The following are a list of common forms used in my practice. Some people fill them out during our first meeting together and some people like to fill them out prior to meeting. Feel free to print these out and bring them to our first meeting. The last two forms may or may not be relevant to you. I’m happy to answer questions about any of the forms.
Charlotte Redway, LCSW
2306 NE Glisan St
Portland, OR 97232
(503)888-3238
Consent for Services
Philosophy
My practice is based on an exciting and growing body of collaborative, feminist, and narrative therapy ideas. I engage with these ways of thinking during out meetings together and in consultation outside of our meetings. I find non-pathologizing, competency-based, and respectful practice to be most generative. When I meet with people, I like to join them in their world and listen to stories about their lives. I listen for social, cultural, and political contexts that impact people’s relationship with problems. I don’t see people as problems; rather “the problem is the problem.” Together, we look at how the problem has influenced their life and watch for exceptions to this. When these unique outcomes are found, we delve into what made this possible which often leads to rich conversations about possibilities, hopes, and desires.
Education and Experience
I am a licensed clinical social worker (LCSW) in the state of Oregon. I have a BA in psychology from Mount Holyoke College in South Hadley, Massachusetts. I have my Masters in Social Work from the Smith College School of Social Work in Northampton, Massachusetts. I have also completed extensive training in Narrative therapy through the Dulwich Centre in Adelaide, Australia. If you are interested in knowing more about my education and experience, please ask.
Appointments
Meetings are generally 50 minutes of face to face time. They can be scheduled by calling me at 503-888-3238. This phone allows you to leave confidential messages. I may not be able to call you back immediately, but will do so as soon as possible. If you are unable to reach me and are having an emergency, you can call the Multnomah County Crisis Line at 503-988-4888 or go to the nearest hospital emergency room.
Cancelled Appointments and “No-Shows”
If you are not able to make an appointment, please let me know 24 hours in advance. If I do not receive 24 hours of notice, you will be charged for the session. Often insurance companies will not cover the cost of missed sessions, so you will need to pay “out of pocket.” I will use the time, even if you are not present, to think about our work together.
Your Rights
- You have the right to expect that as a Licensed Clinical Social Worker, I have met the minimum qualifications of training and experience to have obtained such a license.
- To examine public records maintained by the Board and have the Board confirm my credentials. You can contact the Board at Oregon State Board of Licensed Clinical Social Workers 3218 Pringle Rd S.E., Suite 240, Salem, OR 97302. Telephone: (503) 378-5735.
- 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 such 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 or neglect; 2) Reporting imminent danger to yourself 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 against this therapist.
- To be free from discrimination on the basis of race, gender, religion, sexual orientation, or other unlawful category.
Supervision and Consultation Regarding our Work Together
Though I am bound by the ethics of confidentiality, and do not break these, I want you to know that I sometimes seek supervision or participate in consultation groups regarding the meetings that I have with people. These are great spaces to generate ideas and come up with helpful ways to improve our skills. In these settings, I always talk about the people with whom I meet with the utmost respect. In order to maintain your confidentiality, I do not disclose identifying characteristics. If you are interested in knowing more about this, please feel free to ask.
Agreement and Consent
I request and authorize Charlotte Redway to provide me with individual, couples, and/or family therapy. I have a general knowledge of the nature and purpose of my therapy. I acknowledge that no guarantee has been made relative to the results that may be obtained.
______________________________________ ____________
Client Signature Date
Charlotte Redway, LCSW
2306 NE Glisan St
Portland, OR 97232
(503)888-3238
Info Sheet
Legal Name:
Preferred Name:
Today’s date:
Date of birth:
Mailing Address (including city, state, and zip code):
Home phone: _____-_____-_____
Is it alright for me to leave you a message on this phone: Y N
Cell phone: _____-_____-_____
Is it alright for me to leave you a message on this phone: Y N
Work phone: _____-_____-_____
Is it alright for me to leave you a message on this phone: Y N
Email: _________________________________
Important activities in your life (ie: work, school, hobbies, etc…):
Important people in your life (ie: friends, family, teachers, etc…)
Emergency contact name:
Emergency contact phone number:
How were you referred to me:
Charlotte Redway, LCSW
2306 NE Glisan St.
Portland, OR 97232
503-888-3238
Confidentiality Agreement
The work that we do together in the therapeutic setting is confidential and private. I will not share anything about you with anyone else unless I have your written permission to do so.
Sometimes it is helpful to have your permission to exchange information about you with others. If this is the case, we will discuss why this could be helpful and what information would be shared. You are free to decide if you wish to give me permission or not to contact others and share information. If you decide that you would like to give me permission, I will have you sign a form called a “release of information.”
It is important for you to know that some things, by law, cannot be kept private. Here are some exceptions to confidentiality:
1. If I am subpoenaed to testify in court, I may have to give information without your permission. This happens only in a few instances, usually around issues of child custody or possible criminal behavior.
2. If I suspect that harm has come to a child, adolescent or elderly person, or that child, adolescent, or elderly person may be harmed in the future, state law requires me to report this to the authorities.
3. If I learn that someone or something might be seriously harmed in the future or that a client intends to commit a crime of violence, it is my responsibility to protect others by informing them and the authorities.
4. If a medical emergency occurs, information necessary to help you may be shared with a physician or other skilled professional.
It is important that you understand both your rights to privacy and the limits to these rights. I encourage you to discuss any concerns that you may have about privacy with me during our first meetings or at any time that it may be of concern to you.
My signature verifies that the confidentiality information is clear to me.
____________________________________________ ____________
Client Signature Date
Charlotte Redway, LCSW
2306 NE Glisan St.
Portland, OR 97232
503-888-3238
Fee Agreement
The following statement applies to fee and appointment policies related to receiving services from Charlote Redway, LCSW. The services I may receive are listed below. I agree to the following terms and fees for the services offered.
Payment of Fees (Initial the option you choose below).
_______ Private Pay
I understand that I am responsible for payment of fees in advance or at the time of service unless other arrangements have been made. Fees for individual, couples, and family therapy are $100 per 50 minutes.
I understand that if I do not cancel my appointment 24 hours in advance, I will be responsible for the full cost of the appointment at our next meeting.
_______ Insurance Coverage*
I understand that my insurance company will be billed for therapeutic services. I also acknowledge that I am responsible for paying any deductibles and co-payments in accordance with the requirements of my specific insurance plan. I understand that if my insurance company does not cover these services, I am responsible for payment of services in full. The fees billed to 3rd party payors are usual and customary.
I understand that if I do not cancel my appointment 24 hours in advance, I will be responsible for the full cost of the appointment at our next meeting. I also understand that most insurance companies do not cover missed appointments, so I will be expected to cover this cost myself at our next meeting.
*Note:
If I am billing your medical insurance for our meetings, please note that I am required to bill under a diagnostic code. The most common codes I use are adjustment disorder with depressed mood or with anxiety. I understand that circumstances in our lives are always changing and we are always adjusting. Yet ‘disorder’ is not a word I would use if not required. Other than this mention, I usually complete this billing form outside of our therapeutic meetings. Please feel free to ask me any questions about this or let me know if you want to participate more fully in completing the billing form.
Payment and Insurance Coverage Responsibility
I have read and understand the above policies and fees, payment responsibilities, and missed appointment policies.
_________________________________________
Client Signature and Date
Charlotte Redway, LCSW
2306 NE Glisan St
Portland, OR 97232
(503)888-3238
Release of Information
Regarding:______________________________________________ Date:_______
I authorize Charlotte Redway to contact:
Name:__________________________________________________________________
Contact information:
For:
- ____ Release information FROM person or agency above.
- ____ Release information TO person or agency above.
The following information may be released:
____ Medical ___ Assessment of problems facing a person/family
____ History ___ Chemical dependency information
____ Summary of work together ___ Other (please specify):____________________
For the following purpose:__________________________________________________
_______________________________________________________________________
_______________________________________________________________________
I understand that such information cannot be released without my specific consent. This authorization is valid for 90 days or until _______________ unless revoked in writing at any time specified in advance.
_______________________________________________ ____________
Client Signature Date
Charlotte Redway, LCSW
2306 NE Glisan St
Portland, OR 97232
(503)888-3238
Child Therapy Agreement
Name of Child: ______________________________________________Date of Birth:________
1.) My role as therapist for your child is to create a therapeutic and safe environment for the sharing and working through of your child’s feelings related to your divorce, and other issues that may be interfering with your child’s optimal development. It is understood that it is essential for the benefit of your child that I maintain neutrality in any divorce-related disputes. In the event that any custody or divorce disputes continue, you agree that you will not use me or my therapy records in legal proceedings so that I may remain a therapeutic resource for your child.
2.) It is understood that I am not conducting a custody evaluation, or an abuse investigation. If you or I believe that either of these need to be conducted, those services would be obtained from another independent professional who would be the one to give the results directly to your attorneys, With your permission and/or under legal guidelines, I would provided information directly to the qualified professional or agency conducting those investigations to assist in their research and recommendations.
3.) It is understood that both parents give permission for me to release any information obtained during the course of therapy to the other if I believe it is in the best interest of your child. However, it is also understood that for me to be the most help to your child, each parent needs to feel they can be honest about whatever difficulties they are having with parenting in their household. Therefore, I will discuss with each parent only issues with their child occurring in their own household. It is understood that my role is not as a “go-between” to share information about one household with the other.
4.) If conflict between parents appears to be interfering with your child’s treatment and well-being, I may recommend mediation, or a parent coordinator, to help resolve conflicts.
5.) It is understood that the purpose of all sessions, individual or family sessions, is for the benefit of your child. If you have unresolved feelings about your ex-spouse and your own adjustment to the divorce and visitation issues, these should be addressed wit your own therapist and not with me, your child’s therapist.
6.) In the event that either or both parents become dissatisfied and decide to end their child’s therapy, it is understood and agreed that it would be in the best interests of your child to schedule a final “goodbye” therapy session rather than being pulled abruptly out of therapy.
I understand and agree with the treatment conditions as stated above. I support the goal of this treatment as being for the best interests of my child. I understand that I the terms of this agreement are violated, my child’s therapy may be damaged and may require termination.
Parent/Guardian: ________________________ Date: ______