Professional Disclosure Statement and Informed Consent

Jennifer L Heine MA, LPC

Healthy Connections Counseling, LLC | 1297 Wallace Rd NW Suite B Salem, OR 97304

971-719-8864 | humanconnections@outlook.com

Professional Disclosure Statement

Philosophy & Approach: My passion is facilitating healthier, happier individual and family growth, building compassion and connection! My approach involves creating and maintaining a safe place to share and explore life stories – those of family, friends, strengths, and challenges. Our greatest feelings of happiness and joy, or deepest loss and grief involve our feelings and levels of connection and closeness with others. As Dr. Dan Siegel explains, we are “Wired for Connection,” biologically, we are biologically created to attach and interconnect with each other. From this perspective our personal history and current life reveals insight into why we feel, think, and behave in certain ways. It is my privilege to share this therapeutic time with you to allow your story to unfold, gain insight into yourself, and build on your strengths to create the life and relationships you want.

Formal Education & Training: I hold a Master of Arts in Clinical Mental Health Counseling from George Fox University, accredited by the Council for Accreditation of Counseling & Related Educational Programs (CACREP). Major Coursework included Human Development, Individual, Couples, Group and Play Therapies, Psychopathology & Appraisal, Addictions, Emotion-Focused Therapy, and Interpersonal Neurobiology & Pharmacology. As a Licensee of the Oregon Board of Licensed Professional Counselors and Therapists, I abide by its Code of Ethics. Continuing education is required with a focus on increasing knowledge and/or skills in substantive areas relevant to this profession.

Payment for Services: All payment and insurance arrangements are made at the time of service. I accept Pacific Source/OHP Insurance and private cash pay.

Client’s Bill of Rights: As a client of a licensee, you have the following rights as established by the Oregon State Board of Licensed Professional Counselors and Therapists (OAR833-60-001):

• To expect that a licensee has met the minimal qualifications of training and experience required by state law:

• To examine public records maintained by the Board and to have the Board confirm credentials of a licensee;

• To obtain a copy of the Code of Ethics;

• To report complaints to the Board;

• To be informed of the cost of professional services before receiving the services;

• To be assured of privacy and confidentiality while receiving services as defined by rule and law, including the following exceptions:

1) Reporting suspected child abuse;

2) Reporting imminent danger to client or others;

3) Reporting information required in court proceedings or by client’s insurance company, or other relevant agencies;

4) Providing information concerning licensee case consultation or supervision; and

5) Defending claims brought by client against licensee;

• To be free from discrimination because of age, color, culture, disability, ethnicity, national origin, gender, race, religion, sexual orientation, marital status, or socioeconomic status.

Complaints or Concerns: If you have any questions or concerns about any aspect of therapy please inform me immediately so I may address your concerns. Alternatively, you may also contact the Board at the following address and phone number:

Oregon Board of Licensed Professional Counselors and Therapists

3218 Pringle Rd SE Suite 250 Salem, OR 97302-6312.

Telephone: (503) 378-5499 Email: lpct.board@state.or.us

Website: www.oregon.gov/OBLPCT

Consent to Treatment

By your signature below, you are indicating that you have read and understand this statement and have had opportunity to ask questions about, and seek clarification of, anything unclear to you.

Consent to Treatment: Your signature below indicates you have fully read and understand the Professional Disclosure Statement, and consent to treatment under the conditions listed above. You may also revoke your signature and agreement anytime in writing.

Client’s Signature: _______________________________ Date____________

Therapist’s Signature: ____________________________ Date____________