Statement of Informed Consent and Acknowledgment & Receipt of Professional Disclosure Statement for:

Melissa Gomsrud, MA, LCP, NCC

Counseling for Creative Change, LLC (541) 222-9724

Riverview Business Park

1901 Garden Ave, Suite 213

Eugene, OR 97403

melissa@counselingccllc.com                 www.counselingccllc.com

Welcome! This document is intended to inform you of office my policies, document your rights and responsibilities, and to familiarize you with my approach to therapy. Please feel free to discuss any questions, thoughts, or concerns you may have with me prior to signing, or at any point in the future.

Philosophy and Approach: My style is warm, supportive, and down to earth. I use a variety of therapeutic approaches including Cognitive Behavioral Therapy, Narrative Therapy, Brief Solution Focused Therapy, and Family Systems Theory to assist you in sharing your story, identify negative beliefs, resolve conflicts and accomplishing peaceful change. It is my belief that problems are often developed and sustained through well-established, and often unconscious, habits of thinking and behavior. I provide a safe and supportive setting, and have a respectful and practical approach, to addressing problems. I work in partnership with you, utilizing your strengths and resources to create positive change.

Education and Training: I am a Licensed Professional Counselor (LPC #C1466) with a Masters Degree in Counseling Psychology from Lewis & Clack College in 2000. I am also a Nationally Certified Counselor (NCC #63398). As a Licensed Professional Counselor, I abide by the Code of Ethics of the Oregon Board of Licensed Professional Counselors and Therapists. In order to maintain my licenses I participate in continuing education focusing on topics relevant to the therapeutic process.

Benefits and Risks: Participation in therapy has been shown to significantly benefit people who undertake it for personal growth, symptom reduction, and behavioral change. Therapy does, however, carry some risks. Risks may include: uncomfortable feelings which can result from the exploration of difficult or unpleasant aspects of past or current experiences or discomfort from attempts to stretch oneself by engaging in new behaviors, relational skills and coping strategies. For children and adolescents this may manifest in behavioral reactions. The most notable risk is a lack of positive impact on presenting concerns.  Potential risks may be avoided by not entering into therapy.

Best outcomes of therapy are typically associated with the following:

* Consistent attendance, active effort and collaboration, both on your part, as the client

and/or parent or guardian and on my part as the therapist.

* A positive relationship between therapist and client. Therefore, if at any time you feel

uncomfortable or dissatisfied with our relationship or work, it is important that we discuss this so that we can make the appropriate adjustments to our work together or, if needed, I can assist you with referral to another professional.

Appointments, Fees, and Insurance: Each appointment will usually be approximately 50 minutes in length. Please see my billable fee information.  Also, if you choose to pay in full (without any insurance billing) at the time of each session, I will discount your fee to $100 per session. When we schedule an appointment, I reserve that time especially for you. Therefore, you are responsible for letting me know at least 24 hours in advance if you need to cancel. Late cancellations or no show appointments are your financial responsibility and cannot be billed to insurance, or other third party payers.  Also, if you are unresponsive for 60 days I will close your case. Over 60 days of no communication is seen as your voluntary termination of services with me. Additionally, please know that I, Melissa Gomsrud, will not provide any testimonies or letters for any custody disputes.  Nor am I qualified to write emotional support animal letters; or respond to certain other types of letter requests. 

With regards to payment, I accept cash, checks, credit cards and most types of health insurance. I keep a percentage of my practice open to people who are uninsured, or underinsured, and cannot afford the full fee. Sliding scale openings are subject to availability. Your insurance coverage is dependent on your carrier, and on your particular plan. Important questions to ask your insurer are:

* Does my plan cover mental health/ behavioral health benefits?

* Does my plan reimburse for an LPC (Licensed Professional Counselor)?

* What is my yearly deductible, and how much of it has been met?

* What is my co-pay, or co-insurance, for an out-of-network provider; versus a participating/preferred provider? * How many sessions per year does my health insurance cover?

* What is the coverage amount per therapy session?

* Is approval required from my primary care physician?

Emergencies: 

You can leave a confidential message for me at (541) 222-9724. Crisis, emergent situations, or safety concerns, particularly, suicidal thoughts and/or self-harm, or suspected child abuse are appropriate reasons to access phone support. However please be aware that I am often not immediately available. Please immediately access the following crisis services when I cannot be reached directly:

* For Children and Adolescents: Mental Health Crisis Team 1-888-989-9990

* For Adults: White Bird (541) 687-4000

* For immediate safety concerns, or a life threatening emergency, go directly to your local emergency room or call 911.

As a client of a Licensed Professional Counselor (LPC) you have the following rights:

* 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.

Your Protected Health Information (PHI) is protected by state and federal law (HIPAA). This information can only be disclosed with your express permission, or as required or permitted by law. In general, I may not disclose any personal information without your permission, and I aim to protect confidentiality, and keep your information private. Any electronic device I use to access PHI is password protected to prevent unauthorized access. However, there are certain conditions in which I may be permitted, or required, to disclose certain information without your express consent. They are as follows:

For Treatment Purposes: At times I may discuss a case with a professional colleague. In these instances I will omit or change any identifying information. This disclosure is purely to enhance my skill and treatment in a specific situation and is used judiciously. Any colleague is also bound by HIPAA laws.

 Without Authorization: The following are disclosures that may be required by law in certain circumstances:

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 being the object of discrimination on the basis of race, religion, gender, or other unlawful category while receiving services.

Anyone may contact the Board of Licensed Professional Counselors and Therapists at 3218 Pringle Rd SE #250, Salem, OR 97302-6312. Telephone: (503) 378-5499

Statement of Informed Consent and Acknowledgment & Receipt of Professional Disclosure Statement:

By signing, and/or giving verbal consent, to this Statement of Informed Consent, I acknowledge that I have read and received a copy of Melissa Gomsrud's Professional Disclosure Statement, including HIPAA privacy and confidentiality information, agree to abide by its terms, and have had any questions or concerns about its contents addressed by Melissa Gomsrud, LPC, NCC. I understand that I may request a paper copy of this information at anytime, whether I sign and give consent in a digital, or paper format. Furthermore, my signature, or electronic signature, below indicates that I have voluntarily agreed to enter myself and/or my child into therapy. I understand that, by law, I need not sign or enter into this agreement; and that I may choose to discontinue therapy at any time.