Painted 1999 by my Mother, Lynne Grigsby.
Deborah Lynne Grigsby (Debbie), Licensed Professional Counselor (LPC - C4249),
MA-MHC, National Certified Counselor (NCC)
My NPI # is 1205266046.
SVPFS, LLC dba Siuslaw Valley Counseling
1490 1st Street, Unit 1 ~ Florence, Oregon 97439
Email Contact: [email protected]
541-999-1913
Counseling Information and Consent for Treatment
Welcome to Siuslaw Valley Counseling. In order to better serve you, I would like to provide you with some information about my services. This information will be discussed during your first appointment. If you have any questions, please let me know.
What is counseling? Counseling is person-centered and goal-focused. Counseling, whether individual, couples, or group, focuses on resources, solutions and strategies to deal with your presenting problem.
Your counselor will ask about many areas of your life. The focus of therapy will be on working toward your specific goals. In order for counseling to be effective, it is necessary for you to take an active role. Participation involves discussing your concerns openly, completing assignments, and providing feedback to your counselor about the progress of counseling.
Your First Appointment: During your first visit, you will discuss your concerns and goals for treatment. This session will help both you and your counselor decide how you can best be helped. These services may consist of individual, couples or group counseling or possibly a referral to a therapist or service provider that may be more appropriate to your needs.
Sessions: There is no limit for duration of my counseling sessions. Depending on your issues and goals, counseling may consist of one or several sessions. I may refer you to alternative sources of treatment if I have determined that I, as your therapist, cannot provide the necessary services to address your needs.
Cancellations and No-Shows: I expect that you will notify me in advance if you are unable to keep an appointment. Your appointment time will be given to another client if you do not keep your counseling appointment, and do not call to cancel. You will be billed for the missed session if you do not call to cancel the appointment. You will need to call and schedule a new appointment if you wish to continue counseling, which must be done 48 hours in advance.
Confidentiality and Records: Counseling often involves sharing sensitive, personal, and private information. Recognizing this, laws and ethical guidelines require that all interactions with me, including content of your sessions, your records, scheduling of or attendance at appointments, and progress in counseling are confidential. No record of counseling is contained in any academic, educational, or job placement file. While information will not be released to anyone outside the counseling office without your written permission, in order to provide you with the best possible treatment, I confer with my supervisor.
Exceptions to Confidentiality: For the vast majority of clients, no exceptions to confidentiality are made; however, there are some exceptions to confidentiality, which you should know about before you begin counseling. We are legally required and/or have a policy to disclose information to:
a. protect you or someone else from imminent danger
b. report suspected abuse of children, the elderly or the disabled
c. respond to a court subpoena
d. known or suspected sexual exploitation of a client by a past therapist.
e. report physical violence or threatened violence toward your therapist
In any of these situations, your counselor would reveal only the information needed to resolve this immediate crisis or risk of danger. If your counselor believes you are in danger of hurting yourself or others, your counselor may contact people in a position to prevent harm. This includes but is not limited to the person listed as your emergency contact, family members, close friends, and appropriate medical, school, and legal authorities.
Risks & Benefits of Counseling: In therapy, you risk learning things about yourself or your relationships that you don’t like. Often growth cannot occur until you confront issues that cause you to feel sadness, sorrow, anxiety or pain. Your therapist will be there to support you as you accept the responsibility for making the choices and changes that are required to achieve your goals. There is also the risk that therapy may not resolve your problem or that therapy alone may not be sufficient. Should this be the case, the therapist will explore alternative plans with you. As with any powerful treatment, there are some risks as well as many benefits with therapy. You should think about both the benefits and risks when making any treatment decisions. For example, in therapy, there is a risk that clients will, for a time, have uncomfortable levels of sadness, guilt, anxiety, anger, frustration, loneliness, helplessness, or other negative feelings. Clients may recall unpleasant memories. These feelings or memories may bother a client at work or in school. Also, clients in therapy may have problems with people important to them. Family secrets may be told. Sometimes, too, a client’s problems may temporarily worsen after the beginning of treatment. Most of these risks are to be expected when people are making important changes in their lives. Finally, even with our best efforts, there is a risk that therapy may not work out well for you. While you consider these risks, you should know also that there are many benefits to therapy. People who are depressed may find their mood lifting. Others may no longer feel afraid, angry, or anxious. In therapy, people have a chance to talk things out fully until their feelings are relieved or the problems are solved. Clients’ relationships and coping skills may improve greatly. They may get more satisfaction out of social and family relationships. Their personal goals and values may become clearer. They may grow in many directions—as persons, in their close relationships, in their work or schooling, and in the ability to enjoy their lives. I will enter our relationship with optimism about our progress. Rest assured that I will not take on clients I do not think I can help.
Change of Contact Information: You are asked to provide me with your most current address and phone numbers so that you may be reached in case of scheduling conflicts or emergencies.
ACKNOWLEDGMENT/CONSENT FOR TREATMENT: I acknowledge that I have read and understand the information described above, and I authorize Deborah Lynne Grigsby (Debbie) of SVPFS, LLC dba Siuslaw Valley Counseling to provide for my care.
I understand that I may withdraw this consent in writing and terminate treatment at any time.
Print Name _______________________________________________________
Signature___________________________________Date__________________
If the client is a minor:
Legal Guardian/Parent Name__________________________________________
Legal Guardian/Parent Signature_______________________________________
Date_____________________
PLEASE RETAIN SECOND COPY OF THIS CONSENT FOR YOUR PERSONAL RECORDS
MA-MHC, National Certified Counselor (NCC)
My NPI # is 1205266046.
SVPFS, LLC dba Siuslaw Valley Counseling
1490 1st Street, Unit 1 ~ Florence, Oregon 97439
Email Contact: [email protected]
541-999-1913
Counseling Information and Consent for Treatment
Welcome to Siuslaw Valley Counseling. In order to better serve you, I would like to provide you with some information about my services. This information will be discussed during your first appointment. If you have any questions, please let me know.
What is counseling? Counseling is person-centered and goal-focused. Counseling, whether individual, couples, or group, focuses on resources, solutions and strategies to deal with your presenting problem.
Your counselor will ask about many areas of your life. The focus of therapy will be on working toward your specific goals. In order for counseling to be effective, it is necessary for you to take an active role. Participation involves discussing your concerns openly, completing assignments, and providing feedback to your counselor about the progress of counseling.
Your First Appointment: During your first visit, you will discuss your concerns and goals for treatment. This session will help both you and your counselor decide how you can best be helped. These services may consist of individual, couples or group counseling or possibly a referral to a therapist or service provider that may be more appropriate to your needs.
Sessions: There is no limit for duration of my counseling sessions. Depending on your issues and goals, counseling may consist of one or several sessions. I may refer you to alternative sources of treatment if I have determined that I, as your therapist, cannot provide the necessary services to address your needs.
Cancellations and No-Shows: I expect that you will notify me in advance if you are unable to keep an appointment. Your appointment time will be given to another client if you do not keep your counseling appointment, and do not call to cancel. You will be billed for the missed session if you do not call to cancel the appointment. You will need to call and schedule a new appointment if you wish to continue counseling, which must be done 48 hours in advance.
Confidentiality and Records: Counseling often involves sharing sensitive, personal, and private information. Recognizing this, laws and ethical guidelines require that all interactions with me, including content of your sessions, your records, scheduling of or attendance at appointments, and progress in counseling are confidential. No record of counseling is contained in any academic, educational, or job placement file. While information will not be released to anyone outside the counseling office without your written permission, in order to provide you with the best possible treatment, I confer with my supervisor.
Exceptions to Confidentiality: For the vast majority of clients, no exceptions to confidentiality are made; however, there are some exceptions to confidentiality, which you should know about before you begin counseling. We are legally required and/or have a policy to disclose information to:
a. protect you or someone else from imminent danger
b. report suspected abuse of children, the elderly or the disabled
c. respond to a court subpoena
d. known or suspected sexual exploitation of a client by a past therapist.
e. report physical violence or threatened violence toward your therapist
In any of these situations, your counselor would reveal only the information needed to resolve this immediate crisis or risk of danger. If your counselor believes you are in danger of hurting yourself or others, your counselor may contact people in a position to prevent harm. This includes but is not limited to the person listed as your emergency contact, family members, close friends, and appropriate medical, school, and legal authorities.
Risks & Benefits of Counseling: In therapy, you risk learning things about yourself or your relationships that you don’t like. Often growth cannot occur until you confront issues that cause you to feel sadness, sorrow, anxiety or pain. Your therapist will be there to support you as you accept the responsibility for making the choices and changes that are required to achieve your goals. There is also the risk that therapy may not resolve your problem or that therapy alone may not be sufficient. Should this be the case, the therapist will explore alternative plans with you. As with any powerful treatment, there are some risks as well as many benefits with therapy. You should think about both the benefits and risks when making any treatment decisions. For example, in therapy, there is a risk that clients will, for a time, have uncomfortable levels of sadness, guilt, anxiety, anger, frustration, loneliness, helplessness, or other negative feelings. Clients may recall unpleasant memories. These feelings or memories may bother a client at work or in school. Also, clients in therapy may have problems with people important to them. Family secrets may be told. Sometimes, too, a client’s problems may temporarily worsen after the beginning of treatment. Most of these risks are to be expected when people are making important changes in their lives. Finally, even with our best efforts, there is a risk that therapy may not work out well for you. While you consider these risks, you should know also that there are many benefits to therapy. People who are depressed may find their mood lifting. Others may no longer feel afraid, angry, or anxious. In therapy, people have a chance to talk things out fully until their feelings are relieved or the problems are solved. Clients’ relationships and coping skills may improve greatly. They may get more satisfaction out of social and family relationships. Their personal goals and values may become clearer. They may grow in many directions—as persons, in their close relationships, in their work or schooling, and in the ability to enjoy their lives. I will enter our relationship with optimism about our progress. Rest assured that I will not take on clients I do not think I can help.
Change of Contact Information: You are asked to provide me with your most current address and phone numbers so that you may be reached in case of scheduling conflicts or emergencies.
ACKNOWLEDGMENT/CONSENT FOR TREATMENT: I acknowledge that I have read and understand the information described above, and I authorize Deborah Lynne Grigsby (Debbie) of SVPFS, LLC dba Siuslaw Valley Counseling to provide for my care.
I understand that I may withdraw this consent in writing and terminate treatment at any time.
Print Name _______________________________________________________
Signature___________________________________Date__________________
If the client is a minor:
Legal Guardian/Parent Name__________________________________________
Legal Guardian/Parent Signature_______________________________________
Date_____________________
PLEASE RETAIN SECOND COPY OF THIS CONSENT FOR YOUR PERSONAL RECORDS
