Susan J. Bramlette, LMFT 1/1/09

CascadeCrestProfessionalCenterFlandersMedicalBuilding

108 SE 124th Ave2250 NW Flanders St. #310

Vancouver, WA98684Portland, OR97210

(503) 956-5144 (503) 956-5144

FAX: 360.254.3926Fax: 503.229.0176

A. Professional Disclosure Statement and Policies

Welcome…thank you for choosing us to help address your healthcare needs today.An intake appointment mayrequire60 –75 minutes, as needed, while later appointments are generally50 minutes in length. Beginningtherapyisamajordecisionandyoumayhavemanyquestions. Please feel free to askandwewilldoourbesttogiveyouinformation on practice policies, state and insurance law, and your private healthcare information rights.

We honor your time and Thank You for your patience when waiting.

Appointments can run up to ten minutes after when a prioremergency mandates.

50-minute Sessions beginning at ten minutes after will complete on the Hour.

Sessions beginning on the Hour will Complete at ten minutes ‘til to allow for Appointment-setting, co-pay receipt, and smooth transition.

Preparation of your copay is greatly appreciated.

Susan Bramletteearnedamastersdegreein Marriage and Family TherapyattheUniversityof Oregon and NorthwestChristianCollege, Eugene, OR. SheislicensedbytheStatesofOregon, Washington, andIdahoand treats adolescents,adults,andfamiliesusingindividualandfamilytherapy resources. She is a clinical member of the American Association of Marriage and Family Therapists (AAMFT.org) and a member of Psi Chi, the American Psychological Association Honor Society.

As an LMFT of the Oregon State Board of Licensed Professional Counselors & Therapists and the Washington Department of Health Service Professionals, I abide by the Code of Ethics of:

Oregon Board of Licensed Professional
Counselors and Therapists
3218 Pringle Road SE Suite 250
Salem, OR97302-6312
(503) 378-5499

and the Washington Department of Health Service Professionals ()

Client Name:______and Contact Preferences

May we contact you at home yes/ no? (circle one) At work yes/ no? (circle one)

By cell phone yes/ no? (circle one) Via email______yes/ no? (circle one)

Best contact method/place/time? ______

B. Communication: An Open Therapeutic Approach

Your counselorpractices systemic, Bowenian Intergenerational andcognitive-behavioraltherapyformost presenting problems, while eclectic treatmentapproachesare alsoresourced when needed. Between-session assignments help speed progress toward reaching your goals.Treatmentpractices,philosophy, orlimitationsandrisksof therapy maybediscussed in early sessions. Feel free to communicate your preferences and comfort level to Susan at any time.

Business matters may be attended to before or after session.Finding the correct “fit” with a healthcare provider is always the first step, so it’s important to address questions early on andalso feel free to discuss your changing needsat any time throughout the therapeutic season.

C. Confidentiality, Notice of Privacy Practices, and Client Rights

Yourverbalcommunicationandclinicalrecordsareheld in strict confidence,except when:a) information(date of service, etc.)is sharedwithourstaff toexpedite your insurance billings,b)informationissharedwithyourinsuranceprovider in ordertoprocessyourclaim,c)informationprovided by youand/oryouchild/elderdisclosesphysicalorsexualabuse, which byOregon, Washington, and IdahoStateLawIamrequiredtoreporttotheDepartmentofChildrenandFamilyServices,d)yousignareleaseofinformation requestingtohavehealth care informationshared with physicians, disability insurers, specific others,or,e)youprovideinformationthatinformsmeyouareindangerofharmingyourselforanother, f) informationnecessaryforcasesupervisionorconsultationand/or,h)when disclosure is requiredbylaw.

Records are retained for seven years. Request for access to stored records in transitional situations may be made through Dr. James Boyer, P.C., LMFT, at 503.224.3522.

______I/we have read and understand this Notice of Privacy Practices and Client Rights.

D.Emergency Situations

In anemergencysituation wheretheclientorhis/herguardiandeems thatimmediateattention is necessary, contacttheemergencyservicesinthecommunity(911) immediately.Susan Bramlette willfollow uptheseemergencyserviceswithcounselingandsupporttotheclientand/or yourfamily in a timely manner, as you request.Please advise usas soon as possible at503-956-5144 after obtaining emergency care.

Emergency Contact:______Telephone:______

______(initial)Permission is given to contact the above individual to discuss treatment needs deemed emergency in nature. Client preferences:____________

__) telness telephone to Linda, our Health Information Specialist.

E. Coordination of Treatment/ Prescribing Physician

If you wouldliketo authorize permissiontocommunicatewithyourprimarycarephysicianand/orpsychiatrist, please indicate below.Your consent is valid for one year or until such time as consent is revoked in writing.

____Youmaynotify my physician(s) ____Ideclinenotification of myphysician at this time.

Current Medications:______

Prescribing Physician’sName/Specialty:______

Clinic/City:______Telephone or FAX:______

F. Financial/InsuranceInformation

Insurance providerswith whom we have current contract agreements are:

MHN Managed Health NetworkEAP ConsultantsODS

NEAS EAPDefinity Deer Oaks

Cigna Behavioral HealthAPS EAPPBH (Providence)

MBH Magellan (single case)Value Options/ GreatWest/Nike

Tricare/TriwestNDBH New Directions HumanaCare

UBH United Behavioral HealthThe Holman Company BH

EAP Preferred Pacificare Health Corp. Services/Adidas

Please ask concerning other insurancesassingle-case agreements are sometimes available. For more information on insurance or financial matters, feel free to consult with your therapist.

Insured clients please call the number for Behavioral/Mental Health or EAP Serviceslisted on your insurance card for instructions, providingthe following information:

  1. Client and Insured’s identification/Group/Authorization information.
  2. Insurance Company, type (EAP or Mental Health benefit), Date of Authorization Start, Deductible/Deductible satisfied? Please bring your card to the first session.
  3. Information given by your insurance company about number of sessions now authorized, authorization number,co-payment requirements, as well as the specific billing address and telephone number.

If you have not met your deductible,insurance rate fee is due at each session until the deductible is satisfied. My deductible is $______. It is not satisfied/satisfied (circle one).

My copay is: ______.My payment today is:______.

Please advise immediately of any changes to your insurance plan or benefits.Thanks.

G. Fee Schedule for Services

As a courtesy we will bill your insurance or third-party payor for you, then advise of denied claims. We ask that you pay your copay or non-insurance session fee at the start of each visit.

Individual Appointment (90806, 50 minutes):$ 90.

Intake Appointment (90801, 90 minutes):$125.

Couples, Family Therapy (90847, 50/70 minutes):$125./165.

Group Therapy (90853, 90 minutes)$ 30.

Calls/Letters/Forms Requested by Client $50.

Missed Appointment Fee (billed via Paypal)$20.

Prepaid Block/ Ten Sessions$750.

Payment/checks should be made and/or mailed to Susan Bramlette, LMFT, 2250 NW Flanders St. #310, Portland, OR97210. Thank you.

WE ACCEPT PAYPAL VISA OR DEBIT PAYMENTS, invoiced via Email (convenient for HSA accounts) Preferred email:______.

Your fees can be paid by Visa or Debit card at:

______(initialed) Client Agreement:If my insurance company denies payment of my claim for any reason, I accept responsibility to forward balance due at thetime of statement or phone tomake arrangements for payments.After 60 days an unpaid balance on my account I will be charged 2% invoicing fee a month on remaining fees due. I am responsible for any fee charged to our office by an outside agency to collect the payment owed.

______(initialed) Iunderstand my anticipated fees for therapy and/or I will contact my provider with any questions about fees. (Please initial. Thanks!)

H. LATE CANCELLATION POLICY

______(initialed) IfIneedtocancelorrescheduleanappointment,I willgive24hoursadvancenotice at: 503.956.5144 or pay the missed appointment fee of $20. via email request on Paypal.

Wesincerelyappreciateyourcollaboration with these policies.

Please discuss any questions you may have regarding the information in this disclosure statement with Susandirectly in session, or callduring business hours at the number above.

I understand this statement. I give permission to begin treatment with Susan Bramlette, LMFT.

Signature______Date______

Signature______Date______

Client Questions:

______

Consent for Treatment of Child/ Adolescent:

I/We consent that______may be treated as a client of Susan Bramlette, LMFT. At times it maybe necessary to schedule appointments during school hours. We ask for your cooperation to provide timely treatment for you and your children. [Please note: both parents should consent to treatment where possible and have the right to be informed of treatment outcomes and the welfare of the child except as a court rules otherwise.]

Signature______Mother / Date______

Telephone/best time:)______

Signature______Father /Date______

Telephone/best time:______Signature______Guardian /Date______