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T. Christopher Portman, Ph.D.                          Licensed Psychologist                           Bellingham, WA 98229

                                             

                                                                      PRACTICE POLICIES and AGREEMENTS

Please read this page carefully, then sign and return.

 

Thank you for selecting me as your psychological services provider.  I hope that our relationship will be a benefit to you.  As a client of mine you have freedom of choice. I will encourage you to ask questions and make requests, and you may end counseling at any time.  My role is that of facilitator, not decision-maker, over your life.  

            My service to you will be focused on your emotional wellness. This may include a variety of strategies and ideas that we develop together that can lead to greater contentment and better choices in your life.

 

LIMITS OF MY COUNSELING SERVICES:

 

You are best served if therapy remains focused on your concerns.  It would not be ethical of me to accept gifts, social or business invitations, or to relate to you in any way other than as a professional psychologist.

 

Please note: without your request for other psychological services, ours will be a counseling/therapy relationship only. Once we begin on that basis, I will not be your advocate for other purposes such as assessments or letters for attorneys, courts, mediators, probation officers, DSHS, DOT violations, employers or any other third parties. Such services have different procedures, expectations, and judgmental components that can confound the effectiveness of a pure counseling relationship. So, if you seek these other types of services, please let me know prior to our initial counseling appointment so that we can establish our relationship on that basis.

 

PAYING MY FEE

My counseling fee is private pay by credit card. There are only 2 or 3 insurance companies that I remain contracted with, so if you are hoping to use insurance let me know in advance of any services. Appointment openings are limited.

If I am considered an out-of-network provider by your insurance company, I would be happy to give you a formal diagnostic statement and receipt that you may submit to your insurance company at any point after you have paid me for one or more sessions. You can send this "super bill" to your company, and they may reimburse you for some or all of what you have paid.

CANCELLATIONS AND MISSED APPOINTMENTS:

 

Because my time has been reserved for you, please notify me at least 24 hours (one full business day) prior to your scheduled appointment if you are unable to attend.  I reserve the right to charge you for appointments broken or cancelled without 24 hours advance notice.  You will be responsible for paying an $80 fee for the session you missed.    

 

CONFIDENTIALITY: 

 

You have “privileged communication” when you see a licensed psychologist whether in an office or online. All issues discussed in your treatment sessions are confidential and highly protected.  No information about you will be released without your written consent.  I may “staff” or discuss your case with professional associates, but without identifying who you are.  Exceptions to confidentiality are the following:

 

  1. Washington State Law requires reportage of any instances of abuse of a child, developmentally disabled person, or dependent adult.

  2. The law also requires reportage of persons who are in imminent danger of harming themselves or someone else.

  3. I may be compelled to disclose confidential information by a court of law or agency legally mandating our services.

 

Also, I use a video therapy connection called Doxy.me.  It is HIPPA-compliant regarding protection of confidentiality and used by many medical practices. You need to be aware however, that like many electronic communication systems, absolute safety cannot be guaranteed.

 

I authorize Dr. Portman to provide psychological services.  I have read the above and understand my responsibility and agree to the terms.  This documents my informed consent.

 

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