Parent/Guardian:__________________________________ Date:_______________________