Professional Disclosure Statement

Janine DeBacker, MA, LMHC
601 Main Street, Suite 300
Vancouver, Washington 98660
971.222.6924
Professional Disclosure Statement and Informed Consent Agreement

Welcome to my practice. This document contains important information about my professional services and business policies. Please read it carefully and jot down any questions you might have so that we can discuss them at our next meeting. When you sign this document, it will represent an agreement between us.

Education
I have a Bachelor of Art in psychology from Wichita State University and a Bachelor of Science in nursing from University of Kansas. I have a Master of Art in counseling from George Fox University. I am a Licensed Mental Health Counselor in Washington state.

Counseling Services
Psychotherapy is not easily described in general statements. It varies depending on the personalities of the counselor and client, and the particular problems you bring forward. I may use many different methods to address your concerns. Counseling calls for a very active effort on your part. In order for the therapy to be most successful, you will have to work on things we talk about during our sessions and at home.

Counseling may have benefits and risks. Since therapy often involves discussing unpleasant aspects of your life, you may experience uncomfortable feelings like sadness, guilt, anger, frustration, loneliness, and helplessness. On the other hand, therapy has benefits for people. It often leads to better relationships, solutions to specific problems, and significant reductions in feelings of distress. However, there are no guarantees of what you will experience.

Our first few sessions will involve an evaluation of your needs. By the end of the evaluation, you and I will prioritize your goals and consider a possible treatment plan. You should evaluate this information along with your own opinions of whether you feel comfortable working with me. Therapy involves a large commitment of time, money, and energy, so you should be very careful about the therapist you select. If you have questions about my procedures, we should discuss them whenever they arise. If your doubts persist, I will be happy to help you set up a meeting with another mental health professional for a second opinion.

Appointments
I normally conduct an evaluation that will last from 1 to 2 sessions. During this time, we can both decide if I am the best person to provide the services you need in order to meet your treatment goals. If therapy is begun, I will usually schedule one 45-minute session per week at a time we agree on. Once an appointment hour is scheduled, please provide 24 hours advance notice of cancellation. If you do not give me 24 hour notice, you will be personally responsible for the fee of the session, unless we both agree the circumstances were beyond your control. If you do not have a scheduled appointment, and it has been over 60 days since our last therapeutic session, our client/therapist relationship will be terminated. If you want to see me at a later date, please call and set up for an intake session.

Contacting Me
I am often not immediately available by telephone. If you leave a message on my phone, I will make every effort to return your call within 24 hours. If you are difficult to reach, please inform me of some times when you will be available. If I will be unavailable for an extended time, I will provide you with the name of a colleague to contact, if necessary. In case of emergency, please call 911 or the Vancouver Crisis line at 360.696.9560.

Professional Records
The laws and standards of my profession require that I keep treatment records. You are entitled to receive a copy of your records, or I can prepare a summary for you. Because these are professional records, they can be misinterpreted and/or upsetting to untrained readers. If you wish to see your records, I recommend that you review them in my presence so that we can discuss the contents.

Professional Fees and Payment
My fees are $80 for a 45-minute session, or copay along with your insurance coverage. Payment by cash or check is due at the time of service. I do have a sliding scale, if financially necessary.

Confidentiality
In general, the law protects the privacy of all communications between a patient and a counselor. I can only release information about our work to others with your written permission. Exceptions exist.

• In most legal proceedings, you have the right to prevent me from providing any information about your treatment. In some proceedings involving child custody and those in which your emotional condition is an important issue, a judge may order my testimony if the issues demand it.

• Legally I am obligated to take action to protect others from harm, even if I have to reveal some information about a patient’s treatment. For example, if I believe that a child [or an elderly person or disabled person] is being abused, I must file a report with the appropriate state agency.

• If I believe that a patient is threatening serious bodily harm to another, I am required to take protective actions. These actions may include notifying the potential victim, contacting the police, or seeking hospitalization for the patient. If the patient threatens to harm himself/herself, I may be obligated to seek hospitalization for him/her or to contact family members or others who can help provide protection.
Client Rights
I abide by the legal and ethical code of the Washington State Board of Health Counselor Licensing Program and you have protections defined through state regulation and administered by the Department of Health. If you have concerns they should be brought up with me immediately. You may also report any concerns you have to the board at the following address:
Department of Health, Counselor Programs
Post Office Box 47869
Olympia, Washington, 98504-7869

Informed Consent
Your signature below indicates that you have read the information in this document, consent to treatment, and agree to abide by its terms during our professional relationship. Your signature indicates that you have received a copy of this Professional Disclosure Statement and Informed Consent Agreement, and the Notice of Privacy Practices (HIPPA).

Client’s Signature: ___________________________ Date: ___________

Therapist’s Signature: _________________________ Date: ___________