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Welcome to Willamette Valley Family Center Thereafter WVFC. This form contains information about fees, insurance billing practices, psychotherapy treatment, confidentiality and WVFC’s HIPAA compliance. Should you have additional questions after reading this policy statement, do not hesitate to ask for clarification. We will give you a copy of these policies. Please keep them for your records.

Consent to Treatment

The practitioners of Willamette Valley Family Center are committed to providing quality care that meets the practice guidelines and ethical standards for practitioners. As such, we work jointly with clients to achieve positive results, understanding that psychotherapy has both benefits and risks. One risk is remembering unpleasant events. Anxiety, guilt, depression, fear, anger, loneliness and/or feelings of helplessness can occur when one begins to explore current and past feelings. At the same time, psychotherapy can be of benefit to people who undertake it. It can lead to a significant reduction in stress, better relationships, and resolution of specific problems. While we do expect that you will benefit from therapy, there is no guarantee that your condition will improve or that you will be cured. You have the right to stop treatment at any time and/or request appropriate referrals from your therapist.

Oftentimes, clients come to therapy with difficulties that are best treated with brief interventions. This involves a time-limited, problem-focused and solution-oriented method of treatment. The best results can be expected when both the practitioner and the client take an active role in assessing the current difficulties, agreeing on a successful outcome and planning creative solutions to meet your goals. The frequency and type of treatment will be decided between you and your practitioner and be subject to your verbal agreement. Alternative therapies for your condition do exist and can be discussed with your practitioner. Should your practitioner become disabled or deceased, another practitioner at WVFC will take over your care or help you transition to appropriate treatment elsewhere.

By signing below, you agree to participate with your practitioner in psychological or psychiatric treatment, exams, and/ or diagnostic procedures, which at this time or in the future are advisable. Your signature also indicates that you understand that the purpose of these procedures will be explained to you upon request. All procedures are subject to your agreement. Finally, you understand that while the course of treatment is designed to be helpful, your practitioner can make no guarantee about the outcome of the treatment.

Office Policies

After Hours Coverage

In the event that you need to speak with someone immediately, please call the office. Twenty-four-hour coverage is provided through our answering service. Please be aware that you may be speaking to a practitioner other than your own when you call after hours. You may also call your family physician or go to the nearest hospital emergency room. In case of an emergency, you may also contact the Crisis line at 503-655-8401 (Clackamas County), 503-988-4888 (Multnomah County), or 503-291-9111 (Washington County).

Legal Proceedings and Court Involvement

If you are involved in, or anticipate being involved in, legal or court proceedings, please notify your practitioner as soon as possible. It is important for the practitioner to understand how, if at all, your involvement might affect your work together. Each practitioner has individual policies concerning what type of court proceeding/legal involvement in which they are willing to participate.

In the event, you are entering treatment because you have been asked to obtain a psychological/ psychiatric evaluation it is important for you to know the difference between treatment and evaluation, and to recognize that treatment is not a substitute for an evaluation or an appropriate method to attain evaluation results. If you need an evaluation, your practitioner can assist you in finding an appropriate provider.

Your practitioner will not be party to any legal proceedings against current or former clients. Clients entering treatment are agreeing to not involve their practitioner in legal/court proceedings or attempts to obtain records of treatment for legal/court proceedings when marital or family therapy has been unsuccessful in resolving disputes. In the event of court proceedings (such as, but not limited to, divorce and custody disputes, injuries, lawsuits, etc.), your practitioner can only disclose information you have given consent to release and cannot disclose information about family members or parties involved in treatment without their consent. This prevents misuse of your treatment for legal objectives.

Professional Fees and Billing Practices 

The payment of all professional fees is the direct obligation of the client, regardless of any insurance policy coverage for psychological and psychiatric services. Our fee is based on prevailing standards in the community. As community standards change, our fees may change accordingly.

It is your responsibility to check and determine your insurance benefits (Deductible, co-payments and co-insurance etc.), and determine whether or not the practitioner you are seeing is contracted with your specific insurance plan. It is also your responsibility to obtain prior authorization for services (if necessary) through your insurance company. Your co-payment is due at each appointment. This co-pay is determined by your specific insurance benefit plan. The amount of your co-pay may change according to the length of your treatment. If any of the proposed services create an unacceptable financial burden, please talk with your practitioner before the service begins so acceptable arrangements can be made. We accept personal checks, money order, cash, VISA and Mastercard. There is a fee associated with checks returned due to insufficient funds.

Fees may also be charged for:
1) Telephone consultation time initiated by the client.
2) Time spent on letter or report writing on behalf of the client.
3) Appointments that are missed without notice or canceled/rescheduled without prior days notice.

WVFC’s policy is to charge for missed appointments or late cancellations. Insurance companies do not cover these charges. They are the clients’ responsibility. Cancellations can be phoned into the office any time, day or night to (503) 657-7235.

We will bill your insurance company or EAP unless you instruct otherwise. You will receive a monthly statement from our office reflecting all unpaid charges. In the event that your insurance company denies mental health services, please discuss the situation with your therapist. When you choose to continue treatment beyond the limits of insurance coverage, you become responsible for 100% of the bill. If an overpayment occurs, your credit will be refunded to you. Please note: Clients choosing not to bill an insurance company will also receive monthly statements.

In the event the Center is unable to collect the necessary funds to settle a client account, this account may be turned over to an outside collection agency. Full payment or partial payment (if negotiated with your therapist) is expected by the end of the month following notification. The center does not accept responsibility for collecting your insurance claim or for negotiating a settlement on a disputed claim. You are responsible for payment of your account, including any unpaid insurance claims.

Grievances and Appeals: Most insurance companies have specific appeals and grievance procedures concerning the authorization process and / or any complaints you might have about your care. Your psychologist/psychiatrist can assist you in obtaining information and forms you might need for either procedure. You may send any complaints about your care directly to the insurance company also. If you do have complaints or questions about your care, it is appropriate to first speak with your provider in an effort to resolve any differences.

Your signature below acknowledges your receipt of these Office Policies and your agreement to the procedures that are explained.