New Client Information
*This information will also be provided to you & reviewed with you at your first visit*
General Counseling Practice Information
PRIVACY: Our discussions will not be shared with anyone unless you give me written permission.
Exceptions to Privacy:
If I am convinced you are going to hurt yourself
If I am convinced you are going to hurt someone else
If you report any ongoing child, elder, or sexual abuse
I am typically in the office Tuesdays and Thursdays from 12pm until 7pm. If you text, call or email at other times, I will get back with you when I return to the office.
Tuesday & Thursday appointment times: 1230pm, 130pm, 230 pm, 330 pm, 430pm, and 530pm. On Mondays, Wednesdays and Fridays, I have one appointment slot at 530pm.
If you experience a life-threatening emergency, please call 911 or go to your nearest hospital emergency room immediately.
If I am going to be out of town, I will give you the name and phone number for another therapist if you feel you will need to speak to someone while I’m gone.
APPOINTMENTS: If you are unable to attend, please contact me (text, email, phone) as soon as you know you won’t be coming.
Session length depends on your insurance; some insurance only allows 45 minute sessions while others allow 55 minute sessions.
If you are 15 minutes late (or more) for your appointment, you will be rescheduled.
If you no-show your scheduled appointment, I will not automatically reschedule your appointment. You are responsible to contact me and reschedule.
If you no-show more than once, you will be charged $20. You will also be placed on a same-day appointment program.
If you schedule and then cancel appointments repeatedly, you will be placed on a same-day appointment program.
If you are a self-pay client, you are expected to pay at the time of your appointment.
If we are filing insurance, I will bill you once a month for any co-pays or fees not covered by your insurance.
You can pay with cash, check or credit card.
Please realize that providing therapy is my livelihood – I depend on you to attend and pay for your sessions.
Insurance does not cover the expense of my presence in court; therefore you are responsible for paying my standard hourly fee for the entire time I am at court.
We will discuss any court appearance prior to your requesting my presence.
Professional Disclosure Statement
Philosophy & Approach: I believe that with persistence and effort, everyone can improve their lives to his/her personal satisfaction. I utilize cognitive-behavioral, positive psychology, and reality therapy interventions to develop appropriate life expectations and enhanced positive coping strategies, which can lessen mental health symptoms as well as improve the quality of life. I abide by the Code of Ethics adopted by the Board.
Formal Education & Training: I have a Master of Arts degree in Counseling from Dallas Baptist University. My education focused on general counseling practices, and included theory, testing, diagnosing, research, and best practices. I have been a licensed counselor since 2001. I have active counseling licenses from Oregon and inactive licenses from Missouri and Texas. I have advanced training in Dialectical Behavior Therapy and the Neurosequential Model of Therapy. I have a PhD in Public Safety Leadership with an emphasis in Criminal Justice from Capella University.
As a Licensee of the Oregon Board of Licensed Professional Counselors and Therapists, I abide by its Code of Ethics. To maintain my license, I am required to participate in 20 hours of continuing education, taking classes dealing with subjects relevant to this profession.
Fees: I accept several insurances. I will bill you for any co-pays or fees not covered by your insurance.
As a client of an Oregon Licensee, you have the following rights to:
Expect that a licensee meets the qualifications of training and experience required by state law;
Examine public records maintained by the Board and to have the Board confirm credentials of a licensee;
Obtain a copy of the Code of Ethics (Oregon Administrative Rules 833-100);
Report complaints to the Board;
Be informed of the cost of professional services before receiving the services;
Be assured of privacy and confidentiality while receiving services as defined by rule or law, with the following exceptions: 1) Reporting suspected child abuse; 2) Reporting imminent danger to you or others; 3) Reporting information required in court proceedings or by your insurance company, or other relevant agencies; 4) Providing information concerning licensee case consultation or supervision,; and 5) Defending claims brought by you against me.
Be free from discrimination because of age, color, culture, disability, ethnicity, national origin, gender, race, religion, sexual orientation, marital status, or socioeconomic status.
You may contact that Board of Licensed Professional Counselors and Therapists at
3218 Pringle Rd SE, #250, Salem, OR 97302-6312 Phone: 503/378-5499
For additional information about this counselor, consult the Board’s website.
INFORMED CONSENT FORM FOR PSYCHOTHERAPY AND COUNSELING
Therapy is a relationship that works in part because of clearly defined rights and responsibilities held by each person. As a client in psychotherapy, you have certain rights that are important for you to know about because this is your therapy. There are also certain limitations to those rights that you should be aware of. As a therapist, I have corresponding responsibilities to you, too.
I do not have 24-hour emergency or on-call coverage. If you believe you will need a therapist with 24-hour coverage, I will assist you with a referral. If you experience a psychiatric emergency, you should call 911 or go to the nearest hospital emergency room rather than waiting for me to get in touch. I am typically away from the office several times in the year for vacations or professional meetings. If I will not be responding to messages during my absences, I will notify you ahead of time and give you the name of a colleague you can contact if the need arises.
YOUR RESPONSIBILITIES AS A THERAPY CLIENT
You are responsible for coming to your session on time and at the time we have scheduled. Sessions last for 45-50 minutes. If you are late, we will end on time and not run over into the next person’s session. If you are more than 15 minutes late, you will not be seen. If you miss a session without canceling or cancel with less than twenty-four (24) hours’ notice, you will be charged a small fee for that session, unless circumstances beyond your control have caused your cancelation. If you miss a scheduled appointment, you must contact me to reschedule – I will not automatically reschedule your appointment.
Should a habit of not attending your scheduled appointments develop, you will be placed on a same day appointment program until commitment to attending sessions has been demonstrated.
You have the right to ask questions about anything that happens in therapy. I’m always willing to discuss how and why I’ve decided to do what I’m doing, and to look at alternatives that might work better. You can feel free to ask me to try something that you think will be helpful. You can ask me about my training for working with your concerns, and can request that I refer you to someone else if you decide I’m not the right therapist for you. You are free to leave therapy at any time, although I recommend finding a way to give me advance notice so that I can help you end treatment well and consolidate gains (please see section on Ending Therapy).
MY RESPONSIBILITIES TO YOU AS YOUR THERAPIST
With the exception of certain specific exceptions described below, you have the absolute right to the confidentiality of your therapy. I cannot and will not tell anyone else what you have told me, or even that you are in therapy with me without your prior written permission. Under the provisions of the Health Care Information Act of 1992, I may legally speak to another health care provider or a member of your family about you without your prior consent, but I will not do so unless the situation is an emergency. I will always act so as to protect your privacy even if you do release me in writing to share information about you. You may direct me to share information with whomever you chose, and you can change your mind and revoke that permission at any time. You may request anyone you wish to attend a therapy session with you. You are also protected under the provisions of the Federal Health Insurance Portability and Accountability Act (HIPAA).
If you elect to communicate with me by email at some point in our work together, I am willing to respond briefly by return email, but please be aware that email and other electronic media are not completely confidential. I do not use an encrypting program on email at this time.
The following are legal exceptions to your right to confidentiality. I would inform you of any time when I think I will have to put these into effect.
If I have good reason to believe that you will harm another person, I must attempt to inform that person and warn them of your intentions. I must also contact the police and ask them to protect your intended victim.
If I have good reason to believe that you are abusing or neglecting a child or vulnerable adult, or if you give me information about someone else who is doing this, I must inform Child Protective Services or Adult Protective Services immediately.
If I believe that you are in imminent danger of harming yourself, I may legally break confidentiality and call the police or the county crisis team. I am not obligated to do this, and would explore all other options with you before I took this step. If at that point you were unwilling to take steps to guarantee your safety, I would call the crisis team.
If you and your partner decide to have some individual sessions as part of the couples therapy, what you say in those individual sessions will be considered to be a part of the couples therapy, and will probably be discussed in our joint sessions. Do not tell me anything you wish kept secret from your partner. I will remind you of this policy before beginning such individual session.
I keep brief records of each session noting the dates we meet, the topics we cover, progress reports from the client’s perspective, interventions and impressions from the therapist and next steps.
If a third party such as an insurance company is paying for part of your bill, I am normally required to give a diagnosis to that third party in order to be paid. Diagnoses are technical terms that describe the nature of your problems and something about whether they are short-term or long-term problems.
Individual therapy or couples therapy is $175 per 50-minute session. You will be asked to pay for each session at the time of the session. Payment can be by check or credit card. A statement of the month’s sessions will be furnished to you on the first of each month for the previous month’s sessions and payments. You can use the statement for tax purposes or for reimbursement.
There is direct billing with some insurance companies, including Medicaid.
Clients work via a private contract and informed consent with Peggy Defazio and are liable for charges of her services without any limits that would otherwise be imposed by any insurance company.
V. COURT APPEARANCE
I understand that there may be a time when you feel the need to have me in court on your behalf. I strongly discourage this action. My experience has been that the direct testimony of a mental health provider does not influence the court’s decision. If you insist on having me in court, you will be responsible for paying my full hourly fee for the entire time I am in court, whether I am called to testify or not. Payment must be made prior to my appearance. An alternative is to request a treatment summary statement that you and your lawyer can present without my presence.
VI. ENDING THERAPY WELL
I want to make your therapy as successful as possible. For that reason, it works best to find a rhythm and structure to the beginning stages with sessions that meet regularly. To support your leaving, I request several weeks of notice prior to your actual leaving to allow you to have an experience of leaving well, with a sense of completion. If I initiate terminating you from our therapy, it will be because I feel that I am not able to be helpful to you any longer. My ethics and license requires that I offer quality service and have my clients’ needs as paramount in my treatment planning. If I no longer feel that I am the best or right practitioner for you, I will offer referrals to other sources of care, but cannot guarantee that they will accept you for therapy or how they will approach your treatment.
MY TRAINING AND APPROACH TO THERAPY
I earned a Master’s of Arts in Counseling from Dallas Baptist University in 1999. I have an active Licensed Professional Counselor (LPC) license in Oregon and inactive LPC licenses in Texas and Missouri. Earning and maintaining an LPC requires supervision from an experienced LPC and regular continuing education. My areas of special training and expertise include: cognitive behavioral, solution focused, emotional freedom technique, positive psychology and reality therapy approaches. I also use animal-assisted therapy with my therapy dog; his presence is optional, please let me know if you do not want him in your sessions.
If you’re not satisfied with the treatment you are receiving, I encourage you to talk with me about it so that I can respond to your concerns. You have the right to contact my licensing board if you feel it is appropriate:
Board of Licensed Professional Counselors & Therapists
3218 Pringle Rd SE, #250, Salem, OR 97302-6312 Phone: 503.378.5499
CLIENT CONSENT TO PSYCHOTHERAPY
I have read this statement, had sufficient time to be sure that I considered it carefully, asked any questions that I needed to, and understand it. I understand the limits to confidentiality required by law. I understand the fee per session and my rights and responsibilities as a client, and my therapist’s responsibilities to me. I know I can end therapy at any time I wish.