Lola Broomberg
LPC
541 Willamette
Street, suite 207A
Eugene, OR
97401
541-686-8119
General
Information and Policies:
Welcome, This document is intended to inform you about
my policies, your rights and responsibilities and to familiarize yourself with
my approach to therapy. Please read it carefully and feel free to discuss any
aspect of this paper with me now or at any time during your treatment.
Philosophy
and Approach: I believe that each of us is a unique
person and that we experience the world on many levels: intellectual,
emotional, physical, social and spiritual. For optimum health, we seek to
understand and make sense of our lives at all these levels. I believe that
every client has the resources within themselves to support their growth
towards living a healthy life. I support my clients in reframing their life
stories to incorporate situations in which they chose to make empowered
personal choices. I utilize a mindfulness-oriented approach and I am influenced
by gestalt and feminist therapy.
Formal
Education and Training:
I am a Licensed Professional Counselor with a Masters
Degree in Counseling Psychology from Oregon State University. I am also a
Nationally Certified Counselor.
As a Licensed Professional Counselor, I abide by the
Code of Ethics of the Oregon Board of Licensed Professional Counselors and
Therapists.
Benefits and
Risks:
Most people benefit from therapy oriented towards
personal growth that facilitates intentional life changes or adjustments. The
process will invite you to explore past and present relationships, unresolved
issues and patterns of response to stress. On occasion clients may experience
emotional discomfort during or after we talk about difficult experiences. Please
discuss this with me. Our ability to maintain an open dialogue about our work
together is a vital factor in the healing process. While there can be no
guarantee of our meeting all your goals, I hold a sincere commitment to facilitating
a meaningful therapeutic outcome. Therapy is concluded when we mutually agree
that goals have been satisfactorily addressed or there is another reason for
stopping. You are free to terminate counseling at any time, however, I
recommend at least one final session to assess our work and clarify remaining
goals.
Counseling
Relationship: Each
counseling session lasts 55 minutes. I will attend to time and will let you
know when we are close to the end of a session. As far as regularity of
scheduled sessions, I work with clients to support their growth and development
on their terms. Many clients like to come in for counseling once a week, some
come in every two weeks and others come in when they feel the need for a
tune-up. I am also able to meet clients more frequently during times of crisis.
I will assist you in deciding how often you would like to meet.
* Does your plan cover mental health benefits?
* Does your plan reimburse for an LPC (Licensed Professional Counselor)?
* What is your yearly deductible and how much of it has been met?
* What is your co-pay (the amount you will pay to me) for an
out-of-network provider versus a participating/preferred provider?
Appointments
and Cancellations: Please try to be on time for your
session as I will not be able to provide you extra time if you are late. For
therapy to be most effective, it is important to attend your appointments
regularly. You are responsible for reserved appointment times. Cancellations
should be made at least 24 hours in advance to avoid charges for the reserved
time. Consideration is given for emergencies.
No- shows or
last minute cancellations will be charged the full sesson
fee. Insurance will not be billed for a no-show
Communication: You can text or leave a confidential voicemail for me
at 541-686-8119 or email me at lolabroomberg@gmail.com. I will return your call
as soon as possible.
Emergencies: If I do not get back to you in a
reasonable time call White Bird crisis line at 541 687 4000, 911 or report to
your nearest medical emergency room.
As a client
of a Licensed Professional Counselor 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, including the following
exceptions:
1) Reporting suspected child abuse;
2) Reporting imminent danger to client or others;
3) Reporting information required in court proceedings
or by clientÕs 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.
Feel free to contact the Board of
Licensed Professional Counselors and
Therapists at 3218 Pringle Rd
SE #250, Salem, OR 97302-6312. Telephone: (503) 378-5499
I have read, understood and received a copy of
this document
Client Signature
date
Lola Broomberg LPC
541 Willamette,
Suite 207A
Eugene Oregon
97401
541 686 8119
Notice Of Privacy Practices
This notices describes how medical/mental health
information about you may be used and disclosed and how you can get access to
this information. Please read carefully.
I am required
by applicable federal and state law to maintain the privacy of your health
information. I am also required to give you this Notice about my privacy
practice, legal obligations and your rights concerning your health information.
(ÒProtected Health Information or PHIÓ). I must follow the privacy practices
that are described in this Notice (which may be amended from time to time). For
more information about my privacy practices or for additional copies of this
Notice, please contact me using the information listed in Section 11 G of this
notice.
I may use and
disclose PHI without your written authorization, excluding Psychotherapy Notes
as described in Section11, for certain purposes as described below. The
examples provided in each category are not meant to be exhaustive but instead
are meant to describe the types of uses and disclosures that are permissible
under federal and state law.
I may use and disclose PHI in order to
provide treatment for you. For example, I may use PHI to diagnose and provide counseling service to you. In addition, I may disclose PHI
to other health care providers involved in your treatment.
I may use or disclose PHI so that
services you receive are appropriately billed to, and payment is collected
from, your health plan. By ways of example, I may disclose PHI to permit your
health plan to take certain actions before it approves or pays for treatment
services.
I may use and disclose PHI in connection
with health care operations, including quality improvement activities, training
programs, accreditation, certification, licensing or credentialing activities.
I may use or disclose PHI when I am
required or permitted to so by law. For example, I may disclose PHI to
appropriate authorities if I reasonably believe that you are a victim of abuse,
neglect or domestic violence or the possible victim of other crimes. In
addition, I may disclose PHI to the extent necessary to avert a serious threat
to your health or safety or the health or safety of others. Other disclosures
permitted or required by law including the following: disclosures for public
health activities; health oversight activities including disclosures to
judicial and law enforcement officials in response to a court order or other
lawful process; disclosures for research when approved by an institutional
review board; and disclosures to military or national security agencies,
coroners, medical examiners and correctional institutions or otherwise as
authorized by law.
a.
State law requires me to obtain your
authorization to disclose your health information to the state of Oregon for
payment purposes.
b.
For private clients, state law requires me to
obtain your authorization to disclose your health information for payment
purposes.
Notes recorded by me documenting the
contents of a counseling session with you
(ÒPsychotherapy NotesÓ) will be used only by me and will not otherwise be used
or disclosed without your written authorization.
11. Your
Individual Rights
You may request access to your medical
record and billing records maintained by me in order to inspect and make copies
for your records. All requests for access must be made in writing. Under
limited circumstances, I may deny access to your records,
I may charge a fee for the costs of copying and sending you any records
requested. If you are a parent or legal guardian of a minor, please note that
certain portions of the minorÕs medical record will not be accessible to you.
You
may request and I will accommodate, any reasonable written request for you
to
receive PHI by alternative means of communication or at alternative
locations.
You have the right to request a restriction
on PHI used for disclosure for treatment, payment or health care operations.
You must request any such restriction in writing addressed to the Privacy
Officer as indicated below. I am not required to agree to any such restriction
you may request.
Upon written request, you may obtain an
accounting of certain disclosures of PHI made by me. This right applies to
disclosures for purposes other than treatment, payment or health care
operations, excludes disclosures made to you or for disclosures otherwise
authorized by you, and is subject to other restrictions and limitations.
You have the right to request that I
amend your health information. Your request must be in writing. And it must explain
why the information should be amended. I may deny your request under certain
circumstances.
You have the right to obtain a paper copy
of this notice by submitting a request to the Privacy Officer at any time.
If you desire further information about
your privacy rights, or are concerned that I have violated your privacy rights,
you may contact the Privacy Officer, Lola Broomberg
at 541-341-3477. You may also file written complaints with the Director, Office
for Civil Rights of the US Dept of Health and Human Services. I will not
retaliate against you if you file a complaint with the Director or me.