Professional Disclosure Statement

Capstone Counseling, LLC

Please correct the errors described below.

Philosophy and Approach:

My role as a counselor is to be a facilitator. I believe that all families and individuals have within themselves resources and strengths that can promote healthier lives. Some circumstances or crises can exhaust people’s emotional and physical coping resources, necessitating outside assistance. I believe both counselor and client play a vital and equal role in the restorative journey. Within that partnership, a mutual agreement of goals is developed. My approach focuses on helping clients become aware of unhealthy patterns in order for change to occur, promoting a more fulfilling life and loving relationships. This journey may worsen symptoms before improving. Unpacking unresolved conflicts or strained or ruptured relationships can be painful. A discussion with your Primary Care Physician (PCP) may be advisable to rule out a medical issue as the cause. You may feel it beneficial for me to communicate with your PCP. If you so desire, you may sign a written consent form for me to confer with your PCP.

Number of Visits: The number of sessions needed depends on many factors. We can discuss this following the completion of your initial evaluation.

Therapy Sessions: If you arrive late, we will have less time in which to work, and progress may be delayed. I will keep track of time and remind you when the session is about to end.

I voluntarily agree to receive mental health assessment, care, treatment, or other services authorized considered necessary and advisable by Johnnie C. Burt, LPC.

I understand that I will be asked to participate in the development of a mutually agreed-upon treatment plan

I understand that if I am unable to contact Johnnie C. Burt, LPC in an emergency, I will follow my crisis plan or I will call the 24-hour crisis and information hotline at: (503) 585-4949, and in case of emergency I am to call 911

I understand that I am obligated to inform Johnnie C. Burt, LPC if I am in any way dissatisfied with the services she is providing.

Legal Issues: In order to protect confidentiality and the treatment relationship, it is my policy never to participate in any legal proceedings involving current or former clients. This means that I will not testify in cases of divorce, child custody, workers’ compensation, competency, or any other legal actions.

I understand and agree by signing this form, I will not to involve Johnnie C. Burt, LPC, in legal/court proceedings, or to attempt to obtain records of treatment for legal/court proceedings. that I will not involve in legal/court if I am in any way dissatisfied with the services she is providing.

Education, Training and Experience:

I hold an interpreting certificate in American Sign Language and obtained a Bachelor’s Degree of Psychology & Special Education from WOU. I hold a Master’s Degree in Counseling from George Fox University. I am a trauma-informed therapist with training in Eye Movement Desensitization and Reprocessing (EMDR), FLASH EMDR, tapping, neurofeedback, sand tray therapy and play therapy.

Confidentiality/Ethics Statement

As a Licensed Professional Counselor in Oregon and a Mental Health Counselor in Washington, I will abide by the state code of ethics as well as the ethical codes of my national associations. To maintain my licenses (C2305 & LH 60278516) I am required to participate in annual continuing education. Confidentiality is key for the therapeutic relationship. All counseling is confidential, including minors over fourteen years old. Any information shared in the counseling session is private and will remain in the therapy room. Possible exceptions to confidentiality include, but are not limited to, the following situations: suspected child abuse, suspected abuse of elderly or disabled individuals, suspected sexual abuse, when the client communicates threat of harm to self or others, when a third party communicates to the therapist that a patient is threatening harm to self or others, when insurance company requests information, is ordered by the court, or filing of a complaint to the board. Please bring to my attention any questions about confidentiality so that we can discuss the matter further.

Rights of patients include but not limited to being able 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; 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, religion, gender, or other protected category while receiving services. (Oregon Board of Licensed Professional Counselors & Therapists 3218 Pringle Road SE, #120, Salem, OR 97032-6312 503-378-5499 http://www.oregong.gov/oblpct)

I understand state laws require Johnnie C. Burt, LPC, to report to the appropriate agency any suspected physical, emotional, sexual, child, or elder abuse or neglect.

I understand Johnnie C. Burt, LPC, reserves the right to intervene with the proper authorities if she learns of someone’s specific intent to harm himself/herself or to harm someone else.

I understand that in the event that Johnnie C. Burt, LPC, becomes incapacitated or dies, it will become necessary for another therapist to take possession of my file and records.

Reporting information may be required in court proceedings or by client’s insurance company or other relevant agencies;

I understand that Capstone Counseling, LLC and KOT Books, LLC will need to be provided information to obtain payments from my health insurance or other payee.

Payment for Service: Fee Schedule

Intake/Assessment (60 min.) Individual Session (30 min.) Individual Session (45 min.) Individual Session (60 min.) Family Session Psychotherapy Crisis (1-60 min) Psychotherapy Crisis (additional 30 min.) EMDR (90 min.)

$185.00 $85.00 $150.00 $175.00 $175.00 $185.00 $85.00 $260.00

I understand the Fee Schedule

As a courtesy, Capstone Counseling, LLC and KOT Books, LLC, will bill your insurance for you. It is your responsibility to verify coverage, deductibles, co-pays, and any needed physician referrals. You are responsible for your portion of the fee. Any payments and/or co-pays are required at each session.

I must provide 24-hours’ notice of cancellation or be charged $60.00

I authorize the office of Capstone Counseling, LLC to release any information necessary to expedite insurance claims, including diagnoses. Some insurers may also require assessments, treatment plans, and/or the full text of my chart.

I will notify Johnnie C. Burt, LPC, of any change in my health insurance, employment, or contact information

** Consent to Treatment: I hereby consent to treatment for myself and/or my minor child by Johnnie C. Burt, LPC. I have reviewed the contents of this document and agree to comply with all of its provisions. I understand all charges involved in these services will be my responsibility, and I have had an opportunity to ask questions about billing, fees, office policies and my rights to privacy. Revised 1/1/18

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