Therapist-Client Informed Consent and Services Agreement
Introduction: Welcome to Clearwater Associates, LLC. This document contains important information about our
professional services and business policies. Therapy is not easily described in general statements. It varies depending
on the personalities of the therapist and client, and the particular problems you are experiencing.
Before beginning, we will meet for a clinical interview. To assist us in understanding your concerns, we will talk about
your reasons for seeking therapy, your history, and other relevant information. We will review your initial paperwork,
discuss recommendations and answer any questions you may have. Together we will decide how to proceed.
Risks and Benefits: Therapy often leads to better understanding of self, solutions to problems, decreased feelings of
distress, and better relationships. While there are no guarantees of what you will experience, most people benefit from
therapy. However, because therapy often involves discussing challenging aspects of your life, you may at times
experience difficult emotions or discomfort.
Appointment, Cancellations and Fees: All office hours are by appointment. Fees for services are as follows: $160 for
a 45- minute individual session, $175 for a 60 – minute individual session, $185 for a 45-minute family or couple’s
session, $200 for a 60-minute family or couple’s session, and $275 for our 60-minute initial clinical interview. Extended
sessions may be prearranged or provided if determined clinically necessary.
To avoid receiving a late cancellation charge, please provide 24 hour notice. Late cancellations and or missed
appointments are billed at the rate of the appointment missed.
All professional services related to legal proceedings are billed at a rate of $300 per hour. Additional time spent on your
behalf outside of our sessions, such as clinical phone calls or e-mails or texts, preparing letters, evaluating psychological
test data, preparing psychological reports, or conferring with other professionals, will be billed at $45 for 1- 15 mins, $90
for 16- 30 mins, $135 for 31-45 mins, and $175 for 46 – 60mins. Bank charges for returned checks are your
responsibility.
The contract for professional services and payment is with you. If you choose to use your health insurance coverage, we
will provide you a statement that you may submit to your health insurance or other 3rd party payer. For clients with
medicare, we are not medicare providers and there is an additional sheet for you to complete.
Accounting: We use a bookkeeping service, LouAnn Nelson Accounting, and Consulting Services, to handle your account
and payments. Information necessary for this will be provided to them. If you have any questions about your bill, you
may contact LouAnn Nelson at cwbilling@cwpdx.com, or you may speak with us directly.
Contacting Us: We often are not directly available by telephone. When we are unavailable, you may leave a voicemail
message on our phone. Our voicemail is available 24 hours, 7 days a week. We make every effort to return phone calls
within one business day. If we are out of the office and not checking voicemail, we will advise you of this in our outgoing
message. When we are away from our office for an extended period, a professional colleague will be available to you if
needed; in those cases, only the information necessary to provide interim services is made available to the covering
professional.
Michelle Bobowick, PsyD
2222 NW Lovejoy St #406
Licensed Psychologist
Portland, OR 97210
503.232.0992
clearwaterpdx.com
Rev. 11/2/2015 – Parenting initial paperwork
Michael Leidecker, PsyD, LPC
Licensed Professional Counselor
503.975.0101
E-mail and text communications are to be used for scheduling purposes only unless otherwise discussed and agreed
upon.
Confidentiality: Federal HIPAA regulations allow medical and mental health treatment providers, including therapists, to
coordinate care and to share information about mutual clients that may be beneficial for client’s treatment. In most
situations, we will only release information about your treatment to others if you sign a written authorization form.
However, it is important that you be aware that we may disclose information in the following situations:
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If we have knowledge that a child, a person with disabilities, or an elder is currently suffering abuse.
If there is a clear and imminent danger of physical harm to yourself or others, or if there is a medical emergency.
If we are ordered to do so by a court of law or if you file a worker’s compensation claim.
We may make disclosures to seek consultation with other mental health professionals. These individuals are
required to maintain the same standard of confidentiality.
Please note: Your signing of this Therapist-Client Informed Consent and Services Agreement gives us permission to
exchange information for coordination of care, consultation, and exchange of initial paperwork between Clearwater
Associates, LLC therapists.
Reminder: The confidentiality of information communicated via cellular telephones, e-mail, internet and fax cannot be
assured.
Emergences: If you are unable to reach us and feel that you are in an emergency situation and cannot wait for our
return call, contact your county crisis line (in Multnomah County the number is 503.988.4888), call 911, or go to the
nearest emergency room.
Legal Proceedings/Court Involvement: Our goal is to support clients to achieve therapy goals, not to address legal
issues that require an adversarial approach. Clients entering into treatment are agreeing not to involve us in legal/court
proceedings or to obtain records of treatment for legal/court proceedings. This prevents the misuse of your therapy
treatment.
If you are involved in or anticipate being involved in a legal or court proceeding, please notify us immediately. It is
important for us to understand how, if at all, your involvement in these proceedings might affect our work together. If
you are required by a court to obtain an evaluation, be aware that therapy is not a substitute for an evaluation. If you
need an evaluation, we will be happy to help you find a provider that offers this service.
Professional Records: We are required by Federal law (Health Insurance Portability and Accountability Act, known as
HIPAA) to protect the privacy of personal information. A copy of our Notice of Privacy Practices notice is available to you
on our website. In the event of death or severe disability, we have made provisions in this practice to safeguard and
maintain records, and the non-impacted therapist will be your contact person for access to records if necessary.
Thank you for carefully reading this document. We are happy to answer any questions that you may have.
Michelle Bobowick, PsyD
2222 NW Lovejoy St #406
Licensed Psychologist
Portland, OR 97210
503.232.0992
clearwaterpdx.com
Rev. 11/2/2015 – Parenting initial paperwork
Michael Leidecker, PsyD, LPC
Licensed Professional Counselor
503.975.0101
Acknowledgement of Therapist-Client Informed Consent and Services Agreement
I have received and read this Therapist -Client Informed Consent and Services Agreement. I
have had an opportunity to ask questions about the information provided. My signature below
indicates that I voluntarily consent to receive services by Clearwater Associates, LLC, and to
abide by the terms of this agreement. I understand that after therapy begins, I have the right
to withdraw my consent to therapy at any time, for any reason, except to the exte nt that
action has been taken in reliance on my previous consent.
And my signature below indicates that a notice describing the HIPAA privacy act has been made available to me.
Client Name (Please print): ______________________________________________________
Client Signature: ______________________________________________________________ Date: _______
Legal Guardian Signature: _______________________________________________________Date: _______
Michelle Bobowick, PsyD
2222 NW Lovejoy St #406
Licensed Psychologist
Portland, OR 97210
503.232.0992
clearwaterpdx.com
Rev. 11/2/2015 – Parenting initial paperwork
Michael Leidecker, PsyD, LPC
Licensed Professional Counselor
503.975.0101
Client Information
Today’s Date: ____________
Name: ____________________________________________________________________________________________
Street address: ____________________________________ City: _________________State: ____Zip:_______________
Primary Phone #: __________________________________ Type: cell
home
work
Msg. OK?: ⃝ Yes ⃝ No
Alternative Phone #: _______________________________ Type: cell
home
work
Msg. OK?: ⃝ Yes ⃝ No
E-mail: _________________________________________
Msg OK: ⃝ Yes ⃝ No
Emergency Contact: ______________________________
Relationship to you: ____________ Phone#:_____________
Who referred you? ________________________ What is your relationship with this person? _____________
May I contact this person to thank him or her for referring you? ⃝ Yes ⃝ No
DOB:_______ Age: ______ Gender: __________ Sexual Orientation: _________________
Please describe your ethnic, cultural, religious and or spiritual practice background: ____________________________
Highest grade or level of education: _________ Current occupation:_______________________________
Relationship:
single partnered
married
separated
divorced
widowed
other: _______________
Please briefly describe what brought you to therapy:
__________________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
Please list any concerns you may have around your weight, relationship to food, nutrition, and/or body image:
__________________________________________________________________________________________________
__________________________________________________________________________________________________
Have you ever been in therapy before? ⃝ Yes ⃝ No If yes, please list: (include name and dates)
__________________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
Previous psychiatric hospitalizations or intensive outpatient treatment? ⃝ Yes ⃝ No If yes, please list.
__________________________________________________________________________________________________
Michelle Bobowick, PsyD
2222 NW Lovejoy St #406
Licensed Psychologist
Portland, OR 97210
503.232.0992
clearwaterpdx.com
Rev. 11/2/2015 – Parenting initial paperwork
Michael Leidecker, PsyD, LPC
Licensed Professional Counselor
503.975.0101
Have any family members been diagnosed or treated for mental health conditions? ⃝ Yes ⃝ No If yes, please list
family members and conditions. _______________________________________________________________________
__________________________________________________________________________________________________
Do you currently consume alcohol? ⃝ Yes ⃝ No
If yes, list average number of drinks per occasion: _______ frequency/days per week: _______
What is the maximum amount of drinks consumed during one occasion in the past year?: ______
Do you have any concerns about your alcohol or substance use?
⃝ Yes ⃝ No
Have family members or friends expressed concern about your drinking? ⃝ Yes ⃝ No
Any previous treatment for alcohol or substance use/abuse? ⃝ Yes ⃝ No
Is there any alcohol or substance use in your home now that concerns you? ⃝ Yes ⃝ No
Was there any alcohol or substance use in your home growing up that concerned you? ⃝ Yes ⃝ No
Do you have a history of problematic use of prescription /non-prescription drugs? ⃝ Yes ⃝ No
Have you ever had thoughts of wanting to end your life? ⃝ Yes ⃝ No
Have you ever attempted to harm yourself? ⃝ Yes ⃝ No
If yes, when? _____________________
If yes, when? _____________________
Have you had serious thoughts of harming another person? ⃝ Yes ⃝ No
If yes, when? _____________________
Is there any violence or other abuse in your home that concerns you? ⃝ Yes ⃝ No
Was there any violence or other abuse in your home growing up? ⃝ Yes ⃝ No
Are there any firearms in your current place of residence? ⃝ Yes ⃝ No
Have you ever been convicted of a crime? ⃝ Yes ⃝ No
Are you currently involved in or do you anticipate involvement in legal proceedings? ⃝ Yes ⃝ No
Michelle Bobowick, PsyD
2222 NW Lovejoy St #406
Licensed Psychologist
Portland, OR 97210
503.232.0992
clearwaterpdx.com
Rev. 11/2/2015 – Parenting initial paperwork
Michael Leidecker, PsyD, LPC
Licensed Professional Counselor
503.975.0101
Name of Primary Care Physician: ______________________________
Phone # for PCP: _____________________________
Clinic Name: ____________________________
Last Physical: _________________________________________
Current health concerns or illnesses (include allergies):
__________________________________________________________________________________________________
__________________________________________________________________________________________________
Past medical problems and surgeries:
__________________________________________________________________________________________________
Are you on any psychiatric medication? ⃝ Yes ⃝ No
If yes, please list include dosage.
__________________________________________________________________________________________________
Have you previously been prescribed psychiatric medication? ⃝ Yes ⃝ No
If yes, please list.
__________________________________________________________________________________________________
Are you taking any other kinds of medication or vitamins? ⃝ Yes ⃝ No
If yes, please list dosage and reason.
__________________________________________________________________________________________________
Describe your sleep (how many hours, night waking, difficulty falling asleep):
__________________________________________________________________________________________________
Have you gained or lost weight without trying in the last six months? ⃝ Yes ⃝ No
Do you exercise regularly? ⃝ Yes ⃝ No
If yes, please describe type and frequency.
__________________________________________________________________________________________________
Do you drink caffeine? ⃝ Yes ⃝ No
If yes, please describe type and frequency.
__________________________________________________________________________________________________
Do you smoke cigarettes? ⃝ Yes ⃝ No If yes, how many cigarettes do you smoke per week? _______
Did you smoke cigarettes in the past? ⃝ Yes ⃝ No
Michelle Bobowick, PsyD
2222 NW Lovejoy St #406
Licensed Psychologist
Portland, OR 97210
503.232.0992
clearwaterpdx.com
Rev. 11/2/2015 – Parenting initial paperwork
Michael Leidecker, PsyD, LPC
Licensed Professional Counselor
503.975.0101
Please list your immediate family members/significant persons (including parents, siblings, children, partner):
Name:
Age:
Live with you
Relationship to you:
_________________________________
__________
⃝ Yes ⃝ No ________________________________
_________________________________
__________
⃝ Yes ⃝ No ________________________________
_________________________________
__________
⃝ Yes ⃝ No ________________________________
_________________________________
__________
⃝ Yes ⃝ No ________________________________
_________________________________
__________
⃝ Yes ⃝ No ________________________________
_________________________________
__________
⃝ Yes ⃝ No ________________________________
_________________________________
__________
⃝ Yes ⃝ No ________________________________
*At end of this packet, you will see 2 forms. Please fill out these forms.
1. DSM – 5 Self –Rated Level 1 Cross-Cutting Symptom Measure- Adult - answer for yourself.
2. DSM- 5 Parent/Guardian Self-Rated Level 1 Cross-Cutting Symptom Measure – Child 6-17 – answer based on
your observations of your child.
Michelle Bobowick, PsyD
2222 NW Lovejoy St #406
Licensed Psychologist
Portland, OR 97210
503.232.0992
clearwaterpdx.com
Rev. 11/2/2015 – Parenting initial paperwork
Michael Leidecker, PsyD, LPC
Licensed Professional Counselor
503.975.0101
Payment Plan
Client Name: ____________________________________________________ Date________________________
1. I agree that payment for services is my responsibility. I understand that Clearwater Associates, LLC will provide
me with a monthly statement.
Please mark the preferred option below:
______ I intend to pay with check/cash monthly.
______ I intend to pay with credit card monthly.
2. I understand that any outstanding balances including missed sessions or late cancellations will be charged to the
credit card below after 30 days.
Please initial your consent to the above ______
I, the undersigned, authorize Clearwater Associates, LLC and/or or LouAnn Nelson with LouAnn Nelson Accounting and
Consulting Services to charge the account below for services according to the payment plan indicated above.
Signature of Client: ___________________________________________________Date: __________________
Signature of card holder if different than client: ____________________________________Date: __________________
___ ___ ___ __ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___
Credit Card Information (required)
*Please note: The portion of this form containing your credit card information will be destroyed permanently by secure
means at the completion of services and after any outstanding balance has been paid.
Card Number:__________________________________Exp. Date: (mm/yy) ________ CVC (3 digit # on back ): _____
Name of card holder: _______________________________________________________________________________
Billing Address for card:______________________________________________________________________________
Street
City
State
Zip
Michelle Bobowick, PsyD
2222 NW Lovejoy St #406
Licensed Psychologist
Portland, OR 97210
503.232.0992
clearwaterpdx.com
Rev. 11/2/2015 – Parenting initial paperwork
Michael Leidecker, PsyD, LPC
Licensed Professional Counselor
503.975.0101
Michelle Bobowick, PsyD
2222 NW Lovejoy St #406
Licensed Psychologist
Portland, OR 97210
503.232.0992
clearwaterpdx.com
Rev. 11/2/2015 – Parenting initial paperwork
Michael Leidecker, PsyD, LPC
Licensed Professional Counselor
503.975.0101
Michelle Bobowick, PsyD
2222 NW Lovejoy St #406
Licensed Psychologist
Portland, OR 97210
503.232.0992
clearwaterpdx.com
Rev. 11/2/2015 – Parenting initial paperwork
Michael Leidecker, PsyD, LPC
Licensed Professional Counselor
503.975.0101