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Terms and Policy

Policies and Service Agreement

Welcome to my practice. I appreciate your giving me the opportunity to be of help to you. This form provides you with information that you need in order to make an informed choice regarding your therapy. If you have any questions please do not hesitate to ask and I will address them during your intake appointment.

Therapy Process

To provide you with the best possible care, it is important that I have a clear understanding of what brings you to treatment. To assist me in this process, I will ask you to complete several forms. During our initial meetings I will also ask you detailed questions about your current and past functioning, including family and work history, past mental health problems, previous treatment, history of abuse or trauma and drug and alcohol use. Based on this information we will develop goals and an agreed upon treatment plan. This treatment plan will dictate the approach we will take, the frequency, and duration of treatment. During this period, I will determine if I can be of benefit to you. I do not accept clients who I believe I cannot help. In such a case, I will give you a number of referrals that you can contact.

Participation in therapy can result in a number of benefits to you, including improved coping skills, improved interpersonal relationships, and resolution of the specific concerns that led you to seek therapy. Your personal goals and values may become clearer and you may grow in your ability to enjoy life more fully. Working towards these benefits however requires effort on your part. Psychotherapy requires your active involvement, honesty, and openness in order to change your thoughts, feelings, and behaviors. An important part of your therapy will be practicing new skills that you will learn in our sessions. Change will sometimes be quick and easy, but more often it will be slow and frustrating, and you will need to keep trying. My goal is to help and support you through these changes and I encourage feedback or concerns you may have about any aspect of the process. If at anytime you feel misunderstood, have doubts about the effectiveness of your treatment, or believe that treatment is misguided, it is important that you bring this to my attention. Open communication and feedback need to occur throughout treatment and I will periodically ask you for input. During therapy, remembering, or talking about unpleasant events, feelings or thoughts can result in uncomfortable levels of sadness, anxiety, anger, frustration, loneliness, fear, or other negative feelings. Problems may even temporarily worsen after beginning of treatment but this is to be expected as you make important changes in your life and should subside as the therapy progresses. However, attempting to resolve issues that brought you to therapy in the first place, such as personal or interpersonal relationships, may result in changes that were not originally intended. Finally, despite even our best efforts, there is the possibility that therapy may not work out well for you. During the course of therapy, I am likely to draw on various psychological approaches according, in part, to the problem that is being treated and my assessment of what will best benefit you. These approaches include cognitive-behavioral, family systems, mindfulness, and relaxation, interpersonal, developmental, or psycho-educational.

Telehealth Services

Telehealth is the remote delivery of clinical information and health care service using telecommunications technology. This information and services may include client medical records, live two-way audio and video conferencing, and instant messaging. Telehealth is a significant and rapidly growing component of health care. Worldwide millions of individuals use telehealth as part of their care and an increasing number of consumers download health and wellness applications for use on their mobile phones. According to the American Telemedicine Association, telehealth has been backed by decades of research and demonstrations and has been found to be a safe and cost-effective way to extend the delivery of health care. The benefits of telehealth include:

        -  improved access to healthcare by bringing healthcare services to individuals in distant and remote locations and allowing                    healthcare providers to expand their reach.

         - reduced healthcare costs.

         - improved quality as shown by numerous studies indicating that services delivered via telehealth are as good, if not superior,              to traditional in-person services particularly with regard to mental health care where better outcomes and client satisfaction                are reported.

          -Increased consumer demand since using telehealth reduces travel time and related stresses for the individual as well as                    offering access to providers that might not otherwise be available.

Although rare, there are potential risks associated with the use of telehealth. Possible risks may include: despite reasonable efforts on my part, the transmission of sensitive information could be disrupted or distorted by technical failures (e.g. poor resolution of images); the transmission of sensitive information could be interrupted or accessed by unauthorized persons; and/or the electronic storage of sensitive information could be accessed by unauthorized persons.In addition, the telethealth modality may not be appropriate for everyone. I will tell you if I believe you would be better served by face-to-face services and will refer you to a practitioner in your geographical area who can provide such services, if necessary. Since I do not provide emergency or crisis services within my practice, and will refer you to the appropriate services if it seems that distance support through telehealth, is not clinically appropriate for you at this time. I contract with several HIPAA compliant video platforms and use practice management software. The service I use requires you to register and login through the secure client portal via my webpage. This allows us to communicate through safe and secure written messaging, video, and instant message sessions while keeping sensitive information protected. All of my client records are stored securely online to ensure your privacy and I am the only one who has access to your encrypted information. The online services I use to communicate, conduct videoconferencing and chat sessions, and store records each utilize state of the art HIPAA-compliant security. You are responsible for information security on your computer or device. If you decide to keep copies of our confidential clinical correspondence on your computer or device, it is your responsibility to keep that information secure. I ask that you determine who has access to your computer and electronic information prior to our sessions. This would include family members, co-workers, supervisors, and friends. I encourage you to only communicate through a computer that you know is safe, i.e. wherein confidentiality can be ensured. Be sure to fully exit all online telehealth sessions. I encourage you to find a location for our sessions with proper lighting, limited audio and visual distractions, and a sound barrier to prevent others overhearing the session. There is the possibility of an interruption in service due to technical difficulties or poor visual quality. In the event that this happens, I will re-initiate the session. If reconnection is not possible, please have available the telephone you listed as your primary contact so that I can call you during that time. Please be aware that I cannot be held responsible for disruptions or interruptions to our communications.


If at any point during treatment, I assess that I am not effective in helping you reach your therapeutic goals or if another form of therapy, that I cannot provide, is indicated, I will discuss this with you and, if appropriate, terminate treatment. In such a case, I will give you a number of referrals that may be of help to you. You have the right to terminate therapy at any time. If you would like to stop therapy, I ask that you agree to attend at least one session to discuss our work together, review your progress, and close our relationship in a healthy way. If more that 30 days have passed since our last contact, and I have not received any communication from you, I will accept this as your notice that you no longer wish to continue treatment and that our therapeutic relationship is terminated.

Confidentiality and Exceptions

All information, disclosed within sessions and the written records pertaining to those sessions, is confidential and may not be revealed to anyone without your written permission, except where disclosure is required or permitted by law. If you would like me to share information or records, you will need to sign a release of information form. In couple and family therapy, or when different family members are seen individually, confidentiality and privilege do not apply between the couple or among family members. Dr. Hediger will use her clinical judgment when revealing such information. Records will not be released to any outside party unless authorization is obtained from all adult family members who were part of the treatment. In cases of divorce or separation, both parents must give consent for treatment of their child as well as authorize any release of information. If you are planning on using your insurance to pay for therapy, I will disclose a diagnosis for your treatment. If the insurer asks for further information, I will discuss this with you prior to disclosing any information. On occasion, I may consult with other professionals about concerns or the course of treatment, however, your identity will always be kept confidential, and any identifying information will be changed. What follows are some exceptions in which your privacy cannot be kept confidential (for more details see also Notice of Privacy Practices form).

When Disclosure Is Required By Law: Some of the circumstances where disclosure is required by the law are: when there is a reasonable suspicion of child, dependent or elder abuse or neglect; and when a client presents a danger to self, to others, to property, or is gravely disabled.

When Disclosure May Be Required: Disclosure may be required as the result of a legal proceeding by or against you. If I am subpoenaed or court ordered to testify, I may have to give information about you without your permission. If this does happen, I will make every attempt to contact you.

Legal Proceedings

Psychotherapy is for the improvement of your psychological functioning and is not intended to be used for the purposes of current or future legal proceedings (e.g. custody, divorce, civil proceedings, etc). My goal is to support my clients to achieve therapy goals and not to address legal issues that require an adversarial approach. It is important for you to know that I will not be a party to any legal proceedings against current or former clients. It is agreed that if there are legal proceedings (such as, but not limited to divorce and custody disputes, injuries, lawsuits, etc.), neither you (client) nor your attorney, nor anyone else acting on your behalf will call on Dr. Hediger to testify in court or at any other proceeding, nor will a disclosure of the psychotherapy records be requested.

Email, Text Messaging and Social Media

It is important to be aware that e-mail correspondence and text messaging are not considered confidential mediums of communication. Communication through theses mediums should be limited to non-sensitive correspondence such as appointment scheduling, billing, and reminders. I will not respond to clinical concerns via regular email. If you would like to send personal or clinical information please do so via the secure client web portal on my website at I will not engage in a social relationship on any social media site. This is based on a concern for the potential loss of privacy and blurring of the therapeutic relationship.

Contact and Emergency Procedures

If you need to contact me between sessions, please either leave me a voicemail at (541) 556-8332 or message me via the secure client web portal on my website at I check messages daily and will get back with you as soon as possible. In the instance, I will be unavailable for an extended period of time I will provide you with a referral in advance. Due to the nature of my practice, I am unable to provide emergency services. If, however, you have an urgent matter and cannot wait for a response, you should contact the SAMHSA's National Helpline at (800) 662-HELP (4357) serving individuals and family members facing mental and/or substance use disorders or the National Suicide Prevention Lifeline at (800) 273-TALK (8255). If you or someone else is in imminent danger of harm, then you are instructed to call 911 and/or go to your nearest emergency room.

Appointments and Cancellations

Sessions are scheduled for 45 or 55 minutes. The first appointment can last up to 60-75 minutes in order to gather all the necessary information. Sessions are usually scheduled weekly but could occur more or less frequently depending on the needs of your particular situation. If I am ever unable to start on time, I ask your understanding. I assure you that you will receive the full time agreed to or you will be charged only for the time used. If you are unable to keep a scheduled appointment, please let me know as far in advance as possible to reschedule. Failure to give a 24-hour advance notice of cancellation may result in a $50.00 charge for the session. Please note that insurance companies will not pay for missed or canceled sessions.

Fees, Payments, and Billing

My fees are $275 for an initial assessment and $250 for subsequent sessions unless otherwise contracted with your insurance provider. Payment is due at the time of service. Additional professional services, including telephone conversations lasting longer than 15 minutes, letter and report writing, consultation with other professionals, longer sessions, preparation of records or treatment summaries, and time spent performing any other service you may request of me will be charged at the same rate unless otherwise indicated and agreed. If you choose to use your health insurance coverage, as a courtesy service, I will submit claim forms on your behalf and provide whatever reasonable information your insurance company requests but I cannot guarantee that they will pay. Insurance companies and policies vary in the amount of coverage, deductibles, and co-payments and it is your responsibility to verify the specifics of your coverage. Insurance companies may not cover all issues and conditions which are the focus of psychotherapy and may consider some services outside of the benefit provided and as a result elect not to pay for them (e.g. telephone consultations, preparation of letters and reports, missed appointments, etc.). Be advised that you (not your insurance company) are responsible for full payment if your insurance company rejects a claim or pays it in part. Disclosure of confidential information may be required by your health insurance carrier in order to process claims and many insurance companies require you to authorize me to provide them with a clinical diagnosis. On occasion, I may need to provide additional clinical information such as a treatment plan or copies of the record. I assure you that I will share only the minimum necessary to secure payment. Failure to pay fees may result in discontinuation of treatment. If there is any problem with my charges, my billing, your insurance, or any other money-related point, please bring it to my attention and I will do the same with you. Such problems can interfere greatly with our work and they must be worked out openly.


If you are unhappy with what is happening in therapy, I hope you will talk with me about it so that I can respond to your concerns. I take such issues seriously, and with care and respect. If you believe that I've been unwilling to listen and respond, or that I have behaved unethically, you may file a complaint to either: the Oregon Board of Psychology Examiners, Salem, Oregon 97302, www.Oregon.Gov/obpe, or the Arizona Board of Psychologist Examiners, Phoenix, Arizona 85007, You are also free to discuss your complaints about me with anyone you wish, and do not have any responsibility to maintain confidentiality, since you are the person who has the right to decide what you want kept confidential.

( Type Full Name )
Notice of Privacy Practices

Notice of Psychologists' Policies and Practices to Protect the Privacy of Your Health Information


I.  Uses and Disclosures for Treatment, Payment, and Health Care Operations

I may use or disclose your protected health information (PHI), for treatment, payment, and health care operations purposes with your consent. To help clarify these terms, here are some definitions:

       PHI: includes any individually identifiable health information received or created by my office or me.

       Health information: is information in any form that relates to any past, present, or future health of an individual.

       Treatment, Payment and Health Care Operations:

           - Treatment is when I provide, coordinate or manage your health care and other services related to your health care. An                      example of treatment would be when I consult with another health care provider, such as your family physician or another                  psychologist.

           - Payment is when I obtain reimbursement for your healthcare. Examples of payment are when I disclose your PHI to your                    health insurer to obtain reimbursement for your health care or to determine eligibility or coverage.

           - Health Care Operations are activities that relate to the performance and operation of my practice. Examples of health care                  are quality assessment and improvement activities, business-related matters such as audits and administrative                                  services, and case management and care coordination.

       Use:applies only to activities within my office such as sharing, employing, applying, utilizing, examining, and analyzing                      information that identifies you.

       Disclosure: applies to activities outside of my office such as releasing, transferring, or providing access to information about you        to other parties.

       Consent: refers to your consent and agreement to my releasing your PHI.

II. Uses and Disclosures Requiring Authorization

I may use or disclose PHI for purposes outside of treatment, payment, and health care operations when your appropriate authorization is obtained. I may use or disclose confidential information (including but not limited to PHI) for purposes of treatment, payment, and healthcare operations when your written informed consent is obtained. I may use or disclose PHI for purposes outside of treatment, payment, and healthcare operations when your appropriate written authorization is obtained. An authorization is written permission above and beyond the general consent that permits only specific disclosures. In those instances when I am asked for information for purposes outside of treatment, payment and health care operations, I will obtain an authorization from you before releasing this information. I will also need to obtain an authorization before releasing your psychotherapy notes. Psychotherapy notes are notes I have made about our conversation during a private, group, joint, or family counseling session, which I have kept separate from the rest of your medical record. These notes are given a greater degree of protection than PHI. I will also obtain an authorization from you before using or disclosing PHI in a way that is not described in this Notice.

You may revoke all such authorizations (of PHI or psychotherapy notes) at any time, provided each revocation is in writing. You may not revoke an authorization to the extent that:

(1)    I have relied on that authorization.

(2)    If the authorization was obtained as a condition of obtaining insurance coverage, and the law provides the insurer the right to contest the claim under the policy.

III. Uses and Disclosures with Neither Consent nor Authorization

I may use or disclose PHI without your consent or authorization in the following circumstances:

       Child Abuse: If I have reasonable cause to believe that a child with whom I have had contact has been abused I may be required to report the abuse. Additionally, if I have reasonable cause to believe that an adult with whom I have had contact has abused a child, I may be required to report the abuse. In any child abuse investigation, I may be compelled to turn over PHI. Regardless of whether I am required to disclose PHI or to release documents, I also have an ethical obligation to prevent harm to my patients and others. I will use my professional judgment to determine whether it is appropriate to disclose PHI to prevent harm.  If there is a child abuse investigation, I may be compelled to turn over your relevant records.

       Mentally Ill or Developmentally Disabled Adults: If I have reasonable cause to believe that a mentally ill or developmentally disabled adult, who receives services from a community program or facility, has been abused, I may be required to report the abuse. Additionally, if I have reasonable cause to believe that any person with whom I come into contact has abused a mentally ill or developmentally disabled adult, I may be required to report the abuse. Regardless of whether I am required to disclose PHI or to release documents, I also have an ethical obligation to prevent harm to my patients and others. I will use my professional judgment to determine whether it is appropriate to disclose PHI to prevent harm.

       Adult and Domestic Abuse: If I have the responsibility for the care of an incapacitated or vulnerable adult, I am required to disclose PHI when I have a reasonable basis to believe that abuse or neglect of the adult has occurred or that exploitation of the adult's property has occurred.

       Elder Abuse: If I have reasonable cause to believe an elder with whom I have had contact has been abused, I may be required to report the abuse. Additionally, if I have reasonable cause to believe that an adult with whom I have had contact has abused an elder, I may be required to report the abuse.

       Serious Threat to Health or Safety: If you communicate to me an explicit threat of imminent serious physical harm or death to a clearly identified or identifiable victim(s) and I believe you have the intent and ability to carry out such a threat, I may have a duty to take reasonable precautions to prevent the harm from occurring, including disclosing information to the potential victim and the police and in order to initiate hospitalization procedures. If I believe there is an imminent risk that you will inflict serious harm on yourself, I may disclose information in order to protect you.  I must limit disclosure of the otherwise confidential information to only those persons and only that content which would be consistent with the standards of the profession in addressing such problems.

       Health Oversight: When authorized by law, I may be required to disclose your PHI to a health oversight agency for activities, such as audits, investigations, inspections, licensure actions or other legal proceedings.  A health oversight agency is a state or federal agency that oversees the health care system.

       Judicial and Administrative Proceedings: If you are involved in a court proceeding and a request is made for information about the professional services I provided you and/or the records thereof, such information is privileged under state law, and I will not release information without a court order or the written authorization of you or your legally appointed representative. The privilege does not apply when you are being evaluated for a third party or where the evaluation is court-ordered. You will be informed in advance if this is the case.

       Worker's Compensation: I may disclose PHI as authorized by and to the extent necessary to comply with laws relating to worker's compensation or other similar programs, established by law, that provide benefits for work-related injuries or illness without regard to fault.

       Section 164.512 of the Privacy Rule: This includes certain narrowly-defined disclosures to law enforcement agencies, to a health oversight agency (such as HHS or a state department of health), to a coroner or medical examiner, for public health purposes relating to disease or FDA-regulated products, or for specialized government functions such as fitness for military duties, eligibility for VA benefits, and national security and intelligence.

IV. Patient's Rights and Psychologist's Duties

Patient's Rights:

       Right to Request Restrictions: You have the right to request restrictions on certain uses and disclosures of certain PHI. However, I am not required to agree to a restriction you request.

       Right to Receive Confidential Communications by Alternative Means and at Alternative Locations: You have the right to request and receive confidential communications of PHI by alternative means and at alternative locations. (For example, you may not want a family member to know that you are seeing me. Upon your request, I will make alternative arrangements regarding billing.)

       Right to Inspect and Copy: You have the right to inspect or obtain a copy (or both) of PHI and psychotherapy notes in my mental health and billing records used to make decisions about you for as long as the PHI is maintained in the record. I may deny your access to PHI under certain circumstances, but in some cases, you may have this decision reviewed. On your request, I will discuss with you the details of the request and denial process.

       Right to Amend: You have the right to request an amendment of PHI for as long as the PHI is maintained in the record. I may deny your request. On your request, I will discuss with you the details of the amendment process.

       Right to an Accounting: You generally have the right to receive an accounting of disclosures of PHI for which you have neither provided consent nor authorization (as described in Section III of this Notice). On your request, I will discuss with you the details of the accounting process.

       Right to a Paper Copy: You have the right to obtain a paper copy of the notice from me upon request, even if you have agreed to receive the notice electronically.

       Right to Restrict Disclosures When You Have Paid for Your Care Out-of Pocket: You have the right to restrict certain disclosures of PHI to a health plan when you pay out-of-pocket in full for my services.

       Right to Be Notified if There is a Breach of Unsecured PHI: You have a right to be notified if: (a) there is a breach (a use or disclosure of your PHI in violation of the HIPPA Privacy Rule) involving your PHI; (b) that PHI has not been encrypted to government standards; and (c) my risk assessment fails to determine that there is a low probability that your PHI has been compromised.

Psychologist's Duties:

       I am required by law to maintain the privacy of PHI and to provide you with a notice of my legal duties and privacy practices with respect to PHI.

       I reserve the right to change the privacy policies and practices described in this notice. Unless I notify you of such changes, however, I am required to abide by the terms currently in effect.

       If I revise my policies and procedures during your course of treatment or evaluation, I will notify you by mail.

V. Questions and Complaints

If you are concerned that I have violated your privacy rights, have questions or you disagree with a decision I made about access to your records, please contact me first.  However, if you are still not satisfied with our resolution, may also send a written complaint to: Office of the Secretary, U.S. Department of Health and Human Services, 200 Independence Avenue, S.W., Washington, D.C. 20201. You will not be penalized in any way for filing a complaint.

VI. Effective Date, Restrictions and Changes to Privacy Policy

This notice is in effect as of August 1, 2017.

I will limit the uses or disclosures to the extent that such limitation does not affect my right to make a use or disclosure that is required by law or, when in good faith, to use or disclose to avert a serious threat to health or safety of a person or the public and such use or disclosure is made to a person or persons reasonably able to prevent or lessen the threat (including the target of the threat).

I reserve the right to change the terms of this notice and to make the new notice provisions effective for all PHI that I maintain. If changes are made, I will provide you with a revised notice.

( Type Full Name )
Consent For Treatment

I have received and reviewed all information contained in the Policies and Service Agreement.

I hereby acknowledge that I have been offered a copy of the Notice of Privacy Practices (Notice of Psychologists' Policies and Practices to Protect the Privacy of Your Health Information).

I understand the limits to confidentiality required by law.

I accept financial responsibility for payment of all fees at the time of service, unless other arrangements have been made. I hereby authorize the release of all information necessary to secure the payment of benefits as well as the use of my signature on all insurance submissions. I herby authorize the payment of insurance benefits from my insurance company to Dr. Hediger. Furthermore, I understand that I am financially responsible for all charges that are denied by the insurance company, as well as for any deductible and/or co-payments.

I consent to having treatment services provided by Dr. Hediger including, psychological evaluation, treatment, and diagnostic procedures that are deemed advisable during the course of my treatment.

I have been informed about the potential risks and benefits of therapy.

I understand that maximum benefit will occur with consistent attendance and that I may, at times, feel conflicted about my therapy, as the process can sometimes be uncomfortable.

I understand that there is an expectation that I will benefit from psychotherapy, but there is no guarantee this will occur.

In the event that the identified client is a minor, I affirm that I am their legal guardian with the authority to authorize mental health services for them.

I understand that my questions about the process and progress of treatment are encouraged and always welcome. I understand that I have the right to stop therapy whenever I wish or to seek services elsewhere (including the right to ask for and receive referral resources).

I understand that I must inform Dr. Hediger of all cancelations at least 24 hours before the time of the appointment. If I fail to cancel and do not show up, I may be charged $50 for that appointment, not payable by insurance

I have read, understand, and agree to the above stated rules and conditions for treatment.

( Type Full Name )