Alison Stawicki, MS, NCC

1603 NE 16th Ave  Suite C  Portland, OR  97232

503-329-4283

Please read the following Professional Disclosure Statement carefully.  It will inform you about my background and therapeutic approach as well as your rights as a client.  In order for therapy to be most effective, it is important that you make an informed commitment to our work together.  After you have read this form and the following Informed Consent Form carefully, please ask me any questions you have before you sign them.  Your signature indicates that you have received this information and understand the services I provide.

Philosophy and Approach:  I believe that therapy is a “team effort” between therapist and client.  My role as the therapist is to aide my client in tuning in to their inner wisdom and unlocking their innate ability to grow and heal.  I seek to aid my clients by facilitating the creation of awareness of the needs that drive clients’ behaviors.  My work is grounded in an eclectic theoretical orientation; drawing significantly upon Interpersonal and Gestalt theories, Internal Family Systems, Hakomi techniques and mindfulness, and a Humanistic approach.  My approach seeks to recognize the client in the context of their social environment and personal relationships.  I believe that individuals take part in repeated patterns of behaviors that can at times serve unhealthy needs.  I strive to help the client understand their role in these interactions, discover what needs are being met by these behaviors and/as well as whether these needs are healthy while validating the clients’ fears and strengths.  I see insight and awareness as the key to total wellness.
 

Formal Education and Training:  I completed my masters degree in counseling with an emphasis in Community Counseling at Portland State University in 2006.  This program is accredited by the Council for Accreditation of Counseling and Related Programs (CACREP).  My coursework focused on a foundation in all theoretical orientations in the following areas: family systems, mental health, addictions, group, and multicultural counseling; career and lifestyle planning; assessment; ethics; treatment planning; human development.  I have also completed several trainings in grief and bereavement counseling, domestic violence, and Hakomi therapy and mindfulness training.

I hold a Bachelors of Arts in Sociology from the University of Wisconsin-Madison.
 

Supervisor Information:  I am currently a state registered intern under the supervision of Debbie Bensching, LCSW (503-944-5032).   If you have any questions regarding this I will be happy to explain the details of this training requirement.
 

Hours and Session Length:  I hold office hours on Mondays, Thursdays, Fridays, and Sundays.  Appointments required outside these hours may be arranged under special circumstances with adequate notice.  Sessions are 50 minutes in duration.  It is important for therapeutic progress to keep all scheduled appointments.  If you are unable to attend a scheduled appointment, please notify me with at least 24 hours notice.  Failure to appear at a scheduled session without notification of cancellation will result in being charged the agreed upon usual and customary fee for that session.
 

Fees:  My usual and customary fee for a 50 minute individual session is $60 payable in cash, check, or money order.  All fees are due at the beginning of session.  Failure to pay session fees at the start of a session will result in the immediate rescheduling of that session.  I offer a sliding fee scale in times of financial need that will be determined during the initial session between client and therapist.
 

As an Oregon registered intern under supervision of the Oregon Board of Licensed Professional Counselors and Therapists, I will abide by its Code of Ethics

As a client of an Oregon registered intern under supervision you have the following rights:

  1. To expect that a registered intern has met the minimal qualifications of training and experience required by state law:
  2. To examine public records maintained by the Board and to have the Board confirm credentials of a registered intern;
  3. To obtain a copy of the Code of Ethics
  4. To report complaints to the Board;
  5. To be informed of the cost of professional services before receiving the services;
  6. To be assured of privacy and confidentiality while receiving services as defined by rule and law, including the following exceptions: a) Reporting suspected child abuse; b) Reporting imminent danger to client or others; c) Reporting information required in  court proceedings or by client’s insurance company, or other relevant agencies; d) Providing information concerning licensee case consultation or supervision; e) Defending claims brought by client against registered intern;
  7. To be free from being the object of discrimination on the basis of race, religion, gender, or other unlawful category while receiving services.

You may contact the Board of Licensed Professional Counselors and Therapists at 3218 Pringle Rd SE #250, Salem, OR 97302-6312 Telephone: (503) 378-5499

I have read and understand the Professional Disclosure Statement of Alison Stawicki, MS, NCC

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Client Signature                                                                                Date