CONFIDENTIALITY FORM
© Ruth Parvin, 2000
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Please print and fill out forms. Return to Dr. Ruth Parvin
2925 S.E. Taylor Portland, OR 97214


Confidentiality of Therapy Services and Fees for Services

     This outlines the legal and ethical guidelines covering confidentiality and fees. In general the information you share with a counselor is protected from disclosure to a third party. There are a few narrow exceptions to this requirement. These exceptions apply to all therapists. To help you be a well-informed consumer of mental health services, the exceptions to the requirement of confidentiality are spelled out below. It is important to understand, however, that it is extremely rare for records or other information to be released concerning a client's participation in counseling, except to insurance companies if insurance is used to pay part of the fee without the client's specific written consent. Consent for disclosure may be withheld, and may be canceled in writing at any time.

Exceptions to Confidentiality
Confidential information may be disclosed without your consent in the following circumstances:

1. If you present an immediate risk of serious physical harm to yourself or others, we must disclose confidential information to prevent this harm from occurring.

2. If you are abusing a minor or an elder or if you are a minor or elder being physically or sexually abused, your therapist may have a duty to report the abuse. Similarly, if you have a contagious disease and are wantonly engaging in activities that threaten the safety of others, there may be a duty to report this behavior.

3. If you are under 18, under Oregon law, I may begin providing you counseling services without your parents' consent. However, unless you are legally emancipated or have lived apart from your parents while being self-sustaining for a period of 90 days before obtaining treatment, I am required to involve your parents before the end of treatment. I do not have to involve your parents if they are not interested or if I find that there are clear clinical indications that they should not be involved. In most cases, it is to your benefit to have your family involved.

4. If you bring a lawsuit or make a complaint to a regulatory body concerning the counseling services you receive from me, I may disclose confidential information for the purpose of defending against your complaint;

5. If a court order requires release of your records in the context of a civil or criminal case, I must respond. (Courts issue such orders under very narrow circumstances);

6. If you come to counseling on court order, you may have to sign consent for reports to be made to the court.

7. If you use insurance for services, the insurance company will require some limited information about your diagnosis and therapy.

8. Finally, I meet on a regular basis with a couple of other therapists to consult about cases. I do this without using client names. This helps ensure that you are getting the best care possible by helping me look at additional ways to help you with your problems. These consultations are part of my quality control program and bring my services into compliance with various regulations and laws.
Fee Policies
     As a business person I must pay for insurance and other overhead costs in a timely manner. To do that, I rely on clients paying their fees in a timely manner. I am always willing to discuss fees and to try to make arrangements to insure the continuity of your care if your financial or insurance situation changes.

     My standard fee is $ 125 for the first session and $100 per hour for individual/family/couple therapy. A therapy hour consists of fifty minutes together and 10 minutes for session record keeping. I reserve the right to charge for phone calls that last longer than 10 minutes. Please ask me about the cost for other services such as report writing, Xeroxing, court testimony.
     Payment is due each session unless other arrangements are made. Insurance does not cover missed sessions. You must cancel 24 working hours before your appointment to avoid being billed unless you are ill or in serious crisis. Bills which are not paid in a timely manner will be turned over to a collection agency.
     I have read this statement and have been offered the opportunity to discuss it with my counselor. I agree that information for the purposes of billing and treatment may be released to my insurance company.

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