Alison Stawicki, MS, NCC

1603 NE 16th Ave  Suite C  Portland, OR  97232

503-329-4283

INFORMED CONSENT

My Credentials

I hold a Masters of Science Degree in Counselor Education with an emphasis in Community Mental Health Counseling from Portland State University awarded to me in August of 2006.  I am a Nationally Certified Counselor as accredited by the National Board for Certified Counselors, Inc as of April 2007.  I am an Oregon State Registered Licensure Board Intern under the Oregon Board of Licensed Professional Counselors and Therapists as of May 2007.  Part of the process of working towards my licensure includes that while a Board Intern I am under direct supervision of a Licensed Professional Counselor (LPC).  My supervisor’s name is Debbie Bensching, LCSW whom I meet with several times a month to discuss client caseload issues and concerns. 

Fees

My usual and customary fee for an individual 50 minute session is $60.  I offer a sliding scale based on need.  All fees are payable at the beginning of each session.  Failure to pay session fees at the start of a session will result in the immediate rescheduling of that session.  If financial hardship occurs which affects your ability to pay for counseling, I ask that you discuss this with me before choosing to cancel sessions in the hope that accommodations may be worked out. 

Cancellation and No Show Policy

Counseling is by appointment only.  You are responsible for keeping your own appointment and arriving on time.  In the event that you cannot keep your appointment, it is your responsibility to notify me 24 hours in advance and reschedule otherwise you will be charged the full session fee.  It is important for therapeutic progress to keep all scheduled appointments.  Frequent cancellations could result in the loss of services.  Arriving on time to your sessions is expected in order that you may fully benefit from counseling.  Sessions will end promptly 50 minutes from the scheduled start time.  Extending session time to accommodate for lateness will only occur at my discretion. 

Alcohol and Drug Policy

Alcohol and drugs can interfere with your counseling process.  Please refrain from using alcohol or drugs prior to your counseling appointment.  If I perceive that you are under the influence, I may terminate sessions at my discretion and charge the full fee for that session. 

About Counseling 

I believe that most clients have the ability to resolve their own problems with a counselor’s assistance.  Some people will need only a few sessions to achieve their goals; others may require months or even years of counseling.  Some may want to continue even after problems are addressed, in order to enhance their growth and well being.  I offer counseling services for varying lengths of time determined on a case by case basis depending on client need.

While I may offer tools for change and growth, it is your responsibility to use those tools.  You have the right to refuse any technique or negotiate modification of any technique that you believe may be inappropriate for you.  As a client, you have the right at anytime to discuss the positive and negative effects of counseling with me.

It is important that you are aware that there are risks involved in the counseling process.  You may experience interruptions in normal patterns, feelings, and social relationships.  In addition, some issues may worsen before they get better.  You are in complete control and may end your counseling relationship at any point.  Should you, or I, believe a referral is needed, I will make an appropriate referral.  It is your responsibility to pursue referrals and recommended resources.

Although counseling sessions and groups may be very personal, our relationship is professional rather than social.  Contact with me will be limited to individual counseling and/or group sessions occurring exclusively within the confines of my office space.  You will be best served if sessions concentrate exclusively on your concerns.  If I encounter you in public, in order to preserve your privacy, I will not acknowledge you or the nature of our relationship unless you have given me permission otherwise.  According to my professional code of ethics I am not permitted to accept personal gifts of any kind.

Emergencies

My schedule does not permit me to be on call 24 hours a day.  Therefore in any emergency please contact one of the 24 hour local crisis lines to speak to a trained counselor.  Multnomah County:  503-988-4888      Washington County:  503-291-9111 

Ethics and Grievances

All services will be rendered in a professional manner consistent with accepted ethical standards.  It is impossible to guarantee any specific results regarding your goals.  However, together we will work to achieve the best possible results for you. 

If you are dissatisfied with my services, please inform me.  If I am not able to resolve your concerns, you may report your complaint to my supervisor listed earlier.  If you still have questions or concerns, you can make a formal complaint to the Oregon Board of Licensed Professional Counselors and Therapists at 3218 Pringle Road SE #160, Salem, OR  97302-6312
 

Confidentiality 

Confidentiality is defined as keeping private the information shared between client and counselor.  It is important that you know that confidentiality cannot be guaranteed.  A statement signed by you is required before any information may be released to any person or agency with the following exceptions as required by law:

  1. Statements indicating that acts of abuse and/or neglect toward a child, disabled person, elderly, or otherwise vulnerable adult have been committed or there is intent to commit such acts
  2. Statements of any intention to harm oneself or to commit suicide or to harm or commit homicide with respect to a readily identifiable person
  3. When a court of law subpoenas information shared by you with me as your counselor
  4. Information that would facilitate treatment of a medical emergency
  5. Defense of claims brought against me or my practice by others
  6. Information provided for professional consultation with my designated supervisor
  7. Sexual exploitation, abuse, illegal, and otherwise unethical and unprofessional conduct by a mental health provider
  8. Authorized disclosure
  9. If you are a minor, access to your records by parents

When possible I will inform you of my need to share information regarding your case. 

Telephone Confidentiality 

In the event that I must contact you for the purposes of appointment cancellations or to give/receive information efforts are made to preserve confidentiality and safety.  Please list where I may reach you by phone and how you would like me to identify myself.

If this information is not provided below I will use the contact information provided on your client information document and will identify myself by first and last name.
 

Preferred Telephone Contact Number:____________________________________________________
 

How Would You Like Me to Identify Myself:______________________________________________
 

Consent Agreement 

I have read and understood this consent form and have had an opportunity to have my questions answered.  I agree to the above limits of confidentiality and understand their meanings and ramifications.  I voluntarily enter myself into non- residential counseling services with Alison Stawicki, MS, NCC.  It is without any pressure or coercion that I sign this consent.
 

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Client’s Printed Name                                    Client’s Signature                                             Date

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Clinician’s Printed Name                              Clinician’s Signature                                       Date