Andrew Rose, LCSW
Professional Counseling Services
Licensed Clinical Social Worker – OR: L7190 CA: LCS23396
(503) 547-4695 www.AndrewLCSW.com
PRIVATE PRACTICE POLICIES & INFORMED CONSENT TO TREATMENT AGREEMENT
This agreement is made between Andrew Rose (referred to as "therapist" herein), and client (as signed/submitted after the client has read this agreement).
Welcome to my psychotherapy practice. This document contains information about the policies of my practice as they relate to our therapeutic work together. My training and education includes:
Cancellations: If you need to reschedule or cancel an appointment with me for any reason, I request that you provide me with at least 24 hours advanced notice. If you miss a session and you do not provide me with at least 24 hours advanced notice, you will be charged my full rate for your missed session (except in cases of serious and unexpected emergencies). If you are late for your session, your session will still end at the regularly scheduled time. Please note: I have a three “no shows” policy; this means that if you “no show” three times without notifying me, then we will discuss ending counseling with me and referrals to other counselors as needed.
Professional Fees: My professional fee is $100 per each 50 minute counseling session, payable by PayPal.
For clients using EAP coverage, you will receive a limited number of sessions which will be fully funded by your EAP service. We will discuss the option of continuing counseling with me after your EAP sessions have been used. However, there is no obligation to continue counseling with me after your EAP session are used.
Confidentiality/Privacy Practices Policies: Law generally protects the confidentiality of all communications between a client and their counselor/psychotherapist, and all written records are also protected by law. I may only release information to others about our work together with your written permission, except when used for treatment/payment/health care operations - which includes billing EAP for covered services. There are a few exceptions to confidentiality as stipulated by law, which can require my disclosure about you and our work together. While these situations are rare, it is important that I inform you of the following exceptions to confidentiality:
Couples Counseling “No Secrets” Policy: If you and your partner work with me for couples counseling, and you communicate anything with me outside of the session time, this information will be considered part of the couples therapy and will need to be discussed during our joint couples counseling sessions.
Consultation: There are times when my consultation with other professionals is beneficial to providing the best client service possible. Clients' names and identifying information are never mentioned, and client anonymity and confidentiality is fully maintained.
Limits on the Intent of Treatment: I do not engage in treatment services for the purpose of custody evaluations, immigration evaluation, mediating divorce/separation disputes or for the purpose of making recommendations regarding placement, custody or caregiver competency. I also do not provide assessments for disability applications or hearings. If you have concerns or questions about any of these topics, please address them immediately with me for future clarification. I would be happy to suggest the type of professional who might better assist you in any of these topics.
Emergencies: You are welcome to leave me a message at any time. However, I am not always available to call you back immediately. If you have an emergency requiring immediate attention, please call 911, or go to the emergency room. If you are experiencing an emotional crisis then you can call the national crisis suicide hotline at 1-800-273-8255 as needed. Please also call and inform me of the emergency or crisis, and I will do my best to call you back as soon as possible.
Ending Treatment: In general, ending counseling is usually a joint decision between client and therapist. If you decide to end or take a break from counseling please discuss the reasons with me, so we can create closure and discuss any other possible referrals. If you stop attending our sessions without notice, I will attempt to contact you. If I am unable to reach you I will assume (unless other arrangements have been made) that you have chosen to terminate counseling with me.
Disclaimer: The therapist reserves the right to refuse service to anyone whose needs are beyond therapist scope of practice. The therapist will offer referrals to qualified practitioners whenever possible, should he be unable to provide services.
Personal Responsibility and Release of Healthcare Related Claims: The client acknowledges that he or she takes full responsibility for their own life and well-being and all the decisions made during and after the period of counseling. The client releases the therapist from any and all liability, damages, causes of action, allegations, suits, sums of money, claims and demands whatsoever, in law or equity, which the client ever had, now has or will have in the future against the therapist.
If the terms of this agreement are acceptable to you, please electronically sign the acceptance below. By doing so, the client acknowledges that they have read and understand, accept and agree to abide by the terms of this agreement.
Signed and Agreed by: Andrew Rose, LCSW
Professional Counseling Services
Licensed Clinical Social Worker – OR: L7190 CA: LCS23396
(503) 547-4695 www.AndrewLCSW.com
PRIVATE PRACTICE POLICIES & INFORMED CONSENT TO TREATMENT AGREEMENT
This agreement is made between Andrew Rose (referred to as "therapist" herein), and client (as signed/submitted after the client has read this agreement).
Welcome to my psychotherapy practice. This document contains information about the policies of my practice as they relate to our therapeutic work together. My training and education includes:
- Masters in Social Welfare, UC Berkeley – received in 1998
- Licensed Clinical Social Worker, California Board of Behavioral Sciences – received in 2006
- Licensed Clinical Social Worker, Oregon Board of Licensed Social Workers – received in 2016
Cancellations: If you need to reschedule or cancel an appointment with me for any reason, I request that you provide me with at least 24 hours advanced notice. If you miss a session and you do not provide me with at least 24 hours advanced notice, you will be charged my full rate for your missed session (except in cases of serious and unexpected emergencies). If you are late for your session, your session will still end at the regularly scheduled time. Please note: I have a three “no shows” policy; this means that if you “no show” three times without notifying me, then we will discuss ending counseling with me and referrals to other counselors as needed.
Professional Fees: My professional fee is $100 per each 50 minute counseling session, payable by PayPal.
For clients using EAP coverage, you will receive a limited number of sessions which will be fully funded by your EAP service. We will discuss the option of continuing counseling with me after your EAP sessions have been used. However, there is no obligation to continue counseling with me after your EAP session are used.
Confidentiality/Privacy Practices Policies: Law generally protects the confidentiality of all communications between a client and their counselor/psychotherapist, and all written records are also protected by law. I may only release information to others about our work together with your written permission, except when used for treatment/payment/health care operations - which includes billing EAP for covered services. There are a few exceptions to confidentiality as stipulated by law, which can require my disclosure about you and our work together. While these situations are rare, it is important that I inform you of the following exceptions to confidentiality:
- - If a client presents a danger to self, others, or is gravely disabled, I may be required to take protective action including notifying the police, notifying the potential victim(s), notify the client's family or emergency contacts, or seeking appropriate hospitalization for the client.
- - If there is reasonable suspicion of abuse or neglect of a child, dependent adult, elder, or person receiving mental health treatment - I am required to report this to the appropriate agency.
- - If there is a court order or other legal requirement to disclose information about you and our work together.
- - If you tell me about the behavior of a health or mental health care provider, which informs me that this provider has either a. engaged in sexual contact with a patient, include yourself or b. is impaired from practice in some manner by cognitive, emotional, behavioral or health problems, then the law requires me to report this to their licensing authorities.
- - If any of the above situations occur, I will attempt to discuss them, and actions I take, with you.
Couples Counseling “No Secrets” Policy: If you and your partner work with me for couples counseling, and you communicate anything with me outside of the session time, this information will be considered part of the couples therapy and will need to be discussed during our joint couples counseling sessions.
Consultation: There are times when my consultation with other professionals is beneficial to providing the best client service possible. Clients' names and identifying information are never mentioned, and client anonymity and confidentiality is fully maintained.
Limits on the Intent of Treatment: I do not engage in treatment services for the purpose of custody evaluations, immigration evaluation, mediating divorce/separation disputes or for the purpose of making recommendations regarding placement, custody or caregiver competency. I also do not provide assessments for disability applications or hearings. If you have concerns or questions about any of these topics, please address them immediately with me for future clarification. I would be happy to suggest the type of professional who might better assist you in any of these topics.
Emergencies: You are welcome to leave me a message at any time. However, I am not always available to call you back immediately. If you have an emergency requiring immediate attention, please call 911, or go to the emergency room. If you are experiencing an emotional crisis then you can call the national crisis suicide hotline at 1-800-273-8255 as needed. Please also call and inform me of the emergency or crisis, and I will do my best to call you back as soon as possible.
Ending Treatment: In general, ending counseling is usually a joint decision between client and therapist. If you decide to end or take a break from counseling please discuss the reasons with me, so we can create closure and discuss any other possible referrals. If you stop attending our sessions without notice, I will attempt to contact you. If I am unable to reach you I will assume (unless other arrangements have been made) that you have chosen to terminate counseling with me.
Disclaimer: The therapist reserves the right to refuse service to anyone whose needs are beyond therapist scope of practice. The therapist will offer referrals to qualified practitioners whenever possible, should he be unable to provide services.
Personal Responsibility and Release of Healthcare Related Claims: The client acknowledges that he or she takes full responsibility for their own life and well-being and all the decisions made during and after the period of counseling. The client releases the therapist from any and all liability, damages, causes of action, allegations, suits, sums of money, claims and demands whatsoever, in law or equity, which the client ever had, now has or will have in the future against the therapist.
If the terms of this agreement are acceptable to you, please electronically sign the acceptance below. By doing so, the client acknowledges that they have read and understand, accept and agree to abide by the terms of this agreement.
Signed and Agreed by: Andrew Rose, LCSW