Jocelyn Wagman, LCSW, MPH
Jocelyn M Wagman Counseling
(503) 470-1484
New Client Consent Form
Welcome to my practice! This document contains important information about my professional services and business policies. When you sign this document, it will represent an agreement between us.
What to expect
I will strive to make therapy a collaborative experience in which we work together to make progress toward your goals. Research shows that the quality of our relationship is the most important factor in how successful therapy is, so I will check in with you about how you’re feeling in the relationship and solicit your feedback throughout our work.
After an initial consultation to determine if I am a good fit for you, we will determine frequency and timing of meetings. Generally, I like to start with weekly meetings, with the option to reduce to every other week depending on your needs and preferences.
We will meet via Google Meets video platform, a Health Insurance Portability & Accountability Act (HIPAA)-compliant platform. You will receive email invitations to these meetings. My email is also HIPAA compliant, although yours may not be. Likewise, my voicemail is HIPAA-compliant. (Please see separate tele-mental health consent form for details).
Availability & Communication
Because I am a solo-practitioner in part-time private practice, I am unlikely to be able to meet the needs of clients in crisis, or clients needing case management or wrap-around care services. I will supply you with a list of crisis resources and we will discuss a crisis plan in the event that these services are needed. I will also not be able to be involved in court cases/legal proceedings unless subpoenaed.
I will endeavor to respond to your emails and phone calls within two business days. I will notify you if I plan to take time away from my practice and we will discuss how to best meet your needs during that time.
I see clients on Tuesdays, Wednesday and Thursdays. We will work together to determine a day and time that suits you.
Fees, Payment, Insurance, & Attendance
My usual fee is $150/session (50-60 minutes); I offer a $10 off discount to private pay clients because of the reduced paperwork burden. I am not an in-network provider with any commercial insurance plans; I do accept OHP Care Oregon.
For clients with commercial insurance: I accept payment through Thrizer, a HIPPA-compliant automatic payment system. You will be asked to put a payment method on file and billing will occur after each session. Thrizer can automatically submit a claim to your insurance company for potential reimbursement. I encourage you to look into the Out of Network Benefits your plan offers – many plans partially reimburse for these services once a deductible is met. If you need an alternative payment method, please alert me and we can discuss options. I will fill out forms and provide you with whatever assistance I can in helping you receive the health insurance benefits to which you are entitled; however, it is very important that you find out exactly what mental health services your insurance policy covers. Carefully read the section in your insurance coverage booklet that describes mental health services. If you have questions about the coverage, call your plan administrator. You may also see the Out of Network Benefits Information document on my website for more guidance.
I will collect your payment each time we meet, unless we make another arrangement. I do charge for missed appointments and appointments that aren’t canceled at least 24 hours in advance, unless the situation is due to sudden illness or emergency.
If you do not arrive for a planned session, I will reach out to you via your preferred contact method to check on your general well-being (and may follow up with any safety procedures as is appropriate). In non-crisis situations, I will assume you are not interested in pursuing additional treatment with me after two no-show/no-call sessions. No-shows are charged at full fee. You will not be charged for any sessions I cancel. I will do my best to notify you well in advance about upcoming vacation weeks, or any need to change or cancel an appointment.
If you would like Thrizer to submit claims to your insurance company, I will have to formally assign you a diagnosis. If this is the case, we can discuss what diagnosis fits best and any concerns you have about this (including privacy implications). Sometimes I have to provide additional clinical information such as treatment plans or summaries, or copies of the entire record (in rare cases). This information will become part of the insurance company files and will probably be stored in a computer. Though all insurance companies claim to keep such information confidential, I have no control over what they do with it once it is in their hands. In some cases, they may share the information with a national medical information databank. I will provide you with a copy of any report I submit, if you request it.
I revisit my fee structure annually, and I will give clients notification 2-3 months if a change occurs. If your circumstances change and include unusual financial hardship, we may negotiate a fee adjustment or payment installment plan.
For OHP Care Oregon clients: You will not pay out of pocket for our sessions. I will have to assign you a formal diagnosis and share it with Care Oregon for billing purposes. We will discuss this during our first few sessions.
Client Rights & Confidentiality
The things we discuss and my records are private and confidential, with a few exceptions:
If you are in danger of harming yourself or someone else: I am legally required to notify the appropriate authorities.
In cases involving suspected abuse of a child or vulnerable adult: I am legally required to report this to child or adult protective services.
In the case that your records are subpoenaed by a judge: I will follow legal requirements while also making every attempt to maintain the privacy and confidentiality of your record.
In all other cases, your consent is required to share your personal information. When I seek consultation from other therapists, I will maintain confidentiality. Your record also remains confidential after termination of services. You may request access to your record at any time. I maintain your record using HIPAA-compliant tools.
Anyone receiving psychotherapy from a social worker has the following rights under Oregon Law:
∙ To be treated with respect and dignity
∙ To be provided competent services in accordance with accepted quality of care standards.
∙ To have information about you kept confidential except in the circumstances described above.
∙ To view all information regarding you or your child.
∙ To know the name and training of anyone who works with you or with your child.
∙ To be treated fairly and not be discriminated against because of race, sex, sexual or gender orientation, religion, national origin, age, or disability
∙ To actively participate in the development or modification of your services.
∙ To withdraw this consent for services at any time.
∙ To contact the Oregon Board of Clinical Social Workers at 3218 Pringle Rd., Salem, OR 97302, 503-378-5735, for further information or to lodge a complaint.
Guardian of records: In case I am suddenly unable to continue to provide professional services or to maintain client records due to incapacitation or death, I have designated a colleague who is a licensed therapist as my professional executor/guardian of records. If I die or become incapacitated, my professional executor will be given access to all of my client records and may contact you directly to inform you of my death or incapacity; to provide access to your records; to provide psychological services if needed; and/or to facilitate continued care with another qualified professional if needed. If you have any questions or concerns about this professional executor arrangement, I will be glad to discuss them with you.
Professional Records
The laws and standards of my profession require that I keep treatment records. Your records will be stored in a “cloud” through Simple Practice Electronic Health Record. I have signed a HIPAA Business Associate Agreement with this company, and they are obligated by federal law to protect these records from unauthorized use or disclosure. I also follow strict security procedures in maintaining your security and privacy, including utilizing firewalls, malware software, complex passwords and disk encryption on any devices upon which your information is stored. Even with all this in place, security cannot be guaranteed.
You are entitled to receive a copy of these records at any time. If I believe that seeing your records would be harmful to you in some way, I will be happy to send them to a mental health professional of your choice should you need me to coordinate your care, or if you begin services with a different therapist. With any disclosure, I aim to disclose the least amount of information possible to achieve the desired purpose.
You must make the request in writing; I will respond to you within 5 working days, and will provide copies of your records within 15 days. You will be charged an appropriate fee for any time spent in preparing information requests, and if you request copies of your file, I will charge you not more than $.25 for each page.
Typically, a copy of your records will be provided, or, if it is deemed more appropriate, a summary of your records can be prepared for you. Because these are professional records, they can be misinterpreted and/or upsetting to untrained readers. I recommend that you review them in my presence so that we can discuss the contents.
By law, your records will be kept for 7 years following termination of therapy. After 7 years, they will be destroyed in a manner that preserves your confidentiality.
Termination
Therapy may be terminated by you at any time. It is generally more constructive and useful when at least one week's notice (or more) is given, so that a final session can be scheduled to explore the reasons for ending and to summarize our treatment together, as well as to provide referrals to any other appropriate services.
Complaints
If you have a concern or complaint about your treatment, please talk to me about it, preferably in person. I want to encourage you to advocate for yourself at all times, even if this means you disagree with me. I take your opinion very seriously, and I will address your complaint with respect.
If you believe I have been unwilling to listen and respond, or that I have behaved unethically or illegally, you may contact the Oregon Board of Clinical Social Workers, which oversees licensing, and they will review the services I have provided:
Oregon Board of Licensed Social Workers
3218 Pringle Rd., Salem, OR 97302
503-378-5735.
Mutual Expectations
Your rights include: freedom from discrimination, safety, a collaborative relationship, the right to discontinue work at any time, confidentiality, and the right to submit complaints to my governing board. Expectations of you include: full participating in treatment, discussion of discontinuation prior to ending therapy; keeping appointments and canceling 24 hours in advance of appointments; informing me of any changes in contact information or finances that affect therapy; informing me if you are seeing another therapist; and informing me of any medication change, substance abuse, high risk behaviors or suicidality.
My rights and responsibilities are to uphold all policies and disclosures as outlined in this letter. I will also adhere to my ethical code of conduct and provide you with the highest quality of therapy services possible.
Consent & Contact Information:
I have read the above statement and understand my rights and responsibilities. I understand that there are no guarantees of cure in the practice of therapy. I understand my rights to confidentiality as well as the limitations. I have received a copy of this form for my records.