Get the free Counseling Information Disclosure Statement - LionTree Counseling

Lionel Counseling Meg Jesse, M.A. 2100 NE Broadway St., Suite 319A Portland, OR 97232 5039856344 Phone 5035125230 Fax www.LionTreeCounseling.com Tax I.D.× 270541374 NPI: 1720394315 Counseling Information

How to fill out counseling information disclosure statement

How to fill out a counseling information disclosure statement:

1. Start by gathering all the necessary information such as your name, contact details, and the name of the counseling center or therapist you are seeking services from.
2. Read the counseling information disclosure statement carefully to understand the purpose and content of the document. It is important to be aware of what information will be disclosed and how it will be used.
3. Begin filling out the personal information section, providing accurate details about yourself, including your full name, address, phone number, and email address. Ensure that all information is up to date.
4. The next section may require you to provide emergency contact information. This is important in case of any unforeseen circumstances that may require someone to be contacted on your behalf. Insert the name, phone number, and relationship of your emergency contact.
5. Proceed by carefully reviewing the authorization and consent section of the disclosure statement. This section may include information about the therapist's code of ethics, confidentiality policies, and consent to release information to certain parties.
6. If you agree with the terms and conditions stated in the consent section, sign and date the form to indicate your acknowledgement and understanding of the disclosure statement.
7. Some counseling information disclosure statements may include additional sections such as financial responsibilities, cancellation policies, and privacy practices. Make sure to carefully read and fill out all sections relevant to your situation.
8. Double-check all the information you have entered to ensure accuracy and completeness. Mistakes or omissions may lead to complications later on, so it's crucial to provide accurate information.
9. Save a copy of the filled-out counseling information disclosure statement for your own records. It serves as a reference point for any future discussions or inquiries.
10. Finally, submit the document as instructed by the counseling center or therapist. They may require you to bring a physical copy to your first appointment or ask you to send it electronically.

Who needs a counseling information disclosure statement?

1. Individuals seeking therapy or counseling services from a professional therapist or counseling center.
2. The document is essential for both new clients who are starting their counseling journey and returning clients who may need to update their information or reconfirm their consent.
3. The counseling information disclosure statement ensures transparency between the therapist and the client by outlining the purpose, privacy policies, and information sharing protocols, promoting a safe and ethical therapeutic environment.

For pdfFiller’s FAQs

What is counseling information disclosure statement?

Counseling information disclosure statement is a document that outlines the disclosure of information related to counseling services provided to clients.

Who is required to file counseling information disclosure statement?

Counselors, therapists, or mental health professionals who provide counseling services are required to file the counseling information disclosure statement.

How to fill out counseling information disclosure statement?

The counseling information disclosure statement can be filled out by providing relevant information about the counseling services offered, client confidentiality policies, and any potential risks or benefits associated with counseling.

What is the purpose of counseling information disclosure statement?

The purpose of counseling information disclosure statement is to inform clients about the counseling services, confidentiality policies, and any applicable rules and regulations.

What information must be reported on counseling information disclosure statement?

The counseling information disclosure statement must include details about the counselor or therapist, counseling services offered, confidentiality policies, potential risks and benefits of counseling, and any relevant contact information.

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