Claudelle R. Glasgow, Psy.D., LLC
2143 NE Broadway, #6 Portland, OR 97232
- I agree that I am responsible for the fees to my therapist, including any fees not paid by medical insurance. I agree to pay on the date of the session. I understand that I am responsible for paying in full for appointments cancelled with less than 48 hours notice, and that insurance companies will not reimburse for any portion of such cancellations.
- I have been informed of my therapist’s private practice procedures and policies. My questions or concerns regarding them have been addressed. I understand the extent of and limitations on confidentiality and privacy that exist between myself and my therapist.
Client Rights and Responsibilities:
- I have been informed of my client rights and responsibilities, including information on my Oregon HIPAA rights. All of my questions or concerns regarding this have been addressed. I understand that I am consenting to treatment with my therapist, that my pursuit of such services is voluntary, and that I may terminate these services at any time.
Health Insurance Information and Precertification:
- I have provided all current and necessary health insurance information and I am aware that it is my responsibility to keep all health insurance information up to date. I am aware that if I do not do so, the necessary precertification may not be obtained, which could interfere with insurance coverage for services provided. I understand that I am responsible for payment of any sessions that the insurance company does not cover.
Release of Information Authorization:
- I have had the opportunity to authorize (or decline to authorize) communication between my therapist and all other professionals involved in my healthcare, such as my primary care physician, my psychiatrist and other mental health care providers (if applicable)