Lola Broomberg LPC
541 Willamette Street, suite 207A
Eugene, OR 97401
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 email@example.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
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 client’s 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. (“Protected Health Information or PHI”). 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 (“Psychotherapy Notes”) 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 minor’s 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.