Annelise Heitman, M.Ed., LMFT

328 W Broadway, Eugene, OR 97401

Welcome! This document outlines your rights as a client and what you can expect from therapy. Please read this carefully and feel free to ask any questions you may have. ___________________________________________________________________________________

Therapeutic Expectations

The foundation of effective therapy is based in a relationship of trust, openness, safety, and respect. I understand therapy is a joint endeavor. The feedback I provide my therapist about what is helpful and not helpful is essential. Throughout therapy but particularly in the initial sessions we will assess the pace and style that will most likely meet my individual needs.

 

When suitable, Annelise may introduce exercises such as role playing, guided imagery, expressive movements, or interactive partner activities for couples. Annelise will provide a description of the activity and allow me the opportunity to decide whether or not I feel it will be comfortable and/or helpful to me.

 

I understand that therapy is a cooperative effort between Annelise and myself. I have been informed that therapy will at times involve discussing issues that may be distressing and that this process is intended to help me. I may experience changes in my relationships or temporary worsening of symptoms. I will also likely experience moments of greater personal awareness, insight, healing and celebration.

 

Many people find that meeting on a regular weekly basis, especially in the early stages of our work, gives a sense of consistency to the process. Therapy can be intensive and frequent, occasional and supportive, short or long term, and a place to return for further work down the road. I can consult with Annelise about frequency of sessions but understand that I am ultimately in charge of how often we meet.

 

Therapy has been shown to have significant benefits but it is important that my actions outside of therapy mirror the intentions I set in session. I understand that there are no guarantees the therapy process will work for me and if needed, my therapist will provide me with alternative referrals. Either Annelise or I can choose to end therapy at any time. This decision is best accomplished with mutual consultation. Likewise, it can be quite useful to have a closure session for completion and goodbyes. ___________________________________________________________________________________

Confidentiality

I understand that the work we do together is private. I can share with whomever I wish, but Annelise will not discuss our work with anyone without written permission from me, unless the situation fits the exceptions below. If I refer someone to Annelise, she will not confirm or deny any contact with that person, nor will she tell that person that she knows me. If we happen to see each other outside Annelise's office; at a social event or grocery store for instance – the decision to approach or acknowledge Annelise is up to me. She will not make the first move. I am welcome to greet her, keeping in mind that confidentiality becomes more complicated if either of us is accompanied.

 

Exceptions to confidentiality:

- Annelise will consult with colleagues, without revealing my identity when she believes it would be helpful to her work with me.

- In the case of joint/relational therapy, if Annelise believes that information discussed individually is essential to the relational therapy she will consult with me about ways to bring the information to the relational session.

- If Annelise has good reason to believe that I will harm another person, she must attempt to inform that person and warn them of my intentions. Annelise must also contact the police and ask them to protect the intended victim.

- Annelise is a mandatory reporter which means, if Annelise has good reason to believe that I am abusing or neglecting a child, vulnerable adult, or animal, or if I give her information about witnessing someone else who is doing this, she will inform the appropriate authorities. This includes disclosure of past or present sexual relations between someone 18 and over with someone under 18 or between two minors who are 3 or more years apart in age. This also includes physical violence occurring between adults in a home where minors are present.

- If Annelise believes that I am in imminent danger of harming myself, she may legally break confidentiality and call the county crisis team or police as well as my emergency contact person. If possible and appropriate, Annelise would explore all other options with me first. If at that point, I am unwilling to take steps to guarantee my safety, Annelise would have to take the necessary steps to help ensure my safety.

- If ordered by a judge to disclose information about my therapy, including my clinical file and session notes, Annelise will have to obey the order.

While it is her legal responsibility to disclose information in any of the above situations, it is Annelise's desire and ethical responsibility to help me through stressful times such as these. ___________________________________________________________________________________
Fees, Insurance, and Payment

• The fee for individual or couple’s sessions is negotiated on a sliding scale up to $195/hr based on client’s stated ability to pay. Groups will meet for up to 90 minutes for up to $75 per member per session. Payment in full is required at each session and Annelise can give a “superbill” weekly or monthly that I can submit to my insurance company for reimbursement. I am aware that insurance companies require a formal diagnosis to be assigned and sometimes require session notes and/or a treatment plan to be disclosed in order to ensure therapeutic services are “medically necessary”. I authorize the release of any information necessary to process my claims.

• If Annelise’s fee is ever a barrier for me, I'm encouraged to discuss this with her to see if other arrangements can be made. I understand that Annelise's fee may change with 30 days written notice to me. Returned checks for insufficient funds will incur a $30 fee.

• I understand that Annelise has a limited amount of appointments available per week and she will reserve one of those for me. If I miss an appointment or cancel with less than 24 hours notice, it is difficult or impossible for her to fill that spot and therefore I will be required to pay a $100 fee for the missed session. If this happens more than twice, I will be responsible for the full fee for subsequent missed sessions. Exceptions can be made for unavoidable emergencies such as hospitalization. Work conflicts and lack of childcare are not causes for exception. If I’m not feeling well, I understand telehealth is encouraged if possible, rather than cancelling. I understand my insurance company will not provide reimbursement for missed/cancelled sessions. If I miss or cancel up to 5 times in a year, Annelise will discuss this with me and may discontinue services with me. I understand that if I commit to attending a group I will be charged for even those sessions I miss unless I obtain prior approval from Annelise.

The “Email, Phone-calls and Letters” section below, outlines additional fees. ___________________________________________________________________________________
Limits to Treatment
- Annelise does not provide emergency services. Appointments will typically occur for 55-60 minutes on a weekly or bi-weeky basis unless other arrangements are discussed and agreed upon. I am encouraged to call 911 or the White Bird Crisis Line (541-687-4000) if an emergency arises between sessions.

- Annelise does not provide psychological evaluations, forensic evaluations (ex. collecting information in a legal proceeding) or expert testimony for the court in child custody, divorce proceedings, etc. If Annelise is subpoenaed to appear in court, even if called to testify by another party, I understand I will be required to reimburse her for a full days work at an hourly rate of $200, as well as for any time spent preparing or for additional expenditures incurred by her.

- Annelise does not provide medical evaluations or prescribe medication. If I am seeking these services, I may ask Annelise for a referral. ___________________________________________________________________________________

Email, Phone-calls, and Letters

- Emails can be an efficient way to provide Annelise with non-emergency information. I am aware that HIPAA policies prevent her from replying with therapeutic feedback via email because this is not a secure format for confidential communication. Her response will be reserved for the next time I meet with her in person.

- I am free to leave a message on Annelise's confidential voicemail at any time, day or night. Annelise checks for voicemail during her regular business hours Tuesday-Friday 9am-7pm. She will do her best to return my call within 24 hours of receiving it. Phone consultations that exceed 10 minutes per week will be billed at a prorated standard session fee and unfortunately insurance does not provide reimbursement for this service.

- Coordination of care can be an essential part of treatment. With my written consent, Annelise may make phone-calls or provide letters or documents to other necessary third-parties. If these services exceed 10 minutes per week I will be personally billed at the prorated standard session fee. Annelise will strive to keep these calls to a minimum however, quality of care is her top priority. __________________________________________________________________________________________

My Rights

• I understand that I have certain rights as stated by the Oregon Board of Licensed Professional Counselors and Therapists which are printed on Annelise's Professional Disclosure Statement.

• I have the right to considerate, safe, and respectful care without discrimination as to race, ethnicity, national origin, gender, sexual orientation, age, religion, size, ability, or source of payment.

• I have the right to be safe from sexual harassment or sexual contact.

• I have the right to review my records and request the release of that information to another professional.

• I have the right to ask questions, make decisions about my or my child's treatment, or disagree with

  Annelise at any time.

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  I have reviewed this information and been given a copy of my therapist's Professional Disclosure Statement and received the Privacy Practices Notice. My therapist has adequately answered all of my questions.

  I authorize Annelise Heitman, LMFT to provide therapy services. It has been my choice to request services from Annelise. I may terminate our work together at any time.

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Client Signature Date

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Guardian/s Signature/s Date

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Therapist Signature Date

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ANNELISE'S PRIVACY PRACTICES DOCUMENT