Brandeis J. Zaklan, M. Ed.

School Counseling & Marriage and Family Therapy Certification Anticipated 2013 Member of the ASCA American School Counselors Association and CSI Chi Sigma Iota Counselor & Academic Honor Society 615 SW Harrison Suite # 506 Portland, Or 97207 541-497-3202 CLIENT INFORMATION AND AGREEMENT FOR COUNSELORS IN PRIVATE PRACTICE

I am pleased that you have chosen me as your counselor. This document is in keeping with the standards of practice for the State of Oregon Board of Licensed Professional Counselors and Therapists, and was designed to inform you about my background and to insure that you have a clear understanding of our therapeutic relationship. It is my belief that the therapeutic relationship between counselor and client is a very personal one, consisting of authentic shared interaction between two people; the most crucial aspect of this relationship is trust. To assist in facilitating this trust, I want to share with you my professional beliefs, background, and most importantly your rights as my client. Please, read this statement prior to our first session. I am a graduate level student in my first year of a Master Level School Counseling program at Portland State University. I am currently completing my practicum - clinical supervised courses to prepare me for the challenges and demands of the therapeutic relationship. The graduate program I am completing is accredited by the Council on Accreditation of Counseling and Related Education Programs (CACREP). My approach to therapy is eclectic. I prescribe to the Humanistic approach of unconditional positive regard, empathy, and genuineness, while utilizing a variety of other theories including Cognitive behavior strategies such as direct teaching of skills and assigning homework to help you become more mindful of who you are to achieve the goals we have developed for you during the course of our therapeutic alliance. I also believe that humor when utilized appropriately is a positive therapeutic tool. I whole heartedly believe in the inherent dignity and value of each individual and the unique role that individual plays in the world. All clients will be treated with respect for their cultural background, religious views, and sexual orientation. People seek therapy for many different reasons; regardless of those reasons the therapeutic relationship is a joint effort and cannot be successful without your hard work, energy and courage. Therapy sessions will provide a safe environment for you to explore your thoughts, feelings, your reactions to yourself, and others. Just as you have the right to decline or accept any suggestions of the therapeutic approach, you also have the right be informed of any potential risks. Typical risks in therapy include, but are not limited to; uncomfortable feelings of guilt, anxiety, anger or frustration. It is also important you to understand that during the process of changing, current relationships may become strained because of your personal growth. However, keep in mind that our mutual goal is to increase your sense of authenticity, you learning to trust your inner voice, and increasing your congruency between actualizing self (ideal self) and your real self. The path to self-awareness varies for each client, and the pace of therapy will be determined by you. Together we will evaluate your progress and determine how will need to meet to achieve your goals. After our initial meeting I may find it necessary for you to visit a physician to rule out any biological causes for your distress before continuing forward in the counseling process. In the case of issues or concerns beyond my scope of competence, I will make every effort to refer you to more qualified professionals. Additionally, I may recommend therapy groups or alternatives to counseling, such as books, and nutritional or exercise therapy. My counseling services are limited to the scheduled sessions we have together. Should the situation arise that you find yourself in emotional crisis or that your mental health requires emergency attention, you should proceed to the nearest hospital emergency room or dial 911 if you are unable make your way to the hospital, and request mental health services. In order to create the trust necessary in a positive therapeutic alliance our sessions will be very intimate; it is important for you to recognize that our relationship is one of a professional nature, rather than a personal one. Please, do not invite me to social gatherings, give me gifts, or ask me to relate to you in and way outside of our therapeutic relationship. If you see me out in public, with respect for your confidentiality I will not initiate contact. As part of the equality of the therapeutic alliance created during our sessions, you will learn a great deal about me. However, it is important that you remember that you are experiencing me only in my role as a professional counselor. My counseling practice is limited to clients seen during practicum at the clinic, and while under the supervision of a licensed professional therapist. Pursuant to the expectations outlined in the Code of Ethics for Licensed Professional Counselors and Therapists outlined by the state of Oregon, at all times I will take seriously the responsibilities of a professional counselor, with your client welfare in mind and ensuring I do no harm, while acting with integrity, and protecting your confidentiality. I will keep confidential everything and anything that you tell me, unless any of the following apply: 1) You specifically direct me to tell someone else, 2) I determine that you are a danger to yourself or others, 3) I am ordered by the court to disclose information, or in keeping with ORS 192.518(2) and 675.765(1), unless otherwise ordered by the court; parents shall have access to the client records of juveniles who are receiving professional services from the licensee; 4) ORS 676.150 Reporting Obligations, 5) ORS 676.160 676.1;80 Processing Complaints Against Health Professionals, 6) ORS 676.205 - 676.230 Continuing jurisdiction of health licensing boards, 7) ORS 419B.005-419B.050 Child Abuse Reporting, 8) ORS 124.050 - 124.095 Elder Abuse Reporting.

At any time you are dissatisfied my services for any reason, please let me know. Should you find that I am unable to adequately resolve your concerns, you may report your complaints to Dr. Temperance Brennan, my supervisor here at the PSU Clinic, or to the State of Oregon Licensed Professional Counselors Board of Examiners: 3218 Pringle Rd. SE, Suite 250 Salem, OR 973026312; 503-378-5499; or online at lpct.board@state.or.us. I do not currently hold a license, but am under the license of my supervisor and his license is #: 12345678888. The fee for counseling services at the PSU Clinic is $15 per each 50 minute session. While I can assure each counseling session will be conducted with the utmost professionalism and adherence to the code of ethics, I cannot guarantee any specific results regarding your counseling goals. The fee for each session will be due prior to the session beginning. Cash, cashiers checks, money orders, or personal check s are acceptable forms of payment. Receipts for all fees paid will be provided upon payment or as requested. Appointments must be cancelled 24 hours in advance or you will be responsible for payment in full for the missed session. If you are utilizing some type of managed healthcare plan that covers the services offered here at the PSU Clinic, your copay will need to be paid at the beginning of the session and the remaining fees will be billed to your insurance. Keep in mind that some insurance plans only reimburse for a limited number of visits per year, and should you exceed that limit, you are welcome to continue to receive services from me, but you will be solely responsible for the entire cost of each session for all visits exceeding the maximum number of visits allotted you. Most health insurance companies will reimburse clients for counseling sessions, some wont. I will be glad to complete any necessary forms related to your reimbursement provided you by the insurance company. The reimbursements should be directed to you, and not assigned to me. It is your responsibility to know your insurance providers policy on this issue. Health insurance companies may require me to diagnose your mental condition indicating you have an illness prior to them agreeing to reimburse you. Should a diagnosis be required, you should know that I will provide the least damaging diagnosis possible to the insurance company and will inform you of the diagnosis I intend to submit, prior to doing so. I also want you to understand that the diagnosis is only a descriptive title to communicate a diagnosis, and that you are not your diagnosis. You have the right to terminate my services at any time, and I reserve the right to terminate services for the following reasons: 1) Counseling is done, not helping, or harming, 2) I feel I am at risk, 3) You have not paid for my services, 4) I am impaired and unable to provide you counseling. In the event that I should terminate my counseling services, I will work with you to refer you to someone else and provide you with as much advanced notice as possible. Please, feel free to list any questions you have and bring them with you to your first visit. I will be sure to address all of your questions and concerns. Consent for Treatment By signing below, you indicate that you have read this disclosure, that your questions have been answered and that you understand the above information. Your signature also indicates that you are consenting to receive counseling services. Acknowledgement of Notice of Privacy Practices My signature indicates that I have received a separate copy of the HIPAA Notice of Privacy Practice and had an opportunity to ask any questions I may have. Video or Audio Recordings of Sessions I understand that the therapy sessions at the PSU Clinic will be recorded so they may be reviewed and discussed with the supervisor, and in order to help my counselor facilitate better understanding and increased knowledge of the therapeutic process. Grievance Process I have read and understand the grievance process. Client Rights, Responsibility and Confidentiality My signature attests that I have read, and fully understand my rights as a client as outlined in the Client Bill of Rights from the Code of Ethics (OAR 833-060-0020(13)), as well as my responsibilities. Additionally I am aware of the limits of confidentiality.

___________________________________Client Signature

_________________________________Date

___________________________________Counselor Signature

__________________________________Date