PLEASE READ THE FOLLOWING IMPORTANT INFORMATION ABOUT USING THIS SERVICE, BOTH ONLINE AND OFFLINE

Information on this page is effective as of July 1, 2007 and replaces any previous or comparable documents.

If we will be meeting face-to-face, you will be given forms containing most of the following information, which you must sign to receive services.

If we will be meeting via Internet or telephone, this document serves as our contract.  You will “sign” this contract with your electronic signature.  You do that by checking the “I agree” button and clicking the “Submit” button on any form that you submit to me for services.  Every time you request a service you will be asked to agree to the PURR.  If you have any questions about this information, please do not hesitate to contact me.  I will answer any questions you might have related to the PURR, free of charge, via email.

INFORMED CONSENT

Thank you for choosing me, Alden L. Miller, MS, LPC, to work with you.  I am pleased that you have selected me as your counselor.  I realize starting counseling is a major decision and you might have many questions, and selecting a compatible therapist is not always easy.  This document is designed to inform you about my background, the counseling process, what you and I can expect from each other, and to ensure you fully understand how information you provide me about yourself may be used and disclosed, and how you can get access to this information.  Please review the following information carefully.  If you have other questions or concerns, I will try my best to give you all the information you need.

ABOUT ME AND MY PRACTICE

Currently, I hold Oregon and Utah licenses, as a marriage and family therapist.  In Oregon, I also hold a license as a Professional Counselor. The Oregon Board of Licensed Professional Counselors and Therapists publishes an annual directory of all currently licensed in Oregon to practice in this field.  You can write the Board at 3218 Pringle Rd. SE, Suite 250, Salem, OR 97302-6312, or telephone them at (503) 378-5499.  Licensing requires that I participate in continuing education requirements, as adopted, ascribe to the Oregon Code.  I received a Bachelors of Science degree in psychology and a Masters Degree in Educational Psychology from The University of Utah.  These departments are respectively accredited by the American Psychological Association; The American Association of Marriage and Family Therapy, of which I was a clinical member for twenty-five years.  I hold national certifications as a Master Addictions Counselor through NBCC and the NAADAC Certification Commission.  I am a CADC III in Oregon.  Since 1984, I have served on the Bay Area Hospital Courtesy Staff as an Allied Health Professional, as well as Blue Mountain Hospital in John Day, Oregon.  I have practiced for (State Licensed) not-for-profit settings serving people suffering with emotional/mental and/or addictive compulsions and co-occurring conditions which merit consultation and support by a Licensed or Qualified mental health professional.  As a Certified Distance Counselor through NBCC, I offer an encrypted distance counseling service over the Internet.

My counseling practice is limited to adults (clients 18 years of age and older).  I accept only clients I believe have the capacity to resolve their own problems, with my assistance.  I believe, as people become more accepting of themselves, they are more capable of finding happiness and contentment in their lives.  However, self-awareness and self-acceptance are goals that sometimes take a long time to achieve.  Some clients need only a few counseling sessions to achieve these goals, while others may require months, or even years, of counseling.  If counseling is successful, you should feel you are able to face life’s challenges in the future, without my support or intervention. 

Although our sessions may be very intimate, emotionally and psychologically, it is important for you to realize we have a professional relationship, rather than a personal one.  Our contact will be limited to the paid sessions that you have with me.  Please do not invite me to social gatherings, offer me gifts, or ask me to relate to you in any way other than in the professional context of our counseling sessions.  You will be best served if our relationship remains strictly professional and if our sessions concentrate exclusively on your concerns.  Should our sessions extend over a period of time, you may learn a great deal about me as we work together during our counseling experience.  However, it is important for you to remember you are experiencing me only in my role as a professional, not as a friend.

Should the circumstance arise that we find ourselves in the same social situation or other public space, I will not address you, nor will I indicate that I know you in any way, so as to protect your confidentiality.  If you decide, however, to acknowledge me (which I would not expect you to do, but which is okay, if you so choose), I will reciprocate, on the assumption you feel comfortable, in that situation, acknowledging that you know me.  Understand that, if I am with other individuals, I will not make any introductions, and my conversation with you at that time will be very brief.  This is not to be construed as being rude, but rather, again, as a means of protecting your confidentiality.

The overall goals of psychotherapy are to help you solve problems that may be limiting your satisfaction with life and to help you better cope with feelings and experiences you might be encountering in your life.  To that end, my approach is to design a treatment plan based on your presenting concerns at our initial session.  At a minimum, the treatment plan will consist of your primary issue with which you are currently struggling, the definition of that problem (e.g., what are the “symptoms”), the goal(s) we will be working toward together, objectives to achieve the goal(s), and the possible interventions to attempt to accomplish the objectives, as well as the projected time frame (e.g., number of anticipated sessions) necessary to achieve satisfactory results.  It is possible to work toward more than one goal at a time, however, no more than three goals should be pursued at any given time.

There are both benefits and risks to counseling\psychotherapy, and in most cases the benefits significantly outweigh the risks.  The benefits most individuals experience include resolution of a crisis or problem, feeling understood, increased hope. The process I use is commonly known as “increased self-esteem and greater self-awareness, increased self-confidence, and taking an active role in one’s life".  The most common risks are temporary periods of emotional distress related to changes in your life situation and your relationship with yourself and others, including changes in your relationship with your therapist.  It is possible you may experience changes in your life that could produce disruptions and turmoil before you discover the positive benefits of therapy.  If you feel you are not making reasonable progress or believe you are getting worse and not better, you should immediately bring this to my attention for discussion.

The process I use is commonly known as “talk therapy.”   Basically, in order for me to know you better and develop a deeper understanding of your problem or concern, you will share with me what you are thinking and feeling, as well as your experiences around the situation (your behavior).  However, in addition to talk therapy, I often employ a variety of techniques to aide in the clinical process.  During a session, it might be helpful to utilize guided imagery, relaxation techniques, hypnosis, deep breathing, art therapy techniques using clay, paints or drawing, using music, engaging in movement or meditation, and so on.  While most of these techniques are more useful in a face-to-face counseling session, I often utilize some of them with my online counseling clients as well, when appropriate.  I will provide feedback when appropriate, will challenge ideas or behaviors that might be hindering your level of satisfaction in life, will suggest new ways to see the world, will approach a problem in a holistic way rather than a narrow view, and will generally assign some relevant homework assignment to be completed between sessions.  As sessions are generally only once or twice a week, much of the “work” to improve your situation will take place between our meetings.

I honor the uniqueness of each individual and believe no one approach works for every client.  In my experience, the client-therapist relationship provides the foundation for a successful therapeutic experience, and I nurture that relationship by creating a safe and trusting environment in which to connect and work together.  I consider myself a collaborative partner in your therapy and a privileged witness to your journey.  My approach to therapy is one of integration of mind, body, spirit and the creative force to manifest change.  My practice is eclectic and holistic, grounded in modern Western clinical perspectives (such as psychodynamics, cognitive, Adlerian, and Jungian theories) augmented by the significant contributions and insights of the Eastern perspectives (such as transpersonal psychology and humanistic psychology theories).  My style is relaxed, warm, open and interactive. 

Information disclosed to me in our private sessions must be kept confidential (private) unless you have granted me written permission to release such information.  There are exceptions to this protection of your privacy as dictated by laws, and are explained fully in the following section, entitled “Limits of Confidentiality".

If at any time, for any reason, you are dissatisfied with my services or feel you would be better served  by another therapist, please let me know.  If I am unable to resolve your concerns to your satisfaction, I will provide you with the names of at least three other therapists you might wish to contact for additional counseling (for face-to-face clients in the South Coast Bay Area).  For online clients, if I know of a therapist in your area that might be helpful, I will assist with that referral.

LIMITS OF CONFIDENTIALITY

The professional relationship you and I will share is confidential.  I treat all information received as confidential, regardless of whether it is in a face-to-face context or in an online or telephone context.  If you are interested in online therapy or telephone consultation, your information will be treated in the same manner as if your were a face-to-face client in my private office.

Should you wish me to disclose anything you have revealed to me in a therapy session, whether face-to-face, via email, online chat, IM, or telephone consultation, you MUST sign a Release of Information form authorizing me to do so (this includes, but is not limited to, insurance companies, other therapists,  and medical and legal professionals).  Otherwise, simply making a verbal request of me to reveal such information will not suffice.  To view a copy of he Release of information you must complete, sign, and return to me, please click here.
For online chat, instant messaging (IM), web-cam, and telephone clients:  To further protect your confidentiality and privacy, when you submit your request form for services and schedule your appointment, you will receive a confirmation email from me through a secure email server.  That email will contain a code name and a password.  When we begin our online or telephone session, you will be asked to provide the code name and password sent to you in that email.  This will let me know you are, in fact, the individual who signed up for the service, and will be a way for me to authenticate your identity.  It is imperative you protect your code name and password!

For email clients:  To further protect your confidentiality and privacy, I strongly encourage you to sign up for a FREE email account at safe-mail.  Unlike many email accounts that simply transfer information back and forth as standard alphanumeric text, safe-mail actually encrypts the email so you have maximum security and privacy.  You are, of course, welcome to use any email account you may have.  Regardless of how encrypted and email might be, if someone has access to your computer and/or password, they can read anything on your computer you can, so always protect your password, and if privacy is a concern for you, limit the number of individuals who have access to your computer.

There are a few instances where I am required to disclose confidential information about you WITHOUT your consent when the law mandates such a disclosure.  Regardless of your legal residence, I operate my practice under the laws of the state of Oregon

THE LAW REQUIRES I VIOLATE CONFIDENTIALITY WHEN:

1.  DANGER TO SELF:  If I believe you pose an imminent danger to yourself (e.g., you are going to commit suicide), or if, based in my clinical judgment the risk of you committing suicide is high, then I will be forced to take appropriate action to ensure your safety.

2.  DANGER TO OTHERS:  If you disclose to me you intend to harm a specific individual, I am required to breach confidentiality in order to protect the safety of the individual you intend to harm.

3.  CHILD ABUSE:  You disclose you are abusing a child (including, but not limited to physical or sexual abuse), or if, by statements you make in therapy, it is apparent to me a child is likely being abused by you, I must violate confidentiality and report that information to the appropriate authorities.

4.  ELDER ABUSE:  You disclose you are abusing an individual over the age of 65 (including, but not limited to physical or sexual abuse), or if, by statements you make in therapy, it is apparent to me an elder individual is likely being abused by you, I must violate confidentiality and report that information to the appropriate authorities.

EMERGENCY SITUATIONS

I am not available 24 hours a day, and should an emergency arise, you might not be able to reach me.  Should such an emergency arise, I ask you to follow one of the following protocols:

Call 911 (if the service is available in your area).

• Immediately go to the nearest emergency room.
• Call your local county mental health crisis hotline number
• Call the National Suicide Prevention Crisis Hotline at 1-800-273-TALK (8255)
• If you do attempt to reach me and get my voice mail, please follow the recorded instructions regarding emergencies.

NEVER USE EMAIL, ONLINE CHAT, WEBCAM, OR INSTANT MESSAGING AS A MEANS TO CONTACT ME DURING AN EMERGENCY!

 

GENERAL CLIENT RIGHTS & RESPONSIBILITIES

There are various rights you have as my client, as well as some specific responsibilities.  In addition, there are additional rights identified in the HIPAA Notice of Privacy Practices.  These rights and responsibilities are as follows:

AS MY PRIVATE CLIENT, YOU HAVE THE FOLLOWING RIGHTS:

1. You have the right to confidentiality.
2. You have the right to withdraw from client status at any time.
3. You have the right to ethical treatment as defined by the Ethical Standards of the American Counseling Association as well as the American Counseling Association’s Standards of Practice.
4. You have the additional rights listed under the HIPAA Notice of Privacy Practices below.

AS MY PRIVATE CLIENT, YOU HAVE THE FOLLOWING RESPONSIBILITIES:

1. You have the responsibility to keep your scheduled appointment.  Failure to cancel a scheduled appointment at least 24 hours in advance will result in 50% of your regular fee being due. (Example:  If your appointment is 6:00 PM Tuesday, you must cancel by 6:00 PM Monday).  Failure to cancel a scheduled appointment at least 6 hours in advance will result in 100% of your regular fee being due. (Example:  If your appointment is 6:00 p.m. Tuesday, you must cancel by 12:00 p.m. Tuesday)  Any missed appointment not cancelled will result in 100% of your regular fee being due. (a) All face-to-face clients must CALL to cancel their appointment (this applies to individuals, couples, families, groups, seminars, and workshops). (b) All telephone clients must CALL to cancel their appointment.(c) All online chat, IM, and web-cam clients may CALL or EMAIL to cancel their appointment, and the automatic date/time stamp will be used; a CALL is preferable to EMAIL.(d) Email clients do not need to cancel, as appointments are not scheduled for those services.
2. You have the responsibility to take charge of your own growth. The therapy process is designed to support you and encourage you to make positive changes in your life, not to make those positive changes for you.
3. You have the responsibility to obtain help in an emergency, as described in Emergency Situations, above.

TREATMENT, POLICY, AND GUARANTEE DISCLOSURE:

1. You understand engaging in counseling and psychotherapy is a voluntary process, and you can terminate your therapy at any tine preferably by informing me of your desire to end therapy.
2. You understand I DO NOT guarantee results of any kind.  Specifically, I cannot guarantee your situation will resolve or improve, that you will be come happier, feel less tense or depressed, save a relationship, stop a specific behavior, obtain a better or different job, increase your self-esteem, etc.  I DO guarantee I will offer support, encouragement, feedback, and treatment suggestions to you when appropriate, and will work with you to help you achieve your counseling goals.
3. You understand it is my policy to charge a $30.00 check return fee and a $10.00 late fee for any  balances due exceeding thirty (30) days.
4. You understand you must cancel your appointment 24 hours in advance; otherwise, you will be responsible for paying for the missed session.
5. You understand, if you do not pay for your face-to-face therapy at the end of the session (e.g., forgot your check book), you must submit payment prior to receiving additional therapy, which means payment will be required at the beginning of the next scheduled session.
6. You understand if you arrive late for your scheduled appointment, the session will end at the regularly scheduled time, and the full amount for that session will still be due.
7. You understand, in receiving therapy, there may be periods of emotional discomfort either during or between our sessions.
8. You understand that clinical records will be maintained as long as you are my client.  After a period of three months of not engaging with you for counseling, all records will be destroyed by shredding.  If you return as a client after that time, a new file will need to be created.
9. You understand, while I have a broad knowledge about a variety of clinical issues, I am not a specialist for every possible clinical diagnosis.  Therefore, in keeping with generally accepted standards of practice, there may be occasions when I might consult with other mental health professionals regarding the management of your case.  The purpose of this consultation is to ensure quality of care, and during these consultations every effort will be made to protect your identity and maintain your confidentiality.

FINANCIAL ISSUES AND DISCLOSURES

At this time, I do not accept insurance or third party payments in my private practice.  All of my services (face-to-face and online) are provided as “out of pocket” only, which means you are charged a certain fee for a specific service you pay yourself before or immediately after the service is rendered.  For clients seeking services online or via telephone it is important to note most insurance companies and managed care systems will not pay for telephone or online counseling services.

For any service provided outside my private office (such as email, online counseling through chat, IM or web-cam and telephone consultations), the full fee must be paid in advance of receiving the service. 

For any service provided in my private office (such as individual, couples, family, or group therapy), the full fee must be paid immediately following receiving the service. 

In some instances, such as for workshops or seminars, even when provided in my private office, the full fee must be paid in advance of the service.  (There are occasions when a seminar or workshop is offered and the pre-payment consists of a deposit - typically 30% to 50% of the total cost - with the balance due within 14 days of the event or at the time of the event.  These special circumstance seminars and workshops will be clearly identified on the Fees page of my site.)

Acceptable forms of payment for Internet and telephone services:

• All major credit cards (Visa, Mastercard, American Express, Discover, e-Check, and PayPal)
• Electronic bank transfers
• Online checks
• ATM/debit cards
• Exceptions:  If an Internet or telephone client prefers to mail a personal check* or money order for services, that is an option, however, if you wish to use this option, you must email me beforehand to set this up.  Never send cash through the mail.  I DO NOT ACCEPT CASH IN THE MAIL!

Acceptable forms of payment for in-person services:

• All major credit cards (Visa, Mastercard, American Express, Discover, e-Check, and PayPal
• Electronic bank transfers
• Online checks
• ATM/debit cards
• Personal checks*
• Money Orders
• Cash

*In the event of a returned check, in addition to the amount owed being due, there will be an additional $30.00 returned check fee.  All unpaid balances will incur a $10.00 late fee if not paid in full within thirty (30) days.

Special Notes About Fees for Internet and Telephone Services:

• All prepaid fees for Internet and/or telephone services are NON-REFUNDABLE. There are no exceptions.
• In cases where there may be technical difficulties preventing our scheduled session (e.g., power failure, DSL down, etc.), the session will be rescheduled for another time. (a) If the difficulty is on my end, I will telephone you to inform you of the problem as soon as possible, but no later than the scheduled time.  If you go online to the designated chat room, IM session, or web-cam session and I do not show up within 10 minutes, please have available the telephone you list as your primary contact so I can call you during that time. (b) If the difficulty is on your end, you must telephone me to inform me of the problem no later than the scheduled appointment time.  If you do not telephone me by the time our session would have ended, you will be charged for that session as a missed appointment.
• Sessions purchased in multiples are good for one year from the date of purchase.  (For example, if you purchase 5 email sessions, you do not have to use them all at once.  You could use one or two now, then six months later use the rest if you choose.)
• Gift certificates for Internet and telephone counseling are available.  Please contact me if you would like more information about that option.

SLIDING FEE SCHEDULE DISCLOSURE

For Internet-based and telephone counseling clients

I do not offer a sliding scale fee for any of my Internet or telephone counseling services.  All fees are listed on the Fees page of my website.  You can, however, purchase sessions in quantity, and the more sessions you purchase at one time the lower the individual session price.

For Face-To-Face clients

I do not offer a sliding scale fee for couples, family, or group counseling and psychotherapy, nor do I offer a sliding scale fee for my workshops or seminars. 

My full fee for individual counseling fee is $65 for a 55 minute, face-to-face session.

There are some not-for-profit organizations where you can access services at a lower rate.  If you are unable to afford my minimum fee, I will be happy to provide you with referrals to counseling services where you may qualify for lower fees.

I do not offer any sliding scale or payment adjustments for the following services:  My full fee for couples counseling is $65.  My fee for family counseling (up to 6 people) is $100.  My fees for support groups range between $1 to $20 depending on the group.  My fee for psychotherapy groups range between $50 and $100, depending on the group.  My fee for seminars and workshops varies, depending on the nature of the event.

COORDINATION OF TREATMENT

I do not, as a matter of routine, request my clients to give me permission to inform your primary care physician that I am treating you.  On a case-by-case basis, I might make this request, or there might  be an occasion you would want me to contact your primary care physician and/or psychiatrist on your behalf.  In those cases, you would need to sign and return the Release of Information form.

HIPAA NOTICE OF PRIVACY PRACTICES

This notice describes how medical/mental health information about you may be used and disclosed and how you can get access to this information.  Please review it carefully.

The effective date of this notice is Friday, June 1, 2007.

I only release information in accordance with state and federal laws and the ethics of the counseling profession as described above.

This notice describes my policies related to the use and disclosure of your healthcare information.

Use and disclosure of protected health information for the purposes of providing services.  Providing treatment services, collecting payment and conducting healthcare operations are necessary activities for quality care.  State and federal laws allow me to use and disclose your health information for these purposes.

TREATMENT:  Use and disclose health information to:

• Review of treatment procedures to ensure what I am doing is effective.
• Consultants
• Referrals
• Clinical supervision provider

PAYMENT:  Use and disclose health information to:

• Process and collect fees

HEALTHCARE OPERATIONS:  Use and disclose health information for:

• Review of treatment procedures to ensure what I a doing is effective
• Review of business activities
• Certification compliance and licensing activities
• OTHER USES AND DISCLOSURES WITHOUT YOUR CONSENT:
• Mandated reporting
• Emergencies
• Criminal damage
• Treatment alternatives
• As required by law and outlined above under Limits of Confidentiality

CLIENT RIGHTS

Right to request where I contact you

• You must indicate where I can contact you on the counseling session form.  You will be asked to state yes or no as to whether I can contact you on your home telephone, your office telephone your cell phone, your email, or other point of contact.

Right to release your medical records

• Written authorization is required for me to release your records.  To do this, you may complete, sign, and return the release of information form.
• You have the right to revoke the release of information at any time.
• Revocation is not valid to the extent I have already acted on the release of information prior to its being revoked.

Right to inspect and copy your medical billing records

• You have the right to inspect and copy any billing records I have, related to your services.
• I have the right to decline such request if it is deemed that honoring that request would be harmful to you in some way.
• If the request is honored, you will be responsible to cover the costs of copying, mailing, etc.

Right to add information or amend your medical records

• You may request to make an amendment to your records, and this request must be in writing.
• The request may be denied if it clearly contradicts factual information in the record.
• If the amendment is denied,m you gave the right to file a disagreement statement.
• The disagreement statement and my response to it will be filed in the medical record.

Right to accounting of disclosures

• When I disclose your information based on your request to do so, I may keep some records of who I sent it to, when I sent it, and what I sent.  You can get an accounting (a list) of many of these disclosures.

Right to request restrictions on uses and disclosures of your healthcare information

• You may request certain restrictions on how your information is used and disclosed; however, I am not obligated to agree if it is deemed inappropriate or harmful in some way.

Right to complain

• If you have a complaint, I request you first address it with me to see if we can resolve it.
• If you still feel unsatisfied, you may contact the U.S. Department of Health and Human Services.

Right to receive changes in policy

• There may be a time or times when I update my practice policies and procedures, and you are entitled to a copy of those changes.

For all Email and Telephone clients:  By checking the “I Agree” box at the bottom of the Counseling Session Form and clicking “Submit,” you are indicating you have read the above INFORMED CONSENT, including the sections entitled “About Me and My Practice,” “Limits of Confidentiality,” “Emergency Situations,” “General Client Rights and Responsibilities,” “Financial Issues,” “Coordination of Treatment,” and “HIPAA Notice of Privacy Practices,” that you fully understand them, and that you agree to accept them without condition or exception.

For all Face-To-Face clients:  You will be given a copy of these documents to read and sign in my office.

Grievances:  If you feel you have been violated by me in any way, whether physically, sexually, financially, or otherwise, you may contact the Board of Licensed Professional Counselors and Therapists at 3218 Pringle Rd., SE, Suite 250, Salem, OR 9732-6312, or by calling 503-378-499, or by going to their website at www.lpc.lmft@state.or.us

Please be aware that if your email account has spam-guard or a junk-mail feature, you might need to disable it to receive my email response, or look in your spam or junk folder for my reply. Emails should be sent to amiller@onlinecounseling-psychotherapies.com. I assume no responsibility for emails that get re-directed into a spam or junk mailbox.

 

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