Professional Disclosure Statement Daniel J Blumhardt, M. Ed.

, Registered Intern Location: Community Counseling Clinic Portland State University Graduate School of Education 615 SW Harrison St. / PO Box 751 / Portland, OR 97207-0751 Phone 503-725-4620 Introduction: The purpose of this document is to provide you with information you need to have before beginning counseling with me. This information includes my qualifications, training, therapeutic approaches, and fees, but also your rights as a client. Please carefully read over the details. Feel free to ask any questions you have! About My Approach to Counseling: I provide individual, couples, and family counseling. I believe that counseling is most effective when it is personalized both to the client, and to the problems brought to our sessions together. However, all clients may expect a listening ear, mutual respect, collaborative problem solving, and empowerment to deal with issues brought to counseling, which includes at a minimum encouragement to have well-developed goals, make personal choices in line with those goals, the development of life skills, and tapping into internal and external resources to help you continue on successfully after counseling. Additionally, I place a strong emphasis on approaches that are proven to help clients and on the common factors that have proven to play an important part in successful therapy regardless of the approach used. Formal Education and Training: I am working towards a Masters Degree in counseling from Portland State University in Portland, Oregon. I am also currently pursuing licensure in the State of Oregon. As a student at Portland State University, I have taken a wide range of courses essential for effective counseling such as Theoretical Foundations, Human Development, Abnormal Psychology, Ethics, Marriage, Couples, and Family Counseling, and Career Development. Additionally, I am a member of the American Counseling Association, The Oregon Counseling Association, and the American School Counseling Association. As a Registered Intern of the Oregon Board of Licensed Professional Counselors and Therapists in accordance with ORS 675.720, I will abide by its Code of Ethics. I am under the ongoing supervision of Will Meek, Psychologist. You will be asked to sign a release so that my supervisor may be able to provide input into our sessions as needed, for your benefit, as well as for my development as a counselor. For more information on the supervision process or the code of ethics, please feel free to ask. The Code of Ethics provides all counselors with a high standard of professional conduct. As will be discussed in our initial session, our relationship will be strictly professional and within the confines of our sessions together, which is one aspect of my ethical responsibility to keep our sessions focused on your needs as a client. Your Rights: Your rights are very important and will be respected as a client. As a client of an Oregon Registered Intern, it is important that you know you have the following rights in accordance with the Client Bill of 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, such as found in ORS 675.765, which states that a licensee or any employee of the licensee shall not disclose any communication given the licensee by a client in the course of noninvestigatory professional activity when such communication was given to enable the licensee to aid the client It further states that there are a few very specific exceptions to this law you need to be aware of: o 1) Reporting suspected child abuse; o 2) Reporting imminent danger to client or others; o 3) Reporting information required in court proceedings or by clients insurance company, or other relevant agencies; o 4) Providing information concerning licensee case consultation or supervision; o 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.

Fees: Each 50-minute session is $15. If there is any reason this limits your ability to get services, please let me know so we can discuss options to ensure you get help. Missed, rescheduled, or late appointments will be billed at the normal rate of $15 if notification is not given within 24 hours of the scheduled appointment. Due to our competitive rates, we currently do not accept health insurance. Payment is due at the beginning of the session. Complaints: If you have a specific complaint, please know you may register one with the Oregon Board of Counselors and Therapists at: 3218 Pringle Rd SE #250 Salem, OR 97302-6312 (503) 378-5499 By signing below, you are indicating that you have carefully read, and understand, each section in this statement. Client Name(s) Therapist Signature

Client Signature

Client

Signature All sections included Writing, Formatting, Readability Confidentiality / Bill of Rights Documents supervision properly Appropriate representation of self Cites appropriate law Overall 10/10 10/10 10/10 5/5 3/3 2/2 40/40

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